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Health plans providing detailed cost estimates of doctor visits

Patients could come to a physician’s office with down-to-the-penny prices and compare negotiated rates for multiple physicians and hospitals.

By — Posted May 15, 2012

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Health insurers have replaced online tools that showed only rough guesses as to how much a doctor’s visit will cost with new ones that estimate specific dollar amounts for both overall and patient out-of-pocket costs.

During the past year, several health plans have released new versions or made significant updates to their cost estimation tools. The newer tools show not just a negotiated price but also the anticipated cost to a patient based on his or her benefit plan, as well as how much of the deductible is met. The projection is accompanied by a disclaimer noting that the insurer can’t guarantee its accuracy, but insurers say their updated tools are far better than the old versions.

“There was a confluence of factors in the last year or so. … I think that there’s just this absolute recognition of the need to do this more effectively for consumers,” said Dena Bravata, MD, chief medical officer for Castlight Health, a San Francisco-based firm that provides online health care cost estimates to patients on behalf of employers and health plans. On May 1, the 4-year-old company announced it had received a round of $100 million in venture capital financing.

Health plan executives say they hope the improved tools will mean consumer-directed health care meets its potential, encouraging patients to shop for the best care at the best price.

Precise estimates could boost the power the health plan has to drive patients to certain physicians over others. For example, Aetna is using the cost estimates and clinical quality data to suggest nearby high-quality, lower-cost physicians to members searching for a doctor.

The American Medical Association has raised concerns about cost comparison tools that give physician-specific information, citing research showing that cost profiling often is incorrect. A 2010 RAND Corp. study found that Massachusetts insurers using cost profiling miscategorized as many as 22% of physicians.

The AMA cited the RAND research in a July 2010 letter to insurers calling on them to back off physician cost profiling until an independent third party could vouch for its accuracy.

Health plans say they have been careful to develop cost estimates in a way that allows physicians to see what members see. Plan representatives also said physician websites and local network representatives are able to help a doctor find out what cost data are presented and to correct any inaccuracies.

The AMA and other physician organizations also have been critical of health plans’ listing cost information in isolation from meaningful quality indicators.

Dr. Bravata said it’s essential to pair cost information with clinical quality indicators, something all health plans say they do.

“If patients see only cost information, they will use cost as a proxy for quality,” she said. The latest cost estimation tools list some indication of relative clinical quality, though that depends on the plan and the physician. In some cases, the clinical quality “data” are simply a listing of a physician’s board certifications.

Cigna, based in Bloomfield, Conn., introduced a new version of its cost estimation tool in March, with much more detailed out-of-pocket cost projections and another major difference: The “Find a Physician” tool gives members not only the names and addresses or physicians, but an estimate of how much an office visit with that doctor will cost. Those projections are based on six years’ worth of claims data, said Marie Jinks, director of e-Business for Cigna. So far, 90% of the estimates are within 10% of the actual cost when the patient sees the physician and a claim is generated, she said.

In March, Jinks said, 300,000 people conducted 1 million searches using Cigna’s network directory tool, and 200,000 of those searches produced a cost estimate.

Chris Riedl, head of Consumerism and Product Innovation at Aetna, said the Hartford, Conn.-based plan did a major update to its tool two years ago and has made smaller updates this year, including a tool to help members project out-of-network care costs.

Jay Eisenstock, head of Provider eSolutions at Aetna, said the cost estimate tools could help physicians: When patients know ahead of time how much care will cost, they are more likely to be ready to pay their share at the time of service. (See correction)

WellPoint, the Indianapolis-based parent company of Blues plans in 14 states, launched its Care Comparison tool in 2006. Since then the tool has been adopted by the other members of the Blue Cross and Blue Shield Assn., said George Lenko, WellPoint’s program director for national network initiatives.

Like Aetna and Cigna, WellPoint’s most recent updates to Care Comparison show an out-of-pocket estimate based on members’ own benefit information and how much of their deductible is met. “People expect this information to be at their fingertips,” Lenko said.

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