Every healthcare consumer faces two major decision points—what plan to choose, and how to access low cost, high-quality care when they get sick. While much has been said about plan choice, particularly with the rise of insurance exchanges, it is the latter decision point that is becoming more critical with the fast rise of high-deductible plans, where decisions on which providers to use have a major financial impact on the consumer.

The challenge to the industry is to collect information that consumers now find valuable and present it to them in a relevant way, without overwhelming them with too much information. This requires combining skills such as data visualization and consumer psychology, to give enough information to “nudge” consumers in the right direction, but ensuring that they feel in control of their care decisions.

The ingredients to implement this vision exist already. What is needed is a bold rethinking of how healthcare organizations are seen today, evolving from current roles to that of health advisors. Giving useful information to their members in their most challenging moments, and helping them navigate the healthcare system more effectively will reduce medical costs, improve outcomes and increase consumer loyalty for the long term.

When consumers initially choose health plans, they are mostly balancing premiums and deductibles against access to as many providers as possible. At that moment, it can be extremely difficult to predict medical costs, and therefore out-of-pocket expenses, unless they are managing chronic conditions or known issues.

While tools to help with plan choice are important, in some ways they are less helpful than tools that help consumers make decisions once they need care, typically months after they’ve made a plan choice.

Today, most consumers use referrals as their main approach for choosing healthcare providers. These decisions could and should be made using data, but there are three major challenges today.

  • Current tools are too broad, not specific enough. Tools like Healthgrades or ZocDoc rely on consumer feedback, on a 1-to-5 rating scale. This is useful to capture consumer satisfaction and bedside manner, but it excludes clinical and cost components.
  • Price transparency is still a barrier. Network contracting makes it difficult to compare costs, and under the current system, both payers and providers have an incentive to keep these contracted rates confidential. It is also difficult to compare prices across procedures because patients are different – comorbidities or complications after surgery, for example, can result in significantly higher costs for otherwise similar procedures.
  • Outcomes data are still generic, difficult to translate to individual circumstances. It is now easier to research measures such as readmission rates by hospital, for example, and use those as an initial guide when looking for care. However, better providers tend to attract higher-risk patients, skewing their results. Raw measures of performance need to take patient risk factors (age, weight, comorbidities) into account to be useful.

Consumers need tools where they can supply detailed information about their healthcare challenges – including context on other medical conditions, as well as environmental factors such as nutrition, family, geography and work – and then use that information to create a plan of care in line with the members’ needs around cost, access and quality.

While it would be daunting to develop this kind of tool for every diagnostic code, the focus should be on complex, disruptive episodes of care, such as major surgery, cancer care or transplants. By focusing on high-cost health events where consumers can plan their care in advance and are looking for guidance, there is a much higher chance of success in reducing costs and improving outcomes.

Rather than just reporting on historical costs of a particular surgery at a particular hospital, for example, these tools must provide guidance throughout the whole episode of care.

  • Pre-procedure preparation, whether it is physical therapy, nutrition, identifying caregivers or working with employers to make accommodations. This is more than just cost averages, but what kinds of preparatory steps were most effective for similar patients, and how to implement those steps effectively.
  • How to choose a provider for the procedure, using data on cost and quality that is relevant to the patient’s medical condition and comorbidities, not just generic averages.
  • After a procedure, provide patients with real information on how long recovery could take, based on real claims data from patients like them, or extrapolating from similar patients; how much rehab will be needed; what strategies for pain management were most effective; how to go back to work, how to stay motivated and emotionally engaged, among other needs.
  • The vision here is to go beyond compiling cost tables for a specific procedure. It is about creating engagement through the weeks or months that the member will be interacting with the healthcare system, to create a situation where the member feels they have been substantially guided through every step of the process.

Some of this information could be crowdsourced; some could be obtained from claims or member surveys after procedures. Patient forums are quite popular online, as people that have overcome healthcare challenges are eager to share their hard-earned wisdom with others. Insurance companies can tap into their members’ knowledge for this content.

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Carlos Ariza

Carlos Ariza

Carlos Ariza is a healthcare expert for PA Consulting Group.