Physician-patient communication

Can Price Transparency in Health Care Really Lower Costs?

By M2|2019-08-21T14:53:39+00:00August 20th, 2019|Health care spending, Health Care Trends, Hospitals, Insurance, Out-of-pocket spending, Physician-patient communication, Providers, Reimbursement, Uncategorized|

Can Price Transparency in Health Care Really Lower Costs?

Telling patients what they will pay for their health care services is a key stepping stone to more efficient use of health care dollars. Consumers, employers, payers, and the system as a whole would likely benefit if the true cost to the patient were made available before a patient receives a health care service or product.

Several states already have laws on the books requiring health care providers to make at least some price information available on at least some procedures. Some states also run centralized databases where different payers report what they get paid for different services. Additionally, the federal government requires hospitals to post a list of standard charges on the internet.

The Trump Administration wants providers to further expand the price and quality information to consumers, and issued an Executive Order (EO) on Improving Price and Quality Transparency in American Healthcare to Put Patients First in late June. The order aims to help consumers make “well-informed decisions” and expand transparency efforts that provide information “which patients can research and compare before making informed choices based on price and quality.”

More specifically, the EO directs the U.S. Department of Health and Human Services (HHS) to require hospitals to publish negotiated rates in a searchable, consumer-friendly format for 300 “shoppable” services.

You Can Shop if You Want To

Consumers are being asked to make more of these decisions on their own, as we’ve described in previous posts. My home state of Colorado has a shopping tool like the one the EO has in mind. It took me less than a minute to get the result below from the Colorado Center for Improving Value in Health Care (CIVHC) for an MRI scan of a leg joint within 15 miles of my ZIP code:

Shop for Health Care Services – MRI Scan, Leg joint (CPT 73721)

Seems pretty obvious that while the closest option, seven miles away, is Centura Health St Anthony Hospital, they would charge me $510 for the scan. If I drive another five miles, I would only have to pay $150 at Denver Health Medical Center.

“Shoppable,” but Perhaps Not “Buyable”

According to the Health Care Cost Institute (HCCI), “For a health care service to be ‘shoppable’, it must be a common health care service that can be researched (“shopped”) in advance; multiple providers of that service must be available in a market (i.e., competition); and sufficient data about the prices and quality of services must be available.” HCCI estimates that approximately half of out-of-pocket spending is spent on “shoppable ambulatory doctor services.”

The problem is, you might be able to research and compare certain services with upgraded information, thus improving your shopping experience, but you might really struggle to buy the service that is lower in cost.

Using the example of lower-limb MRIs, a 2018 study titled Are Health Care Services Shoppable? Evidence from the Consumption of Lower-Limb MRI Scans found that people typically drive by multiple lower-priced providers to get to their final treatment location. Why? Because that is where the patient’s referring provider sends them. The study shows “the influence of referring physicians is dramatically greater than the influence of patient cost-sharing or patients’ home ZIP code fixed effects.”

In particular, “physicians who are vertically integrated with hospitals are more likely to refer patients to hospitals for lower-limb MRI scans.” We’ve written previously about how costs vary dramatically by site of care. That also means patient cost-sharing varies. We are asked to pay more out-of-pocket for a service we could get elsewhere. But that would mean 1) shopping and 2) acting against the advice of a provider. Not impossible tasks, but difficult for sure.

Increased transparency means you can shop for services, but that is only half of the problem. Yes, it is important to have price and quality information. If the problem were a technical one, more information would lead to different decision making. But in fact, changing the way a consumer selects a health care service – even a “shoppable” service – is an adaptive problem. That is, it requires a change in the way people think, prioritize, and behave.

Additional information on quality and price is definitely necessary, but if I drive by two Centura Health facilities with lower cost MRIs to get to the HealthOne facility my referring provider recommended, I would also need some encouragement, at least, to go against my physician’s recommendation.

It looks like we health policy types have more work to do.

Small Step Service Design Thinking – The Case of the Patient Appointment

By M2|2019-03-15T15:51:47+00:00March 13th, 2019|Physician-patient communication, Providers, Uncategorized|

Small Step Service Design Thinking – The Case of the Patient Appointment

As we last week, M2 authored a chapter entitled “Using Small Step Service Design Thinking to Create and Implement Services that Improve Patient Care,” in Service Design and Service Thinking in Healthcare and Hospital Management published by Springer. Today we share highlights from the first case study we feature in the chapter.

