Eight Ways to Help Patients Navigate Healthcare Costs

While employees’ wages have remained mostly stagnant, family insurance premiums for employer health plans have increased 20% since 2011. Furthermore, more than 50% of individuals have a plan with a deductible of $1,000 or higher per month, says Joan Budden, MPA, president and chief executive officer, Priority Health, a health insurer based in Grand Rapids, Michigan. Consequently, four in 10 insured adults say they struggle to afford their deductible.

Historically, the cost of health services has been hidden behind a cloak of secrecy. In some cases, people avoid getting necessary care because they don’t think they can afford it, Budden says. Other times, they pay more than necessary because they weren’t aware that lower cost options were available.

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The first step in helping consumers navigate the cost of care is to provide them with a basic understanding of what healthcare services actually cost.

“A lack of transparency is a huge problem that the healthcare industry needs to address,” Budden says. “Members deserve to have this information.”

Here are eight ways that health insurers can help patients navigate care.

1. Provide cost estimates

The healthcare industry sits on a mountain of data in electronic health records, but the industry has yet to fully tap into the data’s potential.

“Payers and providers can leverage technology to automate analysis of historical claims data and provide patients with cost estimates before treatment or the final bill,” says Matt Hawkins, MBA, CEO, and board member of Waystar, a company focused on simplifying and unifying healthcare payments. “Based on similar claims that have been approved or denied by a patient’s provider, predictive analytics can give the patient a confident estimate of what they will ultimately pay for a procedure.” Price estimation technology can empower a patient with information so they understand a procedure’s cost ahead of time, check insurance eligibility, and determine their ability to pay.

Priority Health provides members with easy-to-use, digital tools to help them understand their healthcare costs. In 2015 it launched the Cost Estimator tool with the goal of providing members with estimates of their out-of-pocket costs on services and procedures. The tool provides members with pricing that is specific to their own health plan and includes their deductible and copays.

“Our effort moves beyond the traditional approach of offering historical averages and instead focuses on information tailored to a specific individual,” Budden says. Priority Health pre-processes claims, providing an accurate estimate of the member’s cost for services they’re considering. The insurer has reported millions in shared healthcare savings as a result of the Cost Estimator.

2. Educate consumers

Health insurers can educate consumers on their coverage options and out-of-pocket costs in several ways. They can partner with employers to provide health benefits education at the start of employment or each year during benefits enrollment, says Mark Spinner, president and CEO, AccessOne, which provides patient financing solutions.

Such education can be provided virtually, telephonically, or in person in a large-group setting. Some payers work with employers to ensure employees gain points for participating in online education around health benefits. These points can be applied to the employee’s wellness incentive where wellness programs exist.

3. Simplify the user experience

To help consumers understand exactly what their benefits entail, human resource departments should revisit benefits-related documents, such as Summary Plan Descriptions (SPDs). SPDs present an opportunity to enhance and simplify benefits communications. While these documents are traditionally dense and difficult to understand, human resource departments can add charts, callout boxes, and icons to make documents more appealing and digestible. Some employers are beginning to convert their SPDs into digital, interactive documents that employees can access anywhere and anytime.

“The move to digital allows human resources to track which sections employees visit most, which terms are most often searched on, and how many employees view the document to enhance benefit communications,” says Bridget Lipezker, MBA, senior vice president and general manager, Advocacy and Transparency, DirectPath, LLC, which provides personalized benefits education.

Employers must also leverage multi-channel engagement strategies to keep consumers informed year-round. “With today’s workforce spanning five generations, employers must rethink how they communicate benefits offerings and information to ensure that consumers are getting the right information at the right time,” Lipezker says.

Traditional forms of communications such as flyers and booklets can be reinforced and supplemented with newer methods such as webcasts, on-demand videos, and targeted texts and emails to reach both broad groups of employees and specific individuals.

4. Incentivize cooperation

Steady shifting of healthcare costs from payers to individuals not only intensifies pressure on members’ pocketbooks, but also changes their attitude toward insurance coverage and payment, Spinner says. A growing number of members who find they can’t afford the out-of-pocket expenses associated with their insurance plan have opted out of insurance altogether.

