Consumerism in healthcare has been hailed by many including ourselves as one of the key components in solving the healthcare crisis in the U.S.

“…one of…”

Pushing cost to the patient is merely the first step. Without transparency, consumerism has the potentially devastating affects on the gains that wellness and disease management have begun to make.

Under Consumer Directed Health Plans (CDHP), the patient is responsible for more of the costs. They are often shocked to find that the cost of an office visit is $70, $80, $100 or more. They are distraught to discover that a diabetes maintenance drug runs them $750/month. So while CDHP help to make consumers accountable for the costs they incur, it provides a negative reinforcement as well.

Remembering that the last office visit cost them $80, patients may opt not to go for their annual physical. Aware that the medication was $750 last time, the patient halves the dosage or forgoes the prescription. Not knowing what the cost of a different service is going to be, but having been hit hard for other healthcare expenses, the patient simply avoids or delays care. None of these scenarios bodes well for wellness or disease management.

As a consumer, the patient needs to be educated on how the costs and how the healthcare system works. They need to understand that the annual physical may be covered under wellcare in their plan and comes at little or no cost. They need to know that the same $750 prescription can be had for $450 at a different pharmacy directly across the street. They need to know the cost of services when referred to a specialist before they go, lest they decide they cannot afford the risk of incurring a large expense.

Consumerism without cost transparency and education of the patient/consumer threatens to undo all of the positives that healthcare has been working so hard on in the form of wellness and disease management.

The answer lies in transparency in the system. Make healthcare transparent and the consumers will ferret out the inefficiencies in the system, make rational decisions about trade-offs in quality versus cost, and in the end, the patient/consumer will be the solution to improving the U.S. healthcare system.

Step 1 is Consumerism.

Step 2 is transparency about cost and understanding the health plan.

Step 3 is the consumer stepping in to make rational decisions about what defines quality and what warrants reasonable cost in the market.

That’s right!  Our new cost savings alerts for our TPA and employer clients (i.e. our employee users) are finally here… and boy are they hot stuff.  Now an employee can log into their change:healthcare account to see specific ways they can save money on their prescription expenses.  And all they really have to do is log in!

When they log in and click “YES! SHOW ME HOW NOW!” on the alert, we present them with all the information they need to go about making that smarter healthcare decision.  It sounds crazy… but it really is that simple.

Check it out! (Have no fear… consumers your alerts will be coming soon.)

New Cost Savings Alerts from change:healthcare on Vimeo.

Hi all- I’m Sara, the new summer intern at change:healthcare. I’m only two weeks in, but it has been great so far! Katrina asked me to write a blog post about anything my heart desired involving healthcare. So, I’ve decided to share some of my experiences from the last four weeks I spent doing medical work in Kampala, Uganda. This blog presents a unique opportunity to express some of what I experienced because most people only want to know if I saw a lion or if it was scary. While both of my stays in Africa have been full of adventures (like a safari during which I did see a lion, bungee jumping over/rafting the Nile, and climbing Mt. Kilimanjaro- no big deal), these in no way sum up my time there. This summer my work helped me understand the flaws and successes of the Ugandan healthcare system. I worked at a place called Meeting Point (MP), a rather unique site assignment. It is hard to sum MP in one or two words because it provides so many services to the surrounding community. The assistance MP provides includes adherence counseling; home visits to their HIV positive clients; a welcome home for 40 AIDS orphans; vocational education for older children who never received any formal education; and primary level education to local children. They also supplied food to many of their clients until the resources they received from the World Food Program (WFP) were cut due to the need in the Northern region of the country. Obviously, they cover quite a bit of ground.

Part of my daily routine consisted of accompanying an HIV counselor on home visits in the communities surrounding their offices. Over the course of four weeks, I must have visited over 70 homes and families. The complaints of most involved hunger due to the lack of support from the WFP or the need for school fees to keep their children in school (MP also sponsors hundreds of children’s school fees). I learned so much about the indirect effects the HIV/AIDS epidemic has on the lives of those affected. I met numerous parentless families where children were fending for themselves or families run by grandparents who are now responsible for multiple generations of children. I often met women left caring for as many as eight children on their own due to abandonment (Uganda has the third highest birthrate in the world with a fertility rate of 6.6 children per woman, so large families are the norm). Talk about being a single parent. It was not until I visited a woman named Miriam on my third day of home visits that I saw firsthand the devastating effect HIV/AIDS could have on a person physically.

