There’s been a lot to say about the cost transparency legislation that came out a few years back from CMS. The final step in the legislation is due January 2024 and requires that health plans aka “payers” ensure that their members have access to far more robust and accurate cost of care tools. These enhanced tools must show accurate procedure costs for an episode of care (e.g., knee surgery) and apply where the member is within their plan year (amount of deductible or out-of-pocket met).  

Most payers are well on their way to updating their existing tools hidden in their portals and apps to ‘check the box’ on this legislation.  How many of them are seeing it as a moment to capitalize on consumerism and gain greater market share?   

Will health plan members use the updated cost estimator tools?  

Most health plan digital and business leaders are focused on how to get more traction from members on their apps. One national payer recently shared with us that the existing iteration of the estimate the cost of care tool was only responsible for 2% of traffic.  

 It’s important for health plans to step back and recognize that their members are first and foremost, patients. Patients are already inundated with the provider digital experiences that are far timelier and more relevant in their journey. Providers aren’t afraid to ask you for permission to send even sensitive information in the channel of your choosing. What are payers waiting for? Permission? Then go get it!   

Do you remember the last time you sought care? For me, it went something like this: 

Patient Text message: “Click here to prepare for your upcoming visit.” They’ve easily guided their patients through questions they formerly had to do in-person via paper, making them potentially late to begin an appointment. (E.g. HIPAA forms, insurance validation, COVID symptoms, etc.)  
Patient Text message: “Click here to pay your bill” They’ve guided you to the page where they can see the charges, the insurance applied discounts and their resulting out-of-pocket costs.  
Member snail mail or email: “View your explanation of benefits” – Payers often are later to the party and text is not a commonly used channel. 

One could argue that seeing the detailed EOB come isn’t that compelling unless you’re in sticker shock with your portion of the claim. The bill from the provider who is anxious for you to pay, already came and shows what your health plan paid.   

How can a payer become more relevant to their members?  

Know that they’ll never compete on the trust meter with the providers. Providers are paramount in health plan decision-making. Where does that leave the payer?  

Be specific and timely.
Show up as early and as often as possible to your member and treat them like a consumer of any goods or services. Payers focus too much on showing you what happened after you sought care through an explanation of benefits (EOB) and not enough before you seek care. Providers seek pre-authorizations from payers to ensure members have health plan coverage on more costly procedures. This is your moment, payers. Be proactive. You know that your member has OPTIONS for that care that vary greatly in cost. Make this known to the member. And get moving on a sophisticated preference center to help you reach them as soon as possible through the channel of their choice. 

Don’t bury the top 3 tools members need. Instead, extend them for greater use. 

Find a Doctor, find costs for Rx, and find costs for procedures 
Don’t be shy with your tools and think the only place for them is within an authenticated portal or app. If a payer is suffering from low portal usage, why not make it easier to get the member to these top tools from your public page. Enter your Group Number and off you go. 
Drive growth: Also do not think of these tools as ‘member only.’ Imagine you’re a prospective member and you have two companies’ plans to choose from. Are you going to choose the one who gives you all the real costs for known prescriptions and upcoming procedures or the one that won’t expose that content to you? Build trust if you want that slice of business.  

Imagine this: 

I prefer text messages to other channels. My health plan asks me what level of content I’m comfortable receiving via text. My health plan sends a me a text that says, “We see that your <insert dr. name here> has referred you for a foot surgery to <insert surgeon name here.> That surgeon is NOT within the health plan’s network. We suggest these three in-network options for you (graphic compares docs and costs). <I select one.> Given where you are in your plan year, you’ve met your deductible and your out-of-pocket cost would be X$$. Click here to make an appointment.”  

What might ultimately happen with all this price information being shared?  

From a B2B perspective, there’s no doubt that savvy brokers are already using the publicly posted “Top 500 procedure” files to put pressure on payers during new sales and renewals. Payer C-suite executives have also responded to surveys indicating that they’ll conduct analysis of prices in their market and adjust to ensure competitiveness.  

From the consumer perspective, this will finally give individuals a better sense of cost to help drive important health decisions. The quality metrics are not yet integrated, but I see that happening at some point to give a future integrated score. At that time, the health plan should suggest high value (cost and outcomes) to their members.  

Our Digital Healthcare Strategy team helps payers better understand their audiences and create tools that drive action and inspire constituent satisfaction.

Contact us today for more information.