Accounts Receivable Management Strategies to Ensure Timely Payments in Rural Clinics

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Accounts Receivable Management Strategies to

Ensure Timely Payments in Rural Clinics

Anthony N. Medel

Walden University

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Walden University

College of Management and Technology

This is to certify that the doctoral study by

Anthony Natividad Medel

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by

the review committee have been made.

Review Committee

Dr. Roger Mayer, Committee Chairperson, Doctor of Business Administration Faculty

Dr. Warren Lesser, Committee Member, Doctor of Business Administration Faculty

Dr. Judith Blando, University Reviewer, Doctor of Business Administration Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

Walden University

2019

Abstract

Accounts Receivable Management Strategies to Ensure Timely Payments in Rural

Clinics

Anthony Natividad Medel

MBA, University of Phoenix, 2005

BSHS, University of Phoenix, 2003

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Business Administration

Walden University

April 2019

Abstract

Healthcare business leaders in a rural clinic setting can enhance profitability by

implementing strategies to ensure timely payments. The purpose of this multiple case

study was to examine strategies applied by healthcare leaders in rural clinics to improve

profitability. The population included 10 rural clinic managers and billing staff from 5

rural clinics in the southwestern region of the United States. The conceptual framework

for this study was Wernerfelt’s resource-based value theory. Implementing Yin’s

multiple-step data analysis process, data from semistructured interviews were transcribed,

coded, and analyzed to identify strategies used by rural clinic managers and billing staff

to enhance profitability. Four primary themes emerged regarding revenue cycle

management that could increase profitability, including developing effective

communication between medical providers and billing staff, implementing payment plan

strategies, ensuring accuracy of billing claims, and consistently reviewing open

receivable accounts. The implications of this study for positive social change include

insights for clinic managers in the development of strategies to increase cash from

accounts receivables, which may contribute to the financial stability of the clinic and

improve the provision of healthcare for citizens of the southwestern region of the United

States.

Accounts Receivable Management Strategies to Ensure Timely Payments in Rural

Clinics

Anthony Natividad Medel

MBA, University of Phoenix, 2005

BSHS, University of Phoenix, 2003

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Business Administration

Walden University

April 2019

Dedication

I dedicate my study to my wife, Karen. You have been with me through every

step of this process, and I could never thank you enough for standing by side in this

process. I love you very much, and I look forward to sharing the rest of my life with you.

To my children, Cheryl, Andrew, Kaitlan, and Alexander, for all of the times that I

missed your activities. To my brothers and sister Steve, Manuel, Rene, and Christina, as

the family is everything. Also, I dedicate this doctoral study to the memory of my parents

Manuel Young and Clementina Natividad Medel for instilling in me a strong work ethic

and a faith in God that can never be broken.

Acknowledgments

First, I thank God the Father Almighty for his guidance, and granting me the

strength, patience, and perseverance to complete this educational journey. With God, all

things are possible and I would not have made it without the strength and faith that His

presence in my life.

I thank my family, friends, and coworkers for their support, encouragement, and

listening to me throughout this process and providing uplifting words during the most

difficult times in this process. Thank you to my maternal Aunts and Uncles as we have

had some pass away during this time, but I have kept them all in my heart and blessed

that they were a part of my life. Thank you to Dr. David E. Bealer (1955-2016), for a

meeting we had back in 2016 and providing words of wisdom, encouragement, and

support, your memory will not be forgotten.

Finally, I thank my Chair, Dr. Roger Mayer. You have worked with and assisted

many doctoral graduates by providing your time, encouragement, and most of all support.

Thank you for everything that you have done to help students reach their educational

goals, and you came into my life at a time when I needed direction and you far exceeded

this task. Also, thank you to my committee members Dr. Warren Lesser, Dr. Robert

Hockin (1950-2019), Dr. Jill Murray, and Dr. Judith Blando for your feedback and

dedication to help students place an emphasis on the quality of work produced. This has

been an unforgettable journey, and I will be eternally grateful for all those who have been

there for me along the way.

Table of Contents

Section 1: Foundation of the Study ......................................................................................1

Background of the Problem ...........................................................................................1

Problem Statement .........................................................................................................2

Purpose Statement ..........................................................................................................2

Nature of the Study ........................................................................................................3

Research Question .........................................................................................................4

Interview Questions .......................................................................................................4

Conceptual Framework ..................................................................................................5

Operational Definitions ..................................................................................................6

Assumptions, Limitations, and Delimitations ................................................................7

Assumptions ............................................................................................................ 7

Limitations .............................................................................................................. 8

Delimitations ........................................................................................................... 8

Significance of the Study ...............................................................................................8

Contribution to Business Practice ........................................................................... 9

Implications for Social Change ............................................................................... 9

A Review of the Professional and Academic Literature ..............................................10

Resource-Based Value Theory ............................................................................. 12

Alternative Theories.............................................................................................. 19

Historical Involvement by Government in the Health Care System..................... 22

Health Care Financial Options and Medical Care ................................................ 26

Fee-For-Service (FFS) vs. Value-Based Purchasing (VBP) ................................. 31

Accounts Receivable Management and Health Care ............................................ 38

Transition .....................................................................................................................41

Section 2: The Project ........................................................................................................42

Purpose Statement ........................................................................................................42

Role of the Researcher .................................................................................................42

Participants ...................................................................................................................45

Research Method and Design ......................................................................................47

Research Method .................................................................................................. 47

Research Design.................................................................................................... 48

Population and Sampling .............................................................................................50

Ethical Research...........................................................................................................52

Data Collection Instruments ........................................................................................54

Data Collection Technique ..........................................................................................57

Data Organization Technique ......................................................................................59

Data Analysis ...............................................................................................................61

Reliability and Validity ................................................................................................63

Reliability .............................................................................................................. 64

Validity ................................................................................................................. 65

Transition and Summary ..............................................................................................67

Section 3: Application to Professional Practice and Implications for Change ..................68

Introduction ..................................................................................................................68

iii

Presentation of the Findings.........................................................................................68

Theme 1: Communication Between Medical Providers and Billing Staff ........... 70

Theme 2: Payment Plan Setup .............................................................................. 73

Theme 3: Accuracy of Billing Claims .................................................................. 77

Theme 4: Consistent Accounts Receivable Reviews ............................................ 79

Overall Findings Applied to the Conceptual Framework ..................................... 83

Applications to Professional Practice ..........................................................................84

Implications for Social Change ....................................................................................85

Recommendations for Action ......................................................................................86

Recommendations for Further Research ......................................................................87

Reflections ...................................................................................................................88

Conclusion ...................................................................................................................88

References ..........................................................................................................................90

Appendix A: Interview Protocol ......................................................................................136

Appendix B: Interview Questions ....................................................................................137

List of Figures

Figure 1. The resource-based view ....................................................................................16

Section 1: Foundation of the Study

Effective revenue cycle management in rural clinics is essential to their economic

sustainability (Lubberink, Blok, van Ophem, & Omta, 2017). In the initial phase of a

revenue cycle strategy, a healthcare organization summarizes potential revenue outlets

based on the volume of patients and mix of insurance payers (Johnson & Garvin, 2017).

Revenue, in the form of accounts receivable collection processes, of healthcare

organizations are unlike most with other industries (Mindel & Mathiassen, 2015).

Healthcare providers must deal with multiple payers and unique rules such as bundled

payments, case-based payments, copayers, and contractual allowances (Hernandez,

2017). Healthcare managers must deal with payment delays, challenges by payers for

services provided and unreimbursed services (Cascardo, 2015). Thus, healthcare clinic

managers must develop strategies to address these revenue cycle challenges in order to

obtain timely payments from patients and their insurance payers.

Background of the Problem

Developing an effective means to collect payment for health services rendered

during a routine visit is a challenging task in the health care industry. Rural clinics that

serve a high number of indigent patients would close without adequate reimbursement.

The goal of the Medicaid program enacted in 1965 was to provide medical services to

lower income individuals and families (Leemon, 2014). The passage of the Affordable

Care Act (ACA) in 2010 became another form of health coverage introduced to the

public. It provides health insurance to the uninsured, which constitutes approximately

27.3 million individuals or 8.6% of the population (United States Census Bureau, 2016).

Other forms of coverage or payment can include private pay insurance plans, direct

payment, and a sliding fee scale based on one’s ability to pay (Barbaresco,

Courtemanche, & Qi, 2015). Clinic managers and financial support staff will benefit from

successful strategies to obtain timely payment for medical services from patients, which

relate to strategies for collecting accounts receivables.

Problem Statement

Rural clinic managers struggle to generate cash flow from unpaid patient accounts

(Lail, Laird, McCall, Naretto, & York, 2016). Healthcare organizations spend roughly

$26 billion on revenue cycle management addressing reimbursement and collection

processes (Hayes, Subhan, & Lakatos, 2015). The general business problem was that

healthcare leaders do not develop effective revenue cycle strategies and cash flow

shortfalls may threaten the survival of the organization. The specific business problem

was that some rural clinic managers lack strategies to obtain timely payments from

patients and insurance payers.

Purpose Statement

The purpose of this qualitative multiple case study was to explore strategies rural

clinic managers use to obtain timely payment from patients and insurance payers. Study

subjects included clinic managers from five rural clinics in southwestern region of the

United States who have incorporated strategies to obtain timely payment from patients

and insurance payers. The implication for positive social change could come from

insights for clinic managers when they develop strategies to increase cash from accounts

receivables, which may improve the financial stability of the clinic and increase the

wellbeing of individuals in southwestern region of the United States.

Nature of the Study

The three research methods are qualitative, quantitative, and mixed methods

(Denzin & Lincoln, 2011). Qualitative researchers gather in-depth data, discover the

meaning of the unknown, and reconstruct stories of participants on a conceptual level

(Guba & Lincoln, 1994). I have selected the qualitative methodology to recognize

multifaceted comprehensive medical services performed in rural clinics. A quantitative

researcher focuses on empirical evidence by using statistical processes (Petrescu &

Lauer, 2017). A quantitative methodology was not an appropriate method, because I was

not examining numeric data with statistical processes. The mixed methods methodology

incorporates both quantitative and qualitative components (Polit & Beck, 2010). This was

not a suitable choice, as I do not intend to incorporate statistical methods to explore my

research question.

I considered four qualitative research designs, including (a) phenomenology, (b)

ethnography, (c) narrative design, and (d) case study. Phenomenology researchers

emphasize the meaning of participants’ lived experiences (Moustakas, 1994). The

phenomenology design was not appropriate for this study because my goal was not to

explain the meaning of the participants’ lived experiences. Ethnography researchers

emphasize the meaning of the participants’ expression of culture (Symons & Maggio,

2014). I do not propose to explore a participant’s individual customs or culture and an

ethnography design was not appropriate for this study. A narrative design provides the

researcher the opportunity to focus on the lives of individuals as told through their own

stories (Denzin & Lincoln, 2011). I did not intend to focus on the lives of the participants

through their own stories and rejected a narrative design for this study. I used a case

study design to explore the research question as the case study approach allows the

researcher to view the issue in a natural setting.

Research Question

What strategies do rural clinic managers use to obtain timely payments from

patients and insurance payers?

Interview Questions

1. What strategies do you use to obtain timely payments from your patients and

insurance payers?

2. What strategies do you use to collect from uninsured and underinsured

patients?

3. What strategies do you use to manage doubtful accounts and bad debt?

4. What strategies does your organization use to ensure staff complete billing

forms correctly with no errors that delay payments?

5. What techniques does your office staff use to collect copayment either before

or after the patient visit?

6. How does the organization provide training to the billing staff to ensure they

are able to meet the organization’s standard for timely collections?

7. How does the organization ensure that the billing staff has the current training

or professional development regarding health information technology?

8. What billing techniques does the organization use that would be a

competitive advantage over other similar organizations?

9. What are the necessary attributes and abilities of a biller to ensure continued

profitability and sustainability for the organization?

10. What additional information can you make available that accounts receivable

strategies ensure timely payment from patients and insurance payers?

Conceptual Framework

The resource-based value theory (RBV) served as the foundation for this

qualitative multiple case study. Wernerfelt (1984) provided an approach in finding a

balance between manipulation of existing resources and the expansion of resources to an

organization’s firm strategic management design to yield increased profits. The RBV

indicates a correlation between profitability and resources as well as managing

organizations’ resources for the long term (Wernerfelt, 1984). RBV theorists and

strategists are contributors in the RBV development.

The healthcare industry exemplifies the RBV within the internal organizational

resources to include attributes, abilities, organizational procedures, and expertise

formulated at the administrative level of an organization (Patidar, Gupta, Azbik, &

Weech-Maldonado, 2016). RBV theorists Warnerfelt (1984) and Barney (1991),

proposed to improve an organization’s efficiency and effectiveness with an increase in

profitability and sustainability. The prevalence of internal resources to maintain a

competitive advantage over rival competitors can be found using RBV. A turbulent

period for the healthcare industry is transpiring due to competition, an adjustment in

reimbursement for services rendered, and struggles in keeping current with health

information technology and electronic medical records (Angeli & Norwood, 2017). The

RBV combines superior resources and competencies to achieve increased financial

earnings. The RBV perspective emphasizes the development of dynamic capabilities and

useful resources as possible foundations for a definite competitive advantage (Kash,

Spaulding, Gamm, & Johnson, 2014).

Operational Definitions

Arizona Health Care Cost Containment System (AHCCCS): A version of the

Medicaid system in the state of Arizona that provides medical benefits to those with

lower to moderate incomes (Langellier, de Zapien, Rosales, Ingram, & Carvajal, 2014).

Contractual adjustments: The difference between healthcare organizations’ fully

charged amounts for services and payments received (Chen et al., 2015).

Contractual allowances: The financial difference between what the healthcare

organization bills and the agreement entered into financial conditions with a third party

payer (Rosolio, 2016).

Customary allowable rate: The rate of reimbursement intended to mirror the

value of the services provided by the provider (Panning, 2014).

Government-funded health plans: A provision as part of social wellbeing to

provide healthcare services to lower income individuals (i.e., disabled, children, and the

elderly; Bradbury, 2015).

Multifaceted health care organization: Healthcare organization with many

different elements or combinations of services or roles provided to customers/patients

(Prowle & Harradine, 2014).

Reimbursement rate (normal/customary): The fee or charge associated based on

the volume of services provided to a customer or patient during an encounter with a

medical provider (Jones & Ku, 2015).

Timely payments: A reimbursement for services rendered by the health care

provider within a payment timeframe defined by the payor (Fitzpatrick, Butler,

Pitsikoulis, Smith, & Walden, 2014).

Assumptions, Limitations, and Delimitations

Assumptions, limitations, and delimitations can limit the methods and

examination of the research within the study. Assumptions and limitations are outside the

scope of the researcher’s control. Delimitations are essential within the context of the

research managed by the researcher. Furthermore, these concepts are integral in outlining

methodology within the context of the research detailed as part of the study.

Assumptions

The rural clinic acknowledged a responsibility to provide the patient with quality

healthcare services regardless of the volume of ailments during an encounter with the

assumption the clinic would be paid. Another assumption was the accounts receivable

management strategies in collecting co-payments or deductibles imposed by

organizational leadership was determinate in the collection of timely payments from the

patient. Second, an essential assumption was specific strategies and methods pertaining to

the collection process were abided by according to company financial policy (Grant,

2014). The last assumption was that implemented revenue management strategies

developed by clinic managers would positively affect payments from patients and

insurance payers.

Limitations

Marshall and Rossman (2016) defined limitations as elements of the study outside

the control of the researcher. A significant limitation of this study was that payment

information could not be gathered from patients or insurance providers. One of the

limitations of this study was that participants potentially could withdraw at any time in

the study thereby skewing the data due to the small sample size. The participants’

interview responses are subject to their personal presumptions (Yin, 2017).

Delimitations

Delimitations define the scope of the research study determined by the researcher

(Yazan, 2015). This study included 10 clinic managers from southwestern region of the

United States to include South County and East County. This study included clinic

managers who reside in Arizona and live in southwestern region of the United States and

who confirmed insurance payers for treated patients.

Significance of the Study

Rural clinic managers and individuals residing in southwestern region of the

United States could benefit from the outcomes of this study. The healthcare industry

prevails as a change agent for reducing costs and improving patient outcomes. Reducing

costs, lowering or bundling healthcare services, and establishing strategic processes in

obtaining payments from insurance payers may result in a higher volume of patients. An

examination of the accounts receivable management processes may provide awareness to

rural clinic managers regarding attaining payment from patients and insurance payers.

Contribution to Business Practice

Rural clinic managers could benefit from this study by understanding their role as

it relates to reimbursement practices. Healthcare leaders must demonstrate strategic

business practices interpreting the development of volume and scale of insurance payors

in conjunction with the business model (Kemperman et al., 2016). The healthcare

business model requires transparency in the reimbursement process of services rendered.

. Ideally, a healthcare organization must provide patients with a high quality of care at

affordable prices to form an organizational culture of accountability (Mkanta, Katta,

Basireddy, English, & de Grubb, 2016). Rural clinic business leaders may gain awareness

of strategies to increase cash flow, which could increase resources necessary to provide

quality services.

Implications for Social Change

Organizational leadership, hospitals, and physician-based groups considering

collaboration could benefit from the results of this study on rural clinics while

influencing the quality of care. The healthcare business model of requiring payment in

advance of services has demonstrated ineffective in the inability to provide adequate

healthcare to underserved communities (LeFevre, Shillcutt, Broomhead, Labrique, &

Jones, 2017). Patients decide their healthcare needs based on the qualities and expertise

of the medical provider (Reddy & Mythri, 2016). Effective cash collection strategies that

allow for payments of co-pays, deductibles and uninsured payments may increase the

likelihood of health care services to residents in underserved communities, which will

impact the patients’ well-being.

A Review of the Professional and Academic Literature

Reviewing prior published research is a strategy researchers use to gain a more in-

depth understanding of a research topic. Lubberink et al. (2017) stated that the literature

review is an essential component of the research because it provides systemic, activities-

based approach to reported context. The purpose of this qualitative multiple case study

coincides with research related to evolving changes in reimbursement. Included in this

section is a review of the academic and professional literature on the RBV theory as used

by other researchers to investigate related research topics. I examined literature from

other scholars who deliberated regarding rural clinic managers’ strategies to obtain timely

payments from patients and insurance payers and my findings aim to help managers

reduce the interruption or delay in receiving payment from patients and insurance payers

for medical services rendered.

The information gathered from this study came from a multitude of sources

including ABI/INFORM Global, ProQuest, SAGE Publications, Google scholar, Wiley

Online, Academic Search Complete, Emerald Insight, MEDLINE, Proquest Central,

Proquest Health and Medical Collection, Proquest Nursing & Allied Health Source, and

EBSCOHost. The keyword search terms for this research included: health care, health

care industry, business model, government involvement, financial options, medical care,

Medicaid, ACA, fee-for-service, value-based purchasing, Resource Base Value, and total

quality management. .

The financial health care models in the literature illustrate how healthcare services

can be efficient and which methods are cost-effective. The reimbursement models

indicate the delivery of healthcare services, efficiency of effective billing procedures, and

exhibit cost-effective methods to develop the success of a healthcare operation. I

presented the value-based purchasing model, which was the defining standard for

healthcare operations’ performance. The core business values of this model consist of

cost control, financial stability, and sustainability of healthcare operations. Consistency

of adequate reimbursement of healthcare organizations maintains sustainability. With this

intention, healthcare organizations determine adequate reimbursement fee schedules

concerning payment for the businesses to remain flexible for future success.

The U.S. healthcare sector has changed as health insurance plans provide an array

of healthcare services. The clinic manager is responsible for reimbursement and assessing

strategic business models for obtaining timely payment within the clinic. The continuity

of care diminishes when patients are required to choose their provider solely based on

insurance coverage. The delivery of healthcare is a focal point for patients who can be

loyal to a medical provider or turn to a competitor for the same services based on

insurance (Hegwer, 2014). The value-based purchasing model holds medical providers

accountable for the cost and quality of care. Healthcare organizations using a value-based

purchasing model focused on cost containment accompanied by quality care, presuming

patients will choose quality. The literature review consists of 299 references from peer-

reviewed journals, government reports, and books with at least 94% of the sources

published between 2013 and 2018, or within 5 years of my expected graduation.

Resource-Based Value Theory

The RBV is a relevant framework for service-based industries where there is a

requirement of trust. The organization’s ability to gain the patient’s trust will increase its

competitive advantage and improve its financial performance (Lin, Chang, & Dang,

2015). The central tenet of RBV theory is that healthcare leaders should focus on

efficient and strategic uses of resources to remain viable (Ozuru & Igwe, 2016). The

profitability of an organization stems from the implementation of strategies based on

resources identified by organizational leaders (Liu, Zhu, & Seuring, 2017). The RBV

model concentrates on the service-concept methodology and is dependent on the

performance of individuals executing roles within the organization. It becomes necessary

to apply resources to provide medical services that benefit the patient. An organization

must consider the implementation of services and equipment, specialty amenities, and

quality improvement for their patients as assets and strengths.

Only recently have researchers and business leaders applied RBV to the

healthcare field. It is a relevant framework because it claims product-based endeavors are

part of a grand business strategy. RBV indicates resources are scarce and unique in

stature; these strategic resources are necessary to maintain a competitive advantage in a

healthcare market (Gerber & Hess, 2017). The financial and operational well-being of the

organization hinges on internal resources within the business (Neghina, Bloemer, van

Birgelen, & Caniëls, 2017). Managers can use RBV to develop a strategic plan for using

internal resources to enhance financial success and sustainability.

Managers in the healthcare industry face difficulties in implementing

RBV strategies when the business is at an early stage of development (Voss, Perks,

Sousa, Witell, & Wünderlich, 2016). Healthcare leaders can base organizational policies

on the RBV theory to specify assets that support the delivery of medical care to patients

(Wilden & Gudergan, 2017). In the healthcare industry, the roles of patients, healthcare

organizations, and medical providers are still evolving. The RBV framework includes a

service delivery model emphasizing employee skills and knowledge expertise which is a

foundational piece of financial success (Ozuru & Igwe, 2016). As healthcare systems

develop towards financial prosperity, the connection with RBV amplifies.

The RBV framework includes strategies to remain competitive. RBV when

applied as a business strategy exposes possible disadvantages involving profitability and

reputation to the organization (Jain & Singal, 2014). The RBV as a strategic business

model proposes using internal resources to outperform competitors. The healthcare

organization used resources to strategically coordinate with the medical practice to secure

a competitive advantage (Abidemi, Halim, & Alshuaibi, 2017), and key resources are

employees, who all need to be included in the strategy (Pinto, 2017). Rural clinics leaders

also consider the revenue cycle process to guarantee payment, a resource that

organizational leaders need to manage. Business leaders manage internal resources in

order to keep revenue consistent with the long-term financial growth of the organization.

In rural clinics, the focal point is services provided to patients (check-up, follow-

up care, or consultation). The healthcare industry is a service-model based exchange, and

with the flow of internal resources and potential employees’ capabilities, a creation of

value will develop over time indicating innovation as the focal theme (Schneider &

Sachs, 2017). RBV within a healthcare organization improves patient outcomes through

the use of internal resources within the healthcare organization towards continuity of care

(Szymaniec-Mlicka, 2016) and guides business strategies towards competitiveness in the

marketplace (Li, Jiang, Pei, & Jiang, 2017). The healthcare industry has integrated RBV

into its business models to drive potential success, economic prosperity, and strategic

preparation.

RBV in the management environment. The methodology of RBV strategy in a

management setting focuses on internal business resources. The healthcare industry is

service-based and must ensure approaches are successful and services provided exceed

those of competitors (Jali, Abas, & Ariffin, 2016). The indicators regarding internal

resources needs rethinking with the managerial emphasis placed on varying differences

and unique characteristics of health care services (Neghina et al., 2017). Successes stem

from creating new and innovative ways to deliver services by reducing costs and passing

on the value to the patients.

