Cost transparency coming into sharper focus

Robin Gelburd Founding president of FAIR Health

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Q&A talks with Robin Gelburd, founding president of FAIR Health, a New York-based nonprofit that aims to advance healthcare cost transparency.

Q: With a grant from the Connecticut Health Foundation, FAIR Health (FH) in September launched a free mobile app called FH Cost Lookup CT, which allows consumers to view zip-code specific pricing data for a wide array of medical billing codes. What sorts of health consumers benefit the most from such an app and why?

A: Research continues to show that most Americans, particularly Hispanic consumers and the newly insured, lack the necessary understanding of health insurance to make informed decisions when selecting a plan, provider or treatment. Yet, consumers are also responsible for an increasing portion of health costs.

Uninsured consumers can use the app, which offers both English and Spanish options, to better understand the “value proposition” of health insurance by estimating their costs for needed services with and without coverage and to estimate their medical and dental expenses for services they will receive, and negotiate their costs beforehand.

Insured consumers can use the app to estimate their healthcare expenses before receiving care to decide whether to go out of network or stay in network. After receiving care they can use the app when reviewing billing forms to decide whether to appeal a reimbursement decision.

Q: The cost information in the app is based on claims data submitted to FH by insurers, which have been averse to publicly disclosing their contracted pricing with providers. Why do insurers share this data with your company?

A: There are many reasons why more than 60 payers and administrators covering more than 150 million individuals contribute data to FH, which is recognized as an independent, trusted steward of medical and dental claims.

First, they receive credits that reduce the licensing fees for the data products, custom analytics and detailed reports they license from FH. They also receive valuable feedback on the quality of the data they submit. All data submitted gets subjected to robust auditing and validation processes at FH.

Moreover, contributors recognize the public service of contributing to the FH data repository. By submitting claims to FH, a contributor ensures that its experience will be represented in a database that is used by payers and all other stakeholders in the healthcare industry nationwide.

Q: A “menu” of healthcare prices in every hospital and doctor's office seems unlikely in the near term, but the private sector has sought to step into the space. In Connecticut, Anthem offers Castlight software to show pricing and quality data to its members. Aetna has a payment estimator tool for its members that shows negotiated rates. Where does FH fit into this broader picture?

A: Some insurers license FH data for use in their member-cost calculator tools. Others “private label” our website, which allows them to capitalize on the value of our data and educational resources while maintaining their own brand and logo. Still others license a link to our site so that their members can benefit from the information we offer. Some plans even license our consumer tools to serve as a resource for their customer-service representatives as they interface with members and field questions and inquiries.

FH data also feature prominently in healthcare consumer protection laws in New York and Connecticut. In Connecticut, consumer protection laws require insurers to use the FH 80th percentile as the 'usual, customary and reasonable' standard for payments for out-of-network emergency services. Many other states that are considering similar legislation are speaking with FH about its data.

Finally, the FH repository is effectively a multi-payer claims database that contains data from major insurers nationwide, including self-insured plans, and features the largest collection of privately billed medical and dental claims data nationwide.

Q: What do you think the future holds for price transparency in health care?

A: While price transparency is a critical starting point for driving improvement in our healthcare system, we also will need clarity to effect real change.

Clarity involves making price data actionable by adding the needed context to support decision making for all stakeholders, including payers, plan sponsors, purchasers, researchers, practitioners and consumers.