Professional Documents
Culture Documents
Tools leverage real-world claims data, plan benefit details and provider contract information
to provide accurate cost estimates.
> Consumers can search for a > Consumers can see out-of-pocket > Users can view network information.
Consumers need help doctor/procedure/medical cost estimates. > Appointments can be scheduled.
eliminating the confusion condition. > Users can track amount paid by > Patient financial responsibility can be
surrounding healthcare > Users can also fill out a form plan vs. amount paid by customer assessed.
options. describing their medical needs to the provider.
that can be shared with providers. > Auto-triggers inform provider of
inquiries.
> The user can access either the > Consumers can find healthcare > The user can access information on > Payment options are
Web or a mobile app. providers in their area/network. treatment plan timelines (i.e., clarified.
> They also have an option to call > Price and quality ratings of evaluation, surgery, post surgery). > Convenient bill payment is
the provider helpline. different providers are also > E-consults are available with offered.
given. physicians for initial assessments. > Providers can track patient
payments.
Enabled by.. Advanced Analytics Big Data Mobility Rule Engines Cloud
Figure 1
Vendors and health plans offer price estimation Accomplishing this requires a holistic competitive
tools to individuals and providers that range from pricing strategy. This strategy must align with the
entering a Zip code and a medical procedure into organizations mission; be integrated with overall
a website to see high- and low-cost providers in revenue cycle management operations; take into
the area, to solutions that provide employers and account local markets and competition; be built
employees with health cost data to help them on accurate data and insights; and use multiple
make more informed spending decisions (see channels and digital tools to help educate and
Figure 1). inform patients, regulatory agencies and third-
party data aggregators about the providers
Other providers publish prices for selected pricing and associated quality metrics.
services. The Surgery Center of Oklahoma, for
example, posts the price of more than 100 pro-
10 HELPING CONSUMERS KNOW
cedures it performs; members of the Wisconsin
THE PRICE IS RIGHT
Hospital Association make price information
11
available to patients; and the Geisinger Health Providers will benefit in the short and long term
System has created the Geisinger MyEstimate by developing a competitive pricing strategy that
tool to offer members more price transpar- helps them shape the story their prospective
12
ency. consumers see and hear when comparison shop-
ping (see Figure 2, page 4). These benefits and
Though limited, these efforts are a step in the opportunities include:
right direction. With the industry interacting
more directly with cost-conscious consumers, Overcoming limits of claims-derived price
providers must ensure they are their consum- data. Claims data alone cannot provide an
ers best and primary source of pricing data and accurate picture of cost and value because it
value delivery. doesnt clearly distinguish between the costs
Quality ratings add another useful dimension Understanding the local/regional competi-
for price comparisons. A higher-cost provider tive marketplace for price optimization. Just
may in fact also deliver better outcomes, such as retailers jockey to price competitively, pro-
as when its greater per-unit cost for a surgical viders will find themselves in a similar position.
procedure is shown to result in fewer readmis- It will be critical to understand historic trends
sions and faster recovery for greater patient in local/regional utilization, demographics,
satisfaction. A provider must take the lead in health issues and consumer sentiment, and be
educating and informing consumers about up to date on competitive offerings. This data
such cost vs. value differences. is necessary to develop a defensible and sus-
tainable pricing model and forces providers
Owning consumer engagement. The ability to conduct strategic pricing exercises to con-
to provide consumers with accurate, timely sider the financial implications of short-term
pricing and quality information is a power- revenue optimization strategies, as well as the
ful first step in creating a great experience. impact on patient volumes.
Analytics, algorithms, automation and even artificial intelligence must work in tandem to turn a variety of data sources into
clear, accurate real-time data that shows the consumer the full price of the service, their out-of-pocket responsibility and
how each of these compares with other providers. Tools leverage real-world claims data, plan benefit details and provider
contract information to provide accurate cost estimates.
Influx of data Price Transparency Tool Results
Out-of-Pocket Responsibility
Current Levels of Insurance Coverage > Statement of out-of-pocket payment
Price estimate based on the consumers responsibility.
current levels of insurance coverage > As close as possible to the amount to be
(deductibles, coinsurance copayment, paid.
etc.).
Price Comparison
> Comparison between different providers on
price and quality.
Provider Master Data and Payer Contracts
Rules-based engines that automatically
query, retrieve and combine data from Other Relevant Information
payer portals with the providers master > Information related to the provider.
data and payer contracts. > Clinical outcomes, patient safety or satisfaction scores.