Rural health clinics need to develop new and innovative ways to build their

patient base and management’s ability to expound, implement, and reintroduce strategic

resources. The healthcare industry must adapt to healthcare reform and seek innovative

processes regarding internal resources to attain a competitive advantage (Lillis,

Szwejczewski, & Goffin, 2015). The control over strategic resources gives businesses a

unique competitive advantage that creates barriers to entry (Ferlie et al., 2015). Managers

following RBV concentrate on their most valuable assets to achieve continued

sustainability. The progression of the RBV is achievable, but a path towards

organizational development follows a period of increased growth to meet an

organization’s financial goals (Maurer & Ryan, 2016). The objective of rural clinics is to

enable access to medical providers, establish growth, become more productive, and

maintain a consistent and sustainable profit margin.

RBV within rural clinics emphasizes using internal resources to improve the

quality of care for patients, stressing improvements toward operational goals and

objectives. The operational and performance goals of a healthcare organization include

balancing healthcare services, reducing costs, and improving patient outcomes

(Adebanjo, Laosirihongthong, & Samaranayake, 2016). Thus, essential characteristics

surrounding RBV within the healthcare environment include producing positive results

while managing revenue collections to provide long-term fiscal sustainability. Healthcare

leaders must continue to focus on the improvement of patient care while ensuring the

financial growth of the medical practice.

RBV methods can contribute to a medical practice’s success by building its

strategic resources and hence improving its competitive advantage (Maurer & Ryan,

2016). Corporate social responsibility also builds organizational goodwill by improving

reputation (Sheikh, 2017). Some medical practices focus on collecting payments from

insurance payers without any impediment or delay in payment (Lai & Gelb, 2015).

Increasing the timeliness of payments is a strategy that increases the competitive

advantage of a clinic.

An organization’s resources align with RBV based upon the value to the

organization (Lin et al., 2015). The service-based model is grounded on an ecosystem of

multiple variables as internal resources become tangible for the strategic betterment of

the organization (Voss et al., 2016). The service-based model goes through a shift where

the focus is on tangible resources creating capabilities for future strategic planning

(Wilden & Gudergan, 2017).

Figure 1. The resource-based view.

RBV in the healthcare setting. RBV principles emphasize the importance of the

delivery of services and resources for rural clinics to set themselves apart from

competitors. Healthcare organizations allocate resources efficiently to give legitimacy to

management and leadership in the decision-making process of RBV (Angelis, Kanavos,

& Montibeller, 2017). Business leaders consider the healthcare organization’s resources

to be valuable assets. The healthcare organization is poised to use all available internal

resources to provide consistency and continuity of care to patients. The internal resources

available to the healthcare organization are well thought-out, have identifiable

characteristics, and designated as VRIO (valuable, rare, inimitable, and organized; Lin et

al., 2015). The VIRO characteristics selected are the foundation for RBV.

The connection between products and services are intertwined and generate

combinations of resources (Benedettini, Neely, & Swink, 2015). The resulting resources

are significant to the rural clinic advantage over competitors, but are not sustainable and

will not benefit the healthcare organization over the course of time (Mweru & dan Muya,

2015). Rural clinic managers use RBV strategies to recognize and implement approaches

to make improvements in efficiency and effectiveness (Teece, 2017). Rural clinics

incorporate resources into their strategic planning for the purposes of financial

achievement (Patidar et al., 2016). Healthcare organizations value internal resources,

which are components of their competitive advantage (Helmig, Hinz, & Ingerfurth,

2014). Their competitive positions regarding administration efficiency influence potential

operational development of competitive strategies (Krzakiewicz & Cyfert, 2017). The

rural clinics’ used for this doctoral study have strategic approaches in line with RBV, as

cost and organizational performance are devices providing the business with

sustainability and competitive advantage for years to come (Abidemi et al., 2017).

Through strategic planning, an organization can establish a competitive

dominance over its rivals (Kash et al., 2014). RBV is becoming a strategic management

model trending towards organizational management, and developing applicability of

external resources within the healthcare industry (Hitt, Xu, & Carnes, 2016). The RBV

framework in the healthcare industry is an innovative approach within the confines of the

management structure and all internal resources within the organization has not been

sufficient to establish RBV within healthcare strategic planning. However, healthcare

organizations are willing to be a part of this rapidly growing model. The U.S. healthcare

sector follows and identifies common strategic initiatives put into practice by hospitals,

community health centers, and urgent care facilities. Accordingly, a broader view of

RBV includes internal viable resources, adding to increased capabilities, employees and

staff, and financial assets (Wilden & Gudergan, 2017).

The healthcare industry consists of operational and clinical professionals and their

collaboration within the health care environment is essential. Business leaders consider

VIRO attributes to be valuable, inimitable, rare, and organized difficult to replace that

lead towards a competitive advantage for the health care organization. The health care

organization’s administration explores competitive advantages coming from within the

firm’s specific resources and limitations, depending on the location (Yang, 2014). The

healthcare profession has organizations that can strategically manage resources to

improve their performance (Evans, Brown, & Baker 2015). RBV’s place within rural

clinics in combination with strategic resource planning remains driven by healthcare

professionals whose objective is quality care.

RBV methods put into place the needed resources to provide patients with the

continuum of care and offer a strategy to sustain competitive advantage (Popli, Ladkani,

& Gaur, 2017). The strategic business model is a representation of the view of a health

care organization reflecting potential sustainability and viability (Goyal, Sergi, &

Kapoor, 2014). The RBV approach, a health care business implementation, is the

building block of competitiveness not only in the present but in the future and reinforces

sustainable benefits for the long-term (Teece, 2017). Rural clinic managers can use RBV

as a reliable business model to properly use internal resources to facilitate sustainment.

The financial results were referencing accounts receivable segments of the business focus

on the strategies implemented by leaders within the establishment. A rural clinic manager

uses RBV in conjunction with its business model to develop financially and clinically to

build the community’s trust.

Alternative Theories

RBV addresses the roles or control of one’s resources as a primary method to

create a strategic advantage over competitors (Popli et al., 2017). Critics indicate the

RBV approach is limited because it focuses on the user of the resource (Gerber & Hess,

2017). The utilization of internal organizational resources becomes part of the landscape,

and the user of the resource takes on a far lesser role in the overall encounter. The

potential for the business to sustain its resources over an extended period will prolong a

fierce competitive advantage during specific phases of time (Lee, 2017). Resource

dependence theory (RDT) has similarities to RBV with the role of the RDT taking on

external environmental linkages within the organization (Shaukat, Qiu, & Trojanowski,

2016). I used both RDT and TQM as analytical frameworks to explore health care

organization management strategies. Wernerfelt (1984) details RBV as a means to use

internal resources and includes components to separate businesses from its competitors.

Resource dependence theory. In 1978, Pfeffer and Salancik addressed resource

dependencies and indicated the effect external resources had on the role of an

organization. Pfeffer and Salancik (2003) detailed that health care organizations are

providers of significant resources, and like other organizations, they need to make

changes to fulfill positive outcomes. RDT indicates organizations require resources from

competing organizations within a similar market to innovate, resulting in distinctive

qualities within competing organizations (Van den Broek, Boselie, & Paauwe, 2017).

Pfeffer and Salancik (2003) stated that organizations have more power drawing from the

interdependence of others and the need for their positions in the marketplace. RDT

describes dependent players in the organization as having a weaker position within the

competitive market to offset structures to collaborate (Christensen, 2016). From the

organizational aspect, minimal information in the form of external constraints affecting

management decisions ought yet to be determined (Pfeffer & Salancik, 2003). RDT has

three specific factors: the significance of the resource to the organization, scarceness of

the resource, and the level of internal organization competition (Selviaridis, Matopoulos,

Thomas-Szamosi, & Psychogios, 2016). Business leaders manage potential constraints

and uncertainties potentially resulting in the acquisition of external resources (Pfeffer &

Salancik, 2003).

The viability of the health care organization is contingent on RDT in which a

strategy may alter a power-dependent relational dynamic (Doyle, Kelly, & O’Donohoe,

2016). Management sets the strategy, and these individuals play a crucial role in the

process and scheming of resource dependencies. Any organization can build resources

both internally and externally to assemble competencies to enter and leave the market and

to take a competitive advantage (Pfeffer & Salancik, 2003). RDT researchers focus on the

use and outcomes of resources utilization (Coupet & McWilliams, 2017). An

organization’s management may devise a scheme to ensure resources remain supported

and seek a clear competitive advantage over market rivals (Pfeffer & Salancik, 2003).

Total quality management. In 1985, Deming addressed the Western style of

management called total quality management (TQM), which introduces organizational

attempts to deliver quality products and services. TQM emphasizes planning and

introducing methods to improve an organization’s products and services to decrease costs

(Deming, 1985). The focus of enhancing quality concentrates on the customer (Deming,

2000), which is supervised by management. Health care managers introduced TQM into

the field in the late 1980s, intending to increase patient satisfaction, reduce costs, and

increase productivity at all levels within the organization (Chiarini & Vagnoni, 2017).

Management is fully responsible for creating processes, ensuring stability, and

establishing strategies for the success of the organization (Deming, 2000).

Deming’s approach centered on process improvement (Matthews & Marzec,

2017). Deming (2000) provides a thorough concept showing that any considerable

improvement must come from actions introduced by operations management. TQM

methodology has in the past focused on the supply side of operations, but now has a

presence in an organization’s services sector (Iqbal et al., 2017). The service-based

industries such as health care apply various TQM improvement practices by enhancing

services and reducing costs for patients during a routine encounter (Deming, 2000). The

implementation of TQM within a health care organization has led to improved processes

in the quality of patient care, patient satisfaction, and increased financial prosperity

(Mosadeghrad, 2015). RBV is the best choice for this study, as the theoretical lens

focuses on quality improvement organizational concepts.

Historical Involvement by Government in the Health Care System

Governmental involvement in the health care system has gone through an

evolutionary process since the initial phase in the early 1900s. The U.S. government

implemented health care services emphasizing the health and welfare of its citizens. The

first model of health care reform began with the Sheppard-Towner Act of 1921, one of

the catalysts in the health care reform movement (Haeder & Weimer, 2015). In

subsequent years following the Sheppard-Towner Act, President Harry S. Truman

tendered a plan for universal health care, a measure unable to pass through the

government (Manchikanti, Helm, Benyamin, & Hirsch, 2017). Haeder and Weimer

(2015) stated that federal health care programs aimed to expand health care services to

influence care reimbursement and financial outcomes, with an overarching goal of

universal health care.

As the movement towards universal health care continued, the health concern

continued into the Great Depression. The Social Security Act of 1935 provided stability

in the health care system and identified residents who were either elderly or disabled to

receive health care through Medicare and Medicaid (Haeder & Weimer, 2015). Federal

and state governments were delivering health services and sharing the cost provided

stability for U.S. citizens and medical providers taking care of the sick and infirm.

Welfare state policies became part of society with the combination of health care

insurance and retirement funding for the public (Mayhew, 2015).

The enactment of Medicare and Medicaid as health care programs did not appeal

to both the federal and state governments and not all states participated initially (Haeder

& Weimer, 2015; Leemon, 2014). The health care recipients in those states receiving

government-funded health care plans have to use either of these health care plans based

on income and age requirements. Individuals who are apathetic regarding health care

dwell on the ineffectiveness of programs established by government leaders. The

individuals receiving health care assistance viewed government intervention in a negative

context by the lack of transparency of the government regarding cost, quality of care, and

treatment outcomes (Maurer et al., 2017).

The principles of health care were to ensure services of value and quality is

accessible to individuals with moderate to lower incomes. The design of health care

reform existed as a social and societal norm, and economic instability has occurred in the

form of a conservative fiscal approach or terms of limited government intervention for

health care services (Schimmel, 2013). Reforming the health care system based on an

economic point of view will provide health care to all citizens as a cheaper and more

efficient alternative (Pineda & Hermes, 2015). In addition, the scope of health care

expansion is to ensure all citizens have access to health care services (i.e., hospitals,

public clinics, and health centers). The health care claim is that individuals pay from their

income if they do not need health care services. However, people should receive health

care services based on need, not income (Nardin, Zallman, Sayah, & McCormick 2016).

Government’s role in health care is not the solution and may hinder positive

advancements in health care reform (Manchikanti et al., 2017). Approximately 45 million

Americans are without health care coverage and millions more deal with lapses in their

health care insurance and are considered to be underinsured (Schimmel, 2013). The

concern with health care reform continues to come from the involvement of the

government, and the government has only marginally controlled health care costs

(Howrigon, 2016). There is market demand for health care services for the millions of

individuals without health care insurance. The health care industry is in a phase of

fluctuation, and the challenge ahead for rural clinics is to identify proactively potential

changes in health care reform.

The reform of health care insurance does not follow in the footsteps of socialized

medicine, as services remain vulnerable now and in the upcoming future. The idea

concerning health care as an inalienable right would regulate and conflict with other’s

rights and freedoms, as coordinating health care services is not the primary focus

(Roberts, 2012). The marketplace is a determinant regarding financial control in health

care with the emphasis placed on profitability and not necessarily on treating the illness

(Darrow, 2015). The concern of state or federal government officials is not to engage in

the agreement of social, economic, or even cultural rights between citizens but to play a

role in the scope of health care reform. Early health care reform had a lasting effect on

legislation in the United States (Durenberger, 2015). There is controversy about

government involvement in health care today, and without consensus, reform cannot take

place. The debate over universal health care is prevalent and divisive, but the right to

have health care remains unsettled with the advent of the ACA.

During the past 50 years, much of the health care system remains pieced together

ensuring individuals have access to hospitals, clinics, doctors, and medical supplies

(Farnsworth, 2015). Business leaders seeking for-profit benefits focus financially on

volume while spending less time providing adequate care (Joynt, Orav, & Jha, 2014). The

extension of health care benefits aimed to ensure those who were uninsured received

sufficient health care assistance, though a segment of the population is still without health

care insurance or is underinsured because of cost control means put in place by the

government (Schimmel, 2013).

The progression of health care services within the American health care system

results from the efforts of the public, private, government, businesses, and other

industries to create a universal health system. The evolutionary process of the American

health care system from a historical perspective exists in addressing enhanced

accessibility to services, upgrading the quality of care, and cost-effectiveness, or control

(Farnsworth, 2015). The U.S. health care system remains segmented into three groups:

government-assisted insurance, private insurance, and no insurance (Marshall et al.,

2016). There are differences between public and private health care, and evidence shows

that private health care according to US standards remains the best option (Nardin et al.,

2016). The idea persists that each citizen is responsible for his or her health care services

and may need to seek health care by any means possible through state-funded, federally

based, or private options.

The American legislature has different methodologies regarding health care

reform, and hence nothing has emerged as a clear means for all citizens to have adequate

health care. The past 50 years of government involvement has led from

Medicare/Medicaid to the ACA with no affordable options to all citizens (Durenberger,

2015). The selection of health care reform models comes from a form of compensation

for health care organizations who can deliver skilled and superior care (Barinaga et al.,

2017). The decision for health care reform comes from the government, which can

fluctuate between liberal and conservative perspectives, but operational or business

functions must address the financial stability of the organizations (Noh, 2016). The

selection of different reimbursement methods, such as fee-for-service (FFS) or value-

based purchasing (VBP) determines the economic outcome of a health care organization

and will be the catalyst for creating a cost-effective health care system (Schneider & Hall,

2017).

Health Care Financial Options and Medical Care

Health insurance representatives base their coverage decisions on factors such as

cost, effectiveness, and outcomes of care. A misunderstanding is to base a model of

health insurance with the resulting cost of delivering care. The government related

options available to U.S. citizens are minimal regarding health care, as they are referred

to as “safety nets.” The fail-safe system set up by the federal government to ensure

necessary care exists for individuals with lower to moderate income (Chokshi, Chang, &

Wilson, 2016). Thirty-one million Americans are without health care coverage, and

health care organizations need possible financial outcomes to provide coverage and care

(Hall & Lord, 2014). The rural clinic manager’s goal is viability in providing a public

health commodity and service (Reddy & Mythri, 2016). Medicaid and the ACA provide

stability of health care services, but individuals at or below the poverty level will use one

model or another irrelevant of the cost (Durenberger, 2015). The number of Americans

without health care coverage is a determining factor regarding reimbursement progress

affecting health care organizations (Kessell et al., 2015).

The quality of health care is a crucial financial consideration in addressing

adequate health care. The viability of health care concerning Medicaid and the ACA was

due to the expansion of Medicaid support to the states ensuring health insurance would be

accessible to low-income adults (Nguyen & Sommers, 2016). The premise towards the

expansion of Medicaid services was not only to meet the growing need for new patients,

but a determinant of the ACA to deliver quality care (Franz, Skinner, & Murphy, 2016).

Patients choose their health care services based on their health insurance and the

necessity of medical treatment or service. Uninsured individuals may experience lower

quality health care in comparison to those with private health care insurance (Nardin et

al., 2016). A rural clinic should implement services and treatment models following

private health care insurance.

The fiscal model for private insurance may not be adequate for all health care

organizations, as there are regional differences in access to appropriate health care. Thus,

if the area does not have a medical specialist, Medicaid and ACA patients, who depend

on the safety-net providers such as community-based health care services, will visit

primary care providers (Nguyen & Sommers, 2016). The advantage of health care

organizations is in facilitating and examining costs to the health care facility, while in

turn ensuring the quality of health care services promoting positive patient outcomes

(Shortell et al., 2015). Rural clinics build a kinship with patients in their regions with an

undertaking that medical services are available in each community. Ultimately, the care

and treatment is available for individuals who are in federal or state health care plans

regardless of the ailment or sickness, and the medical practice will build an assortment of

various payer sources.

The financial barriers associated with the ACA originated from the Massachusetts

Health Reform of 2006. The proposal is to expand Medicaid in a provision to decrease

the number of uninsured individuals. The financial obligation has been the ability of

health care organizations to provide affordable health care insurance to individuals with

moderate to low incomes (Nardin et al., 2016). The quality of health care in the United

States has languished over the past several years; however, costs have soared caused by

the reimbursement process (Choi, Lai, &Lai, 2016). Since the introduction of the ACA in

2010, the number of insured persons has increased by around 20 million, which has

reduced the number of persons not insured (Oberlander, 2017). The rural clinic benefits

with growth in the number of insured but the provision of quality health care is also

essential.

Limitations of both Medicaid and the ACA are a focus of legislators (Nardin et

al., 2016). The changes to the delivery of health care to Medicaid or ACA should not

affect the utilization of health care services or deny needed care (Nardin et al., 2016).

Health care organizations benefit from ACA because providers can generate high net

revenues from the increase in expanded coverage (Glied & Jackson, 2017). The quality of

care given a patient does not affect the amount of reimbursement (Glied & Jackson,

2017).

There is a movement towards personalized health care to hold patients

accountable for their lifestyles and tailored treatments. The principle of customized health

care has a dual purpose of enhancing the quality of health care services while lowering

costs (Teng, 2015). The rural clinic must ensure accountability for the total costs and

move away from past FFS beliefs towards risk-sharing measures (Blumenthal, 2016).

Similarly, the idea of personalized health care and price do not associate with each other,

but there are segments of the health care system to indicate care and treatment are

universal (Teng, 2015). The evidence-based information shows personalized health care

is a cost-effective approach to health care in the United States (Kuramoto, 2014). Overall,

implementing personalized care will bring focus on patient-centered care, but other

aspects are involved such as cost-effectiveness and containment.

The cost savings to the rural clinic does not appear to be evidence indicating

improved patient satisfaction. Personalized health care can educate, teach, and encourage

patient care, leading to financially supportive reimbursement arrangements (Teng, 2015).

Health economics plays an essential role in the identification of a payment system, but

the assurance of quality care will come at a significant cost (Chen & Goldman, 2016).

Preventative care is a necessary part of the quality goals of health care reform. Such an

incentive-based health care policy will enable cost-effective health care for all citizens:

the right care at the right time for the appropriate individuals (Kuramoto, 2014).

Health care reform potentially harms insurance profitability over time due to

shifts in reimbursement payments (Teng, 2015). Health care insurance existed before the

ACA in the form of private insurance, government funded, subsidized, regulated health

care, as Medicaid and Medicare coverage was primarily for the poor and elderly. The

objective was to have health care reform much like Canada, a single-payer system

emulating universal health care (Hall & Lord, 2014). The concept of a universal health

care system exceeds the financial accountability of Medicaid, and expanding Medicaid

would ease the financial burden on the states (Langellier et al., 2014). The concept of a

temporary health care system is universal and far exceeds financial accountability based

on poverty. Expanding Medicaid to ease the financial burden on the states to cover

medical services for individuals who remain uninsured is a temporary solution

(Langellier et al., 2014).

The correlation between financial preferences and health care is a crucial way to

solve the problems that overwhelm state and federal governments. The payment

structures for receiving medical care historically centered on FFS (fee-for-service) and

the capitation rate structure (predetermined rate to reimburse medical providers or

capitated rate or managed care) (Leemon, 2014). Health care organizations are

developing an infrastructure to move from previous ways of thinking about payment

modalities and creating revenue (Conrad, Vaughn, Grembowski, & Marcus-Smith, 2016).

Consequently, risk/reward plays a factor in financial preferences and the delivery of

services to the patient. The customary allowable rates are a risky proposition for rural

clinics due to the flat rate becoming a point of contention for the rural clinic depending

on the negotiation of the signed contract. Health care reform in Medicaid and ACA has

benefits for most Americans, regardless of the patient’s ability to pay. The objective of

health care reform is to provide adequate health care to the patient at a reasonable cost.

The challenges are facing health care financing options and medical care rest on

the patient’s ability to pay. Rural health care facilities face increased challenges in

comparison to urban areas due to differences in levels of income of patients (Allen,

Davis, Hu, & Owusu-Amankwah, 2015). The U.S. government offers rural health clinic

services through Medicare and Medicaid to the needy (Ortiz, Meemon, Zhou, & Wan,

2013). The rural health hospitals in smaller communities are financially unstable, but they

become viable substitutes for the patient in search of health care (Allen et al., 2015). The

mission of rural health clinics is to provide medical services to an underserved population

due to financial and operational issues. The rural clinic managers must contend with the

increased patient flow while managing costs and quality.

Fee-For-Service (FFS) vs. Value-Based Purchasing (VBP)

The duality of rural clinics is to serve the patients who walk through their doors

and manage the financial well-being of the operation. Reimbursements to health care

organizations are important considerations within the health care reform framework

(Oberlander, 2017). Business leaders will need to address reimbursement approaches in

preparing a profitable business model for the future (Gurganious, 2016). With health care

costs rising, reducing costs will lead to a decline in accessibility or value of the American

health care industry (Rudnicki et al., 2016). Thus, changes in coverage for patients to

visit hospitals, health care facilities, and providers will have a profound impact on the

operational bottom line.

Rural clinics link prospective payment for medical services to either FFS or VBP,

which encompasses payment through improved performance and reduced cost. This form

of payment holds health care providers responsible for the costs and quality of their care

and attempts to reduce and identify and reward inappropriate care (Kessell et al., 2015).

In order to establish continuity, rural clinics need a strategy for collecting reimbursement

and payment. FFS or VBP are important financial choices to a health care organization

and for the provider of medical services (Feldman, 2015). The future of health care

reform centers on price and value, and less on status, with the emphasis on conventional

health care economics (Gerben, 2016). Operations management makes decisions

regarding the volume or value of these payment options. Overall, rural clinics select the

most common and reliable payment types to establish consistency in the changing

landscape of health care reform.

The modes of payment for health care services have reached critical levels as

proponents of both sides view each system with flaws. The FFS model places

accountability for costs on medical providers (Feldman, 2015). The majority of health

care leadership analyzes payment reform as an approach to motivate medical providers to

incorporate the delivery of services (Murphy, Ko, Kizer, & Bindman, 2015). However,

the objective is to maximize profits, and the number of services and potential outcomes is

difficult for rural clinics to predict. The rural clinic distinguishes the best possible

payment opportunity for the business to create increased volume. Many contend having

one payment source and a financial plan to address lengthy payment delays is better for

the health care organization (Cascardo, 2015).

