More than half of Americans have experienced the sick feeling that comes with opening a medical bill they assumed would be covered by insurance. Surprise medical bills are on the rise, often driven by services administered at an in-network facility using out-of-network providers.
A Journal of the American Medical Association(JAMA)analysis of privately insured patients showed that between 2010 and 2016, inpatient admissions with an out-of-network bill increased 16%, and emergency department (ED) admissions with out-of-network billing went up more than 10 percent.
As alarming as the number of surprise bills is the impact on patients’ pocketbooks. In the same timeframe, potential patient liability skyrocketed from $804 to $2,040 for inpatient services and from $220 to $628 for ED visits.
Price transparency and accurate estimates are critical to preventing surprise bills and giving patients more control over their healthcare spending. Many providers are experiencing increases in self-pay patients, often because patients have a high-deductible plan that requires significant out-of-pocket before coverage kicks in. As such, patients need the ability to compare prices across providers and get accurate estimates of what they’ll owe before making healthcare decisions.
Why healthcare bill estimates are so difficult
Many factors contribute to the historical absence of bill estimates, but it starts with healthcare payment system fundamentals. Unlike other industries where transactions involve a buyer and a seller, healthcare brings in a third party, the payer, who is typically reluctant to reveal publicly what they pay various providers for services. Contracts, discounts, coding and other variables make it inherently difficult to achieve price transparency.
Price transparency progress
A step toward more price transparency came when the Centers for Medicare & Medicaid Services (CMS) required hospitals to publish their chargemasters online, starting January 1, 2019. Unfortunately, neither consumers nor many hospital employees could translate the data into usable, patient-specific bill estimates. In fact, more than half of hospitals in a 2019 survey said the move created further confusion.
In June 2019, President Trump issued an Executive Order to improve healthcare price and quality transparency. CMS later issued a final rule expanding current requirements for hospitals. These include providing a machine-readable file containing negotiated rates for all items and services annually and a consumer-friendly display of gross and negotiated rates for 300 “shoppable” items and services, including 70 defined by CMS. Insurers would also be required to provide members personalized out-of-pocket costs for all covered services in advance. These new rules are planned to take effect Jan. 1, 2021.
Response from Oliver Lignell, vice president, virtual health, AVIA
Providers have a new tool to help them combat COVID-19: digital. Health systems are proactively leveraging digital assets to help triage, navigate, and treat cases in ways that address concerns and also reduce the spread of the virus to other patients and providers.
Virtual assistants and chatbots can help consumers explore symptoms, accurately triage their needs, and navigate them to the appropriate site of care. These solutions can both reduce consumer worries and potentially inappropriate use of EDs and urgent care clinics.
Virtual visits are another critical digital tool because they allow patients to complete a visit from the safety and comfort of their home without exposing them to crowded and potentially infectious clinical locations and, just as importantly, reduces wait times and crowds at in-person care sites.
Asynchronous virtual visits (store and forward, text/chat) can also be an important (and low-cost) solution. Consumers can initiate a low acuity visit on-demand, when convenient, ensuring their concerns are addressed when desired – with the added benefit of decreasing wait times, creating a more efficient patient flow, and freeing up provider capacity. Such solutions further reduce the pressure on health systems while improving the responsiveness to patients.
Response from Andrea Tait, vice president of Client Value, Orion Health
Digital tools can play a key role as healthcare providers across the globe struggle to maintain the health of their workforce and the capacity of their organizations. Pandemic response is best supported through triaging, testing and treating the affected. Tools like public-facing screeners, pandemic information sites and chatbots can help evaluate millions of people with little to no clinician support.
By triaging individuals, tools like remote patient monitoring and telehealth can be used to monitor patients from their homes and assure others that sheltering in place is sufficient. Remote monitoring tools allow clinicians to monitor more patients and make decisions about who may require testing. Designated testing sites minimize the need for direct interaction between healthcare providers and patients, preserving both the health and capacity of health service providers.
Integrated care pathways and telehealth tools can help clinicians treat more patients at home and discharge those in hospitals who may be safer receiving treatment for other conditions remotely, all while minimizing their own risk. Home and community delivered care is an increasingly essential component of healthcare system sustainability. Now, more than ever, these tools and strategies are fundamental to the future of the healthcare system.
Digital solutions can be employed in seemingly non-traditional ways to both prepare and respond to the impact of the coronavirus. For healthcare organizations, traditional pre-access telephone dialing metrics can be modified. Hospital registration staff, in addition to financial guidance and scheduling, can screen patients for COVID-19 and obtain additional clinical information in advance of arrival.
By identifying potentially infected patients, even before they enter the hospital, hospitals and clinics are able to communicate effectively within the facility and plan for appropriate patient care, monitor and manage potential for healthcare personnel COVID-19 exposure, and inhibit the spread of the disease both within the facility and community.
Equally important and sometimes forgotten, back-end services provided by both hospital staff and revenue cycle vendors yields the same patient communication opportunities. Discharged patient follow up and screening post-discharge keeps the patients connected and engaged with the hospital as well as preserves an open communication line between the hospital and discharged patient.
