big of an issue today are 'surprise medical bills' and are they
just the same leftover unresolved problem HMOs have experienced
for decades, or are there relatively newer wrinkles that
stakeholders must face?"
Executive Vice President, ReviveHealth, a Weber
'Surprise medical bills' are just one symptom of a much
bigger trend...the consumerization of American healthcare. The
rapid growth trajectory of High Deductible Health Plans,
Health Savings Accounts, and public/private health exchanges
has put the consumer squarely in a position, whether they
like it or not, of accountability for their healthcare
destiny: selecting benefits, choosing providers, navigating
care choices, and budgeting medical bills.
unprecedented speed of change, stakeholders are facing a
landscape characterized by:
* Shift of financial
burden and decision-making to individuals
access to volumes of healthcare information
* Technology-driven innovation facilitating personalization
* "SoMoLo healthcare" is the new reality (social, mobile,
Healthcare consumerism is not a fad. And,
consumers want answers as they are forced to compare prices
and interpret bills as well as assess quality and judge
outcomes. With an abundance of choice everything is starting
to look the same: products are standardized, provider
networks overlap, prices are available online, and the
distinction between payer and provider is fading fast.
Consumers are confused and frustrated. They're tired of
healthcare's bureaucratic mess.
Smart health care
companies are responding by creating communities for
connection and communication. These companies get it...if they
push customers to take more personal responsibility for
their health care decisions...financial and clinical...the onus
is on the industry to help customers make value-based
individual choices. Through a combination of technology
tools and re-engineering the customer experience, companies
are making it easier and faster for consumers to access
information, comparison shop, and make purchases in a retail
For healthcare consumerism to
succeed, its foundation must be built on trust and
engagement. Every interaction throughout the healthcare
customer journey needs to be grounded in an integrated
communication stream that deepens engagement through
education, guidance and ultimately, create a two-way value
exchange. Trust and engagement yields customer
empowerment...and empowered patients have lower costs and
Founder and CEO, Cyndy Nayer's Center of Health Engagement
Surprises should be for good things:
twins, birthdays, great report cards, visits from beloved
friends. No one wants to be surprised by unexpected medical
bills. However, surveys have found that about a third of
Americans have been surprised with bills they didn't expect,
and 70 percent of these bills were not for emergencies.
Americans have become better shoppers for care. They
search for lab, image and, yes, costs. Many take the
findings and cross match with their doctor practices, health
systems and/ or insurance carriers. They figure their
copays, they check any residual deductibles that could drive
up the cost. They have a reasonable idea of the expected
So imagine the unwelcome surprise when 40
percent of a procedure is not covered or planned. How does
this happen? If any one of the providers in a procedure (
for instance, the anesthesiologist ) is not covered "within
the plan." Seventy percent of surprises happen to folks who
have done their homework.
This is not an old issue.
Staff are often per diem (rented from an agency) in order to
save expenses. They insert seamlessly into a procedure
because of their expertise. But as a patient is wheeled into
a colonoscopy, as an example, he doesn't often think to ask
if everyone in the room is covered on his insurance plan.
It also happens quite often when the patient seeks
care at a convenient care clinic that is covered in the
health plan, but, again, the nurse practitioner in the exam
room is not.
Bundled payments may solve some of
these issues, such as hospital-centered joint replacements.
However the problem is too big to be solved by bundles,
since many visits are for ear aches, flu symptoms, and so
on, where bundles are too clumsy for estimates. The timeline
to create user cases, ICD code pricing, and more means that
resolution can take many months, if not years, within a plan
product, and there needs to be a formula for each of the
multiples of products within an insurance portfolio.
The best solution would be a "not to exceed price,
guaranteed" for upcoming health care events. Corporations
use these clauses for consultants, construction estimates,
even printing or advertising promotions. Can health plans
figure this out efficiently and in a timely fashion?
MACRA Positioning for Plans and Providers, September 8, 2016
Challenges and Opportunities for Medicare Advantage Plans in
2017, September 22, 2016
Ready or not, MACRA is coming: Stakeholder awareness and
industry implications, September 29, 2016
Provider Sponsored Health Plans, October 5, 2016
Predictive Modeling Web Summit, November 10, 2016
Accountable Care Web Summit , December 14, 2016
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for change in health care
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