Health care reform interests should bring about restrictions on the way rural

clinics decide to accept or deny revenue streams. Health care providers recognize the FFS

model, but in some areas, the bundled payment is part of VBP and is standard for medical

generalists (Kuramoto, 2014). Business leaders determine the soundest payment structure

to ensure medical providers and the business receive compensation while still

emphasizing quality and efficiency (Ojeifo & Berkowitz, 2015). A mode of collection is

not to isolate specialists from accepting one form of payment for services (Palinkas et al.,

2015). Rural clinics comprise of a mixture of general practitioners and specialists.

Health care organizations must anticipate changes in health care reform as cost

conflicts could take place among medical providers regarding lower reimbursement rates.

The perception of clinical equity is something an organization must confront due to cost-

effectiveness or the anticipation of high-quality care and treatment (Kuramoto, 2014).

The health care system has gone through changes in the language of policy and

inconsistency with the delivery of medical services, leading to gaps in coverage,

conflicting outcomes, and inexcusable costs (Larkin, Swanson, Fuller, & Cortese, 2016).

The perspective of the business is to follow any advantage obtained or accept one payer

source over another, focusing on the overall value of the provided services. Rural clinics

address possible changes in the reimbursement fee schedule while identifying potential

opportunities to expand business and cost-effectiveness (Abidemi et al., 2017). Finally,

business leaders establish strategies to separate themselves from competitors and limit the

need for unnecessary risk-taking.

The U.S. health care system has migrated away from an FFS option regarding

reimbursement and is trending towards VBP as a financial alternative. Health care

clinicians are progressing towards VBP for services rendered (Joynt et al., 2017). The

transformation of the reimbursement revenue cycle has caused business leaders to assess

operational infrastructure with the limited resources available in the selection of a

payment model (Granata & Hamilton, 2015). Additionally, enrollment of individuals in

the ACA or Medicaid remains scripted as these plans continue for persons with lower to

moderate incomes (Durenberger, 2015). Business leaders will initiate a plan for accepting

either reimbursement arrangement (FFS or VBP), and the economic impact of the

decision-making process may result in financial implications for days, weeks, months,

and years.

The financial impact of health care reform on health care organizations is not

entirely clear. The FFS model remains monetarily centered on one particular service-

taking place for the patient (Leemon, 2014). Conversely, the VBP payment modality

provides a consistent financial revenue flow for the health care organization, along with

the element of increased quality of care and higher health outcomes for patients (Joynt et

al., 2017). Health care organizations seek revenue streams that provide an incentive base

for the business and do not discourage utilizing capitation rates (Doran, Maurer, & Ryan,

2017). Overall, payment modalities have a financial impact on the organization, and

sustainability is the groundwork for success.

Rural clinics need to focus on the delivery of services to address prospective

payment reimbursement concerns to ensure a consistent source of revenue. This analysis

should emphasize the elements of risk and reward to incentivize to include expectations

on treatment expenses, value, and results (Halfon et al., 2014). Higher expectations fuel

increasing health care costs, as health care organizations plan to improve patient

satisfaction and reduce costs (Moraros, Lemstra, & Nwankwo, 2016). While the U.S.

health care system is meant to provide affordable services, they are often ineffective and

high priced. The business strategies implied by an association with an FFS model serves

as a volume-driven entity, while the modality of VBP promotes costs and quality of care

(Noether & May, 2017). Rural clinics identify a recurring payer source as suitable for

financial growth while providing patients viable health care solutions.

The reimbursement process considers aspects such as improvement in the quality

of care, managed spending, and a patient’s access to health care services. The

involvement of federal and state governments regarding health care is a primary source,

and the Centers for Medicare and Medicaid Services (CMS) is presently in the middle

(Haeder & Weimer, 2015). The directive is to initiate replacing the reimbursement model

of FFS with the model of VBP (Schneider & Hall, 2017). CMS established an enhanced

version of paying for the quality of care (Cassel, Kerr, Kalman, & Smith, 2015). The

justification for change stems from the quality and quantity of the medical services

provided to the patient by the medical provider. Overall, the financial risk implied with

this VBP process emphasizes the value of health care services provided to patients.

The concern about health care exchanges with Medicaid and the ACA focuses on

inducements that reduce health care costs and provide improved service quality. The

research regarding FFS and VBP or bundling of services has lasting fiscal effects on

federal and state governments (Noh, 2016). The budgetary durability of our health care

system rests with federal and state governments determining a balance between cost

containment and quality care (Landers et al., 2016). Accordingly, federal and state

governments have addressed changes regarding health care reform and considered

reducing funds due to sustained debt at federal and state levels (Maurer et al., 2017). The

financial implications of health care reform with the implementation of the ACA remain

a temporary solution with the revamping of health care, as it currently exists.

Medicaid and ACA address cost, utilization of services, and trends in the health

care system. The forecasting of federal and state budgets regarding health care services is

a complex task; roughly, 20% of a state’s budget consists of health care funds, second

only to education (Gerstorff & Gibson, 2016). Health care spending is a national issue

and reforms can result in increased health care expenses (Duijmelinck & van de Ven,

2016). Data collection is important because the resulting reports illustrate the cost

efficiency of programs relative to the type of reimbursement model used (Eggbeer &

Bowers, 2014). Financial and operational strategies that result from data collection

prioritize cost containment, and health care outcomes are essential for the operation to be

successful.

Many individuals affected by health care reform and who are covered by

Medicaid (AHCCHS-Arizona) or the ACA reside in rural communities. Most of these

areas are underserved locations or populations that have other forms of payment for

medical services, including deductibles or co-pays or, for patients with lower to moderate

income, a sliding fee scale payment (Gao, Nocon, Sharma, & Huang, 2017). The

reduction in health care costs may become pivotal to enhance our current health care

system (Nocon et al., 2016). Consequently, smaller community clinics associated with an

entirely different patient base may limit the number of health care providers. The health

care coverage will fall into Medicaid and ACA categories, as they may be a split between

either of these payer sources (Noether & May 2017). Conversely, demand for rural health

care clinics to serve patients with low to moderate incomes remains essential within the

community.

The economic impact of FFS and VBP revolves around increased patient volume

for the rural clinic. Engagement with payer sources remains crucial for the organization,

but a fixed amount of revenue from the FFS or the provision of high-quality care implied

by VBP needs to be taken into account (Noether & May, 2017). Providing better care for

patients, lowering costs, expanding health care coverage for individuals, and reinforcing

infrastructure are the prime objectives (Kessell et al., 2015). Rural clinics thrive on

increased volume, and the distribution of a higher quality of care will equate to lower

costs. The organization’s selection of a particular payment revenue cycle will translate

into future financial success (Lubberink et al., 2017). Overall, the health care industry

faces pressures for reform and to ensure health care services are cost-effective and

delivered with quality.

Accounts Receivable Management and Health Care

An accounts receivable management strategy is a factor in the success of rural

clinics (Aidoo-Buameh, 2014). Members of the management team with expertise in

accounts management and those within the financial department who consult regarding

payment collection are responsible for strategic planning (Lai & Gelb, 2015). Health care

organizations manage their revenue cycles from billing and reimbursement from

insurance companies (Boden, 2014). This highlights the importance of accounts

receivable management, which is vital for the financial well-being of the medical

practice.

The operational working capital is critical to profitability (Talonpoika, Kärri,

Pirttilä, & Monto, 2016), which relies on accounts receivable management (Foerster,

Tsagarelis, & Wang, 2017). A revenue cycle manager aims to ensure the collection of

revenue for the organization (Mindel & Mathiassen, 2015). Payment delays are typical in

the health care profession, unlike shopping at the grocery store or having a vehicle

serviced.

Accounts receivable management involves collecting payment from patients and

insurance payers. The accounts receivable component of any health care organization is

paramount to the level of profitability (Shorr, 2015). Health services are available before

payment, and the provider relies on the patient’s intention to pay. The business model for

reimbursement for services provided by health care organizations is the intention to pay

for the medical provider’s service (Gurganious, 2016). Accounts receivable management

apply strategies to ensure payments made by patients and insurance payers for services

rendered are effective and efficient (Aidoo-Buameh, 2014). Rural clinic managers’ ability

to collect compensation from patients and insurance payers is essential for sustainability

and financial independence.

The collection process enlisted by health care organizations attempts to maximize

the revenue cycle management for the medical practice. The collection of payment for

medical services rendered is not a direct process, but it is essential for the practice to

thrive (Weinstock, 2015). Barriers to the collection process can include billing mistakes,

insurance payers underpaying, or an inability to collect from the right patient due to

misinformation (Shi, Zurada, Guan, & Goyal, 2015). Consequently, the incorporation of

strategic planning within the rural clinic and implementing processes to prevent the lack

of payment from patient and insurance payers becomes significant in the collection

process. The monitoring of accounts receivables ensures payment is timely and that the

dollar amounts owed to the organization decrease over time (Lail et al., 2016). The

traditional form of compensation is the FFS model, as insurance companies pay for each

service provided to the patient (Mabotuwana, Hall, Thomas, & Wald, 2017), and

collecting payment on time is a formula for sustainability.

The accounts receivable management role influences the financial future of the

rural clinic. The knowledge of where the revenue is coming from and the cost associated

with services are vital components. The strategic planning implemented by the financial

manager creates a primary construct for good fiscal control within the health care

organization (Sheet, 2017). Health care organizations receive payment from patients and

insurance payers through a mix of insurance types and payment methods (Loy et al.,

2016). Ultimately, the financial stability of the organization supports the accounts

receivable management strategies, and financial management staff incorporates plans to

maximize profits.

Analyzing accounts receivable revolves around the number of days it takes to

receive reimbursement from the payer including patients, insurances payers, and

government entities (Dong, 2015). The accounts receivable cycle breaks down into time

increments by days, weeks, or months; an improvement in accounts receivable

management will increase efficiency and profits (Aidoo-Buameh, 2014). Additionally,

the incorporation of accounts receivable management strategies into the operations

management will improve the consistency of payment from patients and insurance

payers. Financial managers analyze the mix of patients and insurer plans (Johnson &

Garvin, 2017). The accounts receivable manager strategizes with operations to identify

ways to improve profitability and sustainability through the selection of patients and

insurance types.

The financial and operational benefit of accounts receivable management is

narrowing the margin between profitability and the cost incurred by the health care entity.

The health care industry is going through extreme changes in which reimbursements are

steadily decreasing (Yaduvanshi & Sharma, 2017). Operations management strategies

must direct health care professional towards dealing with financial survival concerns

(Krzakiewicz & Cyfert, 2017). Managing earnings within the context of a health care

organization include reducing costs and increasing cash flow (Dong, 2016). Accounts

receivable management must integrate strategic procedures in collecting payment from

patients and insurance payers to avoid cutting costs or provide ineffective care.

Transition

Section 1 consisted of the foundation of the study; I provided the background of

the problem and purpose statements, nature of the study, research question, interview

questions, and conceptual framework. As part of Section I, I also presented operational

definitions, assumptions, and delimitations. In Section 1, I discussed the importance of

the study and the review of the professional and academic literature on accounts

receivable management strategies used by rural health care clinics to obtain timely

payment.

As part of Section 2, I presented data collection techniques and data analysis. I

finish Section 2 with the reliability and validity of the study. In Section 3, I introduced

the findings and implications of my research. The information consists of the data

collected, applications to professional practice, implications for social change,

recommendations for action, further study, and my reflections as the researcher.

Section 2: The Project

In Section 2, I focus on the factors employed by rural healthcare clinic managers

to implement accounts receivable management strategies to ensure timely payments from

patients and insurance payers. The section included the restatement of the purpose

statement, the role of the researcher, study participants, and the research method and

design. Also in this section, I covered population and sampling, ethical standards, data

collection instruments, and techniques. Furthermore, I concluded Section 2 with data

analysis, reliability, and validity of the study.

Purpose Statement

The purpose of this qualitative multiple case study was to explore strategies rural

clinic managers use to obtain timely payment from patients and insurance payers. Study

subjects included clinic managers from five rural clinics located in southwestern region

of the United States who have incorporated strategies to obtain timely payment from

patients and insurance payers. The implication for positive social change could come

from insights for clinic managers when they develop strategies to increase cash from

accounts receivables, which may improve the financial stability of the clinic and increase

the wellbeing of individuals in southwestern region of the United States.

Role of the Researcher

The role of the researcher is to ensure the quality and value of the study results

(Isaacs, 2014). The qualitative researcher plays a significant role in the methodology and

interpretation of the collected data (Swafford, 2014). In my role as a qualitative case

study researcher, I identified participants and maintained a working relationship with

these participants during the study. I involved myself in every facet of this study

including the selection of participants, selection of an appropriate research method,

collection of data, transcribing interviews, data analysis, and writing an account on the

outcomes.

Researchers incorporate their unique perspective to the research study (Brett et

al., 2014). I have 12 years of healthcare management experience, in which I

independently and objectively collected and analyzed relevant data. This experience

provided me with knowledge that assisted in this doctoral study. In addition, I understand

how my experience could predispose me to bias and this knowledge will help me

minimize my personal bias.

Researchers must possess knowledge of ethical issues and challenges involving

the study with the goal to attain accurate results (Sanjari, Bahramnezhad, Fomani,

Shoghi, & Cheraghi, 2014). The Belmont Report issued in 1979 identified ethical

standards and procedures for researchers to implement while researching human subjects

(U.S. Department of Health and Human Services [USDHHS], 1979). The Belmont

Report includes principles of respect for individuals, beneficence, and justice (USDHHS,

1979). The application of the Belmont Report provides research participants protection

from undue harm or exploitation and ensures confidentiality for participants.

During the study, researchers recognize the potential harmful effects of defined

beliefs or opinions regarding the phenomenon under study (Bradbury-Jones, Taylor, &

Herber, 2014). Researchers implementing a case study methodology should have an

awareness of the issues studied, as this awareness may become influential with the

understanding of the data collected (Yin, 2017). Some researchers may use other

resources and place an emphasis on reviewing the data, as opposed to doing additional

research to determine whether the data is acceptable or unacceptable (D’Andrea &

O’Dwyer, 2017). Researchers need to be neutral during interpretation of the data and

adopting neutrality will assist with potential future studies (Morgado, Meireles, Neves,

Amaral, & Ferreira, 2017). In my role as the researcher, I reduced bias by maintaining

high moral and ethical standards through integrity, professional competence, and

extensively reading prior research related to the study. Researchers must be wary of bias,

and at the same time, avoid having a negative mindset, which could affect objectivity

(Simons, Bester, & Moll, 2017). Hence, to mitigate bias, I maintained an understanding

of the topic and expectations of a researcher.

Researchers can increase the consistency of data collection using an interview

protocol, which enhances the validity of the study (Yin, 2017). With the use of the

protocol, a case study researcher can increase continuity and efficiency with the

collection of data (Yin, 2017). The interview protocol is a vital aspect of the data

collection process, as research design will have an influence on the data obtained and

define the kind of analysis used in exploring the data (Manning & Kunkel, 2015). During

the collection phase of gathering information, it is vital to review the information

immediately as there could be a need to obtain further evidence (Yin, 2017). The setting

up of the interview protocol for a case study is the basis for the audit path leading to the

trustworthiness of data and eventually the quality of the research (Ang, Embi, & Yunus,

2016). Consequently, I used an interview protocol (see Appendix A) to determine a level

of trustworthiness during this study. A researcher must prevent misinterpretations or

decrease bias (Thomas, 2017). The use of the interview protocol will assist me in

reducing bias by treating each of the participants in the same manner.

Participants

A crucial element in choosing participants is that researchers identify participants

with reliable knowledge of the research question (McCalman et al., 2017). The

participants in a study focused on a balance between operational issues surrounding a

patient-centered approach or using the older fee-for-service model for the collection of

payment for services rendered (Pittmam, Masselink, Bade, Frogner, & Ku, 2016).

Research participants should include only those who are readily available and willing to

participate (Yin, 2017). The eligibility criteria for the participants in this study was

individuals who work at a management level, (southwestern region of the United States,

and who confirmed insurance payers for treated patients. Participants included clinic

managers, accounts receivable managers, and the director of revenue cycle. These

individuals remain involved in the direction of payment cycles and putting strategies into

action to ensure payments occur promptly with no disruption to the organization.

The researcher must use strategies for gaining access to each of the preferred

participants from each of the sites. Researchers may use specific resources and

community support to acquire ideal study participants (Katigbak, Foley, Robert, &

Hutchinson, 2016). A gatekeeper is an individual who has power and control over

specific access within an organization, and negotiate terms and conditions to ensure the

best interest of all parties was met (Caretta & Riaño, 2016). The ability to have access to

the gatekeeper is a challenge and building a relationship is a critical aspect of the

foundation of the study (Brooks & Jean-Marie, 2015). Gatekeepers exist within the

organization as responsible representation of the organization and protect the

organizations’ best interests (Rattani & Johns, 2017). As part of the study, I asked the

gatekeeper, Director of Revenue Cycle Management to sign a letter of cooperation (see

Appendix B) in conjunction with IRB approval process from Walden University to work

with the gatekeeper identifying appropriate participants. I used the gatekeeper to identify

appropriate documentation for triangulation of data in this study. Subsequently, after the

gatekeeper signed the letter of cooperation and identified appropriate participants, I

included an introductory letter (see Appendix C) to the participants inviting them to

participate in the study. As part of the introductory letter, I incorporated the informed

consent form which provides confidentiality and protects their privacy. Before

conducting an interview, I asked participants to read, review, and sign the informed

consent form.

Participants have a significant impact on the researcher. The roles of the

researcher and participant deemed to be essential in all aspects of the study (Råheim et

al., 2016). The formation of a working relationship existed early in the study with

participants, as I provided a detailed explanation of the study, events, disadvantages and

advantages of participating in the study, and adherence to confidentiality for participants.

I also went over the study with the potential participants to make sure they fully

understood the purpose of this study before agreeing to participate.

Research Method and Design

The purpose of this qualitative multiple case study was to explore strategies rural

clinic managers use to obtain timely payment from patients and insurance payers. The

researcher can choose between qualitative, quantitative, or mixed research methodologies

to delineate an occurrence (Wilson, 2016). Researchers use a qualitative multiple case

study design to explore and enlighten human experience (Yin, 2017).

Research Method

Rebs, Brandenburg, Seuring, and Stohler (2017) argued that quantitative research

methods like analysis of empirical data produce stronger results than illustrated durable

numerical examples. A quantitative researcher uses systemic numerical indicators, along

with empirical inquiry to comprehend the existence of a phenomenon (Chang, 2017). A

researcher’s selection of quantitative methodology exists as an expertly constructed

process in obtaining clear, concise results either validating or disapproving a hypothesis

(Saxena, 2017). A quantitative research method was not appropriate for this proposed

study due to no testing of relationships among variables. Also, did not use the

quantitative research method for the reason no hypotheses exist for this study.

The researcher bringing a mixed method approach incorporates strategies from

both the qualitative and quantitative methods, and to integrate these practices to reflect

inquire of importance (Mertens et al., 2016). The carrying out of a mixed methods

research is difficult, as opposed to implementing a single research method (Yin, 2017).

The mixed method researchers implement this method of research primarily based on the

phenomenon under inquiry, which needs to be understood (Annansingh & Howell, 2016).

I eliminated the use of the mixed method research model, as I did not incorporate

numerical data in this study. I implemented the qualitative method approach to

investigate and interpret occurrences encountered by the participants.

To remain alert when a research question occurs, it is vital in fulfilling an

outcome in the research methodology (Isaacs, 2014). The exploration of strategies used

by rural health care clinic managers to ensure timely payment from patients and

insurance payers dictate that I selected a qualitative research method. Qualitative

researchers focus on what and how components of events revolve around individual

experiences (Bazzano, Martin, Hicks, Faughnan, & Murphy, 2017). With the use of a

qualitative research method, I improved my understanding of how clinic managers

promptly collect payments amid difficult circumstances. The implementation of a

qualitative research method entails the use of interviewing skills and observation and a

systematic form of deduction to confirm or contradict findings (Arino, LeBaron, &

Milliken, 2016). Researchers use a qualitative methodology to gain more in-depth

information to provide further meaning.

Research Design

I used a multiple case study design to explore the research question as the case

study approach allows the researcher to view the issue in a natural setting. The primary

reason for the research design of a study is to lead the researcher through the collection of

the data, analyze the information, and provide a deduction to the findings (Yin, 2017).

The researcher’s research design focuses on the research question and remains suitable to

conduct the study (Santiago-Delefosse, Gavin, Bruchez, Roux, & Stephen, 2016). The

qualitative researcher can seek to use different design methods including case study,

ethnography, and phenomenological (Colorafi & Evans, 2016).

Researchers use a qualitative multiple case study to reinforce study findings

through replicating research at multiple sites (Solomon & Casey, 2017). Researchers use

the case study design to explore phenomena using numerous data collection methods

(Wang, Sadler, & Shee, 2017). Researchers use a qualitative case study design to focus

on the how and why questions within a study (Fitzsimmons, 2017). I used a qualitative

multiple case study to look at strategies rural clinic managers use to obtain timely

payments from patients and insurance payers.

Ethnographers construct the possibility of exploration of insight and examination

of shared patterns within individuals and cultures (Jaimangal-Jones, 2014). The

researcher using ethnography design engages and learns more about a particular group of

participants based on the interest (Desmond, 2014). Ethnographers engage extensive

periods in the field investigating and connecting with a specific culture group (Rouleau,

de Rond & Musca, 2014).

The examination of the culture within the rural clinic staff potentially could have

provided valuable information. However, the purpose of the study did not include

observation of the rural clinic staff, but reporting strategies applied by rural clinic

managers to ensure timely payments from patients and insurance payers. For this study,

an ethnographic design was not appropriate. Researchers utilizing a phenomenological

design concentrated on the line of inquiry that focuses on the participant lived occurrence

(Ziakas & Boukas, 2014). A phenomenological researcher’s interest is to illustrate what

and how all participants’ respond to the phenomenon encounter (Bourne, 2015). Using a

phenomenological research design, a researcher firmly situates to describe and analyze

possible interpretations from all participants during this investigative process (DeFelice

& Janesick, 2015). The phenomenological research design was not an appropriate design

for this study, as my objective was to delve into strategies used by clinic managers to

obtain timely payment and not to look at participants lived experiences.

The data saturation approach used by the researcher exists on concepts identified

as part of the study, along with the research method and design (Saunders et al., 2017).

Boddy (2016) indicates that data saturation occurs at the point where no new information

or themes detected in the data. A researcher conducting a qualitative research

methodology uses exact data collection methods towards receiving an answer to the

research question (Fusch & Ness, 2015). An occurrence may take place during a study in

which a novice researcher due to their level of data saturation inexperience maybe at risk

and unachievable (Wilkinson & Hayward, 2017). I interviewed rural clinic managers and

financial personnel until I reached a point of data saturation, as indicated by no further

substantial information or new themes emerged.

Population and Sampling

The purpose of this qualitative multiple case study was to explore strategies used

by rural health care clinic managers to ensure timely payment from patients and

insurance payers. The sample population for this study consisted of clinic managers and

financial personnel from rural health care clinics in southwestern region of the United

States. Researchers will select participants based on the role they play within the

organization concerning the research question (Palinkas et al., 2015). A researcher should

be able to justify the inclusion of participants in a study (Cleary, Horsfall, & Hayter,

2014). The participants must meet parameters within the purpose of the study to reduce

the potential risk for inauthentic or improper settings and processes (Khan, 2014). The

selection of participants exists on the premise that the information generated is plentiful

and insightful to the research topic (Mountford & Kessie, 2017). Consequently, the

sampled population supported the research question: What strategies do rural clinic

managers use to obtain timely payments from patients and insurance payers?

I used purposive sampling as the sampling method for this research study.

Researchers use the purposive sampling method to obtain participants based on their

extensive knowledge or verbal expression within a group or subculture of their belonging

(Gentles, Charles, Ploeg, & McKibbon, 2015). The sampling of a study must represent an

accurate alignment of the purpose and ideas throughout the study (Solomon & Casey,

2017). Researchers use sampling to enhance the effectiveness used through the collection

of data to validate the study (Sharafizad & Coetzer, 2017). For this study, I purposively

selected rural clinic managers and financial staff because they are in the position to

provide detailed information and insight into their experience and familiarity with timely

payments.

