Members dig deep

June 1, 2012

Few consumers are able to find adequate cost and quality information that truly helps them make cost-conscious healthcare decisions

However, as health plan members shoulder higher deductibles and steeper out-of-pocket costs, they also face more confusion about price, quality and value. What's demonstrably lacking at a granular level is comprehensive information about the costs consumers ultimately are responsible for paying for office visits, lab work, procedures, hospital stays and more.

Some general cost information exists today-provided by select insurers, hospitals, third-party providers and government agencies-but there is as yet no centralized clearinghouse where pricing and quality information come together to help consumers make informed choices about their care. Such a clearinghouse is virtually impossible to build with the wide variety of benefit plan designs and patchwork of provider contracts.

According to the 2011 National Survey of Employer-Sponsored Health Plans conducted by Mercer, 53% of large employers (500 to 20,000 employees) are planning to add or use CDHPs as the default plan for enrollment. The same group also is transitioning some employer-paid benefits to voluntary benefits (38%) and reducing spending on dependent coverage (32%).

But patients who try to determine their financial responsibility for a certain healthcare service quickly find themselves coming up short on actual cost data. There's no doubt the information is critical if members are expected to become more cost-conscious, savvy healthcare consumers.

What's more, the variation in cost can be significant, as evidenced by a recent University of California, San Francisco, study published online in the Archives of Internal Medicine April 24. In nearly 20,000 routine appendicitis cases at 289 hospitals and medical centers in the state, the study shows a range in hospital charges from $1,529 to nearly $183,000. The median hospital charge was $33,611. If a member were responsible for 20% of the cost, for example, his or her share would range from $304 to $36,000.

The researchers admit that price shopping for medical services might be improbable, given the complex nature of some cases, vast differences in health among patients, insurance coverage and other factors. Key findings show higher charges for older patients, the uninsured and those on Medicaid. Charges at county hospitals were 37% lower than nonprofits, while for-profit facilities were 16% higher.

Individual hospitals, insurers and third-party providers are attempting to bring pricing and quality information directly to healthcare consumers. For example, Aetna was able to provide details on doctor-specific pricing in 2005 and has since upgraded the information made available to members in its Aetna Navigator tool. It provides rates for approximately 190 specialties such as pediatrics, cardiology and internal medicine, for HMO, PPO and POS products in 57 markets.

In March, Cigna announced its pricing tool enhancement. Updated price estimates cover 200 procedures, personalized to an individual's benefit design. Members can compare costs including specialist, facility and related fees, referenced to the real-time status of their deductibles and co-insurance, as well as their available spending account funds.

The plan claims an accuracy rate within 10% of the patient's cost 90% of the time and will launch the feature in a mobile app later this year.