There’s no question, healthcare spending in the United States is out of control. According to a recent Gallup Poll, high cost is the most urgent health problem facing the nation.
The current administration is searching for ways to make healthcare affordable. One idea gaining momentum is pricing transparency—a way to empower patients to act like informed consumers and shop for value-based care. As of January 2019, CMS requires hospitals and healthcare systems to post standard prices (charges) online in a machine-readable format. Although a good first step, it’s clear that simply listing prices without requiring them to be in a user-friendly format that accounts for a person’s insurance is insufficient to create choice for consumers and generate meaningful competition to lower costs.
At University of Utah Health, we know this to be true, because we’ve spent the past 3 years figuring out how to list our prices meaningfully. Our revenue cycle team has worked in close collaboration with our information technology systems and data warehouse teams, clinical departments, our website designers, and patient advisory groups. We’ve gone far beyond the required posting of chargemaster prices in an Excel spreadsheet, which is how most health systems have responded to the recent CMS requirement. We’ve created an interactive tool that provides an accurate estimate of patients’ out-of-pocket expense based on the type of insurance they have (Medicare, Medicaid, private payer, or self-pay), the amount of their unmet deductible, and the availability of co-insurance.
Our efforts have paid off—our pricing transparency tool is considered best-in-class by CMS Administrator Seema Verma and others. And we continue to iterate and make improvements to our out-of-pocket cost estimator. But, still, we’ve learned that we’ll need to do much more to make healthcare more affordable. Following are four reasons why:
Accuracy: Hospital charges were never designed to represent the price to consumers. Nor were they created to stimulate competition or provide individuals with the ability to shop for affordable care via price-point comparisons. They are set to capture the maximum allowable reimbursement from insurers. While the highly inflated prices listed on the chargemaster open up important conversations about how expensive healthcare is, they may also discourage patients from seeking necessary care. For uninsured patients, the listed prices for the vast majority of procedures must seem simply unaffordable. Insured patients are, likewise, unable to know what discounted rates have been negotiated between the hospital and their insurance carrier and how these impact their out-of-pocket costs. University of Utah Health’s online pricing tool gets much closer to the actual out-of-pocket costs, but that highlights the next problem.
Confusion: In trying to estimate more accurately a patient’s out-of-pocket costs, our pricing tool asks questions about a patient’s copay, deductible, coinsurance, and medical procedure details. It turns out that both the US payment system and the practice of medicine are confusing. To prove that point, of the 5,000+ procedure searches since May using our out-of-pocket estimate tool, only about 1,174 finished answering all of the questions and completed the submission. What’s missing in this process is provider input. According to a national survey University of Utah Health conducted, 60% of patients and 71% of employers said they’d like physicians to discuss the cost of care. And most physicians (59%) believe it is their responsibility to do that. Neither the consumer nor the hospital can know exactly which procedure a patient will require for a specific condition. For instance, an individual will likely not know whether she needs a computed tomogram with or without contrast, not to mention if the less costly open surgical procedure is as safe as the minimally invasive laparoscopic approach. One U of U Health study showed that when providers made patients aware of a less expensive option with equally good outcomes, they selected the less costly procedure. Without that conversation, posting prices alone will not truly drive value for the consumer.
Benchmarking: We’ve prioritized pricing transparency at University of Utah Health, but until the majority of systems create user-friendly pricing tools, there will be no easy or accurate way to compare prices. CMS is proposing that health systems will have to post their negotiated prices in a usable format to consumers in 2020. Having this information may help employees better engage with selecting both a healthcare provider and an insurance plan.
Lack of Options: Even if patients are empowered to comparison shop and select high-value, low-cost care, affordable options often don’t exist. Hospitals provide amenities to entice high-income patients, such as private rooms, but don’t offer more affordable options for middle-and low-income patients, who may be perfectly fine sharing a room for a lesser price. The solution to a lack of affordable options in the US may end up in more disruptive solutions, like paying employees to undergo select procedures by US-trained and licensed physicians in other countries. As healthcare systems and providers, we need to begin thinking harder about not only having cost conversations, but creating more affordable options.
As physicians, we know that the cost of healthcare is important to our patients. Now, we have to design a system that acknowledges that a patient’s financial health affects their overall wellbeing. Going forward, physicians will be required to undergo training, starting in medical school, to include the affordability discussion in the treatment plan to assist patients in understanding the financial implications of their decisions. Healthcare systems need to provide the tools and transparency and time so that healthcare professionals can have those conversations. It is one more aspect of our commitment to value-based care and a duty we have to help lower the unsustainable costs of healthcare in the United States.