Financial self-service tools drive members toward smart decisions

TRULY EFFECTIVE technology should simultaneously solve multiple, disparate problems with a single solution, especially considering how operational challenges seem to be increasing with each passing day.

Among the most pressing issues facing health plans are spiraling costs and the inability to get members involved in managing their own healthcare. While not a panacea, emerging financial tools that facilitate members' interaction with the healthcare system-such as online treatment-cost estimators-hold the potential to become a truly effective technology that will help improve those problem areas.

The help couldn't come at a better time, as indicated by the results of the 2010 Financial Healthcare Check-Up survey conducted by the Quicken Health Group, a division of Mountain View, Calif.-based Intuit. According to the study, almost 40% of Americans can't interpret their medical bills or explanation of benefit forms well enough to understand what they are being charged for, if the charges are correct, or why they owe money.

"There will be as many as 15 million new members paying for their healthcare coverage and costs out of pocket, and health plans don't want that avalanche to overwhelm their customer service lines," she says. "The more an insurer can enable people to help themselves, the better it will be for members and for plans."

But just knowing their financial responsibility after the fact won't prompt members to become more frugal in their purchasing. Increasingly, tools that compare provider price points will drive the type of decision making that saves money.

While plans are currently offering some cost-comparison self-service tools, the technology won't fulfill its potential if it only offers non-specific information about a member's care choices and financial responsibilities. The ability to provide accurate cost data is the true measure of usefulness, according to Carey Vinson, MD, vice president of quality and medical performance management at Pittsburgh, Pa.-based Highmark Blue Cross Blue Shield.

"The biggest challenge is finding a way to provide information that is accurate enough for members to compare the costs of specific procedures performed at different facilities," Dr. Vinson says. "Our members need to be able to compare hospitals by name, in an apples-to-apples format."

Highmark members who need a knee replacement, for example, can go to the Web site and determine-within a small range-the total cost for their procedure at each of several nearby facilities. That might sound simple enough, but so many factors comprise the final cost-anesthesiology, lab work, and rehabilitation services, just to name a few-that it took a large-scale effort from Highmark to create a site that reflects the total episode of care expenses accurately.

The plan used claims data to group members together according to diagnosis and procedure, determine the specific facility they used, and after performing a detailed financial analysis, Highmark was able to segment hospitals into one of three groups according to the range of total costs they charged for each procedure. The amount of time and research that went into the project was massive, but it was worth it long run, according to Dr. Vinson.

"When members can combine accurate cost data with a facility's quality data, they can finally start making healthcare decisions based on overall value," he says. "It's never been a matter of people not caring about healthcare costs and value-they just never had any way to make informed comparisons before."

To ensure everyone remains engaged, some plans are using claims data to populate members' personal health records, providing actionable information that members can use for more than just financial decisions, according to Eric Earling, senior communications manager for Seattle-based Premera Blue Cross. Closing the loop provides the final push to help members control costs on their own.

"We recently teamed up with Microsoft to expand the use of information through Microsoft's HealthVault application, by integrating Premera claims data into HealthVault's personal health records," he says. "The data will then be available to individuals even if they move to a different health plan."