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Meanwhile, the more members owe providers, the less likely they are to return for care. One recent study found just 54% of primary care patients return for care when they owe their physicians $100 to $200. Just 42% seek care when their balance is more than $200.

“Given these statistics, health providers and payers have an economic stake in working together to help members navigate health insurance options,” Spinner says. These types of partnerships will become even more critical as members shoulder a greater portion of the costs of care.

5. Offer cash-back rewards

Some employers are offering rewards for employees who choose lower-cost options for medical services or procedures. This incentivizes employees to shop around for healthcare treatments and procedures and through the process helps them understand price variations between services even when they’re in the same network and geographic area, says Lipezker.

Rewards programs work best when the employer communicates the program well and makes it part of the overall benefit program.

Spinner has seen examples of employers and health plans offering incentives for use of lower-cost, high-quality sites for care.

For example, Anthem Blue Cross and Blue Shield in Ohio and its affiliated health plans partner with the Cleveland Clinic Cardiac Concierge Program to provide employees from a national grocery store chain with access to cardiac surgery performed at Cleveland Clinic. The grocery store chain pays 100% of travel costs for members and one companion. Anthem helps coordinate the travel through a medical tourism facilitator.

Spinner is also seeing cash-back rewards programs for members who choose lower-cost care. In Massachusetts, a SmartShopper program offered through Anthem enables members to receive an incentive check each time they choose lower-cost options for care. Under this program, members can earn incentives monthly. Such tools also can have an impact on member care by encouraging providers to find ways to lower costs of care delivery.

6. Provide financial counseling services

As consumers take on more financial responsibility of paying for healthcare, the industry is still opaque-offering no financial guidance for patients and leading to more surprise medical bills and unpaid claims, says Hawkins. A counterparty can work with patients to evaluate financial decisions as they move through the care process and ensure that they’re putting their money in the right services and procedures at the right time.

A professional analysis of the quality and value of care available to a patient can enable smarter spending and better outcomes. It is estimated that $200 billion is wasted annually on unnecessary medical tests and treatment, and with healthcare spending projected to grow at a faster rate than the national gross domestic product over the coming decade, it’s important for patients to have access to an advisor to guide them through the process of evaluating care from a financial perspective, Hawkins says.

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Employers can provide enrollment services that help educate employees on how to select the right health plan based on individual situations, as well as year-round access to benefits experts who can help them choose the best options for healthcare delivery (e.g., should they go to a retail clinic, urgent care, the emergency room, or just wait it out).

“By demonstrating the range of costs associated with the plans themselves and with the point of service, consumers can begin to budget for paying out-of-pocket expenses more carefully,” Lipezker says. As a result, the costs to both the employee and employer decrease.

7. Provide patient advocates

Some employers are beginning to offer patient advocacy services. These services are designed to help make sure that insurance is working the way it’s meant to and that consumers are engaged.

“Access to knowledgeable and experienced advocates who can help employees shop for their healthcare, answer benefit questions, locate in-network providers, and resolve claims issues helps employees make better decisions about their care and enables employers to reduce administrative and healthcare costs,” Lipezker says.

As healthcare costs continue to climb, advocacy services empower employees to be smart consumers, particularly when it comes to understanding medical bills. Advocates can help employees understand each cost included on a medical bill to ensure there aren’t any unnecessary or overpriced charges, Lipezker says. If there are errors, these advocates can work to ensure consumers only pay for what they received. Health plan designers can include references to advocacy services, so that consumers have the information on hand.

8. Offer simple, per-visit copayments

A 2018 analysis shows that balances rose to $781 in 2018 for patients with commercial health insurance coverage-a $314 increase over 2012 figures.

“For members to successfully navigate their healthcare costs, they must have a clear understanding of their health benefits under commercial and government health plans as well as their out-of-pocket costs of care,” Spinner says. “This requires health plans to focus on ways to make it easier for members to navigate health plan choices and benefits, with simple, easy-to-understand approaches to deductibles and copays.”

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.