Response from Matthew A. Michela, president and CEO, Life Image
The coronavirus has manifested the importance of digital solutions and interoperability in a heightened way. The lack of digital connections to community referral sites will impact the safety of patients and healthcare staff. It is imperative during this public health crisis that attending healthcare workers have as much relevant clinical data in advance as possible through digital connections.
Unfortunately, many healthcare organizations are still deploying outdated technology, such as imaging CDs, and the last thing a provider or hospital should want is a patient who is symptomatic or potentially a carrier of a virus to show up with a CD in hand. This presents a problem on multiple levels, from the lack of care coordination to the risk of disease spread.
The technology is available and many large health systems are set up to support digital exchange, so they need to mandate protocols to exchange information in this manner. In the same way that the public is asked to wash their hands and frontline workers are urged to wear masks, healthcare professionals should insist that medical data is received digitally for fast, efficient care.
As we face the COVID-19 pandemic, it is important for hospital organizations to ensure information is delivered in real time, accurately, and highly customized to the intended audience (patients, visitors, clinicians, etc.). It can be beneficial for hospitals to automatically deliver COVID-19 patient education videos tailored for each patient’s demographics, language, and clinical circumstances.
This also includes educational content and notifications (visitor restrictions, live updates, social distancing practices, etc.) on digital signage locations in public areas throughout hospitals. That content can be delivered in notifications or in response to Real-Time Location System (RTLS) triggers (for example, if a clinician enters the room, the patient’s TV will display hand washing reminders).
RTLS integration can also track and report staff entries into patient rooms so hospital leaders have real-time data about potential exposures, isolation violations, or interactions with non-approved staff. Interactive surveys with branch logic can help guide patients to provide vital feedback and report any hand hygiene breaches. Digital meal ordering, service requests, and virtual visits decrease human-to-human contact while helping patients get the food, care, services, and items they need. Live streaming (either soothing content like an aquarium or information sources) can also provide distraction therapy and education for patients in isolation.
In the past few years, healthcare providers have felt the pain of an industry in transition, as regulations evolve, value-based reimbursement takes hold and costs continue to climb. Rural hospitals face additional, unique challenges. Patient volume is shrinking, healthcare workers are hard to find and, because many patients can’t afford high out-of-pocket costs, hospitals often go uncompensated for the care their providers deliver.
The consequences are sobering. Since 2005, 155 rural hospitals have closed, with 16 succumbing to financial pressures already in 2019. As alarming as the number of closures is the rate of increase. From 2005 to 2012, an average of seven hospitals closed each year. Since then, the average has doubled to almost 14 hospitals per year.
Fast action is needed
The rural hospital crisis in America is not going unnoticed. Several bills to improve payment and delivery models have been introduced in Congress. The Centers for Medicare & Medicaid Services (CMS) devised a Rural Health Strategy to expand access to care through telehealth, adjust the Medicare wage index to increase payments for rural, low-wage hospitals, and help transition rural providers to value-based payment models. And, advocacy groups continually push for action.
Effecting change in these ways, however, takes time, something rural hospitals do not have. Nearly half are losing money and 21 percent are at high risk of closing unless their financial conditions materially improve. While rural hospitals can do little to accelerate legislation or adoption of national initiatives, there is an area they can impact quickly on their own: uncompensated care.
Uncompensated care: The realities
Rural hospitals have trouble getting paid for many reasons, starting with patients being uninsured or underinsured. Because rural markets are smaller, there are fewer commercial health insurance options and premiums tend to be higher. Even high-deductible health plans with lower premiums can’t solve the problem, as deductibles and cost-sharing requirements push rural Americans’ healthcare costs relative to income higher than their urban counterparts’.
Rural residents tend to be older, sicker and poorer, and many rely on Medicare and/or Medicaid. Particularly in states that did not expand Medicaid to cover more low-income Americans, churn between eligibility and ineligibility can lead to gaps in coverage. Since rural consumers tend to have lower health literacy, Internet access and cell phone connectivity, they have more difficulty finding and understanding insurance and what they may qualify for. As a result of all these issues, more than nine percent of people in rural areas went without insurance of any kind in 2017.
Family finances are another barrier to paying for healthcare. Nearly half of rural Americans say they can’t pay an unexpected $1,000 expense right away. Four in 10 have had trouble paying medical bills in the past and 45 percent didn’t seek healthcare because they couldn’t afford it.
Changing the patient financial experience
Knowing the challenges their patients face, rural hospitals can take steps to both lighten those burdens and increase collections. Perhaps the most important is to improve the patient financial experience by offering services and assistance people are accustomed to as consumers.
Simplifying registration and financial processes to alleviate fear and frustration is key. As providers across the board are doing, rural hospitals should provide bill estimates and confirm insurance eligibility upfront, so patients know what they are responsible for before receiving care. Using financial assessment tools, registration staff can determine patients’ propensity to pay and personalize payment plans to increase the likelihood of collecting the full amount owed.