Miriam is a woman in her mid-twenties who is HIV positive and has developed tuberculosis because of her weakened immune system. She has been taking both antiretroviral drugs (ARVs) and TB medication for the last four months. The combination of ARVs and TB meds has had a significant effect on her mobility and strength. When I visited Miriam, she could only sit up in her bed and her entire collarbone and all her ribs were visible. The combination of both powerful medications has resulted in peripheral neuropathy (paralysis) on the left side of Miriam’s body and she said she could feel the right side of her body succumbing to paralysis as well. Sitting up took nearly all of her energy. She knew she needed to get to the hospital because of her weakened state, fever, and because her lungs were filled with fluid, but she didn’t have money for transport or any phone credit to call a MP counselor (keep in mind, transport to the hospital would cost roughly 5 USD and a phone call 20 cents). She simply had to wait for someone to visit her. Luckily, the day after our visit the staff arranged for Miriam to go to the hospital to receive care.

While Miriam was the first of many HIV/AIDS patients I met who were suffering a great deal physically, there was a common thread connecting all of their situations- a lack of access to care due to physical and economic barriers. Without the help of the MP counselors and community workers, it is unlikely many of the clients would be able to access the care they need. While numerous HIV/AIDS programs throughout Kampala provide free clinical services and medications, (the running joke is that there are more NGOs than children), what good are they if the services are not accessible? This issue of access does not pervade only the developing world. US residents of urban areas with poor public transportation systems or of scattered rural areas also experience difficulties accessing care. Citizens of both countries face varying levels of economic struggles to receive healthcare services as well. An HIV test at one of the private hospitals in Kampala costs 20,000 Uganda shillings (roughly 9.50 USD), but the average Ugandan makes less than 30 USD each week. If the choices are getting an HIV test or feeding their children, which do you think they will choose? Luckily, MP has worked to overcome both of these barriers by getting out into the communities and ensuring their clients can gain access to the services and care they need.  This practice of meeting people where they are has been the hallmark of the work and projects of Partners in Health, who initiated a similar project here in the US to assist marginalized HIV patients in Boston. Learn more here. (Remember, HIV/AIDS hasn’t skipped over the US. A report published by the District of Columbia’s HIV/AIDS Administration just a few months ago estimated that 3% of people residing in the nation’s capital are HIV positive. Check out the report here.)

While the US healthcare system is anything but perfect, my time in Uganda made me appreciate our system as broken as it may be. The battle against HIV/AIDS in Uganda is one of the continents greatest successes with a national infection rate of “only” 5.4%. Rates, however, are increasing and experts are working to understand why. While I can do a fair bit of complaining about the cracks and flaws of our system, witnessing the healthcare struggles experienced by those in the developing world has definitely given me a new perspective as to how lucky I am to have access to the 37^th best healthcare system in the world. (Uganda is ranked 149^th out of 190 by the WHO.) To learn more about the current HIV/AIDS situation in Uganda and worldwide, you can check out the UNAIDS 2008 Report on the global AIDS epidemic.

Some of the students who attend MP's primary school.

My place of work for four weeks in the district of Namuwongo.

Today, change:healthcare had two great health care questions that I thought I should share with the rest of the change:healthcare community.  Remember, we are hear to help and answer your questions… so let us know if we can be of service!

First user question: I had surgery and received a bill for anesthesia. When I called the insurance co. they informed me the provider was out of network, therefore I was charged per the terms of the contract (40% of bill). I was never told by anyone that the provider was out of network prior to surgery. Am I responsible to pay bill?? I have already reached the maximum annual out of pocket expense BEFORE the anesthesia bill. Do I have any recourse and if so who do I address it with.

This is a great question because it happens frequently.  Oftentimes, the facility will be in-network, but the anesthesiologist is contracted through the facility and out-of-network for you as the patient. Here is the answer:  If the patient signed a contact with the facility that performed the procedure, prior to receiving services, agreeing to pay for services provided by out-of-network physicians, then there really is nothing that can be done.

However, if the patient did not sign any paper work the best place to start conversations is at the facility level. Begin by calling the billing department number included on the bill.  If the patient was not notified prior to surgery that the facility may use out of network physicians, then they should be willing to provide  in-network pricing for those providers.