Big leap versus small step service design

“At the heart of design thinking is the intention to improve products by analyzing and understanding how users interact with products and investigating the conditions in which they operate,” explain Rikke Dam and Teo Siang in a piece published by the Interaction Design Foundation. In health care, understanding how users interact is often the purview of engineers or project managers looking to improve the waiting room experience, or decrease wait times. We call these “big leap” service designs because they take significant time, commitment, and funding from health care organizations.

A small step design, we argue, truly aims to understand the patient’s point of view, instead of forcing a person to work around a process designed to make things easier for health care providers or organizations.

Patient appointments – boring but essential

While the health care system is moving away from fee-for-service reimbursement, it is still the dominant payment approach in the U.S. This means unreimbursed services, for example, setting appointments, are often outsourced to patients. From a patient’s point of view, not scheduling an appointment, or not showing up for one, can mean diagnosis or treatment delays which can lead to worse health outcomes. From a systems perspective, missed appointments are costly and inefficient. Perhaps most importantly from a design perspective, research shows that missed appointments are often blamed on patient inaction which can cause providers to develop negative attitudes and feelings toward patients leading to a decrease in communication and lack of empathy. Missed appointments can also lead to “increased costs of care delivery…reduced patient satisfaction and negative relationships between patients and staff.”

In a fee-for-service environment in particular, it makes sense from the point of view of the provider to recommend a follow-up appointment or make a referral for care, and expect the patient to book the appointment. But appointment nonadherence is a major problem in the U.S. health system with estimates ranging from 20 to 80% appointment nonadherence depending on the type of condition, site of care, and patient demographics.

Is this a people problem, or a process problem?

Since it benefits the patient, it seems obvious that he or she would set a recommended follow-up appointment, or appointment with a practitioner that has been referred to him or her by her current provider. But we know the frequency at which this doesn’t happen is quite high. As Chip and Dan Heath encourage readers to understand in Switch: How to Change Things When Change Is Hard, we may be attributing the patient’s behavior to “the way they are, rather than to the situation they’re in.”

First, let’s empathize.

Design system thinking recommends defining the problem by first empathizing with the end user. A large accountable care organization (ACO) in the Northeast we studied for the book chapter realized they were not immune to the problem of missed appointments, and recognized it was preventing their organization from helping patients achieve optimal outcomes.

The ACO’s small step service design innovation started with empathy. The ACO first worked to understand why their patients failed to follow-up on referrals. If you are not a patient, the answer may surprise you: Patients didn’t feel like they had the expertise to make the best choice.

From a patient’s point of view, they want the best care they can access, of course, but they don’t necessarily know what the “best” care is, or which providers are able to deliver that care for their particular set of circumstances. Further, a list of referrals with several provider names patients are often handed at the end of an appointment can make this anxiety worse. What tools does a patient have to discern between the providers on the list? Is there a difference in quality? Price? Years of experience? Bedside manner? Cultural competency?

Patient-first design extends clinical expertise

The small step service design tested by the ACO in our case study was a coordinated appointment and referral system (ARS). Driven by research showing a patient is more likely to attend a clinical appointment if that appointment is set before the patient leaves the office of the current clinician visit, the clinical leader of the ARS worked with colleagues to pilot a referral and appointment-setting process at the ACO that changed internal processes so patients left appointments with a follow-up or referral appointment already scheduled.

Our case study of the ACO in the Northeast provides a more complete picture of the design steps they used to create a unique appointment and referral system to improve patient adherence to referrals and follow-up appointments. While not the subject of this blog, it should be noted that empathizing with patients was just the first step of the process. Encouraging providers to be more involved in the appointment setting and referral process required building the case for chance across a broad range of internal stakeholders, not the least of which were the staff and clinical experts who would be asked to help patients make this important choice. The goal was to take some of the work off the patient’s plate, but this required building the case with the ACO’s doctors and health care providers for why they should do something differently.

The clinical expert leading the effort explained to us, “I try to tell doctors that we have insider access as clinicians. We get preferential treatment when we are trying to interact with the system. Imagine extending that reach for our patients.”

Through a provider’s eyes, it seems obvious that patients should schedule appointments the provider recommends. But through the patient’s eyes, it becomes more clear that the barriers to appointment-setting may have less to do with lack of interest and more to do with lack of expertise. Extending clinical expertise and “insider access” to patients to improve the rate of appointment setting may seem like a mundane process change, but the ACO in our case study thinks it will have an outsize impact on patient outcomes.

Payers and Providers Focused on Engagement, But Consumers’ Interest in Price Information Still Not Addressed

By M2|2018-02-07T21:24:42+00:00February 7th, 2018|Health Care Trends, Health Plans, Out-of-pocket spending, Physician-patient communication, Uncategorized|

Payers and Providers Focused on Engagement, But Consumers’ Interest in Price Information Still Not Addressed

With the rise in consumer engagement, health plans and providers are making investments in technology and services in order to provide patients with more useful and timely information. The ultimate goal is to help facilitate patient decision making, in an era of increased financial responsibility on the part of consumers. What are the results so far?