Data saturation and gathering takes place after which data collected is repetitious,

and no additional data can be acquired (Pourghane, Ahmadi, & Salimi, 2017). Data

saturation is confirmation of high-quality information tested to solidify the validity and

reliability of the study (Wang, Gellynck, & Verbeke, 2016). A qualitative researcher will

cease the interviewing of additional participants recognizing no further information will

emerge complementing the phenomenon studied (Gligor, Esmark, & Gölgeci, 2016).

Data saturation happens through the beginning analysis of data collected when rural

clinic managers and financial staff provide no new information on strategies to obtain

payments from patients and insurance payers. The sample size of this study was 10 rural

clinic managers and financial staff within the rural clinic setting.

A researcher can use interview surroundings to put the participants in a state of

increased comfort or feelings of ease by conducting interviews in a place of neutrality

and privacy (McGhie-Anderson, 2017). I conducted face-to-face in-depth interviews at

the location of the clinic managers or financial staff members to ensure the wellbeing of

all participants in the study. The participants in the study chose their work setting as a

place of comfort and security to conduct the interviews. The participants feel comfortable

in a face-to-face interview and are placed in a setting to discuss feedback results relevant

to the event studied (Strasser, 2017). The participants provided commentary with

confidence in an environment free from disruption with an ability to share their

observations (Wardale & Lord, 2017).

Ethical Research

The participant informed consent process is critical to control ethics regarding the

research of the study (Graham, Powell, & Truscott, 2016). The method of informed

consent keeps the lines of communication open with the participant and provides

comprehension and education within the context of the study (Gordon, Mullee, Skaro, &

Baker, 2016). By presenting and reviewing the consent form (see Appendix D) with

participants, I ensured the explanation of the study, their rights as participants, and my

contact information as the researcher. Before interviewing the participants, I ensured that

I attained a signed informed consent from each participant. Also, each participant

received a copy of the document for his or her records.

A researcher must allow a participant the opportunity to withdraw from the

research study at any time and without reason (Hinnekens, Vanhee, De Schryver, Ickes,

& Verhofstadt, 2016). The participants received a copy of the informed consent in the

initial phase of the study; provisions within the context of the informed consent allow the

participants to withdrawal at any time (Nilsson et al., 2016). I explicitly stated that the

participants may request to withdrawal or opt out of the study at any time, without

repercussions.

I reiterated to participants that participation was strictly voluntary and no financial

incentives were part of this study. McNaughton, Adams, and Shucksmith (2016) asserted

that offering financial incentives may be ineffective and counterproductive. The

provision to provide monetary incentives or stipends reduced the level of participation

(Begley, McCarron, Huntley-Moore, Condell, & Higgins, 2014). Some financial

incentives offered by researchers encourage participants to provide valuable information

(Smaglik, 2016). I restated that participation in this study was strictly voluntary and there

are no incentives for participation in the study.

I protected the confidentiality of the names of the participants by not including

identifiers that may allow others to determine the names of the participants in the study.

The concealing of participant identities is a primary goal of researchers to ensure

discretion (Raman & Pramod, 2017). To protect the anonymity of participants, I used

pseudonyms to ensure privacy. I ensured that only I have access to the interview

information.

After I collected and analyzed study data, I stored all confidential study

information in a secured file cabinet at my home. After 5 years of securely storing the

data, I intend to shred all interview notes, paper files, consent forms, and delete any

electronic files or data stored in my possession. Finally, I remained compliant with the

requirements outlined by Walden University Institutional Review Board to ensure the

welfare of the participants.

Data Collection Instruments

In qualitative studies, a researcher is the principal data collection instrument (Yin,

2017). As a primary data collection instrument, a qualitative researcher engages directly

with participants, and the engagement will have an impact on the study (Forsythe et al.,

2016). Hasle, Limborg, Grøn, and Refslund (2017) stated that qualitative researchers

collect data through interviews, a review of written organizational and archival

documents, email correspondence, and observations. As a qualitative researcher, I was

the primary data collector for this research study, and I ensured the implementation of the

semistructured interviews as part of this research study.

A qualitative researcher can use semistructured interviews to seek information

and clarification on vital points in the study (Shalhoub, Marshall, & Ippolito, 2017). I

conducted face-to-face semistructured interviews utilizing open-ended formatted

questions to collect data for this study. Researchers who use semistructured interviews

connect with participants and elicit responses about experiences in the study (Fowler,

Coffey, & Dixon-Fowler, 2017). A researcher using semistructured interviews has a

predetermined list of questions going into the study (Van den Berg & Struwig, 2017).

The semistructured interviews for this study comprised 10 prearranged open-ended

questions that primarily focus on the pivotal phenomenon of the study. Each

semistructured interviews lasted 30-45 minutes. During the semistructured interview

process, I asked participants constructive interview questions, stayed accommodative,

and avoided biases.

A qualitative researcher will use triangulation of multiple data sources to develop

a comprehension of the phenomena within the study (Carter, Bryant-Lukosius, DiCenso,

Blythe, & Neville, 2014). A qualitative researcher applies triangulation less as a strategy

for the validation of results than an option to validate the consistency, intensity, and range

of a study (Wilson, 2014). A researcher needs to be exact about the collection and

analyzing of the data to support rigor within the study (Tibben, 2015). I implemented

methodological triangulation to promote the authenticity, consistency, and accuracy of

the study. As a researcher, I employed methodological triangulation by including referred

organizational documental evidence to include IRS Form 990 form, specific health center

data from Health Resources and Service Administration (HRSA), and casual observations

of the environment to enhance my data collected from face-to-face interviews. Arfaoui,

Damak-ayadi, Ghram, and Bouchekoua (2016) stated the selection of methodological

triangulation allows for control over possible bias and the empirical justification for the

study. The data collection methods I used included informal observation, semistructured

interviews utilizing open-ended questions, and an examination of the documental support

within the study. Documental support that I collected consists of policies, internal

organizational data, and other relevant in-house documentation.

Member checking is a proven technique used by qualitative researchers to ensure

the validity and accuracy of the study (Schaik, O'Brien, Almeida, & Adler, 2014). A

researcher will use member checking to ensure the findings become available to the

participants before the completion of the study (McNulty, 2015). To make sure accuracy

and authenticity exist as part of the data collection process, a qualitative researcher can

make use of member checking (West, 2015). I applied member checking by asking

participants to validate my conclusions and emergent themes from the interviews.

A qualitative researcher is the prime data collection instrument and must prevent

any or all misinterpretations from decreasing bias (Thomas, 2017). Researchers use

interview protocols steadily as a gradual progression to direct them through the interview

process (Karen, Kennedy, Hunter, & Maksabedian, 2016). Yin (2017) stated a researcher

could use interview protocols to obtain access to significant participants and coordinate

schedules to complete the collection of data at any time during the study. A researcher

will use interview protocols to focus and concentrate on structural boundaries of the

study to reduce the risk of bias (Venkat, Shank, Rickard-Aasen, Pringle, & Johnjulio,

2017). I consistently applied the same questions, in the same order, to help minimize

investigator bias. Using an interview protocol (see Appendix A), I was able to adapt each

interview consistently reducing researcher bias.

Data Collection Technique

Data collection included open-ended semistructured face-to-face interviews and a

review of documental resources. The data collection techniques of researchers include

detail processes aimed at assembling relevant information connected to the phenomenon

of interest (Eisenhardt, Graebner, & Sonenshein, 2016). A researcher will use multiple

data sources within the same study to ensure validity (Aslinda & Ibrahim, 2016). Data

collection techniques for this doctoral study involved 10 face-to-face semistructured

interviews utilizing open-ended questions (see Appendix E), documental evidence, and

informal observations. All interviews were conducted at the business site and conducted

during regular business hours. Researchers use semistructured interviews to probe

beyond the participant’s responses to gain further insights, perceptions, and experiences

related to the research phenomenon (Peters & Halcomb, 2015). A qualitative researcher

uses semistructured interviews to allow participants to offer their experiences as a

contributor to the study (Campbell, Manns, Hemmelgarn, Sanmartin, & King-Shier,

2016). As a qualitative researcher, I implemented documental support, and informal

observations to explore the strategies required by rural health care clinic managers to

obtain timely payments from patients and insurance payers.

Participants who were willing to participate in the study received the consent form

in advance through an in-person visit. Before conducting interviews, I visited each

prospective participant during an in-person onsite visit to provide and review the

informed consent form (see Appendix D). After the meetings, participants signed the

informed consent documents and provided a copy to me of each signed form. The

following week I called or emailed each of the 10 participants to schedule a date, time,

and place for the interview. Before conducting each interview, I informed participants

that I would be recording the interview using a portable electronic audio recording device

to ensure accurate data transcription.

Researchers use semistructured interviews to explore further insight from the

participant’s perspective to expand on added knowledge of the phenomenon studied

(Yagasaki, Komatsu, & Takahashi, 2015). I used audio recorded semistructured face-to-

face interviews and documental analysis to explore strategies implemented by health care

leaders to increase profitability. A researcher will use semistructured interviews to collect

data identified by participants as experiences during the study (Spinks, Chaboyer,

Bucknall, Tobiano, & Whitty, 2015). The rationale for using this protocol was to make

the process easier and more manageable for the participants. Researchers utilizing

semistructured interviews will have a comprised set of listed open-ended questions with

no preconceived designed response options (Alhaddad, Smith, Robertson, Watman, &

Taylor, 2015).

I followed my prescribed interview protocol (Appendix A) questions to engage in

an extensive exchange with the participants. A prepared researcher will effectively

employ interview questions to evoke hidden or imperceptibly improper data (Mlinar,

Petek, Cotic, Metka, & Zaletel, 2016). A researcher will use informal observations to

access pertinent information as depicted by the participants in the study (Joe, Young,

Moses, Knoki-Wilson, & Dennison, 2016). A researcher will interject realistic actions or

events of participants while observing (Yin, 2017). I carefully assured all these elements

during the interview process by reviewing all journal entries and documented notes at the

conclusion of each interview.

The qualitative researcher uses member checking to allow the participants to

review the interview transcript or data interpreted in the study (Birt, Scott, Cavers,

Campbell, & Walter, 2016). Member checking is the method a qualitative researcher uses

concerning the acquisition of participant feedback and confirming the authenticity of the

findings (Charmaz, 2006; Harvey, 2015). A researcher implements member checking as

part of the interpretative portion of the data collection for increasing confidence and

validity (Dorsey, Conover, & Revillion-Cox, 2014). To ensure reliability within this

study, I presented my findings to the participants with my interpretations of the

interviews and provided them with the opportunity to corroborate the accuracy of my

interpretation of the collected data as part of this study. I emailed my summary to the

participants within 7 days of the interview and asked for a response within 14 days of

receiving the summary. There were no significant changes during the review process, and

all information was confirmed through an email sent to participants verifying all

interview responses. As part of the member checking process, participants confirmed the

accuracy of my interpretations during the interview.

Data Organization Technique

A researcher organizes data based on the relevance of the data to the study

framework (Nielsen & Nielsen, 2015). Yin (2017) detailed that a qualitative case study

researcher should organize data based on the relevance of the research question. A

researcher will organize data in a form that safeguards the integrity and confidentiality of

the information (Van Zyl, Mathafena, & Ras, 2017). My objective was to develop a

proficient data technique; I created a research log utilizing an Excel spreadsheet to keep a

structured record of the dates of the interviews, names of the interviewees, and other data

acquired from participants and online searches. A researcher uses reflective journaling to

document personal accounts with participants along with a provisional for opportunities

for questions, feedback, and critiquing (Baillie, 2015). Also, I maintained a reflective

journal that includes notes from interviews, observations, and analysis of organizational

documents. A qualitative researcher applies coding to aid in the process of data

organization (Chowdhury, 2015). Thus, I used the coding process to assist in the

organizing and retrieval of data in my research log.

Researchers ensure sensitive information remains encrypted and compliant with

ethical guidelines. Researchers initiate protective measures stay in place by using a

password-protected filing system secured in a locked cabinet (Fairfield & Shtein, 2014).

A researcher must ensure data remains secure to prevent unauthorized discovery or use

(Peng & Gala, 2014). To ensure the confidentiality of participants, I stored all data

collected in a password-protected personal computer, and hard copies of information

accumulated will remain secure in a locked file cabinet. Researchers need to

predetermine a retention policy (Cullington et al., 2016). After 5 years of securely storing

the participant data, I intend to destroy all written documents and electronic data from all

electronic devices used to gather information.

Data Analysis

Qualitative data analysis coincides with the exploration, categorizing, and coding

of data into themes (Iancu, Zweekhorst, Veltman, & van Balkom, 2015). Data analysis

entails multifaceted and contextually rooted data generated with the intent to prepare,

manage, and report from the perspective of multiple sources (Patterson, Smith, &

Bellamy, 2015). Data analysis is one of the most challenging aspects of research,

especially for a beginning researcher (Yin, 2017). The data analysis process suitable for

this case study research was methodological triangulation. Wilson (2014) provided a

practical approach regarding the four aspects of triangulation including data, investigator,

methodological, and theory. In methodological triangulation, a researcher implements a

series of data collection techniques and analysis in the exploration of a phenomenon

(Oleinik, 2015). Thus, I employed three collection methods including face-to-face

semistructured interviews utilizing open-ended questions (see Appendix E), review of

organization documents, and informal observations to enhance the validity of the findings

of this study.

Using a logical and sequential process addressing multiple facets of the study is a

crucial component of the researcher’s data analysis process (Pradabwong, Braziotis,

Pawar, & Tannock, 2015). The data analysis process for a researcher begins immediately

after conducting the initial interview and throughout the research process (Fletcher,

2017). A case study researcher will have strategies in place to ensure a prominent role in

linking the collected data to the research question is at the forefront (Yin, 2017). Rose

and Lennerholt (2017) defined the data analysis process consisting of (a) acquiring data

and related sources, (b) extracting, coding, and formatting information in an orderly

manner, (c) grouping data into subject matter, (d) analyzing and assessing text, and (e)

interpreting results and formulation a conclusion. After collecting the data from the

participants through semistructured face-to-face interviews, document reviews, and

informal observations, I immediately transcribed each interview and field notes.

Subsequently, I organized the data into thematic relevance as recommended (Percy,

Kostere, & Kostere, 2015). The coding process ensures themes remain grouped into

categories (Percy et al., 2015). Once coding the data into segmented themes, I presented

my preliminary findings to the participants to confirm the emerging themes through

member checking and follow-up emails to the participants. A qualitative researcher

interprets the data to ensure consistency and significance (Chavira, Bustos, Garcia, Ng, &

Camacho, 2017). I complied, disassembled, and reassembled data to develop a final list

of emergent themes.

The use of computer-based software in the process of data analysis assists

researchers reflect on the data in the thematic development process (Zamawe, 2015). The

options of qualitative data analysis vendors include NVivo, ATLAS.ti, RQDA, and

MaxQDA (Chandra & Shang, 2017). NVivo is an efficient system used by researchers to

assist in interpretation and time management while developing qualitative themes

(Heisler, Firmin, Firmin, & Hundley, 2015). A researcher can use NVivo to influence

data by deriving codes and rules connected to the data to affect bias (Sotiriadou,

Brouwers, & Le, 2014). I applied NVivo 12 Plus software in the data analysis portion to

assist in the retrieval of information and to salvage time.

A researcher will implement a thematic analysis to uncover a collection of

patterns associated with the themes (Braun & Clarke, 2006; Fugard & Potts, 2015).

Researchers use thematic analysis as a means to capture and organize data in a way to

derive meanings and create a detailed understanding (Crowe, Inder, & Porter, 2015). A

researcher should ensure thematic interpretations are a direct reflection concerning the

research question (Henning et al., 2015). Researchers use a thematic analytic process to

ensure appropriate analysis of data (Gallagher, Phillips, Lee, & Carroll, 2015). I used

NVivo 12 Plus for my thematic analysis to create and organize essential themes. Through

the triangulation process, I developed themes with supporting documentation from

financial information reported in the IRS Form 990, specific health center data from the

HRSA form, and my journal notes. Included in my journal notes were comments I made

related to my observations of the environment. The RBV theory was the framework I

used to explore the themes related to improving receivable collections of accounts.

Reliability and Validity

Reliability and validity of a qualitative research study are essential components of

research dependability (Bengtsson, 2016). Reliability and validity are critical standards to

the construct of a qualitative researcher emphasizing objectivity as the primary purpose

of research (Power & Gendron, 2015). In evaluating reliability and validity of a

qualitative study, a researcher can use the criterion of dependability, credibility,

transferability, confirmability, and data saturation (Dubois & Gadde, 2014; Yin, 2017).

The reliability and validity of a study substantiate rigor and integrity of the research

findings (Cypress, 2017). I incorporated reliability and validity strategies during my

study to improve trustworthiness.

Reliability

A researcher should consider reliability within the context of a research study

(Fida et al., 2016). Dependability contains the essentials of stability of data over time

under different conditions (Holm & Severinsson, 2014). A researcher will establish

reliability to ensure details of the qualitative study transpire in a detailed manner

(Eriksson, 2015). To assess dependability, a researcher addresses internal and external

auditing to ensure the reviewing process occurs in a research study (Smith & Smyer,

2015). As a researcher, I preserved an auditing path to augment the assessment of

dependability of this study. The relationship between dependability and quality ensures

the processes and rigor in the study (Lin, Han, & Pan, 2015). In alignment with (Lin et

al., 2015), I employed member checking with participant follow up. Participants

reviewed my preliminary themes and validated my interpretation of the collected data.

Makola (2015) provided a detailed approach that a qualitative researcher uses member

checking to concentrate on emerging themes, confirm findings, and elicit precise results.

A qualitative researcher uses intrinsic and extrinsic motivation in member checking, thus

ensuring themes are precise, thorough, and interpretations are practical (Bassous, 2015).

To enhance the reliability and validity of findings in this study, I established several

sources of data collection including face-to-face semistructured interview using open-

ended questions, a review of organizational documents, and observations. Organizational

documents will include policy and procedures, collection templates, and other significant

internal documents.

Validity

According to Leung (2015), reliability and validity are primary principles for a

study. Validity entails the degree of accuracy of data (Chahal & Dutta, 2015). A

researcher can confirm the validity of a research discovery by upholding the formulation

of internal consistencies in the research process (Slife, Wright, & Yanchar, 2016). To

confirm the validity of the study, a researcher can use to support the fundamentals of

credibility, transferability, confirmability, and data saturation (Bennett & McWhorter,

2016; Yin, 2017).

Credibility. Qualitative researchers can augment the credibility of the findings in

a study by determining dependability from the perspective of the participants (Munn,

Porritt, Lockwood, Aromataris, & Pearson, 2014). Schipper et al. (2014) purposed the use

of reflective journaling and member checking as methods researchers can implement to

confirm findings in the study. A qualitative researcher can establish credibility when a

participant confirms the findings brought about by the researcher (Rosenthal, 2016).

Researchers use member checking to gain further insight into the phenomenon of the

study (Welch, 2017). To address credibility, I established member checking and

reflective journaling. Both techniques allowed me to maintain a comprehensive, detailed

account of the participant interviews and subsequent interpretation of the data.

Transferability. Researchers meet the criteria of transferability if the findings

add meaning to studies in different settings (Rapport, Clement, Doel, & Hutchings,

2015). Researchers can ensure transferability when the results of the research involve a

degree of importance to other groups (Pompeii, 2015). The intensity of transferability

increases as researchers present a detailed description of data (Vermeulen, Niemann, &

Kotzé, 2016). In demonstrating transferability future researchers crossing multiple

disciplines and readers of a study could find the data resourceful and valuable (Smith et

al., 2015). To enhance transferability, I ensured to provide adequate information

regarding the details of my study.

Conformability. The conformability criteria arise from the data accuracy of

information and data provided by participants (McInnes, Peters, Bonney, & Halcomb,

2017; Polit & Beck, 2010). Rich, Viney, Needleman, Griffin, and Woolf (2016) assert

that conformability as the neutrality of the researcher in the research process. A

qualitative researcher can apply conformability by establishing an audit trail by ensuring

the research method is engaged in the study (Ang et al., 2016). I used methodological

triangulation to assure conformability. In methodological triangulation, researchers

employ multiple data collection methods to investigate a phenomenon (Fusch & Ness,

2015). I used different data collection methods including face-to-face semistructured

interview using open-ended questions, a review of organizational documents, and

observations.

Researchers reach data saturation at the point when collecting additional data does

not produce new ideas relating to the phenomenon of the study (Saunders et al., 2017).

Researchers use data saturation to increase the level of reliability and validity of the

findings of a study (Fusch & Ness, 2015). At the point of sufficient data saturation, a

qualitative researcher will cease with interviews (Boddy, 2016). To ensure data

saturation, I continued to conduct interviews until no new or sufficient data to replicate

the themes identified in the study.

Transition and Summary

Section 2 consisted of a comprehensive description of this study. I started Section

2 by restating my purpose statement. Next, I expanded on my role as the researcher with

provisions including in-depth accounts about the participants selected for the study. As

part of Section 2, I described the research method and design along with the population

and sampling. Next, I included ethical research and established data collection

instruments, techniques, and organization. Furthermore, I concluded Section 2 with data

analysis, and methodology addressing reliability and validity.

In Section 3, I presented the research findings and the application of professional

practice and implications for change. In the introduction, I reiterated the purpose

statement and research question. I also presented study findings and applications to

professional practice. Finally, I inquired into the applications for social change,

recommendations for action, further research, reflect on the research process, and

concluded the study.

Section 3: Application to Professional Practice and Implications for Change

Introduction

The objective of this qualitative multiple case study was to explore strategies rural

clinic managers use to obtain timely payment from patients and insurance payers. The

processes and strategies used by rural clinic billing staff establish and maintain

profitability and sustainability for the entire organization. As a result, multiple revenues

generating strategies exist that financial billing staff uses to increase economic prosperity.

After interviewing participants and reviewing other document sources, I identified four

major accounts receivable management strategy themes: (a) communication between

medical providers and billing staff, (b) payment plan set up, (c) accuracy of billing claims

and (d) consistent accounts receivable reviews. These themes represented strategic

approaches to assist financial leaders in collecting payments from patient and insurance

payers in a timely and efficient manner.

Presentation of the Findings

The overarching research question for this study was: What strategies do rural

clinic managers use to obtain timely payments from patients and insurance payers? To

answer the overarching research question, I conducted semistructured face-to-face

interviews with a combination of 10 clinic managers and billing staff from rural clinics in

southwestern region of the United States. During the interview process, I followed an

interview protocol (see Appendix A). I called and spoke with both the Director of

Revenue Management and Accounts Receivable Supervisor to obtain permission to meet

with each participant individually and asked each participant the same set of questions in

the same order. I informed each participant that each interview would be audio recorded

and I would be integrating their responses into the documented results. The

semistructured face-to-face interviews occurred at the request of the Director of Revenue

Cycle, and dates and times were allotted to meet the needs of the research participants. At

the instruction of the Director of Revenue Cycle, who was also the gatekeeper, I received

a list of participants and used the list to organize each individual interview. The

interviews took place over a 2-day time span; however, I returned on a third day to meet

individually with the Director of Revenue Cycle for a followup interview.

The data collection configuration appropriate for this study was methodological

triangulation. Triangulation is collecting and examining multiple data sources (Wilson,

2014). To gain a dynamic understanding of strategies implemented by rural clinic billing

staff and clinic managers to maintain profitability and sustainability for the organization,

I chose this method.

I coded the participants CL1 through CL10. I confirmed my interview data

through methodological triangulation. Additional data sources confirming my interviews

included data from reviewing HRSA documentation and the IRS-990 form along with

casual observations. I also met with both the Accounts Receivables Supervisor and

Director of Revenue Cycle to process accounts receivables strategies for capturing

payment from patients and insurance payers to ensure sustainability and profitability.

Yin (2017) provided researchers with a multiple step data analysis process: (a)

collection, (b) dismantling, (c) aggregation, and (d) interpretation. I used each of these

steps for data collection and analysis. I collected information by taking notes during the

interview process. After each interview prior to ending the recording, I verified the

identity of the participant, their specific job title, and the date and time of the interview. I

also emailed a transcription copy to each participant to allow them to corroborate the

data. I transcribed the taped results with Microsoft Word. The aggregation of the

information occurred as I transferred transcribed audio interview results into NVivo 12. I

used queries, narratives, accounting of the results, and coding to identify significant

themes during the interpretation process.