At this point it can be helpful to contact your insurance company and see what a reasonable reimbursement would be for an in-network anesthesiologist.  This will provide you with a great baseline for negotiating with the hospital.  You may also want to check with them regarding refiling the claim. This will help with getting the insurance company to cover more of the costs.

Second user question: Can a company keep changing insurance carriers every year?  Are employees protected if their doctor then becomes out-of-network?

This is another great question. I imagine that employees are seeing this occur more frequently as health care cost and insurance rates continue to increase.  Here is the answer: Unfortunately, a company can change insurance carriers every year.  This is probably occurring due to increasing rates, which are sometimes upward of 30%.  They are probably having multiple carriers bid on the company’s health insurance coverage and then going with the option that proposes the lowest cost increase. This is a method some companies use in an attempt to maintain health care cost increases.

Unfortunately, employees are entitled to have their physicians included in the company’s new insurance network, or offered protection if a shift in network coverage occurs. The best thing to do in this case is to speak directly with your physician and/or the physician’s billing department.  If you speak with the billing department, inform them of how long you have been a patient, and that your company recently switched insurance companies, making your doctor out-of-network. The physician may be willing to offer you an in-network rate for their services.

If not, make sure you understand how much of the bill you will be responsible for when the doctor’s charges and services are processed out of network.

For more information on understanding In vs. Out-of-Network Healthcare Cost click here (0).

I am soooo behind on sharing everything that is going on around me related to healthcare, employers, consumerism, and the proposed government ‘public plan’ for healthcare [I get 2-3 phone calls a week from various system constituents and politicians posing questions, ideas, or plans around healthcare consumerism].  However, what causes me to perk up is when ‘front-line and in-the-trenches’ discussions surface across the blog-o-sphere such as the one taking place over on Dr. Jay Parkinson’s blog of HelloHealth [click here for the blog post].

Of most interest to me (selfishly) is an insightful comment made by the Orthopod:

…In one of the only examples of its kind, a true randomized placebo trial was published on this in NEJM and there was found to be no difference in outcome for knee scope in pts with joint space narrowing, yet the procedure continues to be done at a very high rate.  Why?  Because it pays $800-$1000.  And it takes 1/2 hour.  In fact there are studies showing that people who get scoped, go on to get a knee replacement sooner.   I don’t know if any committee is the solution.  Since patients don’t pay their own money, they are not incentivized to ask the right questions or be skeptical enough. And the CMS fixed pie system makes the PMD/ specialist war almost inevitable.  Sad.

PUH-LEAZ-EEEEE  go read the full post but MORE IMPORTANTLY read further down where the Orthopod adds a longer follow-up comment.  This frame of reference from the front-line is worth the 10min time it takes to read.

Nice, Jay. Simply Nice and Well framed.

By: Kat Sanders (more info on the author below)

There was a time when you had to choose between engineering and medicine even though you were equally inclined to both. The situation has undergone a vast change today, and you have common ground between technology and medicine in the form of healthcare IT. Although it is a relatively fledgling field, it is beginning to become popular by the day even though there are still various hurdles that need to be crossed. If we’re gunning for the success of healthcare IT and EMR systems across the entire healthcare spectrum, we need to ensure that:

• The doctors are as much a part of it as the tech guys: When a system is designed, it goes without saying that the end user must be the most important person to be considered. It is their use and comfort that must be put above everything else. So a system must be designed to suit doctors’ needs rather than be the most sophisticated of its kind.

• The system is easy enough for even the older doctors to understand: The younger crowd of medicos is more tech-savvy and able to relate to the meeting point between technology and medicine and harness their iPods and iPhones to provide them with the information they need to treat their patients much more efficiently. It’s the older ones who are skeptical about the new-fangled technology and reluctant to use it. They must be targeted, trained and convinced if EMR systems and other IT innovations related to healthcare are to be a universal success.

• The doctors with more experience are roped in for their expertise: One way to involve the older doctors and specialists is to enlist their help in preparing knowledge bases that are then interpreted and translated into IT systems using the correct logic. They are there to give the tech personnel their expertise so that it can be used to provide accurate information when treating patients.

