How Technology Has Changed Medical Procedure Recommendations

by | Sep 27, 2017 | Health Tech

Healthcare is not the most historically transparent industry. As a result, consumers have struggled to figure out how much a procedure will cost them or what their employer paid in the past. That’s now changing as companies create tools to help employees peak behind the curtain. Insurers, TPA’s and government agencies have all started to provide more data about pricing. No single source is perfect – and getting exact pricing can still be difficult – but we now have more transparency than ever before.

Think about procedure pricing more like finding a great mechanic rather than buying a TV online. When buying a TV, you know the exact model number and delivery cost. It’s fixed and easy to compare. When working with a mechanic, once they get under the hood the scope of the job might change slightly but you have a good idea of where the cost will end up. In the same manner, transparency tools can help consumers get a clear picture of how different doctors and facilities price their services.

Part of the mystery that’s developed regarding procedure prices stems from the fact that most doctors and facilities don’t publish their prices. Some mystery is also due to the general disconnect between who is receiving a healthcare service (a person) and who is paying for it (likely the insurance carrier or employer). Transparency may negatively impact the bottom line for some of the parties involved in healthcare, so their behind-the-scenes price negotiation only adds to the confusion (read our post Make Healthcare Shoppable with Price Transparency for more).

The shift to high-deductible health plans (HDHPs) has made employees more conscious of the price of services. In 2006, only 4% of employees were on HDHPs. That soared to 29% in 2016. This shift has helped change employee behavior, but without a good employee healthcare guidance tool like HealthJoy, moving to HDHPs has worked with limited success and added frustration. We make hundreds of recommendations for procedures every month to our members. Our healthcare concierge works with a variety of public, private and proprietary sources when making these recommendations. For the sake of transparency, let’s go over all the steps that one of our concierge and JOY, our virtual assistant, will take to make a single recommendation. Most of the time, we make our recommendations within 24 hours.

  • Gather Member Needs and Preferences – JOY guides members through a series of questions to understand their healthcare needs and preferences. JOY asks about their procedures, how far they would drive, preference of time of day, etc. Employees can always chat or talk directly with a concierge if they prefer.

    Our healthcare concierge reviews the information collected by JOY to create a service ticket. If a member has questions about a procedure, they will often set up a telemedicine visit with a doctor through the HealthJoy app.
  • Procedure Facility Search – Our concierge will then begin the process of researching facilities and doctors for a procedure. We limit our search based on a member’s travel preferences and insurance network. We’ll use data from MRF feeds and carrier portals when working on these searches.
  • Factor in Quality Measurements – The concierge then ranks the remaining providers and facilities for a procedure based on board certification, training (medical school and residency program), experience (years in practice and procedures performed), government data, patient safety score, historical outcomes, and even patient reviews.

    We’ll evaluate the overall healthcare cost, particularly for self-funded groups, where both the employee and employer will bear the burden of costs. We’ll even compare the cash price versus the cost of going in-network. Believe it or not but the cash price for some procedures is cheaper for an employee than going in-network.
  • Review Available Pricing Information – We’ll use government, private and proprietary data to get an idea of historical pricing for both the facility and staff. Many times a specific doctor in the same facility will bill differently for a procedure, or the same procedure by the same doctor may vary greatly based on which facility it will be performed at. Confusing isn’t it? When working with major carriers such as Anthem BCBS, Cigna, or Aetna, pricing is more readily available. But what if an employer is working with a different carrier? We’ll work with the Plan Administrators, group historical claims data, and even reach out to a provider directly to get procedure pricing and make sure it is within expected ranges for the geographic area or less. On top of all this data, when members get their annual benefits enrollment packages, it’s often stored aside somewhere collecting dust and forgotten about. Our Healthcare Concierges will take the member’s FSA, HSA, HRA and any other wellness initiatives tied to the benefit plan that may influence our final recommendation. Some employers will offer HRA reimbursement by going to preferred providers or even pay full cost for a procedure.
  • Pick up the Phone – We are all for using advanced technology but sometimes verifying something on the phone is the best approach. Our concierge won’t make a recommendation without confirming the physician and/or facility is in-network and accepting new patients. We ask if they outsource any work to 3rd parties and confirm pricing when possible. We also will obtain scheduling options while on the phone and even ask about parking. We’ll do anything we can to make our member’s experience the best it can be.
  • Provide a Recommendation – Once complete, we provide members with a recommended provider and relevant information about that provider. We might provide a single or multiple recommendations, depending on the request and findings. This information is delivered via a ticket in the member’s HealthJoy inbox within our app. They can refer to it anytime in the future and ask follow-up questions.

Our concierge staff will go above and beyond to make sure our members are happy. We’ll also contact them after procedures to assist in any post-operative care and make sure that things went as planned. If our members have any unexpected items within a medical bill, we’ll encourage them to submit the bill for review. We constantly remind our members that our concierge and JOY are always available to help with all their healthcare needs.

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