I wrote up my conclusions following the data interpretation. Throughout the data

analysis process, four main themes emerged: (a) communication between medical

providers and billing staff, (b) payment plan setup, (c) accuracy of billing claims, and (d)

consistent accounts receivable reviews. The rural clinic managers and billing staff were

all consistent in terms of their standards regarding these four major themes for accounts

receivables strategies that improve sustainability and profitability.

Theme 1: Communication Between Medical Providers and Billing Staff

All but one of the 10 study participants articulated how consistent communication

between medical providers and billing staff provides stability, which increases

profitability. CL1 explained that specific departments, for example obstetrics and

gynecology, will incorporate billing requirement changes from specific payers regarding

billing for obstetrics and referrals. These changes are communicated to the billing office.

CL1 mentioned that medical assistants (MAs) provide required information regarding

encounters with patients, and all billing codes are used and sent to the insurance company

for reimbursement. CL1 stated, “Without the front desk, without the MAs, and without

the doctors, we wouldn’t be able to bill the claim.”

CL2 explained that it was essential to ensure that billing staff update patient

demographics with correct information. Obtaining correct and timely information

requires a high level of communication between the medical provider and billing staff.

CL2 stated, “We make sure that we [billing staff] go from time to time to the front office

to make sure that they are doing everything correctly and entering everything correctly.”

CL2 explained the importance of ensuring charges match medical diagnoses and

procedures performed by the medical provider. In order to increase communication with

medical providers, billing staff monitors patient accounts to determine if the accounts are

current or inactive. CL4 described effective communication as the process of updating

patient information. CL5 also confirmed the importance of consistent communication

with other departments:

It [billing] affects our doctors, our medical records staff; it is a team effort.

Whatever the front desk person does, what the medical doctor does in the notes,

whatever he is going to charge and a bill to when we get it, as it is truly a team

effort. There is no way to get around it.

CL7 added that they review patients’ financial charts to ensure that payments

occur and verify previous payments. CL8 identified that the primary indicator of prompt

billing was the timely documentation of the services received from the provider to submit

for billing purposes. CL8 in addition stated “the encounter [patient visit] is complete and

submitted for billing within 72 hours.” The timeliness of the billing will ensure that

claims submitted to the insurance payer are received and payment occurs.

CL9 further added that communication with other departments improves billing

accuracy. CL10 focused on how accurate information reduces the possibility of insurance

payers denying or rejecting a claim. CL10 described the importance of closing the

encounter and promptly submitting the claim. CL10 alluded to the open lines of

communication between medical providers and billing staff was important to ensure

correct billing information resulting in increased revenue. During the interview process at

the central billing location, I observed interaction between billing staff, coding staff,

accounts receivable supervisor, and the Director of Revenue Cycle Management. I noted

collaboration within the various departments, which ensured the accuracy and timeliness

of claims.

Gurganious (2016) said that the reimbursement model for services provided by

healthcare organizations is intended to pay for the services the patient received from the

healthcare provider. The profitability of healthcare organizations depends on effective

communication between medical providers and billing staff, who oversee the

reimbursement process for the services provided. The RBV is a relevant framework for a

service-based industry such as healthcare. The concept of providing continuity of care for

the patient and the ability of the organization to win the confidence of the patient

increases its competitive advantage and improves its financial performance (Lin et al.,

2015). Al Achkar et al. (2018) indicated apart from ensuring clinical services remain

adequately compensated, accurate coding and billing reflect the appropriate assessment

of the complexity of medical conditions. CL2 stated ensuring demographic information is

correct, in order to assure correct billing information and avoid declined claims, and

communication between the medical providers and the billing staff are crucial for timely

reimbursement.

CL1, CL3, CL5, CL9, and CL10 shared that consistent communication

departmentally between providers and billing staff are vital and without one another the

claim could not be submitted for payment. These comments align with Mkanta et al.

(2016) who stated that the U.S. health care officials must focus on the cost and quality of

health care and evaluate operational aspects, including scheduling of providers, clinical

methods, payment methods, and management structures. All, but one of the 10

participants confirmed that communication between medical providers and the billing

staff are imperative towards the consistency of billing which affects increased

profitability.

Theme 2: Payment Plan Setup

The second identified theme from this study was the payment plan setup to ensure

that payment occurs at the time of the medical encounter. All 10 participants mentioned

the flexibility of setting up a payment plan that meets the needs of the patients and their

monthly budgetary constraints was important. During the interview process, the study

participants each expressed collectively the ease in which payment plans are setup

specifically to address the patient’s financial needs. CL1 shared that discounts and sliding

fee scale payment are arranged for those patients who are uninsured or under-insured.

CL1 stated:

We can offer a small payment plan for those patients before sending them to

collections even if we do send them to collections, $5.00 or $10.00 a month,

something that can work for them. We work on a payment plan, even if it is a

small dollar amount. Whatever the patient’s financial needs are, that’s what we

work with.

CL2 further added that the sliding fee scale payment option was available and if a

patient comes in with no health care insurance, they are offered a 30-day discount. The

objective of the biller is to collect a form of payment or instead of no payment, a partial

payment is an acceptable means of collection. A sliding fee scale intends to assist the

patient to make a form of payment and helping the patients is a form of excellent

customer service. CL3 stated, “Usually it depends on what the patient can give, and some

patients give $20, and some give $50, it depends on what the patient can do at that time.”

CL4 indicated that if a patient was already in collections, an alternative to making a

payment to the collection company would be that the organization accepts payment in the

billing office. CL4 stated, “We do take a lot of payments from people who are already in

collections. They always say they would much rather talk to us than the people in the

collections.”

CL5 added that a discounted payment plan applies to single individuals, as well as

families and children. CL5 also mentioned that before the patient visits the front desk,

personnel inform the patient of the co-pay or deductible. If the patient cannot afford to

make the entire co-payment or deductible, arrangements occur at the time of the

appointment for payment options. CL6 stated, “We always try to work around and help

them [patients] out if they have little income.” The implementation of the payment plan

ensures revenue for the organization and the ease in which the patient can make a

payment promotes community engagement.

CL7 indicated the flexibility of the payment plan and the expectation is not that

the patient makes the full amount at one time. CL8 added that discounts are offered

depending on a patient’s level of income. CL8 stated, “Payments can pay as little as $15,

$20, $38, and up to $43. Again, based on their income, how many in the household, we

can reduce down their office visits.” CL9 shared the uniqueness of the organization is

their ability to engage the patients in a payment plan that serves both the uninsured and

under-insured population. During the interview process, I had the opportunity to observe

clinic staff engage patients, address their co-pays, and address methods of payment for

their medical encounters. CL10 added that for some of the patients the sliding fee scale is

a primary option. As CL10 stated, “Using a sliding fee scale is a requirement of being a

federally-funded community health center. We offer a type of discounts to low income

patients. We also offer payment arrangements up to 12-month for balances over $150.”

CL10 further added that the health center accepts credit and debit cards and can set up the

payment arrangement through the credit or debit card. Having a payment plan setup

increases flexibility and improves financial options.

Theme 2 findings, payment plan setup, are also relevant to RBV conceptual

theory and an ability of billing staff to win the confidence of patients, which improves

accounts receivable collections. According to Lai and Gelb (2015), the goal of billing

department managers is collecting payments from insurance payers with limited obstacles

or delays. Business leaders manage internal resources to keep revenue consistent with the

organization’s long-term financial growth. The profitability of an organization relies on

the implementation of strategies based on organizational resources (Liu et al., 2017). One

of these corporate organizational procedures is a payment plan. Once the payment plan

setup is confirmed, commitment to consistency in the collections process is essential.

Study participants were specific that operational approaches, such as payment plan setup,

produced positive results by improving customer satisfaction and improving the medical

care experience.

Farnsworth (2015) further confirmed in the literature the evolutionary process of

improving accessibility to services, improving quality of care, and reducing costs affects

the generated revenue. Health care leaders are developing an infrastructure to move away

from previous approaches to payment methods and revenue generation (Conrad et al.,

2016). The evolutionary process of billing from paper to electronic has quickened the

timeframe in which providers receive revenue. In recent literature since this study,

payment collection methodology focusing on factors involving a patient’s insurance plan

as reimbursement potentially may become modified with minimal notice (Tamblyn,

Winslade, Qian, Moraga, & Huang, 2018).

Evidential to the second theme, all 10 participants discussed the importance of

offering a payment plan setup for uninsured and under-insured patients. As a result, the

participants identified that making a payment plan setup available to patients established

a consistent flow of revenue for the organization. The payment plan set up option gives

patients financial flexibility which, in turn, builds community rapport. Chen and

Goldman (2016) alluded to health economics playing a pivotal role in identifying a

payment system that benefits the providers and the patient. By introducing a payment

plan, patients are able to receive care and rural clinic mangers are able to receive timely

payments

Theme 3: Accuracy of Billing Claims

I observed how the billing staff focused on gathering accurate information for

billing claims. All 10 participants mentioned that accuracy in billing was one of the

primary results of prompt revenue collection. Themes 2 and 3 relate to revenue and

profitability, which are connected. Study participants mentioned effective billing ideas

and processes 53 times, which reinforced foundational components for organizational

leaders, clinic managers, and billing.

CL1 stated, “Make sure the ‘I’s are dotted, that everything is completed the first

go around because the more you submit the greater chance you have of the claim not

being paid in a timely manner. The more you work on it, the more it costs the company to

get paid on that claim.” CL2 indicated that the biller who is placing the information on

the claim must ensure that the information is correct with no mistakes. This strategy of

focusing on accuracy reduces the number of claim resubmission due to errors. CL5

further stated, “Each insurance has their time in which we can bill before it is either

processed to pay or it can be denied and they we have some additional time that we have

for denials.” CL5 stressed the importance of gathering the information correctly to

process the claim promptly with an emphasis on receiving the reimbursement quickly

without delay.

CL6 stated, “If there are any errors in the claim, we want to make sure we get that

fixed as soon as possible.” CL6 added that billing on time was the key component; but if

charges remain denied, working on the claim quicker will increase the process of

receiving payment in a shorter period. CL8 added, “As a biller, keeping up with the

changes in the organization with regard to claims billing and processing is important. It is

important to read, research, and keep informed of what is coming up that may affect your

organization, so you can help the organization.” CL10 explained that with the

information technology (IT) and software any errors or missing information that does not

relate to the medical encounter could be detected. The comment from CL10 supported

this conclusion:

A lot of our staff members review the denials and will sparse it out depending on

who is responsible for what aging. Then the charge entry sends them back to the

staff for reviews so not only are they correcting the staff but learning for future

claims the help reduce the same mistakes.

Further, health care leaders must deal with payment delays and unreimbursed

services (Cascardo, 2015). Theme 3 substantiated the overarching research question:

What strategies do rural clinic managers use to obtain timely payments from patients and

insurance payers? In health care, organizations emphasized improved patient satisfaction,

reduced costs and increased productivity at all levels of the organization (Chiarini &

Vagnoni, 2017). Cascardo (2018) concluded that staff training increases the productivity

of billing staff. Revenue cycle leadership must be involved in all aspects of the billing

staff from training, continuing education, coder application, and audit resources to be

successful in the billing of claims (Cascardo, 2018). The goal of leaders is to develop a

fully engaged billing department, which is a critical element of the reimbursement

process.

Other forms of payment include private payment insurance, direct payment, and a

sliding rate based on the ability of the patient to pay (Barbaresco et al., 2015). Angeli and

Norwood (2017) concluded the health care industry is experiencing a turbulent period

due to competition, contractual adjustments in reimbursement for services rendered and a

struggle to keep up with health information technology (electronic medical records). The

transformation of the reimbursement revenue cycle leads to the evaluation of the

operational infrastructure with the limited resources available to select a payment model

(Granata & Hamilton, 2015). Revenue cycle managers, clinic managers and billing staff

must collaborate to ensure that consistent accounts receivable reviews are occurring

steadily.

Theme 4: Consistent Accounts Receivable Reviews

All but two of the 10 participants expressed the importance of consistent accounts

receivable reviews, as a critical component in determining patient accounts and method

of payment. Consistent accounts receivable reviews coincide with theme two, payment

plan setup and theme three, accuracies of billing claims. CL1 shared the importance of

completing a more extensive review of patient accounts. CL1 stated “Make sure that

everything charged is correct; if something is incorrect, we correct it immediately. This

has more to do with doubtful accounts for the collection of payment and consistent

review of patient accounts.” CL2 described the billing activity of the patient accounts and

the importance of determining if the patient has made a payment towards the statement or

if there has been no activity in that patient’s claim. CL2 added:

Once the billing process is done, there is a report that shows a claim rejected, if

something is incorrect, if the claim wasn’t put in right, if the policy number was

wrong, it rejects them. Doing the charge entry daily and then the billing is done

daily, also once that is done and if they are rejected we correct them at the

moment and they get billed again.

CL3 explained that charge entries are corrected based on the accounts receivable

reports that are run on a daily basis. CL3 reiterated that the report flags claims prior to

submission for reimbursement. CL6 emphasized that they run reports daily to ensure that

accounts remain reviewed and that claims to insurance payers are not getting behind due

to lack of payment from the insurance companies. The timeliness of the review of

accounts receivables is dependent on the week, but these reports are worked on

consistently by revenue cycle management leaders, clinic manager, and billing staff. CL7

commented that data analyst staff review the report to determine if the patent is self-pay

or has insurance. Billers review the reports to confirm that third-payer collectors have not

received payment and to follow up on accounts that have not completed payment as this

list could be used for double or triple checking of lost revenue.

CL8 revealed that they continually monitor the patient aged-trial balance to

identify accounts with old outstanding balances. The objective is to review and identify

accounts that require assistance from other departments. CL8 stated, “We send these

reports daily, if these accounts are sitting there for 120 days with no payments, they are

sent back to us, and we then flag them and send them to a third-party collector.” If no

payments transpire on the patient accounts sent by the third-party collector, these

accounts are taken off the books as non-collectible accounts. CL8 added that these reports

are easily located to find out exactly what is going on with these accounts, and those

billing staff who look at the accounts take ownership and ensure that there is not going to

be revenue lost due to irresponsibility or losing focus due to lack of follow-up.

CL9 noted that when accounts receivable staff review reports, they could detect

where the errors occur in the billing process, and the information in the reports are

available to the staff to prevent future mistakes. CL9 added that revenue cycle managers

and billing staff use ageing reports to identify old claims that require additional work. I

observed substantive conversation among billing staff members who discussed collecting

accounts receivable in accordance with organizational standards. CL10 stated, “I think

accounts receivables within the name itself is just making sure all parties are accountable

for their ownership within the process.”

Supporting theme 4, leadership within the accounts receivable component of any

health care organization is of the utmost importance concerning profitability (Shorr,

2015). The consistency of accounts receivable reviews is to decrease barriers to the

collection process may include billing errors, underpayment of insurance payers, or

failure to collect information from the correct patient (Shi et al., 2015). The leaders of

rural clinics also consider the revenue cycle process to guarantee payment as a resource

to be managed by organizational leaders. Accounts receivables claims are reviewed

promptly to ensure the dollar amounts due to the organization decrease over time. (Lail et

al., 2016). The utilization of the consistent accounts receivable reviews is the revenue

cycle manager's strategic plan to create a primary structure for good fiscal control in the

health care organization (Sheet, 2017). The key concept is to ensure the follow through of

the accounts receivable review on a consistent basis leading towards organizational

sustainability.

An example of research contribution for consistent accounts receivable reviews

since the initial proposal approval of this study included Zenilman and Freischlag (2018).

Zenilman and Freischlag addressed the element of a detailed review process examining

every facet of the patient encounter. The pillar of system integration at the organization

includes administrative infrastructure to support the essentials of the review process for

the collection of each patient encounter (Zenilman & Freischlag, 2018). The objective of

the organization is to achieve financial transparency, and this occurs by scheduling a

regular meeting, one-to-one meetings with staff, and ensuring that follow-up happens to

address any concerns brought up by staff members (Zenilman & Freischlag, 2018).

I reviewed available IRS Form 990 and HRSA documentation to support data

collected from interviews. Abzug, Olbrecht, Sabrin, and DeLeon (2016) noted IRS Form

990 information is publically available and includes financial information reported to the

IRS. I calculated two critical metrics of accounts receivable management including

turnover and days sales outstanding (DSO). Turnover (credit sales divided by average

accounts receivable) and DSO (turnover divided by 365) represent key ratios in accounts

receivable management. Turnover at the research site increased from 3.1 to 4.6 between

2015 and 2016, and DSO decreased to from 119 days to 80 days for the same period.

Both ratios represent improvements in accounts receivable management. In the same two

year period the organization saw an increase in total patients (9.4%), uninsured patients

(0.26%), and dual eligible patients with both Medicare and Medicaid (1.27%; HRSA,

2018). The documentation I reviewed supported the importance the organization placed

on account receivable management. CL10 added the following comment:

It has been tedious for the billing department to run all those reports, but in the

long run we benefit. Because now they don’t have to write off because of

eligibility. So it decreases the aging. Because before we would just check the

patient in and we were done. Even as coordinator, we did not know that we were

writing off thousands of dollars just because this wasn’t being done. We were so

separate from them (billers), and we didn’t know the long-term effect it would

have or how much was being written off.

Overall Findings Applied to the Conceptual Framework

The findings revealed strategies rural clinic managers used to obtain timely

payments from patients and insurance payers. These findings supported the conceptual

framework, and Wernerfelt’s RBV as the basis for this study. Wernerfelt’s theory

included a detailed approach to an organizational resource as a strategic management

design to yield higher profits (Wernerfelt, 1984). The RBV indicated a connection

between profitability and resources and the long-term management of the organization’s

resources (Wernerfelt, 1984). Barbaresco et al. (2015) identified forms of payment

including private insurance, direct payments, and a sliding rate based on one’s ability to

pay. The tenets of RBV can be relevant for health care leaders regarding organizational

resources, including administratively formulated attributes, skills, organizational

procedures, and expertise. (Patidar et al., 2016). The concepts established by Wernerfelt

enhanced the theory of resource-based value by Barney (1991) with the concepts of

organizational resources, competitive advantage, and the utilization of sustained

competitive advantage.

Managers play a crucial role in ensuring that billing staff assess the patient’s

insurance coverage and potential form of payment (Barbaresco et al., 2015). Rural clinic

managers must deal with reimbursement delays, insurance payers’ denials for services

provided, and unreimbursed services (Casardo, 2015). Organizational leaders examine

the competitive advantages of the specific resources and limitations of each location

(Yang, 2014). Strategic findings from this study are pertinent to the professional practice

for revenue cycle manager and medical billers.

Applications to Professional Practice

Health care leaders could benefit from this study’s findings by identifying

strategies to increase the collection of payment from patients and insurance payers.

According to Gerstorff and Gibson (2016), roughly 20% of a state’s budget consists of

health care funds. The findings of this study indicate the professional practice procedure

steps followed by rural clinic managers maintaining profitability and sustainability are:

(a) communication between medical providers and billing staff, (b) payment plan setup,

The findings corroborate findings of other researchers, showing that

communication between clinical and billing departments, setting up payment plans,

accuracy in the filing of billing claims and reviewing accounts consistently provide a path

to long-term profitability. The results of this study could be relevant across other

industries and may enhance further understanding of those with minimal management

experience as well as qualified managers. Furthermore, health care policies formulated at

the administrative level incorporate organizational resources including attributes,

abilities, organizational procedures, and expertise (Patidar et al., 2016). Each of the

themes identified supportive strategies to ensure timely payments from patients and

insurance payers to sustain profitability. Organizations increase awareness of ensuring

payments from patients and insurance payers by developing dynamic capabilities and

increasing resources (Kash et al., 2014). Emergent themes in the study represent

strategies that apply to professional practice.

Implications for Social Change

Society could benefit from the results of this study. Approximately 45 million

Americans are without health care coverage insurance and are underinsured (Schimmel,

2013). The findings from this study could lead to tangible improvements to individuals,

communities, and organizations. The findings include strategies to improve the

sustainability of health care organizations. In this study, I focused on rural clinics.

Financial stability of rural clinics directly benefits the health of individuals and the public

health of communities. I found that strategies including communication, attention to

detail, and consistent patient account reviews impact cash flow. Engagement with payer

sources is also crucial to the collection cycle (Noether & May 2017). The staff of rural

clinics provides support to underserved populations. Increased collection rates can result

in the support that rural clinics provide to the wellbeing of underserved communities.

Recommendations for Action

The objective of this qualitative multiple case study was to explore strategies rural

clinic managers use to obtain timely payment from patients and insurance payers. Study

findings identified four major accounts receivable management strategy themes to

increase sustainability and profitability are: (a) communication between medical

providers and billing staff, (b) payment plan setup, (c) accuracy of billing claims, and (d)

consistent accounts receivable reviews. I noted some recommendations to financial

leaders in collecting payments from patients and insurance payers in a timely and

efficient manner to increase overall profitability.

Health care leaders may consider attempting to establish an atmosphere

encouraging a strategic approach for collecting payments from patients and insurance

payers. The leadership develops accounts receivable management strategies and ensures

that the organization’s staff abides by company financial practices, policies, and

procedures (Grant, 2014). The five rural clinics I chose for this multiple case study were

successful clinics committed to helping build a healthy community. Each participant I

interviewed appeared committed to using effective strategies into their daily, weekly, and

monthly schedule to increase collections from patients and insurance payers.

How a company’s managers and staff use their resources is a critical strategic

factor in many industries, and many other fields could benefit from this study. Multi-

faceted health care organizations must adapt to identify new and innovative processes

regarding the use of internal resources to achieve a competitive advantage (Lillis et al.,

2015). The participants from the research organization I selected were reliable and

concise in their approaches to ensure timely collection of payments from patients and

insurance payers. These strategies could assist leaders in other industries.

Recommendations for Further Research

The purpose of this qualitative multiple case study was to explore strategies rural

clinic managers use to obtain timely payment from patients and insurance payers. The

targeted population included 10 rural clinic managers and billing staff from five rural

clinics located in southwestern region of the United States, who have incorporated

strategies to obtain timely payment from patients and insurance payers to maintain

sustainability and profitability. The study findings concerned further research for

numerous reasons. First, the results of the study may extend to other industries in a way

that improves cash collection and payment management.

Second, there are numerous facets of research that other investigators can explore.

For example, there were less significant themes that emerged, such as ways to elicit

information from patients and insurance payers instead of going directly to rural clinic

mangers and billing staff. Finally, researchers could also consider accounts receivable

management strategies, insurance payer-mix types, location, and short and long-term

financial goals of the organization. To promote further discussion of the results, I will

share a summary of the findings with the research participants. Additionally, I will

publish this study through the ProQuest/UMI dissertation database for future researchers

to use and work with my Doctoral Chair to present the results of this study at professional

health care conferences or seminars and to publish my findings in peer-reviewed journals.

Reflections

Completing a DBA has been one of the most demanding, yet, rewarding

opportunities of my life. I knew going into the program would be challenging; however, I

accepted the challenge. Also, I had prior experience in the health care field, but I did not

have any outside experience with the participants before collecting the data. As a

researcher, I understood the importance of maintaining high scholarly and research

standards when conducting interviews. Also, I gained new knowledge about how rural

clinic managers and billing staff are regarding the accounts receivable process to increase

profitability.

My goal as a qualitative researcher was to collect data without personal bias or

preconceived views. I made sure that I consistently addressed the guidelines I wrote in

the initial proposal to ensure the process demonstrated legitimacy. The research

participants provided detailed responses. I was appreciative for that part of the process.

Participants provided precisely and detail orientated responses and conveyed how each

person defined their task and how it related to the team. I learned from participants about

accounts receivable management strategies used to ensure payment for patients and

insurance payers to improve profitability.

