Consumer Price Transparency
Examples – State and National
Websites
State Consumer Health Information
and Policy Advisory Council Meeting
March 24, 2016
Health Transparency Websites
What do consumers want to know:
• How much is that procedure?
• What is included in the costs?
• What are my out-of-pocket costs?
• Where can I get the best care for my money?
• What if I can’t pay?
• Does my insurance cover this test or drug?
https://www.healthcatalyst.com/Key-Overcoming-Challenges-Transparency-in-Healthcare
Couple of Facts:
• 77% of Americans spend time online searching for health information
http://www.makovsky.com/insights/blogs/m-k-health/44-insights/blogs/m-k-health/732-fifth-annual-pulse-of-online-health-survey#sthash.xk5DAusO.dpuf
• Consumers more likely to use health information websites that are easier to navigate
than those perceived as trustworthy - "willing to forego trust to have easier-to-access
information,“.
http://www.prweek.com/article/1386822/easy-navigation-beats-trustworthiness-healthcare-information#9STU0hw65SZEmJrk.99
2
Fairhealthconsumer.org
• Estimate medical and dental service costs for insured and uninsured
• Data source is healthcare claims (charges for 18 billion medical and
dental services), CMS claims (1 billion) and 151 insured plan participants
– Charges are an aggregation of non-discounted fee-for-service and data is based on
100% of payer’s claims for a submission period
– Includes non-discounted charges for all in-and out-of-network claims
– Uses CPT codes and Dental (CDT) codes
• “Consumer Cost Look-up” provides estimated charges, out-of-pocket and
reimbursement (may select Insured/Uninsured)
– Option to add anesthesia charges
– Percentile calculations adjust to show high/low charges
– Shows “usual, customary and reasonable” (UCR) rates; used by insurance carriers to
set out of network reimbursement rates
• Site tracks computer IP address and allows only 15 searches per week
3
Fairhealthconsumer.org
4
Fairhealthconsumer.org
5
Guroo.com
• Provides amounts paid by insurers and patient out-ofpocket expenses
• Source of data is medical and pharmacy claims for 40
million people (from all states)
• Payers include: Aetna, Humana, United Healthcare,
Assurant
• Shows average and range of costs for procedure/care
bundle (national and state):
– Possible treatment program the provider may utilize
– Derived from claims information that combines
inpatient, outpatient and ancillary claims to build an
example of treatment episodes
• Uses ADAM virtual tool; similar to FloridaHealthFinder.gov
• Source: Health Care Cost Institute (HCCI) database
6
Guroo.com
7
Colorado – Comedprice.com
• Colorado State APCD
• Source of data is 14 commercial payers, and Medicaid
– Payers include: Aetna, Assurant, Cigna, Humana, State Farm and United Health Care
• Presents median total amount paid by private insurance, Medicaid or No
Insurance (copay, insurance, deductible)
– Price includes facility fee, professional payments made by insurance, and cost of actual
procedure
– Presents total charged amounts for uninsured
– Currently covers data on cesarean and vaginal births, hip and knee replacement
• Prices are calculated using Treo/3M’s All Patient Refined Diagnosis
Related Group (APR-DRG) and ICD-9 codes
• Provides a cost calculator to help patients estimate their own potential
out-of-pocket share; “My Price” tool allows patients to enter deductible,
coinsurance % and select payer for a more accurate estimate
8
Colorado – Comedprice.com
9
Colorado – Comedprice.com
10
Colorado
11
Colorado
12
CompareMaine.org
Aimed at insured
individuals
Source: 25 million
claims from 49 health
insurance plans; does
not include public
payers (MaineCare
and Medicare).
13
CompareMaine.org
•
•
•
•
Reports average cost based on the
calculated median, represents the amount
paid by the insurer and patients out-ofpocket costs. Information on over 200
healthcare procedures from more than 170
facilities; includes hospitals, physician
practices, specialty care centers, labs, and
radiological and imaging centers.
Total cost may include provider costs paid to
the doctor, nurse, or other healthcare
practitioner, and facility costs.
Accounts for insurance - average combined
cost calculated using average median, figure
includes payments from an insurance
company , co-pays, co-insurance, or
deductible payments from the patient.
Episode includes the main procedure and
related procedures or services occurring 30
days before and after the main procedure
(includes tests, surgery, medical supplies,
follow-up exams, physical therapy, and
related medications). Uses Medical Episode
Grouper© (MEG) by Truven Analytics.
14
Maryland Medical Care Database
15
Maryland Medical Care Database
16
New Hampshire HealthCost
Source: The New Hampshire Comprehensive Health Information System which presents claims data and Health
Employer Data and Information Set (HEDIS) data mandatorily submitted by insurance carriers in the state.
17
New Hampshire HealthCost
•
•
•
•
•
•
Consumers can compare estimated costs
based on actual prices
Website provides estimated total cost for
facilities and professionals in New
Hampshire for insured and uninsured.
Shows medical, dental and services
including MRIs, dental cleanings, and
lab tests
Allows consumers to select insurance
type, deductible and co-insurance;
Provides an estimate based on
bundled services;
Presents case/patient severity and
the accuracy of the cost estimate.
18
New Hampshire HealthCost
•
•
•
Cost estimates are based on median amounts paid by both the
insurance carrier and the patient – or, the "allowed rate" of
payment to health care providers.
– When the patient is insured, the cost to the patient for
covered services is based on a contract between the
provider and the insurance company.
– Uninsured or non-covered services reflect costs based on
charges minus any discount the provider offers uninsured
patients.
Cost are presented bundled and unbundled
– Bundled costs consist of nearly all of the individual charges
associated with the procedure – a button icon and
statement to indicate that the cost of the procedure
shown is an aggregate of the typical costs a patient will
likely pay.
– Unbundled costs are presented with notations to indicate
that the cost and the patient may experience more than
one procedure at a time.
Website also presents the average cost for the 20 most
common lab tests at the 25 lab facilities that do the most lab
tests – represents 47% of all lab tests performed in the state.
19
Discussion
20