Industry Voices—The solution for offering 'shoppable' prices in healthcare is coming

As more Americans are directed to high-deductible plans with high co-insurance, patients must have faster insight into their cost of care before scheduling it. (Valeriya/Getty)

Hospitals are experiencing heartburn over the Centers for Medicare & Medicaid Services directive that they must post their prices for “shoppable” services beginning next year.

This isn’t due to some sort of entrenched aversion to sharing prices with patients.

It’s simply that for decades hospitals have dealt largely with insurance companies instead of patients regarding reimbursement. Almost all of their revenue cycle processes, people and systems have been designed around facilitating payment from a middle person, not directly with the patient. 

To put this into stark perspective, consider the experience of a colleague of mine whose primary care provider ordered a series of chest X-rays and tests for her through the local hospital. Because my colleague has a health plan with a large deductible, she needed an estimate of her cost of care before scheduling the services.

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Once at the hospital, she was directed to the patient access department, where eventually she was summoned to a small cubicle. Inside, a woman sat behind a desk with nothing on it but a computer and a framed picture of a puppy. The latter was abruptly pushed in front of my colleague, presumably for her to think warm and fuzzy thoughts while the patient access staffer spent the next 20 minutes alternating between flipping pages in a thick binder and clicking through different computer screens—all to generate a single cost estimate.

Bored, my colleague asked the woman some idle questions about where she was from and last worked, and learned she’d actually come from Disney. “And this is definitely not Disney,” the woman said in a trembling voice.

Sound surreal? It’s actually a pretty accurate representation of what’s involved in generating a patient estimate in hospitals across the country. (It’s also a vivid snapshot of why patient access employee turnover is so high.)

The process is clearly untenable. In terms of streamlining it, however, there isn’t really another industry that hospitals can look to for examples. Just like hospitals serve patients with different levels of acuity and insurance benefits, service professionals such as electricians, mechanics, accountants and others serve customers with highly variable needs.

But here is where the clouds begin to part. Unlike these other professions, in healthcare a great deal of artificial-intelligence-driven work is being done to automate patient access transactions between hospitals and insurers. In a relevant example, robotic process information and machine learning can combine to compare a patient’s current insurance benefits and hospital’s price for a certain service to then calculate the patient’s out-of-pocket cost.

That’s a very simplified description, but the output is delivered in one of two ways that are scalable for hospitals.

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In the first, hospitals generate the estimate in-house, but directly from an existing system like Epic. There’s no need for a patient access employee to contact an insurer or for the patient to be present. Phone calls and binders aren’t required, either.

Instead, a data provisioning system assesses whether the most accurate benefit information is present, either in an EDI clearinghouse or on the payer’s website. If the latter, robotic process automation—or “bots”—log into the payer’s website with the provider’s credentials and retrieve the patient’s real-time benefits. Additional bots then calculate the patient’s out-of-pocket costs based on what the hospital charges and what the health plan pays.

Of course, that’s not the same as posting prices online, which leads us to the second way to give patients fast and accurate estimates. This option is even more scalable than the first. Hospitals can embed a “self-service calculator” on their websites that allows a prospective patient to enter data in just a handful of fields—providing an insurance plan number, the procedure name and a few other pieces of data. This generates the estimate in less than a minute, and the patient never had to contact the hospital to get it.

That’s a welcome convenience for patients (even for those of us partial to pictures cute puppies).

It’s also a crucial need. As more Americans are directed to high-deductible plans with high co-insurance, patients must have faster insight into their cost of care before scheduling it. In the absence of this understanding, many patients will delay or put off care altogether. Technology that swiftly produces accurate estimates in under a minute answers both a federal mandate and the hospital’s commitment to patient care.