Provider Payer
Figure 2
Developing and protecting the brand. Con- Medicare and Medicare Advantage plans.
trolling the message and owning consumer Aligning prices with an overall strategy and
engagement on pricing will help providers competitive research will enable providers
develop and maintain a consumer-friendly to better justify pricing differences and help
brand. This will be a critical dimension to nur- regulators understand the unique factors
ture as the industry essentially sells direct influencing price in local markets.
to consumers.
Streamlining referrals. As providers build
Increasing point-of-service payment. The solutions that incorporate a better under-
ability to accurately calculate the amount a standing of consumers benefits plans, this
consumer will owe can motivate and stream- data can also be used to present choices for
line payment collection from the patient in-network specialists and ancillary care.
at the point of service, increasing revenue This adds another layer of value for the
opportunities. consumer while also helping integrated net-
works better coordinate care to keep down
Enhancing regulatory compliance. State costs for the consumer. Referral and care
and federal regulators are likely to con- coordination capabilities also enable an inte-
tinue efforts to make healthcare prices clear grated delivery system to deliver more value
and easy to understand to help the indus- to member physicians and ancillaries, espe-
try become price conscious and consumer cially by reducing out-of-network referrals
friendly. The current Centers for Medicare to clinicians with a history of over-utilization
and Medicaid Services (CMS) leadership also or poor outcomes. Patients treated at in-net-
favors pricing transparency to help consum- work facilities by in-network providers avoid
ers understand cost differences between balance billing situations.
The strategy must also incorporate analytics A contact center to assist consumers pricing
for large data sets, and algorithms and rules complex cases.
engines to automate estimation calculations and
their delivery, whether direct to a consumer via
Feedback mechanisms to evaluate consumer
experience and customer satisfaction.
a portal or mobile app, or to patient navigators,
federal/state/employer data repositories and
FOOTNOTES
1 David Schleifer, Carolin Hagelskamp and Chloe Rinehart, How Much Will It Cost? How Americans Use Prices in Healthcare,-
Public Agenda, March 2015, https://www.publicagenda.org/files/HowMuchWillItCost_PublicAgenda_2015.pdf.
2 How Price Transparency Can Control the Cost of Health Care, Health Policy Snapshot Series, March 2016, http://www.rwjf.org/
en/library/research/2016/03/how-price-transparency-controls-health-care-cost.html.
3 TransUnion Survey: Healthcare Cost Transparency Major Factor in Patients Choice of Providers, Health Plans During Open
Enrollment, TransUnion, Nov. 20, 2013, http://newsroom.transunion.com/transunion-survey-healthcare-cost-transparency-ma-
jor-factor-in-patients-choice-of-providers-health-plans-during-open-enrollment.
4 High-Deductible Health Plans, HealthAffairs, Feb. 4, 2016, http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=152.
5 Ibid.
6 Statistics gathered by APCD Council. For more, see interactive map, APCD Council, http://www.apcdcouncil.org/state/map.
7 Melinda Beck, How to Bring the Price of Health Care into the Open, The Wall Street Journal, Feb. 23, 2014, https://www.wsj.
com/articles/SB10001424052702303650204579375242842086688 .
8 Harris Meyer, New Price-Transparency Law Puts Florida in the Consumer Vanguard, Modern Healthcare, April 19, 2016, http://
www.modernhealthcare.com/article/20160419/BLOG/160419918.
9 Data and Transparency, New Mexico Hospital Association, http://nmhanet.org/data-transparency.html, and Transparency in
Healthcare Costs, DHSR, https://www2.ncdhhs.gov/dhsr/ahc/hb834/.
10 Gillian Mohney, Oklahoma Surgical Center Reveals Prices to Patients, ABC News, Aug. 27, 2013, http://abcnews.go.com/Health/
okla-surgical-center-reveals-prices-patients-choice/story?id=20051683.
11 Transparency, Wisconsin Hospital Association, http://www.wha.org/transparency.aspx.
12 How to Adopt a Retail Approach to Boost Healthcare Transparency, RevCycle Intelligence, Oct. 31, 2016, http://revcycleintelli-
gence.com/news/how-to-adopt-a-retail-approach-to-boost-healthcare-transparency.
Keerthi Kumar Dr. Keerthi Kumar is a Senior Manager within Cognizant Business
Consultings Healthcare Practice. He has 15 years of management
Senior Manager, Cognizant
Business Consulting consulting experience across healthcare strategy and transforma-
tion. He is a physician by training and leads the population health
advisory practice. He has advised clients across population health,
value-based care and digital transformation. He can be reached at
KeerthiKumar.tumkursubashchandra@cognizant.com.
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