• The medical personnel are given enough training: A system is only as good as the person using it, so unless a doctor is given training in using the system, it could turn out to be a damp squib. There will be an initial resistance period, but with persistence, doctors who welcome positive changes are able to understand that this is the future of medicine and patient care.

• Any change is consensual and cooperative: And finally, any new changes or additions to the system must be made only with the consent and cooperation of the people who are using them. Only when there is a mutual understanding between the people who write the systems and those who use it will be possible for these healthcare IT systems to become a routine entity in every hospital and healthcare facility across the world.

This article is written by Kat Sanders, who regularly blogs on the topic of surgical tech schools at her blog iScrub. She welcomes your comments and questions at her email address: katsanders25@gmail.com

change:healthcare’s COO Robert Hendrick has been featured  in several stories (practically across the country) for tweeting his outpatient surgery last October. Recently the Kansas City Star plublished a story about ‘Twitter’ titled “More people flock to Twitter as a conduit for information.”

Highlight: “Hendrick is a co-founder of Change:Healthcare, a business that helps clients save money on health care. Hendrick said that twittering his surgery was a way to show people the process and educate them. ‘2 veins down. 2 to go. 1 lower left leg. 1 lower right leg. Top left leg done,’ he tweeted from what he described to his followers as a cold operating room. Twittering, Hendrick said, “gave me a sense of connection to people during the surgery.”

Check out the full story online at the Kansas City Star website or download the PDF here.

As of April 1 in Illinois, they have taken step 1 in protecting the uninsured. A new law caps uninsured patient bills at cost +35%.

Hooray! A good first step!

Now don’t rest on your laurels, Illinois.

Cost plus is great if you can understand the “costs” portion, but most patients do not. Step 2 is to root out the inefficiencies and poor procedures.

For example, it’s reasonable to charge someone an amount for a service well done and efficiently. But for the patient who gets 5 nurses at bedside, 3 specialists and the whole battery of tests to determine that he has a splinter, cost plus is not effective. Cost plus just rewards the hospital with an amount they can pursue aggressively and justifiably in collections. The patient may still be exposed to inefficiencies like improper diagnosis, inappropriate treatment and inefficient practices.

Step 1 is easy. Now for the hard part. Step 2 - improve the standard of care.

Still, congrats to you Illinois!

In a recent survey conducted by Hewitt Associates, about 20% of employers said they are planning to stop offering health benefits over the next three to five years.

Sad… as if we need another player in the health care game to quit! See Workforce Management for more details on the study.

Equally as interesting as those planning on leaving the game are the priorities of the employers who plan to continue to offer benefits. “Promoting employee accountability” was ranked as the number one component of employers 2009 health care strategies. “Offering competitive benefits” and “managing health risk” came in at second and third.

What I have to say is directed at those who plan on dropping benefits and those who plan on keeping benefits and promoting employee accountability:

LET change:healthcare HELP!!! Our site and online tools help employees save money (which saves the employer money) and make smarter healthcare decisions.

The problem is apparent… we are asking employees to be responsible for their health and healthcare when they still do not know what health care really costs, they do not have enough skin in the game ($20 co-pays are not going to increase responsibility) to care, and those who are on CDHPs are lacking the tools to understand how to save money and make better decisions.

The message to employees is simple … we want you to get engaged.  There are tools out there (if we are working with your employer) that will show you simple and tangible ways to save money on your healthcare… tools that will show you what your peers paid (the network price) for services and prescriptions you need, allowing you to proactively research costs and quality, allowing you to become an active participant in your healthcare.

The action for employers… call change:healthcare.  We want to help you preserve your benefits and engage (keep) your employees. We want to help you save 30% on your healthcare.

Healthcare does not have to be daunting and saving money does not have to be hard.  Let us show you how we make both of these things simple!

change:healthcare inc. is seeking a motivated individual looking to gain experience in the fast paced internet-based healthcare technology industry. Tasks for this position would range from assisting with health industry research to evaluating current and competitive products. Assist in coordinating implementation, facilitate/create new marketing campaigns, and participate in the product development process.

Distinguishing Characteristics:
Applicants should possess an interest in healthcare and its impact of society, Web 2.0, social networks, as well as the industry transition to increase quality measures, consumerism, health data exchange, and cost transparency tools. Strong social and communication skills, self-starter, entrepreneurially minded.

Email your resume and cover letter to info@changehealthcare.com.