Fact or Myth: Generational Preferences and Trends in Patient Medical Bill Statement Notification Types

It is often the default assumption in the medical billing industry that paper is necessary and sufficient as a means of collecting patient payments with minimal attention given to patient payment collection strategies for digital patient statement notifications (i.e. email and SMS). When digital notifications are considered it is often assumed that only younger patients will engage.

This report examines that assumption. Medical bill statement notifications received by patients of independent practices were analyzed over time, segmenting patient cohorts by generation (Silent, Baby Boomer, Gen X, Millennial, and Gen Z) and breaking out notifications by paper vs. digital, paper, email, and SMS.

Introduction

Many medical billers are reluctant to adopt digital-first communication strategies or even digital-assisted strategies for patient billing. Assumptions include a belief in a lack of interest from older patients or the belief that established processes already reach as many patients as needed.

These assumptions are challenged by key findings presented in this paper:

1 Digital notifications comprise a near if not absolute majority of all notifications received by patients across all age groups, not just younger patients. In fact, all but one age cohort received the majority of their notifications from digital rather than conventional paper channels, and the sole exception (the Silent generation) received a full 48% of all their notifications by email or text as opposed to conventional paper bills.

2 Contrary to what is commonly presumed, there was no trend for older patients to rely more heavily on paper statements over time. Likewise, there was no identified trend for younger patients to shift to receiving more digital statements over time.

3 Interestingly, although minor, the relative rate of adoption of digital as opposed to paper notifications over time was highest among both the oldest (Silent) and youngest (Gen Z) generations. Conversely, paper trended slightly negative over time as a percent of all notifications specifically for Silent and Gen Z patients.

4

Email notifications experienced pronounced growth as a percent of all notifications over the nearly two year time period analyzed. This was true across all patient age cohorts, but the strength of the correlation increased progressively by age. The strongest correlation was seen for Gen Z (r = .780), followed by Millennials (r = .605). The correlation was weaker though still notable for Gen X (r = .428), but it became relatively minor for Baby Boomers and Silents.

5 SMS notifications followed a temporal pattern that in many ways was the inverse of the trend for email. SMS became a gradually smaller portion of notification composition over time, though this pattern was again more pronounced with the younger generational age cohort. It was a solidly negative correlation for Gen Z (r = -.680) and Millennials (r = -.585), modestly negative for Gen X (r = -.399), and relatively minimal for Baby Boomers. Meanwhile, the trend was actually slightly positive indicating no change or slightly increased adoption of SMS notifications for the oldest generation of patients over time.

An unsurprising finding is that paper notifications are most common for older generations of patients.

More interestingly, the findings suggest that older generations may to some extent be playing “catch up”, with growth rates for digital channels among Silents and Boomers outstripping in pure percentage terms the rate of growth in digital statement use for younger generations.

The fact that even among the Silent generation almost half of all notifications came via digital channels, and that Baby Boomers received more digital than paper notifications at a rate of 64:36, should dispel the myth that older patients are not reachable or are not amenable to patient engagement or payment opportunities through these channels.

Doctors and billers who have resisted digital as a strategy may want to rethink their assumptions in light of these findings.

Methodology

For this analysis, data was pulled by month for all months from December 2018 to November 2020 (24 months in total). For each month the count of statements was queried, as a function of both notification type (email, SMS, paper) and the age cohort of the patient. To distinguish the different age cohorts, the standard Pew Research Center definition was used for the age ranges of each generation and the specific birthday cutoff points that divide them. The generations selected for this analysis were Silents (born 1928 to 1945), Baby Boomers (1946-1964), Gen X (1965-1980), Millennials (1981-1996), and Gen Z (1997-2003).

For Gen Z only data from patients who were over the age of 18 were analyzed, as patients younger than that age likely would have confounded results by having parents or guardians manage the payments.

Paper Notifications

To get clear data on how statement composition was changing over time, while accounting for growth in the number of statements overall, raw data on patient counts was converted to a percentage of all statements for the month for a given age cohort or notification category.

In some cases, the chart data is described using the correlation statistic r, also known as the correlation coefficient, which measures the strength and direction of a correlational relationship. The larger the absolute value of r, the stronger the relationship between the independent and dependent variables. A positive r value reflects a positive correlation, while a negative r value reflects an inverse or negative correlation.

For each month the values for each generational cohort sum to 100%, so fluctuations up or down do not reflect changes in notification volume for that particular age cohort alone but rather how the number of statements sent varied over time relative to the number of statements sent to other cohorts.

The percent composition for a given generation could drop either because they were receiving fewer notifications or because other generations were receiving more notifications and the growth in notifications for other generations exceeded the growth in the number of statements for that generation.

Results

Breakdown of Different Notification Methods by Generation

The proportion of paper notifications reveals a baseline level of monthly variability across generations, but across all age cohorts there was no net upwards or downwards trend in the rate of paper notifications over the 24 month period.

Digital Notifications
Email Notifications
SMS Notifications

Unsurprisingly, paper notifications comprise a greater proportion of all notifications for older generations compared to younger generations. This trend is particularly evident in the rates for Baby Boomer and Silent generation patients.

For digital notifications (i.e. email and SMS), Silent generation patients received a far lower percentage of their overall notifications through digital channels than did any other generation. Nevertheless, even Silent generation patients received nearly half of all their notifications through digital channels (47.9%), confirming that digital channels are significant across all generations.

Breaking out digital notifications between email and SMS, email notifications alone trended towards comprising a greater proportion of patient notifications over time. This trend was most pronounced among the younger generations, especially Millennials (r = .605) and Gen Z (r = .780).

Gen X still showed a significant drift towards emails being a larger component of their statement composition over time (r = .428). However, the significance of this trend declined for older generations. For Boomers the trend was quite muted (r = .159) and for Silent generation patients there was only very minimal growth in emails relative to other statement types (r = .066).

Conclusion

This data makes clear that patients of all ages, whether digitally native or not, increasingly welcome access to a variety of communication methods including email, text, and paper.

Furthermore, contrary to popular belief, older generations are not dramatically less likely to use digital methods for statement notifications (email/SMS), even though older generations are indeed much more reliant on paper statements overall. In fact, there may even be a slight trend towards progressively more SMS use among the older generation as older patients play “catch up” to the higher rates of adoption among young patients in prior years.

This research should inform billers and practices that their patients are more ready than they might think to adopt digital technology.