Health Care Pricing Shouldn’t Be A Surprise For Consumers

Consumers ask a basic question – “how much will this cost?” – for most purchases they make. But for health care, which accounts for nearly $4 trillion in spending, it’s a question that’s almost impossible to answer.

For decades, consumers have navigated the full spectrum of cost and quality initiatives – from the managed care push in the 1990s to the introduction of star measures and online cost calculators – all designed to direct patients to the providers who provided care at the lowest cost. Yet, notably absent from all of these efforts was true transparency around the actual prices for consumers’ medical services.

This black box around health care pricing has become so pervasive that even the most savvy health care consumers are still surprised by unexpected bills or charges. While policymakers have addressed the worst medical surprises – unexpected and exorbitant out-of-network charges – through passage of the No Surprises Act, consumers still bear the extraordinary expense of our opaque health system.

Benefit design, for better or for worse, contributes a fair share to consumers’ confusion. The fact that at any given time, a patient has to reconcile their deductible, coinsurance, out-of-pocket maximums and the myriad of different charges between primary and specialty care as well as hospital visits to gauge what the final bill might be only adds to the reluctance around smart shopping in the first place. High deductible policies transfer more of this unknowable cost burden to consumers.

A trifecta of transparency provisions, including new disclosures mandated by the Hospital Transparency Rule, the Health Plan Price Transparency Rule, and No Surprises Act, have the potential to mitigate the inherent frustration and confusion that comes from shopping for health care. But the system still isn’t oriented to serve patients’ best interests or their health, and these rules will not eliminate the surprise that consumers have every day in navigating bills after they receive care. That needs to change.

Accountable Care & The New “Medical Home”

Accountable care providers may be well positioned to bridge the gap between patients’ care and their understanding about health care costs. Providers and health plans engaged in accountable care recognize that patient engagement requires a constant feedback loop, where care teams are well-versed on consumers’ health needs, but also their benefit design, and other factors influencing their decisions to seek health care.

One way to think of this is as a “new medical home,” an expansion of the concept that has helped transform advanced primary care. This type of engagement should be at the core of any accountable care strategy and can serve as the foundation for more responsive and successful care navigation that can cut down on unfortunate medical surprises.

Several health care companies, like Kaiser Permanente, have fully embraced a digital and in-person support system that proactively and intuitively addresses the range of health and cost concerns that a patient might face. Care teams are able to speak to coverage and benefits alongside diagnoses and treatment plans so that a patient can get support in real-time and ultimately make the best choice about their care. Care teams also provide direct hand-offs on referrals and visits to specialists within respective networks with seamless prompts for patients to schedule their follow-up appointments, all with one click. In most cases, the estimated or actual cost of the appointment is noted at the time of scheduling.

Other approaches to transparency focus on getting better information to the consumer prior to selecting care or treatment. Morgan Health’s portfolio company Castlight Health serves as a digital navigation platform that includes Care Guides and integrates into a medical benefit to ensure that consumers have real-time support on costs and treatment options prior to initiating a medical service. By offering personalized communications with employees via text, email, phone, and chat, they lessen surprise by proactively connecting patients with the care they need with line of sight on the costs.

All patients deserve this level of support and transparency. As Morgan Health’s investment team looks to improve the health care experience more than 150 million Americans with employer-sponsored insurance, we are helping to advance and scale new approaches to accountable care and care navigation so that patients don’t feel stuck, lost or ignored – no matter where they are in the system.

Morgan Health also recognizes that there are significant challenges to overcome before accountable care can realize this fundamental goal for employees and employers. As a basic starting point, streamlining benefit design with simplified copays and coinsurance would demystify insurance confusion for consumers. At the same time, primary care providers would need access to real-time, accurate and usable pricing data that could be seamlessly translated and integrated into electronic health records. The continued delays and lack of progress in delivering meaningful and actionable pricing data will continue to leave patients, employees and employers in the dark.

Greater accountability and transparency will help with the systemwide transformation needed to improve the quality, affordability and equity of care for millions of Americans – only if we demand it.