The Challenges and Opportunities
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Today's Topic

How 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?"

Mark Lutes
 Mark Lutes

Lindsay Resnick
Executive Vice President, ReviveHealth, a Weber Shandwick Company
  '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.

With unprecedented speed of change, stakeholders are facing a landscape characterized by:

* Shift of financial burden and decision-making to individuals
* Increased access to volumes of healthcare information
* Technology-driven innovation facilitating personalization
* "SoMoLo healthcare" is the new reality (social, mobile, local)

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 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 healthcare marketplace.

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 better outcomes.
Henry Loubet
 Henry Loubet

Cyndy Nayer
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 costs.

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?

Upcoming Webinars

MACRA Positioning for Plans and Providers, September 8, 2016
The 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
Trends in Provider Sponsored Health Plans, October 5, 2016
2016 Predictive Modeling Web Summit, November 10, 2016

2016 Accountable Care Web Summit , December 14, 2016


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