Brian Rosman
Health Care For All
Massachusetts
rosman@hcfama.org
“Imagine a department store whose customers
are blindfolded before entering. A shopper might
enter the store seeking to buy an affordable
dress shirt and a tie, but exit it with a pair of
boxer shorts and a scarf. Sometime later, he
would receive an invoice, whose details would be
incomprehensible to him, save for one item: a
dollar amount in a framed box with the words:
“Pay this amount.”
- Uwe Reinhardt
JAMA, 11/13/13
Cost Growth Goal
ACOs
Medical Homes
Global Payments
Malpractice Reform
Mergers Oversight
Public Health
Prevention
Electronic Medical
Records
Health Planning
Medical Loss Ratio
Primary Care
Workforce
Mental Health Parity
End of Life Care
Administrative
Simplification
Transparency Provisions
• Government Transparency
– APCD
– Cost Reports and data
– Annual Cost Trends Hearings
• Utilization Review Criteria
– Insurers must post UR criteria on website
– Effective October 2015
Consumer Price Transparency
1. THE LAW
– Insurers and 3d Party Payers must have tollfree phone number and website to provide
•
•
estimated price
estimated cost sharing (deductible, co-pay)
– Patients can’t be charged more than estimate
if they get those services
– Patients must be warned about unforseen
services
– within 2 days now; real-time on 10/1/14
– Providers must give price information to
uninsured patients
Consumer Price Transparency
2. THE GUIDELINES
– Web sites must be “consumer friendly”
– If insurer requires CPT or other codes,
insurer gets code directly from provider.
Patients need not provide codes.
– Upon request, insurer must provide
prices for multiple providers in clear,
comparable formats
– Must accommodate other languages,
visually impaired
Consumer Price Transparency
3. THE CAMPAIGN
– State contracting with advertising firm
– Web search ads that link to central state
page, with tips and links to all insurers
– Campaign ideas:
A good thing for . . .
• Uninsured
• Out-of-Network Consumer
• Insured patient with deductible or coinsurance
• Reference Pricing
• Public information on variation
• Competition lowers prices
• Providers help steer patients
• Patients have right to know
What Do Consumers Believe?
• Doctors, hospitals, treatments not
viewed as commodities, but as a social
good
• People want care determined by medical
need, not finances
• Poor understanding of cost sharing
dynamics
• Health plans not trusted source of
information
- Lynn Quincy, Consumers Union
Where is the Quality
Information?
• Quality information is
– Non existent
– Difficult to interpret
– Out of date
– Not specific enough to provider &
procedure
Price = Quality = Price
You Get What You Pay For
“I want the best health care. Money’s
no [object]. Either pay the best, or
maybe they miss something with the
other scan. And that one little thing –
you’re dead. Who knows?”
- Focus group participant
People Reject Tradeoffs
“I want to know what treatment will give
me the best results, and I don’t want, in
the back of my head, a cash register
working .”
People Want Revenge
“I don’t care what the insurance is
paying. I pay my – you know, it goes
through my check. They got my money.
It’s time to pay back.”
“That’s something I think we all
collectively would like, to screw the
man, if you will. I don’t care how much
my insurance is paying.”
Do People Shop for Health
Care?
• Physicians drive most decisions about
treatments and location
• Hard to know in advance what services
a patient will need
Would Better Shopping Make A
Difference Anyway?
97%
100%
82%
80%
75%
65%
60%
50%
40%
21%
20%
3%
0%
Top 1%
Top 5%
Top 10%
Top 15%
Top 20%
Top 50%
Bottom
50%
Percent of Population, Ranked by Health Care Spending
Mass State Website Coming
• Information comparing the quality, price and cost of
health care services.
• Data concerning healthcare-associated infections and
serious reportable events
• Definitions of common health insurance and medical
terms
• A list of health care provider types and what types of
services they are authorized to perform
• Factors consumers should consider when choosing an
insurance product or provider group, including
provider network, premium, cost-sharing, covered
services, and tiering
Mass State Website Coming
• Patient decision aids with balanced presentation of the
condition and treatment options, benefits and harms,
with attention to the patient's preferences and values,
and which may facilitate conversations between
patients and their health care providers
• A list of provider services that are physically and
programmatically accessible for people with
disabilities;
• Research regarding ease of use, consult with
organizations that represent health care consumers,
and conduct focus groups that represent a cross
section, including low income consumers and
consumers with limited literacy. The website shall
comply with the Americans with Disabilities Act.
Resources
• Reinhardt , The Disruptive Innovation of Price Transparency in
Health Care, JAMA, 11/13/13
http://jama.jamanetwork.com/article.aspx?articleid=1769895 (see also
http://economix.blogs.nytimes.com/2013/12/12/health-care-prices-move-tocenter-stage )
• Massachusetts Chapter 224 summary
http://bluecrossmafoundation.org/publication/summary-chapter-224-acts-2012
• Quincy, Using Price And Quality Data: What Are The Barriers
Facing Consumers?
http://www.ehcca.com/presentations/hctranssummit1/quincy_ms10.pdf
• Sommers et al, Focus Groups Highlight That Many Patients Object
To Clinicians’ Focusing on Costs, Health Affairs, 2013
http://content.healthaffairs.org/content/32/2/338.full.html
Resources
• Aetna’s “Member Payment Estimator”
http://www.aetna.com/individuals-families/member-toolsforms/member-payment-estimator.html
• Hibbard et al, An Experiment Shows That A Well-Designed Report
On Costs And Quality Can Help Consumers Choose High-Value
Health Care, Health Affairs, March 2012
http://content.healthaffairs.org/content/31/3/560.full.html
• NCSL, Transparency and Disclosure of Health Costs and Provider
Payments: State Actions
http://www.ncsl.org/research/health/transparency-and-disclosure-health-costs.aspx
• Catalyst for Payment Reform, The State of the Art of Price
Transparency Tools and Solutions November, 2013
http://catalyzepaymentreform.org/images/documents/stateoftheart.pdf