State Consumer Health Information and Policy Advisory Council Meeting

March 24, 2016

Consumer Price TransparencyExamples – State and National

Websites

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Health Transparency Websites

What do consumers want to know:• How much is that procedure?• What is included in the costs?• What are my out-of-pocket costs?• Where can I get the best care for my money?• What if I can’t pay?• Does my insurance cover this test or drug?https://www.healthcatalyst.com/Key-Overcoming-Challenges-Transparency-in-Healthcare

Couple of Facts:• 77% of Americans spend time online searching for health information http://www.makovsky.com/insights/blogs/m-k-health/44-insights/blogs/m-k-health/732-fifth-annual-pulse-of-online-health-survey#sthash.xk5DAusO.dpuf

• Consumers more likely to use health information websites that are easier to navigate than those perceived as trustworthy - "willing to forego trust to have easier-to-access information,“.

http://www.prweek.com/article/1386822/easy-navigation-beats-trustworthiness-healthcare-information#9STU0hw65SZEmJrk.99

• Estimate medical and dental service costs for insured and uninsured

• Data source is healthcare claims (charges for 18 billion medical and dental services), CMS claims (1 billion) and 151 insured plan participants– Charges are an aggregation of non-discounted fee-for-service and data is based on

100% of payer’s claims for a submission period

– Includes non-discounted charges for all in-and out-of-network claims

– Uses CPT codes and Dental (CDT) codes

• “Consumer Cost Look-up” provides estimated charges, out-of-pocket and reimbursement (may select Insured/Uninsured)– Option to add anesthesia charges

– Percentile calculations adjust to show high/low charges

– Shows “usual, customary and reasonable” (UCR) rates; used by insurance carriers to set out of network reimbursement rates

• Site tracks computer IP address and allows only 15 searches per week

Fairhealthconsumer.org

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Fairhealthconsumer.org

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Fairhealthconsumer.org

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• Provides amounts paid by insurers and patient out-of-pocket expenses

• Source of data is medical and pharmacy claims for 40 million people (from all states)

• Payers include: Aetna, Humana, United Healthcare, Assurant

• Shows average and range of costs for procedure/care bundle (national and state):

– Possible treatment program the provider may utilize

– Derived from claims information that combines inpatient, outpatient and ancillary claims to build an example of treatment episodes

• Uses ADAM virtual tool; similar to FloridaHealthFinder.gov

• Source: Health Care Cost Institute (HCCI) database

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Guroo.com

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Guroo.com

• Colorado State APCD• Source of data is 14 commercial payers, and Medicaid

– Payers include: Aetna, Assurant, Cigna, Humana, State Farm and United Health Care

• Presents median total amount paid by private insurance, Medicaid or No Insurance (copay, insurance, deductible)– Price includes facility fee, professional payments made by insurance, and cost of actual

procedure

– Presents total charged amounts for uninsured

– Currently covers data on cesarean and vaginal births, hip and knee replacement

• Prices are calculated using Treo/3M’s All Patient Refined Diagnosis Related Group (APR-DRG) and ICD-9 codes

• Provides a cost calculator to help patients estimate their own potential out-of-pocket share; “My Price” tool allows patients to enter deductible, coinsurance % and select payer for a more accurate estimate

Colorado – Comedprice.com

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Colorado – Comedprice.com

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Colorado – Comedprice.com

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Colorado

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Colorado

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CompareMaine.org

Aimed at insuredindividuals

Source: 25 million claims from 49 health insurance plans; does not include public payers (MaineCareand Medicare).

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CompareMaine.org• Reports average cost based on the

calculated median, represents the amount paid by the insurer and patients out-of-pocket costs. Information on over 200 healthcare procedures from more than 170 facilities; includes hospitals, physician practices, specialty care centers, labs, and radiological and imaging centers.

• Total cost may include provider costs paid to the doctor, nurse, or other healthcare practitioner, and facility costs.

• Accounts for insurance - average combined cost calculated using average median, figure includes payments from an insurance company , co-pays, co-insurance, or deductible payments from the patient.

• Episode includes the main procedure and related procedures or services occurring 30 days before and after the main procedure (includes tests, surgery, medical supplies, follow-up exams, physical therapy, and related medications). Uses Medical Episode Grouper© (MEG) by Truven Analytics.

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Maryland Medical Care Database

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Maryland Medical Care Database

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New Hampshire HealthCost

Source: The New Hampshire Comprehensive Health Information System which presents claims data and Health Employer Data and Information Set (HEDIS) data mandatorily submitted by insurance carriers in the state.

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• Consumers can compare estimated costs based on actual prices

• Website provides estimated total cost for facilities and professionals in New Hampshire for insured and uninsured.

• Shows medical, dental and services including MRIs, dental cleanings, and lab tests

• Allows consumers to select insurance type, deductible and co-insurance;

• Provides an estimate based on bundled services;

• Presents case/patient severity and the accuracy of the cost estimate.

New Hampshire HealthCost

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• Cost estimates are based on median amounts paid by both the insurance carrier and the patient – or, the "allowed rate" of payment to health care providers.

– When the patient is insured, the cost to the patient for covered services is based on a contract between the provider and the insurance company.

– Uninsured or non-covered services reflect costs based on charges minus any discount the provider offers uninsured patients.

• Cost are presented bundled and unbundled

– Bundled costs consist of nearly all of the individual charges associated with the procedure – a button icon and statement to indicate that the cost of the procedure shown is an aggregate of the typical costs a patient will likely pay.

– Unbundled costs are presented with notations to indicate that the cost and the patient may experience more than one procedure at a time.

• Website also presents the average cost for the 20 most common lab tests at the 25 lab facilities that do the most lab tests – represents 47% of all lab tests performed in the state.

New Hampshire HealthCost

Discussion

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