Conclusion

Accounts receivable management strategies are essential to organizational

strategic success. The overarching research question of this multiple qualitative case

study was: What strategies do rural clinic managers use to obtain timely payments from

patients and insurance payers? I conducted face-to-face semistructured interviews to

obtain data. I also reviewed HRSA documentation and IRS Form 990s to complement the

data collection. I applied information from the methodological triangulation data

collection process to validate data source themes

Study findings revealed four significant themes regarding accounts receivable

strategies applied by rural clinic billing staff to increase profitability: (a) communication

between medical providers and billing staff, (b) payment plan setup, (c) accuracy of

billing claims, and (d) consistent accounts receivable reviews. The social change

enrichment exists when the rural clinic is successful: operations are effective and

efficient, profits increase, job opportunities proliferate, and cohesion develops within the

community.

References

Abidemi, B. T., Halim, F. B., & Alshuaibi, A. I. (2017). Marketing capabilities and

organizational performance: A proposed model on the moderating effect of

technological turbulence. International Journal of Management Research and

Reviews, 7(6), 626-636. Retrieved from http://ijmrr.com

Abzug, R., Olbrecht, A., Sabrin, M., & DeLeon, E. (2016). Nonprofit financing to the

rescue? The slightly twisted case of local educational foundations and public

education in New Jersey. Nonprofit and Voluntary Sector Quarterly, 45,133-149.

doi:10.1177/0899764014564577

Adebanjo, D., Laosirihongthong, T., & Samaranayake, P. (2016). Prioritizing lean supply

chain management initiatives in health care service operations: A fuzzy AHP

approach. Production Planning & Control, 27, 953-966.

doi:10.1080/09537287.2016.1164909

Aidoo-Buameh, J. (2014). The effect of NHIA debt on accounts payables management in

public hospitals. Asian Economic and Financial Review, 4(8), 1001-1015.

Retrieved from http://www.aessweb.com

Al Achkar, M., Kengeri-Srikantiah, S., Yamane, B. M., Villasmil, J., Busha, M. E., &

Gebke, K. B. (2018). Billing by residents and attending physicians in family

medicine: the effects of the provider, patient, and visit factors. BMC medical

education, 18(1), 1-7. doi:10.1186/s12909-018-1246-7

Alhaddad, B., Smith, F. J., Robertson, T., Watman, G., & Taylor, K. M. G. (2015).

Patients' practices and experiences of using nebuliser therapy in the management

of COPD at home. British Medical Journal Open Respiratory Research, 2(1), 1-9.

doi:10.1136/bmjresp-2014-000076

Allen, J., Davis, A., Hu, W., & Owusu-Amankwah, E. (2015). Residents' willingness-to-

pay for attributes of rural health care facilities. Journal of Rural Health, 31, 7-18.

doi:10.1111/jrh.12080

Angeli, E. L., & Norwood, C. D. (2017). Responding to public health crises: Bridging

collective mindfulness and user experience to create communication

interventions. Communication Design Quarterly Review, 5, 29-39. doi:10.11

45/3131201.3131204

Angelis, A., Kanavos, P., & Montibeller, G. (2017). Resource allocation and priority

setting in health care: A multi‐ criteria decision analysis problem of value. Global

Policy, 8, 76-83. doi:10.1111/1758-5899.12387

Annansingh, F., & Howell, K. (2016). Using phenomenological constructivism (PC) to

discuss a mixed method approach in information systems research. Electronic

Journal of Business Research Methods, 14(1), 39-49. Retrieved from

http://www.ejbrm.com/main.html

Ang, C. K., Embi, M. A., & Yunus, M. M. (2016). Enhancing the quality of the findings

of a longitudinal case study: Reviewing trustworthiness via ATLAS.ti. The

Qualitative Report, 21(10), 1855-1867. Retrieved from

http://nsuworks.nova.edu/tqr

Arfaoui, F., Damak-ayadi, S., Ghram, R., & Bouchekoua, A. (2016). Ethics education

and accounting students' level of moral development: Experimental design in

Tunisian audit context. Journal of Business Ethics, 138, 161-173.

doi:10.1007/s10551-015-2643-z

Arino, A., LeBaron, C., & Milliken, F. J. (2016). Publishing qualitative research in

academy of management discoveries. Academy of Management Discoveries, 2,

109-113. doi:10.5465/amd.2016.0034

Aslinda, A., & Ibrahim, M. A. (2016). The state-centric model of transportation policy in

Mamminasata areas, South Sulawesi. Bisnis & Birokrasi, 23(1), 55-62. Retrieved

from http://journal.ui.ac.id/jbb

Baillie, L. (2015). Promoting and evaluating scientific rigour in qualitative research.

Nursing Standard, 29, 36-42. doi:10.7748/ns.29.46.36.e8830

Barbaresco, S., Courtemanche, C. J., & Qi, Y. (2015). Impacts of the affordable care act

dependent coverage provision on health-related outcomes of young adults.

Journal of Health Economics, 40, 54-68. doi:10.1016/j.jhealeco.2014.12.004

Barinaga, G., Sayeed, Z., Anoushiravani, A., Scaife, S., El-Othmani, M., & Saleh, K. J.

(2017). Using a comanagement model to develop a hip fracture integrated care

pathway. Journal of Health care Management, 62, 107-117. doi:10.1097/JHM-D-

17-00011

Barney, J. (1991). Firm resources and sustained competitive advantage. Journal of

Management, 17, 99-120. doi:10.1177/014920639101700108

Bassok, O. (2015). Interpretative theories as roadmaps to constitutional identity: The case

of the United States. Global Constitutionalism, 4, 289-327. doi:10.1017/S204538

1715000167

Bassous, M. (2015). What are the factors that affect worker motivation in faith-based

nonprofit organizations? Voluntas, 26, 355-381. doi:10.1007/s11266-013-9420-3

Bazzano, A. N., Martin, J., Hicks, E., Faughnan, M., & Murphy, L. (2017). Human-

centred design in global health: A scoping review of applications and

contexts. PLoS One, 12(11), 1-24. doi:10.1371/journal.pone.0186744

Begley, C., McCarron, M., Huntley-Moore, S., Condell, S., & Higgins, A. (2014).

Successful research capacity building in academic nursing and midwifery in

Ireland: An exemplar. Nurse Education Today, 34, 754-760.

doi:10.1016/j.nedt.2013.09.016

Benedettini, O., Neely, A., & Swink, M. (2015). Why do servitized firms fail? A risk-

based explanation. International Journal of Operations & Production

Management, 35(6), 1-37. doi:10.1108/IJOPM-02-2014-0052

Bengtsson, M. (2016). How to plan and perform a qualitative study using content

analysis. NursingPlus Open, 2, 8-14. doi:10.1016/j.npls.2016.01.001

Bennett, E. E., & McWhorter, R. R. (2016). Opening the black box and searching for

smoking guns. European Journal of Training and Development, 40(8/9), 691-718.

doi:10.1108/EJTD-07-2015-0049

Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. (2016). Member checking: A

tool to enhance trustworthiness or merely a nod to validation? Qualitative Health

Research, 26, 1802-1811. doi:10.1177/1049732316654870

Blumenthal, D. (2016). Better health care: A way forward. Journal of American Medical

Association, 315, 1333-1334. doi:10.1001/jama.2016.0590

Boddy, C. R. (2016). Sample size for qualitative research. Qualitative Market

Research, 19, 426-432. doi:10.1108/QMR-06-2016-0053

Boden, T. W. (2014). Fighting the "golden rule". The Journal of Medical Practice

Management: MPM, 30(3), 201-202. Retrieved from https://greenbranch.com

Bourne, B. (2015). Phenomenological study of generational response to organizational

change. Journal of Managerial Issues, 27(1-4), 141-159. Retrieved from

https://www.questia.com

Bradbury, C. J. (2015). Determinants of physicians’ acceptance of new Medicaid

patients. Atlantic Economic Journal, 43, 247-260. doi:10.1007/s11293-015-9454-

Bradbury-Jones, C., Taylor, J., & Herber, O. (2014). How theory is used and articulated

in qualitative research: Development of a new typology. Social Science &

Medicine, 120, 135-141. doi:10.1016/j.socscimed.2014.09.014

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology, 3, 77-101. doi:10.1191/1478088706qp063oa

Brett, J., Staniszewska, S., Mockford, C., Herron-Marx, S., Hughes, J., Tysall, C., &

Suleman, R. (2014). Mapping the impact of patient and public involvement on

health and social care research: A systematic review. Health Expectations, 17,

637-650. doi:10.1111/j.1369-7625.2012.00795.x

Brooks, M. C., & Jean-Marie, G. (2015). The challenges to and the need for international

research in educational leadership. International Journal of Educational

Management, 29, 874-887. doi:10.1108/IJEM-05-2015-0069

Campbell, D. T., Manns, B. J., Hemmelgarn, B. R., Sanmartin, C., & King-Shier, K. M.

(2016). Development of a conceptual framework for understanding financial

barriers to care among patients with cardiovascular-related chronic disease: A

protocol for a qualitative (grounded theory) study. Canadian Medical Association

Journal Open, 4, 304-308. doi:10.9778/cmajo.20160030

Caretta, M. A., & Riaño, Y. (2016). Feminist participatory methodologies in geography:

Creating spaces of inclusion. Qualitative Research, 16, 258-266. doi:10.1177/

1468794116629575

Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use

of triangulation in qualitative research. Oncology Nursing Forum, 41, 545-547.

doi:10.1188/14.ONF.545-547. Retrieved from

Cascardo, D. (2018). The importance of a revenue cycle game plan is that your revenue

team manages it. The Journal of Medical Practice Management : MPM, 33, 231-

233. Retrieved from https:// greenbranch.com

Cascardo, D. (2015). Physician challenges in 2015. The Journal of Medical Practice

Management: MPM, 30, 395-398. Retrieved from https:// greenbranch.com

Cassel, J. B., Kerr, K. M., Kalman, N. S., & Smith, T. J. (2015). The business case for

palliative care: Translating research into program development in the US. Journal

of Pain and Symptom Management, 50, 741-749.

doi:10.1016/j.jpainsymman.2015.06.013

Chahal, H., & Dutta, K. (2015). Measurement and impact of customer experience in

banking sector. Decision, 42(1), 57-70. doi:10.1007/s40622-014-0069-6

Chandra, Y., & Shang, L. (2017). An RQDA-based constructivist methodology for

qualitative research. Qualitative Market Research, 20, 90-112. doi:10.1108/QMR-

02-2016-0014

Chang, C. (2017). Methodological issues in advertising research: Current status, shifts,

and trends. Journal of Advertising, 46(1), 2-20. doi:10.1080/00 913367.2016.127

4924

Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative

research. London, England: Sage.

Chavira, D. A., Bustos, C. E., Garcia, M. S., Ng, B., & Camacho, A. (2017). Delivering

CBT to rural Latino children with anxiety disorders: A qualitative study.

Community Mental Health Journal, 53, 53-61. doi:10.1007/s10597-015-9903-3

Chen, A., & Goldman, D. (2016). Health care spending: Historical trends and new

directions. Annual Review of Economics, 8, 291-319. doi:10.1146/annurev-

economics-080315-015317

Chen, J., O’Brien, M. J., Mennis, J., Alos, V. A., Grande, D. T., Roby, D. H., & Ortega,

A. N. (2015). Latino population growth and hospital uncompensated care in

California. American Journal of Public Health, 105, 1710-1717.

doi:10.2105/AJPH.2015.302583

Chiarini, A., & Vagnoni, E. (2017). TQM implementation for the health care sector. the

relevance of leadership and possible causes of lack of leadership. Leadership in

Health Services, 30, 210-216. doi:10.1108/LHS-02-2017-0004

Choi, A., Lai, D., Lai, T. (2016). Health analytics, economics and medicine toward a

21st Century health care system. Health, 8, 428-443.

doi:10.4236/health.2016.85046

Chokshi, D. A., Chang, J. E., & Wilson, R. M. (2016). Health reform and the changing

safety net in the United States. The New England Journal of Medicine, 375, 1790-

1796. doi:10.1056/NEJMhpr1608578

Chowdhury, M. F. (2015). Coding, sorting and sifting of qualitative data analysis:

Debates and discussion. Quality and Quantity, 49, 1135-1143.

doi:10.1007/s11135-014-0039-2

Christensen, J. K. B. (2016). Does telecare improve interorganisational collaboration?

International Journal of Integrated Care, 16(4). 1-10. doi:10.5334/ijic.2462

Christoun, L. (2015). Prioritizing key academic support systems for Latino English

language learners in Northern Illinois public school districts. Academy of

Educational Leadership Journal, 19(3), 63-83. Retrieved from

https://www.abacademies.org/journals/academy-of-educational-leadership-

journal-home.html

Cleary, M., Horsfall, J., & Hayter, M. (2014). Data collection and sampling in qualitative

research: Does size matter? Journal of Advanced Nursing, 70, 473-475.

doi:10.1111/jan.12163

Colorafi, K. J., & Evans, B. (2016). Qualitative descriptive methods in health science

research. HERD: Health Environments Research & Design Journal, 9(4), 16-25.

doi:10.1177/1937586715614171

Connelly, L. M. (2013). Limited section. MEDSURG Nursing, 22(5), 325-336. Retrieved

from http://www.medsurgnursing.net

Conrad, D. A., Vaughn, M., Grembowski, D., & Marcus-Smith, M. (2016). Implementing

value-based payment reform: A conceptual framework and case examples.

Medical Care Research and Review, 73, 437-457. doi:10.1177/10775587156157

Coupet, J., & McWilliams, A. (2017). Integrating organizational economics and resource

dependence theory to explain the persistence of quasi markets. Administrative

Sciences, 7(3), 1-13. doi:10.3390/admsci7030029

Crowe, M., Inder, M., & Porter, R. (2015). Conducting qualitative research in mental

health: Thematic and content analyses. Australian & New Zealand Journal of

Psychiatry, 49, 616-623. doi:10.1177/0004867415582053

Cullington, H., Kitterick, P., DeBold, L., Weal, M., Clarke, N., Newberry, E., & Aubert,

L. (2016). Personalised long-term follow-up of cochlear implant patients using

remote care, compared with those on the standard care pathway: Study protocol

for a feasibility randomized controlled trial. British Medical Journal Open, 6(5),

1-9. doi:10.1136/bmj open-2016-011342

Cylus, J., Papanicolas, I., & Smith, P. C. (2016). A framework for thinking about health

system efficiency. Health System Efficiency, 46(1), 1-20. Retrieved from

https://www.ncbi.nlm.nih.gov

Cypress, B. S. (2017). Rigor or reliability and validity in qualitative research:

Perspectives, strategies, reconceptualization, and recommendations. Dimensions

of Critical Care Nursing, 36, 253-263. doi:10.1097/DCC.0000000000000253

D’Andrea, R., & O’Dwyer, J. P. (2017). Can editors save peer review from peer

reviewers? Public Library of Science One, 12(10), 1-14.

doi:10.1371/journal.pone.0186111

Darrow, W. W. (2015). The decline and disorganization of public health in the United

States: Social implications. The International Journal of Social Quality, 5, 29-45.

doi:10.3167/IJSQ.2015.050203

DeFelice, D., & Janesick, V. J. (2015). Understanding the marriage of technology and

phenomenological research: From design to analysis. The Qualitative

Report, 20(10), 1576-1593. Retrieved fromhttp://nsuworks.nova.edu/tqr

Deming, W. E. (2000). Out of the crisis. Cambridge, MA. MIT press.

Deming, W. E. (1985). Transformation of western style of management. Interfaces,

15(3), 6-11. doi:10.1287/inte.15.3.6

Denzin, N. K., & Lincoln, Y. S. (Eds.). (2011). The Sage handbook of qualitative

research (4th ed.). Thousand Oaks, CA: Sage.

Desmond, J. (2014). Ethnography as ethics and epistemology: Why American studies

should embrace fieldwork, and why it hasn't. American Studies, 53(1), 27-56.

Retrieved from https://journals.ku.edu/amerstud/

Dong, G. N. (2016). Earnings management in U.S. hospitals. Journal of Health and

Human Services Administration, 39(1), 41-71. https://jhhsa.spaef.org

100

Dong, G. N. (2015). Performing well in financial management and quality of care:

Evidence from hospital process measures for treatment of cardiovascular

disease. BMC Health Services Research, 15(1), 1-15. doi:10.1186/s12913-015-

0690-x

Doran, T., Maurer, K. A., & Ryan, A. M. (2017). Impact of provider incentives on quality

and value of health care. Annual Review of Public Health, 38, 449-465.

doi:10.1146/annurev-publhealth-032315-021457

Dorsey, S., Conover, K. L., & Revillion-Cox, J. (2014). Improving foster parent

engagement: Using qualitative methods to guide tailoring of evidence-based

engagement strategies. Journal of Clinical Child and Adolescent Psychology,

53, 877-889. doi:10.1080/15374416.2013.876643

Doyle, G., Kelly, R., & O’Donohoe, S. (2016). Resource dependence as a mechanism for

survival: The case of the mater Misericordiae university hospital. Voluntas:

International Journal of Voluntary and Nonprofit Organizations, 27, 1871-1893.

doi:10.1007/s11266-016-9735-y

Dubois, A., & Gadde, L. E. (2014). “Systematic combining”-A decade later. Journal of

Business Research, 67, 1277-1284. doi:10.1016/j.jbusres.2013.03.036

Duijmelinck, D., & van de Ven, W. (2016). What can Europe learn from the managed

care backlash in the United States? Health Policy, 120, 509-518.

doi:10.1016/j.healthpol.2016.03.010

Durenberger, S. D. (2015). Health care reform and the American congress. The Milbank

Quarterly, 93, 663-666. doi:10.1111/1468-0009.12155

101

Eggbeer, B., & Bowers, K. (2014). Health care's new game changer. Thinking like a

health plan. Health care Financial Management: Journal of The Health Care

Financial Management Association, 68(10), 52-59. Retrieved from

https://www.hfma.org

Eisenhardt, K. M., Graebner, M. E., & Sonenshein, S. (2016). Grand challenges and

inductive methods: Rigor without rigor mortis. Academy Of Management

Journal, 59, 1113-1123. doi:10.5465/amj.2016.4004

Eriksson, D. (2015). Lessons on knowledge creation in supply chain management.

European Business Review, 27(4), 346-368. Retrieved from

http://www.europeanbusinessreview.com/

Evans, J. M., Brown, A., & Baker G. R. (2015). Intellectual capital in the health care

sector: A systematic review and critique of the literature. BMC Health Services

Research, 15(1), 1-14. doi:10.1186/s12913-015-1234-0

Fairfield, J., & Shtein, H. (2014). Big data, big problems: Emerging issues in the ethics of

data science and journalism. Journal of Mass Media Ethics, 29, 38-51.

doi:10.1080 08900523.2014.863126

Farnsworth, S. S. (2015). Enduring conflicts in the American health care system. The

Journal of Health Administration Education, 32(2), 159-164. Retrieved from

http://www.aupha.org

Feldman, R. (2015). The economics of provider payment reform: Are accountable care

organizations the answer? Journal of Health Politics, Policy & Law, 40, 745-760.

doi:10.1215/03616878-3150038

102

Ferlie, E., Crilly, T., Jashapara, A., Trenholm, S., Peckham, A., & Currie, G. (2015).

Knowledge mobilization in health care organizations: A view from the resource-

based view of the firm. International Journal of Health Policy and Management,

4, 127-130. doi:10.15171/ijhpm.2015.35

Fida, R., Tramontano, C., Paciello, M., Kangasniemi, M., Sili, A., Bobbio, A., &

Barbaranelli, C. (2016). Nurse moral disengagement. Nursing Ethics, 23, 547-

564. doi:10.1177/0969733015574924

Fitzpatrick, P. G., Butler, M., Pitsikoulis, C., Smith, K., & Walden, L. (2014). The case

for integrating health care management courses into the curricula of selected

health care providers. Journal of Management Policy & Practice, 15(4), 92-102.

Retrieved from http://www.na-businesspress.com/jmppopen.html

Fitzsimmons, A. P. (2017). Soldier readiness: Past to present, initial entry training.

Journal of Leadership, Accountability and Ethics, 14(2), 117-122. Retrieved from

http://www.na-businesspress.com/JLAE/jlaescholar.html

Fletcher, A. J. (2017). Applying critical realism in qualitative research: Methodology

meets method. International Journal of Social Research Methodology, 20, 181-

194. doi:10.1080/13645579.2016.1144401

Foerster, S., Tsagarelis, J., & Wang, G. (2017). Are cash flows better stock return

predictors than profits? Financial Analysts Journal, 73(1), 73-99.

doi:10.2469/faj.v73.n1.2

Forsythe, L. P., Ellis, L. E., Edmundson, L., Sabharwal, R., Rein, A., Konopka, K., &

Frank, L. (2016). Patient and stakeholder engagement in the PCORI pilot projects:

103

Description and lessons learned. Journal of General Internal Medicine, 31(1), 13-

21. doi:10.1007/s11606-015-3450-z

Foundation Center. (2018). 990 form. Retrieved from http://foundationcenter.org/find-

funding/990-finder

Fowler, E. A. R., Coffey, B. S., & Dixon-Fowler, H. (2017). Transforming good

intentions into social impact: A case on the creation and evolution of a social

enterprise. Journal of Business Ethics 146, 1-14. doi:10.1007/s10551-017-3754-5

Franz, B. A., Skinner, D., & Murphy, J. W. (2016). Changing medical relationships after

the ACA: Transforming perspectives for population health. SSM-Population

Health, 2, 834-840. doi:10.1016/j.ssmph.2016.10.015

Fugard, A. J., & Potts, H. W. (2015). Supporting thinking on sample sizes for thematic

analyses: A quantitative tool. International Journal of Social Research

Methodology, 18, 669-684. doi:10.1080/13645579.2015.1005453

Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in qualitative

research. The Qualitative Report, 20(9), 1408-1416. Retrieved from

http://nsuworks.nova.edu/tqr/

Gallagher, S., Phillips, A. C., Lee, H., & Carroll, D. (2015). The association between

spirituality and depression in parents caring for children with developmental

disabilities: Social support and/or last resort. Journal of Religion and Health, 54,

358-370. doi:10.1007/s10943-014-9839-x

104

Gao, Y. N., Nocon, R. S., Sharma, R., & Huang, E. S. (2017). What factors are associated

with Medicaid patients’ use of health centers? Journal of Primary Care &

Community Health, 8, 141-146. doi:10.1177/2150131916687919

Gentles, S. J., Charles, C., Ploeg, J., & McKibbon, K. A. (2015). Sampling in qualitative

research: Insights from an overview of the methods literature. The Qualitative

Report, 20(11), 1772-1789. Retrieved from http://nsuworks.nova.edu/tqr/

Gerben, D. (2016). Coming to terms with the IMPACT Act of 2014. The American

Journal of Occupational Therapy, 70(3), 1-6. doi:10.5014 /ajot .2016.703003

Gerber, J. D., & Hess, G. (2017). From landscape resources to landscape commons:

Focusing on the non-utility values of landscape. International Journal of the

Commons, 11. 708-732. doi:10.18352/ijc.745

Gerstorff, J. L., & Gibson, S. (2016). Medicaid encounter data: The next national data set.

Milliman, 6-14. Retrieved from http://us.milliman.com/

Gligor, D. M., Esmark, C. L., & Gölgeci, I. (2016). Building international business

theory: A grounded theory approach. Journal of International Business Studies,

47, 93-111. doi:10.1057/jibs.2015.35

Glied, S., & Jackson, A. (2017). The future of the Affordable Care Act and insurance

coverage. American Journal of Public Health, 107, 538-540.

doi:10.2105/AJPH.2017.303665

Gordon, E. J., Mullee, J., Skaro, A., & Baker, T. (2016). Live liver donors’ information

needs: A qualitative study of practical implications for informed consent.

Surgery, 160, 671-682. doi:10.1016/j.surg.2016.04.022

105

Goyal, S., Sergi, B. S., & Kapoor, A. (2014). Understanding the key characteristics of an

embedded business model for the base of the pyramid markets. Economics &

Sociology, 7(4), 26-40. doi:10.14254/2071-789X.2014/7-4/2

Graham, A., Powell, M. A., & Truscott, J. (2016). Exploring the nexus between

participatory methods and ethics in early childhood research. Australasian

Journal of Early Childhood, 41(1), 82-89. Retrieved from

http://earlychildhoodaustralia.org.au

Granata, R. L., & Hamilton, K. (2015). Exploring the effect of at-risk case management

compensation on hospital pay-for-performance outcomes: Tools for change.