A recent white paper provided the results from a survey of nearly 90 payers, 250 providers (hospitals), and 800 consumers. The paper reveals “concerning gaps between what payers and providers think they’re achieving and what consumers are actually experiencing.”

80% of payers and 72% of providers said “investment in consumer engagement was a top priority” for them. Drivers of change included the transition to value-based care, competitive pressures, and “consumer demand for a more retail-like experience.”

However, while payers and providers are spending as much as a third of their health care information technology dollars on consumer engagement, nearly three-quarters of consumers polled told interviewers, “their experience with providers and health plans hasn’t improved—or has worsened—over the last two years.” Only 21% of consumers indicated their care experience had improved in the previous year.

Cost Information a Top Priority for Patients

Providers are focusing their investments in departments and functions that have a “high degree of personal interaction with patients,” such as ambulatory/outpatient services and inpatient services. Providers said the majority of their consumer-centric investments went toward software solutions (28%), followed by in-person and website investments (both 18%).

Payers, similarly, are focusing on customer service, member education, and marketing departments, with primary investments made in websites, call centers, software, and mobile apps.

Notably, cost information is a “top priority for patients, because they’re increasingly responsible for the cost of their medical care.” However, less than 20% of providers have developed cost-of-care education programs or post prices publicly. And among payers, 80% do not yet provide cost transparency tools.

This paper shines a spotlight on the continuing inability of patients to access the information they want most – pricing and cost data. Consumers are telling their providers and payers what they want; technology alone will not solve the problem. What will it take for the system to respond? Providers and payers are increasing their consumer engagement related to care management, especially with websites, apps and other technology. But as consumers have increased financial responsibility for their care, they will need better information on what their care will cost, ideally before they incur the care.

In general, there is an “alarming engagement gap between consumers, providers, and payers.” But the gap “can be closed if providers and payers would tailor experiences to what consumers want, promote adoption of services and technologies, and solicit feedback.”

While Most Consumers Want to Discuss Costs Before Receiving Treatment, Most Providers Do Not Bring Up Financing Options with Patients

By M2|2018-01-24T21:41:19+00:00January 24th, 2018|Health care spending, Health Care Trends, Insurance, Out-of-pocket spending, Physician-patient communication, Uncategorized|

While Most Consumers Want to Discuss Costs Before Receiving Treatment, Most Providers Do Not Bring Up Financing Options with Patients

Seventy-seven percent of health care consumers say it’s “important” or “very important” to know their costs before treatment; however, most providers are not satisfying these demands, according to a recent article in Healthcare Finance.

Only 18% of health care consumers said that “any of their providers had spoken to them, at any time, about patient financing options in the past two years.” The article summarizes the results of a survey conducted by ORC International and commissioned by patient financing company HealthFirst Financial.

The survey highlights consumers’ interest in financing options for health care services: 53% of the 1,011 U.S. adults surveyed would like to discuss financing options before they receive care, and 57% consider it important or very important that their provider offer ways to extend payments over time with no interest.

However, only 8% received zero- or low-interest financing from a provider. “These findings highlight a huge gap in what patients want and what hospitals, medical groups and other healthcare providers are delivering,” KaLynn Gates, HealthFirst Financial president and corporate counsel, says in the article. “Providers that care for the financial as well as clinical needs of their communities are much more likely to thrive in this era of rising out-of-pockets costs and growing competition for patients among traditional and non-traditional providers.”

Furthermore, “a full 40% of millennials 18 to 36 years old said they’d be very likely or likely to switch providers if a competitor offered low- or zero- interest financing for medical bills.” And among survey participants overall, 29% “said they’d move to different providers that offer attractive payment programs.”

Concerns about covering the cost of care exist in all income brackets; 42% are very concerned or concerned about their ability to pay out-of-pocket medical bills in the next two years, and the number increases to 54% for those with incomes of less than $35,000 a year. Among those with incomes of $100,000 or more annually, the number drops, but still, 24% in this bracket are very concerned or concerned.

Consumers are worried about their ability to pay for unexpected medical expenses; 53% of those surveyed expressed concern about the ability to pay a medical bill of less than $1,000; 35% worry about the ability to pay a bill of less than $500, and 16% are concerned about the ability to pay a bill of less than $250.

