The idea of ordering dinner for one at a restaurant thinking it will probably cost around $30 and then getting a surprise bill one month later for $100 may seem obscene. Yet, this concept continues to be a dogged reality for healthcare consumers. This frustration is compounded by rapidly rising costs. For instance, out-of-pocket expenditures have reportedly been increasing gradually over the past half-decade, averaging $1,124 per capita in 2017, up from $119 per capita in 1970.
But tides are turning, thanks to technology changes, innovative approaches, and even big regulatory shifts over the past few years to put the art of pricing back in consumers’ control. Like in April of 2014, when the Centers for Medicare and Medicaid Services (CMS) released a dataset revealing exactly what it had paid individual physicians for specific procedures. Additionally, over the past decade, a whole industry of transparency vendors has emerged to help close the information gap. Although results have been mixed, many pivotal moments (like Castlight’s 2014 announcement of its initial public offering (IPO) which garnered high interest from investors, for one) suggests there’s unmet demand for answers.
Most recently, government regulators have started focusing on consumer price transparency. Here are two examples:
- Last May, the US Department of Health and Human Services (HHS) proposed a rule to slash Medicare Part D and Medicaid managed care drug rebates and offer consumers point-of-sale discounts. This rule also proposed doing away with safe harbor for drug manufacturers under the federal Anti-Kickback Statute starting next year.
- Last month, the Trump administration passed a new rule (one set to become a hot topic in the 2020 election, no less) that aims to let healthcare consumers know more about how much their healthcare services actually cost.
In short, consumers may no longer have to make their best educated guesses – Is my hospital bill $300 or $1,000, anyway? – and wait to see what their explanation of benefits says they owe, unsure in the meantime of what was covered, what wasn’t, and what should have been somewhere along the way. The drum beats louder and louder heading into September 2020, as does the pressure. In time, this push for greater transparency may spark more competition across the greater health industry. Because of a sudden, more immediate need to innovate, we may see a notable drop in total costs and a notable increase in care outcomes and experiences as more consumers with specific medical needs direct themselves towards high value providers.
But Here’s the Catch
Despite movement from HHS to make it mandatory for hospitals to make data on negotiated prices available for consumers, thereby making it clearer what the payer versus the consumer owes, the thing is, a lot of healthcare is already (technically) shoppable. Here are some movements supporting the empowerment of consumers shopping for healthcare services:
- Cost estimation tools are slowly gaining use, albeit they have limitations depending on what state a consumer lives and which payer he or she’s covered under.
- Bundles and other payment models are increasing the scope of what’s “shoppable”.
- There has been a recent explosion of analytics insights and vendors (just a few names include the payer-provider value-based analytics company, RowdMap, Oliver Wyman’s collaboration to reduce unnecessary care, Practicing Wisely, and Best Doctors, an app offering consumers access to 50,000 virtual specialists). These and many other names are developing more robust, thoughtful ways to think about shoppability (like focusing on quality and appropriateness, not just unit costs).
Assessing Degrees of Shoppability
According to past Oliver Wyman analysis, the most shoppable services in connection to hospital revenue are radiology, colonoscopy, magnetic resonance imaging, orthopedics, gastrointestinal surgeries, and basic cardiovascular procedures. The least shoppable? Emergency and trauma services. We also estimated that between 20 and 35 percent of medical costs fall under that “most shoppable” category. This is a category with extreme price variation – sometimes by a factor of five or more. When patients end up going to where the lowest cost, highest value care delivery is offered, this means that those providers failing to make money (or at least break even) at the new market rate lose both volume and customer share. As ancillaries and more “shoppable” services can drive a high portion of today’s margins, some providers will face large profits, and even sustainability issues.
We still see significant growth in consumers’ ability to shop for healthcare services today and will likely continue to do so over the next several years. The biggest challenge to date, however, is that most consumers don’t understand (or don’t prioritize) “shoppability” in the first place.
Until now. There are a few big reasons for this shift, namely: Medical costs are hitting people’s wallets much harder now than they did, say, five years ago; consumer cost shares are increasing; reference-based benefits and reimbursement are becoming more commonly understood approaches for large (and small) employers under the umbrella of payers with more available tools to drive consumer accountability (including reference-based pricing, tiering networks, and in-network benefit restriction for unnecessary usage).
Twenty-nine percent of firms offering health benefits offer a high-deductible health plan / a health reimbursement arrangement, a health savings account-qualified high-deductible health plan, or both. Large firms (those with over 200 workers) are reportedly more likely than small firms (those with 3 to 199 workers) to offer a high-deductible plan paired with a savings option (58 percent versus 27 percent).
Today, employers are increasingly adding larger incentives (and carrots) for smart shopping decisions (like alternative networks and advocacy).
According to Mercer analysis, one in three – 33 percent – covered employees as of 2018 are in low-cost consumer-directed health plans. (A decade prior, this number was only seven percent.)
Advocacy, navigation, and member engagement platforms and services are increasingly able to leverage insights to help steer an navigate consumers. At-risk providers progressively have access to this data and can refer their members to the lowest cost, highest value options. We’re seeing growing evidence of payers and providers creating data sharing arrangements that overcome historical negotiated rate confidentiality terms.
Government leaders, payers, and employers alike can unlock healthcare’s hidden affordability and value by continuing to empower consumers through a transparency agenda. Those degrees of “shoppability” government leaders are able to address (for example, like how some available tools may only include a couple hundred services when thousands are potentially available) must be addressed now, especially since different consumers find certain prices more “shoppable” or less “shoppable” than others.
What’s Next for Consumers
We predict the biggest opportunities to help members make the right care decisions for their health, well-being, and wallets lie in the navigation, advice, and guidance spaces. Yes, there are lots of people crowding these markets already (like advocacy services, care management teams, provider care managers, and health information startups) – but nobody’s cracked the code just yet.
When the pendulum swings faster than before towards the lowest cost, highest value care sites and providers in favor of more and more shoppable services, this push will one day be enough to flip the hospital system profit model upside down and put traditional value sources under great pressure to function differently or risk becoming obsolete. Winners will be those who can guide members to the best providers, not just negotiate with the very best of providers.