Professional Case Management, 20(1), 14-27.

doi:10.1097/NCM.0000000000000067

Grant, A. (2014). Troubling 'lived experience': A post-structural critique of mental health

nursing qualitative research assumptions. Journal of Psychiatric and Mental

Health Nursing, 21, 544-549. doi:10.1111/jpm.12113

Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative

research. Handbook of qualitative research. Thousand Oaks, CA: Sage

Gurganious, V. S. (2016). Four simple steps to conduct an assessment of your practice.

The Journal of Medical Practice Management: MPM, 31(6), 329-331. Retrieved

from Retrieved from https:// greenbranch.com

Haeder, S. F., & Weimer, D. L. (2015). Inching toward universal coverage: State-federal

health-care programs in historical perspective. Journal of Policy History, 27, 746-

770. doi:10.1017/S0898030615000330

106

Halcomb, E., & Peters, K. (2016). Research would not be possible without participants.

Nurse Researcher, 24(1), 6-7. doi:10.7748/nr.24.1.6.s2

Halfon, N., Long, P., Chang, D., Hester, J., Inkelas, M., & Rodgers, A. (2014). Applying

a 3.0 transformation framework to guide large-scale health system reform. Health

Affairs, 33, 2003-2011. doi:10.1377/hlthaff.2014.0485

Hall, M. A., & Lord, R. (2014). Obamacare: What the Affordable Care Act means for

patients and physicians. British Medical Journal, 349, 1-10.

doi:10.1136/bmj.g5376

Harvey, G., & Kitson, A. (2015). Necessary but not sufficient: Comment on "knowledge

mobilization in health care organizations: A view from the resource-based view of

the firm". International Journal of Health Policy and Management, 4, 865-868.

doi:10.15171/ijhpm.2015.159

Harvey, L. (2015). Beyond member-checking: A dialogic approach to the research

interview. International Journal of Research & Method in Education, 38(1), 23-

38. doi:10.1080/1743727X.2014.914487

Hasle, P., Limborg, H. J., Grøn, S., & Refslund, B. (2017). Orchestration in work

environment policy programs. Nordic Journal of Working Life Studies, 7(3), 43-

62. doi:10.18291/njwls.v7i3.97092

Hay-Smith, E. J. C., Brown, M., Anderson, L., & Treharne, G. J. (2016). Once a

clinician, always a clinician: A systematic review to develop a typology of

clinician-researcher dual-role experiences in health research with patient-

107

participants. BMC medical research methodology, 16(1), 1-17. doi:10.1186/s1287

4-016-0203-6

Hayes, D., Subhan, Z., & Lakatos, J. (2015). Encompass software: Getting started, The

first months and fueling growth. Journal of the International Academy for Case

Studies, 21(5), 83-91. Retrieved from http://www.abacademies.org

Health Resources and Service Administration (2018) Health data center. Retrieved from

https://bphc.hrsa.gov/datareporting/index.html

Hegwer, L. R. (2014). 5 strategies for combating market uncertainty to deliver value:

Innovative health systems are taking aggressive approaches as they prepare for

value-based business models and other changes ahead. Health Care Financial

Management, 68(10), 74-82. Retrieved from https://www.ncbi.nlm.nih.gov

Heisler, E., Firmin, M. W., Firmin, R. L., & Hundley, A. E. (2015). Intrinsic values that

affect men's motivation to participate in female abuse prevention. North American

Journal of Psychology, 17(2), 267-285. Retrieved from http://najp.us/

Helmig, B., Hinz, V., & Ingerfurth, S. (2015). Valuing organizational values: Assessing

the uniqueness of nonprofit values. Voluntas: International Journal of Voluntary

& Nonprofit Organizations, 26, 2554-2580. doi:10.1007/s11266-014-9530-6

Hernandez, N. (2017). Essential financial metrics. Journal of Medical Practice

Management, 32(6), 387-389. Retrieved from https://www.ncbi.nlm.nih.gov

Hinnekens, C., Vanhee, G., De Schryver, M., Ickes, W., & Verhofstadt, L. L. (2016).

Empathic accuracy and observed demand behavior in couples. Frontiers in

Psychology, 7, 1-5. doi:10.3389/fpsyg.2016.01370

108

Hitt, M. A., Xu, K., & Carnes, C. M. (2016). Resource based theory in operations

management research. Journal of Operations Management, 41, 77-94.

doi:10.1016 /j.jom.2015.11.002

Holm, A. L., & Severinsson, E. (2014). Surviving depressive ill‐ health: A qualitative

systematic review of older persons' narratives. Nursing & Health Sciences, 16,

131-140. doi:10.1111/nhs.12071

Howrigon, R. (2016). Payer negotiations in the new health care environment: How to

prepare for and succeed in a value-based world. The Journal of Medical Practice

Management: MPM, 31(6), 354-356. Retrieved from https://greenbranch.com

Iancu, S. C., Zweekhorst, M. B., M., Veltman, D. J., & van Balkom, A. J. (2015).

Outsourcing mental health care services? The practice and potential of

community-based farms in psychiatric rehabilitation. Community Mental Health

Journal, 51, 175-184. doi:10.1007/s10597-014-9742-7

Iqbal, J., Shabbir, M. S., Zameer, H., Tufail, M. S., Sandhu, M. A., & Ali, W. (2017).

TQM practices and firm performance of Pakistani service sector firms.

Paradigms, 11(1), 87-96. Retrieved from http://paradigms.ucp.edu.pk/

Isaacs, A. N. (2014). An overview of qualitative research methodology for public health

researchers. International Journal of Medicine & Public Health, 4, 318-323.

doi:10.4103/2230-8598.144055

Jain, A. K., & Singal, A. K. (2014). Mapping vulnerability: How emerging markets

respond to multinationals. Journal of Business Strategy, 35, 41-48.

doi:10.1108/JBS-11-2013-0112

109

Jaimangal-Jones, D. (2014). Utilizing ethnography and participant observation in festival

and event research. International Journal of Event and Festival Management,

5(1), 39-55. Retrieved from http://www.ijemr.org

Jali, M. N., Abas, Z., & Ariffin, A. S. (2016). Social innovation: A new paradigm of

innovation outcome strategy in the context of strategic knowledge management

processes. Sains Humanika, 8, 47-50. doi:10.1108/JBS-11-2013-0112

Joe, J. R, Young, R. S., Moses, J. Knoki-Wilson, U., & Dennison, J. (2016). A

collaborative case study: The office of native medicine. American Indian and

Alaska Native Mental Health Research (Online), 23(2), 50-63. Retrieved from

http://www.ucdenver.edu/academic s/colleges

Johnson, J. E., & Garvin, W. S. (2017). Advanced practice nurses: Developing a business

plan for an independent ambulatory clinical practice. Nursing Economics, 35(3),

126-141. Retrieved from http://www.nursingeconomics.net

Jones, E. B., & Ku, L. (2015). Sharing a playbook: Integrated care in community health

centers in the United States. American Journal of Public Health, 105, 2028-2034.

doi:10.2105/AJPH.2015.302710

Joynt, K. E., De Lew, N., Sheingold, S. H., Conway, P. H., Goodrich, K., & Epstein, A.

M. (2017). Should medicare value-based purchasing take social risk into account?

New England Journal of Medicine, 376, 510-513. doi:10.105 6/N EJM p1616278

Joynt, K. E., Orav, E. J., & Jha, A. K. (2014). Association between hospital conversions

to for-profit status and clinical and economic outcomes. Journal of American

Medical Association, 312, 1644-1652. doi:10.1001/jama.2014.13336.

110

Jung-Sik, W., & Han-Sung, K. (2016). Study of in-patient cost analysis using hospital

database in Korea. International Journal of Database Theory and

Application, 9(11), 107-118. Retrieved from http://www.sersc.org

Karen, C. O., Kennedy, D. P., Hunter, S. B., & Maksabedian, E. (2016). Feasibility of a

computer-assisted social network motivational interviewing intervention for

substance use and HIV risk behaviors for housing first residents. Addiction

Science & Clinical Practice, 11(1), 1-11. doi:10.1186/s13722-016-0061-x

Kash, B. A., Spaulding, A., Gamm, L. D., & Johnson, C. E. (2014). Health care strategic

management and the resource based view. Journal of Strategy & Management, 7,

251-264. doi:10.1108/JSMA-06-2013-0040

Katigbak, C., Foley, M., Robert, L., & Hutchinson, M. K. (2016). Experiences and

lessons learned in using community‐ based participatory research to recruit Asian

American immigrant research participants. Journal of Nursing Scholarship, 48,

210-218. doi:10.1111/jnu.12194

Kemperman, J., Geelhoed, J., & In Hoog, J. (2017). Brilliant business models in health

care: Get inspired to cure health care. Switzerland: Springer.

Kessell, E., Pegany, V., Keolanui, B., Fulton, B., Scheffler, R., & Shortell, S. (2015).

Review of Medicare, Medicaid, and commercial quality of care measures:

Considerations for assessing accountable care organizations. Journal of Health

Politics Policy and Law, 40, 761-796. doi:10.1215/03616878-3150050.

Khan, S. N. (2014). Qualitative research method: Grounded theory. International Journal

of Business and Management, 9, 224-233. doi:10.5539/ijbm.v9n11p224

111

Krzakiewicz, K., & Cyfert, S. (2017). Dynamic capabilities in strategic choice processes

within organizations. Management, 21(1), 7-19. doi:10.1515/manment-2015-0077

Kuramoto, R. (2014). Specialties: Missing in our health care reform strategies? Journal

of Health care Management, 59(2), 89-94. Retrieved from https://www.ache.org

Lai, C. J., & Gelb, B. D. (2015). Key account teams: Success factors for implementing

strategy. Journal of Business Strategy, 36, 48-55. doi:10.1108/JBS-07-2014-0079

Lail, P. J., Laird, S. S., McCall, K., Naretto, J., & York, A. (2016). Facility closure: How

to get in, get out, and get what is important. Perspectives in Health Information

Management, 13(1). 1-11. Retrieved from http://perspectives.ahima.org/

Landers, S., Madian, E., Leff, B., Rosati, R. J., McCann, B. A., Hornbake, R., & Breese,

E. (2016). The future of home health care: A strategic framework for optimizing

value. Home Health Care Management & Practice, 28, 262-278.

doi:10.1177/1084822316666368.

Langellier, B. A., de Zapien, J. G., Rosales, C., Ingram, M., & Carvajal, S. C. (2014).

State medicaid expansion, community interventions, and health care disparities in

a United States–Mexico border community. American Journal of Public

Health, 104, 94-100. doi:10.2105/AJPH.2014.302013

Larkin, D. J., Swanson, R. C., Fuller, S., & Cortese, D. A. (2016). The Affordable Care

Act: A case study for understanding and applying complexity concepts to health

care reform. Journal of Evaluation in Clinical Practice, 22, 133-140.

doi:10.1111/jep.12271

112

Lee, J. (2017). A review of competitive repertoire-action-based competitive advantage.

International Journal of Business and Management, 12, 120-129.

doi:10.5539/ijbm.v12n11p120

Lee, N. S. (2015). Framing choice: The origins and impact of consumer rhetoric in US

health care debates. Social Science & Medicine, 138, 136-143.

doi:10.1016/j.socscimed.2015.06.007

Leemon, J. (2014). Medicaid under the affordable care act: Fixing the gaps before the

revolution. Public Contract Law Journal, 43(2), 333-351. Retrieved from

http://pclj.org

LeFevre, A. E., Shillcutt, S. D., Broomhead, S., Labrique, A. B., & Jones, T. (2017).

Defining a staged-based process for economic and financial evaluations of

mHealth programs. Cost Effectiveness and Resource Allocation, 15(1), 1-16.

doi:10.1186/s12962-017-0067-6

Leung, L. (2015). Validity, reliability, and generalizability in qualitative research.

Journal of Family Medicine & Primary Care, 4, 324-327. doi:10.4103 /2249-

4863.161306

Lidén, E., & Yaghmaiy, K. S. (2017). The meaning of encounters with health

professionals in primary health care as reported by patients with medically

unexplained symptoms. Nordic Journal of Nursing Research, 37, 70-77.

doi:10.1177/2057158516671449

113

Li, L., Jiang, F., Pei, Y., & Jiang, N. (2017). Entrepreneurial orientation and strategic

alliance success: The contingency role of relational factors. Journal of Business

Research, 72, 46-56. doi:10.1016/j.jbusres.2016.11.011

Lillis, B., Szwejczewski, M., & Goffin, K. (2015). The development of innovation

capability in services: Research propositions and management implications.

Operations Management Research, 8, 48-68. doi:10.1007/s12063-015-0099-z

Lin, C. S., Chang, R. Y., & Dang, V. T. (2015). An integrated model to explain how

corporate social responsibility affects corporate financial performance.

Sustainability, 7, 8292-8311. doi:10.3390/su7078292.

Lin, C., Han, C., & Pan, I. (2015). A qualitative approach of psychosocial adaptation

process in patients undergoing long-term hemodialysis. Asian Nursing Research,

9(1), 35-41. doi:10.1016/j.anr.2014.10.007

Liu, Y., Zhu, Q., & Seuring, S. (2017). Linking capabilities to green operations strategies:

The moderating role of corporate environmental proactivity. International

Journal of Production Economics, 187, 182-195. doi:10.1016/j.ijpe.2017.03.007

Loy, A, Shkedy C. I., Powell A. C., Happe, L. E., Royalty, J. A., & Miao, M. T. (2016).

Do case rates affect physicians' clinical practice in radiation oncology? An

observational study. Public Library of Science ONE, 11(2), 1-9.

doi:10.1371/journal.pone.0149449

Lubberink, R., Blok, V., van Ophem, J., & Omta, O. (2017). Lessons for responsible

innovation in the business context: A systematic literature review of responsible,

114

social and sustainable innovation practices. Sustainability, 9(5), 1-31.

doi:10.3390/su9050721

Mabotuwana, T., Hall, C. S., Thomas, S., & Wald, C. (2017). A model to determine

payments associated with radiology procedures. International Journal of Medical

Informatics, 108, 71-77. doi:10.1016/j.ijmedinf.2017.09.012

Makola, S. (2015). The effectiveness of a meaning-centered intervention in protecting the

well-being HIV/AIDS health educators. Systemic Practice and Action Research,

28(1), 37-49. doi:10.1007/s11213-014-9321-4

Manchikanti, L., Helm, I. S., Benyamin, R. M., & Hirsch, J. A. (2017). Evolution of US

health care reform. Pain Physician, 20(3), 107-110. Retrieved from

http://www.painphysicianjournal.com/

Manning, J., & Kunkel, A. (2015). Qualitative approaches to dyadic data analyses in

family communication research: An invited essay. Journal of Family

Communication, 15, 185-192. doi:10.1080/15267431.2015.1043434

Marshall, C., & Rossman, G. B. (2016). Designing qualitative research (6th ed.).

Thousand Oaks, CA: Sage.

Marshall, A., Nazroo, J., Feeney, K., Lee, J., Vanhoutte, B., & Pendleton, N. (2016).

Comparison of hypertension health care outcomes among older people in the

USA and England. Journal of Epidemiology and Community Health, 70, 264-270.

doi:10.1136/jech-2014-205336

Mason, D. J. (2017). Professionalism in health care organizations. Journal of the

American Medical Association, 317, 1203-1204. doi:10.1001/jama.2017.1753

115

Matthews, R. L., & Marzec, P. E. (2017). Continuous, quality and process improvement:

Disintegrating and reintegrating operational improvement? Total Quality

Management & Business Excellence, 28, 296-317.

doi:10.1080/14783363.2015.1081812

Maurer, M., Mangrum, R., Carman, K. L., Ginsburg, M., Gold, M. R., Sofaer, S., &

Siegel, J. (2017). Setting boundaries: Public views on limiting patient and

physician autonomy in health care decisions. Journal of Health Politics, 42, 579-

605. doi:10.1215/03616878-3856079

Maurer, K. A., & Ryan, A. M. (2016). No hospital left behind? Education policy lessons

for value‐ based payment in health care. Journal of Hospital Medicine, 11, 62-64.

doi:10.1002/jhm.2483

Mayhew, D. R. (2015). Congress as a handler of challenges: The historical record.

Studies in American Political Development, 29, 185-212. doi:10.1017/S0898588

X15000061

McCalman, J., Heyeres, M., Campbell, S., Bainbridge, R., Chamberlain, C., Strobel, N.,

& Ruben, A. (2017). Family-centered interventions by primary health care

services for indigenous early childhood wellbeing in Australia, Canada, New

Zealand and the United States: A systematic scoping review. BMC Pregnancy and

Childbirth, 17(1), 1-21. doi:10.1186/s12884-017-1247-2

McGhie-Anderson, R. (2017). Advanced nursing education: Critical factors that influence

diploma and associate degree nurses to advance. Nursing Education

Perspectives, 38(6), 1-6. doi:10.1097/01.NEP.000000000000022

116

McInnes, S., Peters, K., Bonney, A., & Halcomb, E. (2017). An exemplar of naturalistic

inquiry in general practice research. Nurse Researcher 24(3), 1-10.

doi:10.7748/nr.2017 .e1509

McNaughton, R. J., Adams, J., & Shucksmith, J. (2016). Acceptability of financial

incentives or quasi-mandatory schemes to increase uptake of immunizations in

preschool children in the United Kingdom: Qualitative study with parents and

service delivery staff. Vaccine, 34, 2259-2266. doi:10.1016/j.vaccine.2016.03.009

McNulty, Y. (2015). Till stress do us part: The causes and consequences of expatriate

divorce. Journal of Global Mobility, 3, 106-136. doi:10.1108/JGM-06-2014-0023

Mertens, D. M., Bazeley, P., Bowleg, L., Fielding, N., Maxwell, J., Molina-Azorin, J. F.,

& Niglas, K. (2016). Expanding thinking through a kaleidoscopic look into the

future: Implications of the mixed methods international research association’s

task force report on the future of mixed methods. Journal of Mixed Methods

Research, 10, 221-227. doi:10.1177/1558689816649719

Mindel, V., & Mathiassen, L. (2015). Contextualist inquiry into IT-enabled hospital

revenue cycle management: Bridging research and practice. Journal of the

Association for Information Systems, 16(12), 1016-1057. Retrieved from

https://aisel.aisnet.org

Mkanta, W. N., Katta, M., Basireddy, K., English, G., & de Grubb, M. M. (2016).

Theoretical and methodological issues in research related to value-based

approaches in health care. Journal of Health care Management, 61(6), 402-418.

Retrieved from http://journals.lww.com/jhmonline

117

Mlinar, S., Petek, D., Cotic, Z., Metka, M. C., & Zaletel, M. (2016). Persons with

epilepsy: Between social inclusion and marginalisation. Behavioural Neurology

2016, 1-10. doi:10.1155/2016/2018509

Moraros, J., Lemstra, M., & Nwankwo, C. (2016). Lean interventions in health care: Do

they actually work? A systematic literature review. International Journal for

Quality in Health Care, 28, 150-165. doi:10.1093/intqhc/mzv123

Mosadeghrad, A. M. (2015). Developing and validating a total quality management

model for health care organizations. Total Quality Management Journal, 27,

544-564. doi:10.1108/TQM-04-2013-0051

Morgado, F. F., Meireles, J. F., Neves, C. M., Amaral, A. C., & Ferreira, M. E. (2017).

Scale development: Ten main limitations and recommendations to improve future

research practices. Psicologia: Reflexão e Crítica, 30(1), 1-20.

doi:10.1186/s41155-016-0057-1

Mountford, N., & Kessie, T. (2017). Towards a more holistic understanding of whole

organizational networks: Anthropological approaches in evolving markets.

Electronic Journal of Business Research Methods, 15(2), 74-84. Retrieved from

http://www.ejbrm.com

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage.

Munn, Z., Porritt, K., Lockwood, C., Aromataris, E., & Pearson, A. (2014). Establishing

confidence in the output of qualitative research synthesis: The ConQual

approach. BMC Medical Research Methodology, 14, 108-114. doi:10.1186/1471-

2288-14-108

118

Murphy, J., Ko, M., Kizer, K., & Bindman, A. (2015). Safety net integration: A shared

strategy for becoming providers of choice. Journal of Health Politics Policy and

Law, 40, 403-419. doi:10.1215/03616878-2882267

Mweru, M. C., & dan Muya, M. T. (2015). Features of resource based view theory: An

effective strategy in outsourcing. International Journal of Management and

Commerce Innovation, 3(2), 215-218.Retrieved from

http://www.researchpublish.com/journalss/IJMCI

Nardin, R., Zallman, L., Sayah, A., & McCormick, D. (2016). Experiences applying for

and understanding health insurance under Massachusetts health care reform.

International Journal for Equity in Health, 15(1), 1-8. doi:10.1186/s12939-016-

0397-6

Neghina, C., Bloemer, J., van Birgelen, M., & Caniëls, M. J. (2017). Consumer motives

and willingness to co-create in professional and generic services. Journal of

Service Management, 28, 157-181. doi:10.1108/JOSM-12-2015-0404

Nguyen, K. H., & Sommers, B. D. (2016). Access and quality of care by insurance type

for low-income adults before the affordable care act. American Journal of Public

Health, 106, 1409-1415. doi:10.2105/AJPH.2016.303156

Nielsen, S., & Nielsen, E. H. (2015). The balanced scorecard and the strategic learning

process: A system dynamics modeling approach. Advances in Decision Sciences

2015, 1-20. doi:10.1155/2015/213758

Nilsson, U., Jaensson, M., Dahlberg, K., Odencrants, S., Grönlund, Å., Hagberg, L., &

Eriksson, M. (2016). RAPP, A systematic e-assessment of postoperative recovery

119

in patients undergoing day surgery: Study protocol for a mixed-methods study

design including a multicentre, two-group, parallel, single-blind randomized

controlled trial and qualitative interview studies. British Medical Journal

Open, 6(1), 1-7. doi:10.1136/bmjopen-2015-009901

Nocon, R. S., Lee, S. M., Sharma, R., Ngo-Metzger, Q., Mukamel, D. B., Gao, Y., &

Huang, E. S. (2016). Health care use and spending for Medicaid enrollees in

federally qualified health centers versus other primary care settings. American

Journal of Public Health, 106, 1981-1989. doi:10.2105/AJPH.2016.303341

Noether, M., & May, S. (2017). Hospital merger benefits: Views from hospital leaders

and econometric analysis. 2017, 1-24. Retrieved from http://www.crai.com

Noh, S. (2016). Federal strategies to induce resistant states to participate in the ACA

health exchanges. State and Local Government Review, 48, 227-235.

doi:10.1177/0160323X16685371

Oberlander, J. (2017). The end of obamacare. New England Journal of Medicine, 376(1),

1-3. doi:10.1056/NEJMp1614438

Ojeifo, O., & Berkowitz, S. A. (2015). Cardiology and accountable care. Circulation:

Cardiovascular Quality and Outcomes, 8, 213-217. doi:10.1161./114.001482

Oleinik, A. (2015). On content analysis of images of mass protests: A case of data

triangulation. Quality and Quantity, 49, 2203-2220. doi:10.1007/s11135-014-

0104-x

120

Ortiz, J., Meemon, N., Zhou, Y., & Wan, T. H. (2013). Trends in rural health clinics and

needs during U.S. health care reform. Primary Health Care Research &

Development, 14, 360-366. doi:10.1017/S1463423612000503

Ozuru, H. N., & Igwe, P. (2016). Service expertise and marketing success of government

owned hospitals in Rivers state. Journal of Marketing Development, 1, 66-84.

Retrieved from https://jmdcopen.html

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K.