The survey was commissioned in order to “learn more about how consumers are coping with their medical expenses,” Gates says in the article. “Without providing and communicating these viable financing options, they are likely to delay care or switch providers to find financial help. In either case, providers will be hurt by those choices, and they need to develop a strategy to meet these consumers’ needs.”

Despite these findings, however, another survey, published recently in Health Affairs, finds that while most U.S. consumers support price shopping for health care services, most do not actually seek out information on pricing.

The findings also come at a time when states are taking various measures to improve price transparency for consumers. For example, Ohio has enacted a law aimed at informing patients what health care procedures will cost prior to receiving care. However, the law is currently in limbo, after criticism from hospital and physician groups, who claim the law would slow down access to care.

This HealthFirst survey reinforces what we’ve said in the past and what other studies have shown; for example, we blogged earlier this year about a study published in Health Affairs showing that physicians are missing opportunities for communication to help reduce patient costs. We’ve also written about employers sending patients to high-quality, bargain-priced providers; sometimes these providers are out of town, or out of state, yet employers are still able to save money with this approach, which points to inefficiencies in the health care system.

Clearly consumers need price options, and talking with physicians beforehand about costs would help inform patient decision-making. However, it’s noteworthy that this new survey emphasizes consumers’ desire for financing options; thus, consumers appear to be seeking to base their costs decisions not on actual total costs of services, but on monthly payment options. They are therefore not necessarily taking a savvy approach to overall costs.

One area of cost concern that the survey did not cover, but which is coming up soon for most patients, is the annual deductible that most health plan enrollees must meet. Each year, consumers must consider the re-setting of the deductible on January 1, and factor that into health care choices. This is a particular concern for patients with chronic illness, and it points all the more to the need for consumers to know their costs upfront, before services are provided.

Who should advise patients about exercise?

By M2|2017-10-08T11:52:28+00:00May 26th, 2017|Health Care Trends, Physician-patient communication, Uncategorized|

Who should advise patients about exercise?

In 2015, 20.9% of Americans exercised as recommended every week. Not sure what that recommendation is?

You’re not alone.

According to the CDC, the average American adult should try to get at least 150 minutes a week of moderate-intensity aerobic physical activity, or 75 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of the two. This means walking, running, biking, bowling, gardening, etc.

Less than 21% of Americans actually get this amount of exercise. And several studies show that few people know what the guidelines are, including a British study that shows only 14% of respondents even knew how much exercise they are supposed to get.

We are all busy. It is hard to know what the very latest research says.

But a new study shows the problem may run deeper.

Let’s say you have been diagnosed with cancer and are now undergoing a treatment regimen with an oncology specialist. Would it seem reasonable to ask your doctor for advice on exercise?

A study published in May in the Journal of the National Comprehensive Cancer Network says just that: “Patients want advice and support about exercise while enduring the physiological and psychological side effects of treatment. Furthermore, they prefer that the exercise recommendations come from the oncology provider.”

The gap between what the patient wanted and what the oncologist did in this small study is instructive. 95% of patients told interviewers they felt physical activity was “very important during their cancer treatment.” When focus groups and individual patients were asked, “From whom and how would you like to receive exercise information?” 80% of participants said they wanted advice from their oncologist. Ideally, the patients said, they’d like their doctor to recommend a home-based exercise program.

But more than half of providers wanted to refer patients to another health care professional for exercise recommendations.

Even discussing exercise options was difficult for oncologists, for several reasons. Time constraints, lack of knowledge of a patient’s fitness level, or what kind of program would be appropriate, cost of rehabilitation, lack of transportation, side effects of treatment (for example, fatigue) were all cited as barriers to oncologists recommending exercise programs.

In this particular study, nearly all of the cancer patients wanted their oncologists to discuss physical activity with them, but in reviewing patient-physician transcripts, the researchers found such conversations were “nonexistent.”

As with many best practices in health care, although the evidence-base supports physical activity for most cancer patients undergoing treatment, that doesn’t mean patients can get reliable information on exercise programs from their trusted heath care professionals. In part, the oncologist does not get paid for this interaction. Even if an exercise therapist or similar health care professional were able to collaborate with the oncologist, it might be difficult for the patient to either attend another doctor’s visit, or pay for such a visit. A “shared-care” clinic visit might work well if the focus is to provide health care provider focused care. But the study indicated what these cancer patients really wanted was a home exercise program.

While policymakers and others talk about “patient-centered care,” when it means moving care from a health care institution to a home setting, or asking a trusted provider to be trained in something he or she may not feel expert in, it is very hard to get the system to do what works best for the patient. Bridging the gap between the system we have and the system we want requires patients and physicians to behave differently, but it also requires payers and health systems to change their ways as well.