(2015). Purposeful sampling for qualitative data collection and analysis in mixed

method implementation research. Administration and Policy in Mental Health and

Mental Health Services Research, 42, 533-544. doi:10.1007/s10488-013-0528-y

Panning, R. (2014). Current status of clinical laboratory reimbursement. Clinical

Laboratory Science: Journal of the American Society for Medical

Technology, 27(2), 119-126. Retrieved from http://www.ascls.org/

Patidar, N., Gupta, S., Azbik, G., & Weech-Maldonado, R. (2016). Succession planning

and financial performance: Does competition matter? Journal of Health care

Management, 61(3), 215-227. Retrieved from http://journals.lww.com/jhmonline/

Patterson, J. J., Smith, C., & Bellamy, J. (2015). Enabling and enacting 'practical action'

in catchments: Responding to the 'wicked problem' of nonpoint source pollution

in coastal subtropical Australia. Environmental Management, 55, 479-495.

doi:10.100 7/s00267-014-0409-5

121

Peng, G. C. A., & Gala, C. (2014). Cloud ERP: A new dilemma to modern organizations?

The Journal of Computer Information Systems, 54(4), 22-30.

doi:10.1080/08874417.2014.11645719

Percy, W. H., Kostere, K., & Kostere, S. (2015). Generic qualitative research in

psychology. The Qualitative Report, 20(2), 76-85. Retrieved from

http://nsuworks.nova.edu/tqr/

Peters, K., & Halcomb, E. (2015). Interviews in qualitative research. Nurse Researcher

22(4), 6-7. doi:10.7748/nr.22.4.6.s2

Petrescu, M., & Lauer, B. (2017). Qualitative marketing research: The state of journal

publications. The Qualitative Report, 22(9), 1-42. Retrieved from

http://nsuworks.nova.edu/tqr/

Pineda, G., & Hermes, F. (2015). Incorporation of the health care system in the

west. Colombia Médica, 46(3), 144-149. Retrieved from

http://colombiamedica.univalle.edu

Pinto, J. (2017). A multifocal framework for developing intentionally sustainable

organizations. Current Opinion in Environmental Sustainability, 28, 17-23.

doi:10.1016/j.cosust.2017.07.002

Pittmam, P., Masselink, L., Bade, L., Frogner, B., & Ku, L. (2016). Factors determining

medical staff configurations in community health centers: CEO perspectives.

Journal of Health care Management, 61(5), 364-378. Retrieved from

http://journals.lww.com/jhmonline

122

Polit, D. F., & Beck, C. T. (2010). Generalization in quantitative and qualitative research:

Myths and strategies. International Journal of Nursing Studies, 47, 1451-1458.

doi:10.1016/j.ijnurstu.2010.06.004

Pompeii, B. (2015). The use of public radio as a tool in qualitative geographic research.

GeoJournal, 80, 791-802. doi:10.1007/s10708-015-9647-1

Popli, M., Ladkani, R. M., & Gaur, A. S. (2017). Business group affiliation and post-

acquisition performance: An extended resource-based view. Journal of Business

Research, 81, 21-30. doi:10.1016/j.jbusres.2017.08.003

Pourghane, P., Ahmadi, F., & Salimi, S. (2017). An exploration in women’s perception of

the use of over-the-counter drugs: A content analysis. Iranian Red Crescent

Medical Journal, 19(1), 1-10. doi:10.5812/ircmj.43364

Power, M. K., & Gendron, Y. (2015). Qualitative research in auditing: A methodological

roadmap. Auditing: A Journal of Practice & Theory, 34, 147-165.

doi:10.2308/ajpt-10423

Pradabwong, J., Braziotis, C., Pawar, K. S., & Tannock, J. (2015). Business process

management and supply chain collaboration: A critical comparison. Logistics

Research, 8(1), 1-20. doi:10.1007/s12159-015-0123-6

Pfeffer, J., & Salancik, G. R. (2003). The external control of organizations: A resource

dependence perspective. Stanford, CA: Stanford University Press.

Prowle, M., & Harradine, D. (2014). Austerity and financial governance: A UK case

study of the National Health Service. International Journal of Public Sector

Management, 27, 212-224. doi:10.1108/IJPSM-02-2013-002

123

Råheim, M., Magnussen, L. H., Sekse, R. J. T., Lunde, Å., Jacobsen, T., & Blystad, A.

(2016). Researcher–researched relationship in qualitative research: Shifts in

positions and researcher vulnerability. International Journal of Qualitative

Studies on Health and Well-Being, 11(1), 1-12. doi:10.3402/qhw.v11.30996

Raman, R., & Pramod, D. (2017). A strategic approach using governance, risk and

compliance model to deal with online counterfeit market. Journal of Theoretical

and Applied Electronic Commerce Research, 12(3), 13-26. doi:10.4067/S0718-

18762017000300003

Rapport, F., Clement, C., Doel, M. A., & Hutchings, H. A. (2015). Qualitative research

and its methods in epilepsy: Contributing to an understanding of patients' lived

experiences of the disease. Epilepsy & Behavior, 45, 94-100.

doi:10.1016/j.yebeh.2015.01.040

Rattani, A., & Johns, A. (2017). Collaborative partnerships and gatekeepers in online

research recruitment. The American Journal of Bioethics, 17(3), 27-29.

doi:10.108/15265161.2016.1274800

Rebs, T., Brandenburg, M., Seuring, S., & Stohler, M. (2017). Stakeholder influences and

risks in sustainable supply chain management: A comparison of qualitative and

quantitative studies. Business Research, 1-41. doi:10.1007/s40685-017-0056-9

Reddy, M. S., & Mythri, S. V. (2016). Health-care ethics and the free market value

system. Indian Journal of Psychological Medicine, 38, 371-375. doi:10.4103/0

253-7176.191387

124

Rich, A., Viney, R., Needleman, S., Griffin, A., & Woolf, K. (2016). 'You can't be a

person and a doctor': The work-life balance of doctors in training-a qualitative

study. British Medical Journal Open, 6(12), 1-9. doi:10.1136/bmjopen-2016-

013897

Roberts, C. J. (2012). Dynamics of health care reform: Bitter pills old and

new. Vanderbilt Journal of Transnational Law, 45(5), 1341-1380. Retrieved from

https://www.vanderbilt.edu/jotl/

Rosado-Serrano, A., Dikova, D., & Paul, J. (2018). International franchising: A literature

review and research agenda. Journal of Business Research, 85, 238-257.

doi:10.1016/j.jbusres.2017.12.04 9

Rose, J., & Lennerholt, C. (2017). Low cost text mining as a strategy for qualitative

researchers. Electronic Journal of Business Research Methods, 15(1), 2-16.

Retrieved from http://www.ejbrm.com/

Rosenthal, M. (2016). Qualitative research methods: Why, when, and how to conduct

interviews and focus groups in pharmacy research. Currents in Pharmacy

Teaching and Learning, 8, 509-516. doi:10.1016/j.cptl.2016.03.021

Rosolio, C. E. (2016). Hospital contracts: Important issues for medical groups. The

Journal of Medical Practice Management: MPM, 31(4), 219-222. Retrieved from

https://greenbranch.com

Rouleau, L., de Rond, M., & Musca, G. (2014). From the ethnographic turn to new forms

of organizational ethnography. Journal of Organizational Ethnography, 39(1), 2-

9. doi:10.1108/JOE-02-2014-0006

125

Rudnicki, M., Armstrong, J. H., Clark, C., Marcus, S. G., Sacks, L., Moser, A. J., &

Reid-Lombardo, K. M. (2016). Expected and unexpected consequences of the

affordable care act: The impact on patients and surgeons-pro and con

arguments. Journal of Gastrointestinal Surgery: Official Journal of the Society

for Surgery of the Alimentary Tract, 20, 351-360. doi:10.1007/s11605-015-3032-8

Sage, W. M. (2014). Putting insurance reform in the ACA’s rear-view mirror. Houston

Law Review, 51, 1-33. Retrieved from http://www.houstonlawreview.org/

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., & Jinks, C.

(2017). Saturation in qualitative research: Exploring its conceptualization and

operationalization. Quality & Quantity 52(4), 1-15. doi:10.1007/s11135-017-

0574-8

Sanjari, M., Bahramnezhad, F., Fomani, F. K., Shoghi, M., & Cheraghi, M. A. (2014).

Ethical challenges of researchers in qualitative studies: The necessity to develop a

specific guideline. Journal of Medical Ethics and History of Medicine, 7(14), 1-6.

Retrieved from http://jmehm.tums.ac.ir

Santiago-Delefosse, M., Gavin, A., Bruchez, C., Roux, P., & Stephen, S. L. (2016).

Quality of qualitative research in the health sciences: Analysis of the common

criteria present in 58 assessment guidelines by expert users. Social Science &

Medicine, 148, 142-151. doi:10.1016/j.socscimed.2015.11.007

Saxena, R. (2017). Muddling through the passage of qualitative research: Experiences of

a novice researcher. Vision, 21, 314-322. doi:10.1177/0972262917721423

126

Schaik, S. M., O'Brien, B. C., Almeida, S. A., & Adler, S. R. (2014). Perceptions of

interprofessional teamwork in low-acuity settings: A qualitative analysis. Medical

Education, 48, 583-592. doi:10.1111/medu.12424

Schimmel, N. (2013). The place of human rights in American efforts to expand and

universalize health care. Human Rights Review, 14(1), 1-29. doi:10.1007/s12142-

012-0247-x

Schipper, K., Abma, T. A., Koops, C., Bakker, I., Sanderman, R., & Schroevers, M. J.

(2014). Sweet and sour after renal transplantation: A qualitative study about the

positive and negative consequences of renal transplantation. British Journal of

Health Psychology, 19, 580-591. doi:10.1111/bjhp.12057

Schneider, E. C., & Hall, C. J. (2017). Improve quality, control spending, maintain

access—can the merit-based incentive payment system deliver? New England

Journal of Medicine, 376, 708-710. doi:10.1056/NEJMp1613876

Schneider, T., & Sachs, S. (2017). The impact of stakeholder identities on value creation

in issue-based stakeholder networks. Journal of Business Ethics, 144, 41-57.

doi:10.1007/s10551-015-2845-4

Selviaridis, K., Matopoulos, A., Thomas Szamosi, L., & Psychogios, A. (2016). Reverse

resource exchanges in service supply chains: The case of returnable transport

packaging. Supply Chain Management, 21, 381-397. doi:10.1108/SCM-07-2015-

0265

Shalhoub, J., Marshall, D. C., & Ippolito, K. (2017). Perspectives on procedure-based

assessments: A thematic analysis of semistructured interviews with 10 UK

127

surgical trainees. British Medical Journal Open, 7(3), 1-8. doi:10.1136/bmjopen-

2016-013 417

Sharafizad, J., & Coetzer, A. (2017). Women business owners' start-up motivations and

network structure. Journal of Management and Organization, 23, 206-223.

doi:10.1017/jmo.2016.51

Shaukat, A., Qiu, Y., & Trojanowski, G. (2016). Board attributes, corporate social

responsibility strategy, and corporate environmental and social performance

Journal of Business Ethics, 135, 569-585. doi:10.1007/s10551-014-2460-9

Sheet, B. (2017). Understanding the finances of oncology practice, part 1. Journal of

Oncology, 4, 146-149. doi:10.1200/JOP.0836501

Sheikh, S. (2017). Is corporate social responsibility a value-increasing investment?

Evidence from antitakeover provisions. Global Finance Journal, 1-12

doi:10.1016/j.gfj.2017.08.002

Shi, D., Zurada, J., Jian, G., & Goyal, S. (2015). An adaptive neuro-fuzzy system with

semi-supervised learning as an approach to improving data classification: An

illustration of bad debt recovery in health care. Journal of International

Technology & Information Management, 24(4), 1-24.

doi:10.1109/HICSS.2015.376

Shorr, J. (2015). Ten most commonly asked questions about collections in the medical

practice. The Journal of Medical Practice Management: MPM, 30(4), 281-283.

Retrieved from https://greenbranch.com

128

Shortell, S. M., Colla, C. H., Lewis, V. A., Fisher, E., Kessell, E., & Ramsay, P. (2015).

Accountable care organizations: The national landscape. Journal of Health

Politics, Policy and Law, 40, 647-668. doi:10.1215/03616878-3149976

Simons, R. C., Bester, A., & Moll, M. (2017). Exploring variability among quality

management system auditors when rating the severity of audit findings at a

nuclear power plant. South African Journal of Industrial Engineering, 28, 145-

163. doi:10.7166/28-1-1512

Slife, B. D., Wright, C. D., & Yanchar, S. C. (2016). Using operational definitions in

research: A best-practices approach. The Journal of Mind and Behavior, 37(2),

119-139. Retrieved from https://umaine.edu/jmb/

Smaglik, P. (2016). Activism: Frustrated postdocs rise up. Nature, 530, 505-506.

doi:10.1038/nj7591-505a

Smith, A., & Smyer, T. (2015). Black African nurses educated in the United States.

Journal of Nursing Education, 54, 72-79. doi:10.3928/01484834-20150120-05

Smith, L. M., Wade, C. M., Case, J. L., Harwell, L. C., Straub, K. R., & Summers, J. K.

(2015). Evaluating the transferability of a U.S. human well-being index (HWBI)

framework to Native American populations. Social Indicators Research, 124,

157-182. doi:10.1007/s11205-014-0775-7

Solomon, J., & Casey, A. (2017). A hierarchical model of organizational identification.

Journal of Organizational Psychology, 17(3), 93-111. Retrieved from

http://www.na-businesspress.com

129

Sommers, B. D. (2015). Health care reform's unfinished work--remaining barriers to

coverage and access. The New England Journal of Medicine, 373, 2395-2397.

doi:10.1056/NEJMp1509462

Sotiriadou, P., Brouwers, J., & Le, T. A. (2014). Choosing a qualitative data analysis

tool: A comparison of NVivo and Leximancer. Annals of Leisure Research, 17,

218-234. doi:10.1080/11745398.2014.902292

Spinks, J., Chaboyer, W., Bucknall, T., Tobiano, G., & Whitty, J. A. (2015). Patient and

nurse preferences for nurse handover-using preferences to inform policy: A

discrete choice experiment protocol. British Medical Journal Open, 5(11), 1-8.

doi:10.1136/bmjopen-20 15-008941

Strasser, A. (2017). Delphi method variants in information systems research: Taxonomy

development and application. Electronic Journal of Business Research

Methods, 15(2), 120-133. Retrieved from http://www.ejbrm.com

Swafford, L. G. (2014). Elements and evaluation of qualitative research. Radiation

Therapist, 23(1), 90-91. Retrieved from https://www.asrt.org

Symons, J., & Maggio, R. (2014). 'Based on a true story': Ethnography's impact as a

narrative form. Journal of Comparative Research in Anthropology & Sociology,

5(2), 1-6. Retrieved from http://compaso.eu/

Szymaniec-Mlicka, K. (2016). Impact of strategic orientation adopted by an organization

on its performance, as shown on the example of public health care entities.

Management, 20, 278-290. doi:10.1515/manment-2015-0065.

130

Talonpoika, A.M., Kärri, T., Pirttilä, M., Monto, S. (2016). Defined strategies for

financial work capital management, International Journal of Managerial

Finance, 12, 277-294. doi:10.1108/IJMF-11-2014-0178

Tamblyn, R., Winslade, N., Qian, C. J., Moraga, T., & Huang, A. (2018). What is in your

wallet? A cluster randomized trial of the effects of showing comparative patient

out-of-pocket costs on primary care prescribing for uncomplicated

hypertension. Implementation Science, 13(1),1-14. doi:10.1186/s13012-017-0701-

Teece, D. J. (2017). Towards a capability theory of (innovating) firms: Implications for

management and policy. Cambridge Journal of Economics, 41, 693-720.

doi:10.1093/cje/bew063

Teng, K. (2015). A shift toward personalized health care: Does the Affordable Care Act

provide enough incentive for change? Personalized Medicine, 12, 231-235.

doi:10.2217/pme.14.78

Thomas, D. R. (2017). Feedback from research participants: Are member checks useful

in qualitative research? Qualitative Research in Psychology, 14(1), 23-41.

doi:10.1080/14780887.2016.1219435

Tibben, W. J. (2015). Theory building for ICT4D: Systemizing case study research using

theory triangulation. Information Technology for Development, 21, 628-652.

doi:10.1080/02681102.2014.910635

United States Census Bureau (2016) Arizona population estimates. Retrieved from

https://www.census.gov

131

U.S. Department of Health and Human Services. (1979). The Belmont report. Retrieved

from http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html.

Van den Berg, A., & Struwig, M. (2017). Guidelines for researchers using an adapted

consensual qualitative research approach in management research. Electronic

Journal of Business Research Methods, 15(2), 109-119. Retrieved from

http://www.ej brm.com

Van den Broek, J., Boselie, P., & Paauwe, J. (2017). Cooperative innovation through a

talent management pool: A qualitative study on coopetition in health care.

European Management Journal. 36(1), 1-10. doi:10.1016/j.emj.2017.03.012

Van Zyl, E. S., Mathafena, R. B., & Ras, J. (2017). The development of a talent

management framework for the private sector. SA Journal of Human Resource

Management, 15(1), 1-19. doi:10.4102/sajhrm.v15i0.820

Venkat, A., Shank, G., Rickard-Aasen, S., Pringle, J. L., & Johnjulio, W. (2017).

Screening, brief intervention and referral to treatment implementation in the

emergency department. The Qualitative Report, 22(3), 745-756. Retrieved from

http://nsuworks.nova.edu/tqr

Vermeulen, Y., Niemann, W., & Kotzé, T. (2016). Supply chain integration: A

qualitative exploration of perspectives from plastic manufacturers in Gauteng.

Journal of Transport and Supply Chain Management, 10(1), 1-13.

doi:10.4102/jtscm.v10i1.223

132

Voss, C., Perks, H., Sousa, R., Witell, L., & Wünderlich, N. V. (2016). Reflections on

context in service research. Journal of Service Management, 27(1), 30-36.

doi:10.1108/JOSM-04-2015-0115

Wang, J. J., Sadler, I., & Shee, H. (2017). Managing logistics outsourcing to China:

Business problems and solutions for Australian firms. The Journal of Business

Diversity, 17(2), 10-29. Retrieved from http://www.na-business press.com

Wang, O., Gellynck, X., & Verbeke, W. (2016). Perceptions of Chinese traditional food

and European food among Chinese consumers. British Food Journal, 118, 2855-

2872. doi:10.1108/BFJ-05-2016-0180

Wardale, D., & Lord, L. (2017). Psychogeography – providing a lens on corporate culture

and its potential impact on career success: A novel and efficient approach.

Electronic Journal of Business Research Methods, 15, 99-108. Retrieved from

http://www.ejbrm.com

Weil, A. R. (2015). Medicaid moving forward. Health Affairs, 34, 1092-1095.

doi:10.1377/hlthaff.2015.0526

Weinstock, D. (2015). Does your front desk staff maximize collections? The Journal of

Medical Practice Management: MPM, 31(1), 6-8. Retrieved from

https://greenbranch.com

Welch, S. (2017). Virtual mentoring program within an online doctoral nursing education

program: A phenomenological study. International Journal of Nursing Education

Scholarship, 14, 128-130. doi:10.1515/ijnes-2016-0049

133

Wernerfelt, B. (1984). A resource‐ based view of the firm. Strategic Management

Journal, 5, 171-180. doi:10.1002/smj.4250050207

West, J. L. (2015). A mixed method analysis of the better business bureau's third-party

seal and the extent to which it inculcates trust among consumers. Journal of

Research in Interactive Marketing, 9, 214-238. doi:10.1108/JRIM-09-2014-0055

Wilden, R., & Gudergan, S. (2017). Service-dominant orientation, dynamic capabilities

and firm performance. Journal of Service Theory and Practice, 27, 808-832.

doi:10.1108/JSTP-04-2016-0077

Wilkinson, S., & Hayward, R. (2017). Band 5 nurses' perceptions and experiences of

professional development. Nursing Management, 24, 30-37.

doi:10.7748/nm.2017.e1537

Wilson, V. (2011). Research ethods: Design, methods, case study…oh my!. Evidence

Based Library and Information Practice, 6, 90-91. doi:10.18438/B87W5S

Wilson, V. (2014). Research methods: Triangulation. Evidence Based Library and

Information Practice, 9, 74-75. doi:10.18438/B8WW3X

Wisker, G. (2015). Developing doctoral authors: Engaging with theoretical perspectives

through the literature review. Innovations in Education and Teaching

International, 52, 64-74. doi:10.1080/14703297.2014.981841

Yaduvanshi, D., & Sharma, A. (2017). Lean six sigma in health operations: Challenges

and opportunities—‘nirvana for operational efficiency in hospitals in a resource

limited settings’. Journal of Health Management, 19, 203-213.

doi:10.1177/0972063417699665

134

Yagasaki, K., Komatsu, H., & Takahashi, T. (2015). Inner conflict in patients receiving

oral anticancer agents: A qualitative study. British Medical Journal Open, 5(4), 1-

8. doi:10.1136/bmjo pen 2014-006699

Yang, H. Y. (2014). A cause-effect study on the relationship between human capital

investment practice and human capital for health care management

strategy. Journal of Accounting, Finance & Management Strategy, 9(1), 33-50.

Retrieved from http://performancesforum.org/

Yazan, B. (2015). Three approaches to case study methods in education: Yin, Merriam,

and Stake. The Qualitative Report, 20(2), 134-152. Retrieved from

http://nsuworks.nova.edu/tqr/

Yin, R. K. (2017). Case study research: Design and methods (6th ed.). Thousand Oaks,

CA: SAGE Publications.

Zamawe, F. C. (2015). The implication of using NVivo software in qualitative data

analysis: Evidence-based reflections. Malawi Medical Journal, 27(1), 13-15.

doi:10.4314/mmj.v27i1.4

Zenilman, M. E., & Freischlag, J. A. (2018). The changing paradigm in surgery is system

integration: How do we respond? The American Journal of Surgery, 216(1), 2-6.

doi:10.1016/j.amjsurg.2017.11.031

Ziakas, V., & Boukas, N. (2014). Contextualizing phenomenology in event management

research. International Journal of Event and Festival Management, 5(1), 56-73.

Retrieved from https://www.emeraldinsight.com/journal/ijefm

135

Zhang, J., Zhu, F., Sun, X., Wang, P., & Song, H. (2017). The evolution of intellectual

structure in organization studies between 1990 and 2010: A research based on

bibliometric analysis. Management, 5, 430-449. doi:10.4236/ojbm.2017.53037

136

Appendix A: Interview Protocol

Interview Title: Finding out about competitive strategies rural clinic managers need to

obtain timely payments from patients and health insurance payers.

1. I will begin the interviews with greetings and thank them for their participation in

the interview process. Next, I will make sure I introduce the research topic and

myself to the participants.

2. I will explain the voluntary nature to participate in the study and the opportunity

to withdrawal from the study at any time.

3. I will ensure that participants read and ask any questions related to the study

before agreeing to sign the informed consent form.

4. I will ensure that the participants have a copy of the signed consent form for their

records.

5. I will inform participants that the interview will last between 30 to 45 minutes,

and the interview procedures and that the interview will be audio recorded.

6. I will begin the interview process.

7. I will explain to all participants that as part of member checking procedure, I will

present my interpretations of the interviews to them for corroboration.

8. At the end of the interview process, I will stop audio recording, and thank the

participants again for taking part in the research study.

137

Appendix B: Interview Questions

1. What strategies do you use to obtain timely payments from your patients and

insurance payers?

2. What strategies do you use to collect from uninsured and under-insured

patients?

3. What strategies do you use to manage doubtful accounts and bad debt?

4. What strategies does your organization use to ensure staff complete billing

forms correctly with no errors that delay payments?

5. What techniques does your office staff use to collect copayment either before

or after the patient visit?

6. How does the organization provide training to the billing staff to ensure they

are able to meet the organization’s standard for timely collections?

7. How does the organization ensure that the billing staff has the current training

or professional development regarding health information technology?

8. What billing techniques does the organization use that would be a

competitive advantage over other similar organizations?

9. What are the necessary attributes and abilities of a biller to ensure continued

profitability and sustainability for the organization?

10. What additional information can you make available that accounts receivable

strategies ensure timely payment from patients and insurance payers?