Medical Cost Estimator

The tool that helps avoid surprise medical bills

This test case is dedicated to the improvement of the user experience in calculating medical costs.

Health care prices are vague, and patients are always uncertain about them. As healthcare plans got higher deductibles, coinsurances and out-of-pockets, the affordability of health care has received significant attention. Patients are increasingly wondering how much does it cost.

Therefore, empowering patients with the information they need so they can make decisions based on cost and quality has become an important element of helping patients receive more affordable care.

Equipped with knowledge consumers will drive healthcare quality because healthcare providers will compete for patients and so they will strive to deliver better results as well as competitive prices.

Health insurers will reduce their expenses on compensations and will be able to lower insurance premiums and/or provide better healthcare plans benefits in perspective.

All these factors indicate the need to have a tool that would help patients in calculating medical costs. In fact, there is a variety of new websites and tools on health insurance provider’s websites that provide information directly to patients about the charges that they could face.

Despite this, fewer than 1% of patients used price transparency tools and services. Why are they used so rarely if they are so needed?

I tried to conduct user interviews accompanied with my own research to address this question. Also, I wanted to figure out other complications the patients faced with during choosing healthcare provider and determining the final treatment cost.

Some user interview’s results:

Do you hesitate to get medical care? Why?

- Yes, because the price of the care is uncertain ahead of time. (participant 1)

- Yes. Because they are expensive especially if you are not working or if are self-employed (participant 2)

- No (participant 3)

- No. I always take care of my health (participant 4).

- Yes. Having a plan with high deductible doesn’t let me visit a doctor whenever I need it. I have to pay a lot out of pocket. (participant 5).

If it becomes necessary to consult a doctor where do you usually start? What interests you most of all (besides diagnosis)?

- My insurance website; I need to find one in-network. (participant 1)

- I usually google search for doctors who have the highest ratings. Do you try to find their prices? Not if I have an insurance (with low deductible), if not absolutely (participant 2)

- If it’s something urgent then I go to urgent care, otherwise to my therapist (participant 3)

- When I want go to see a doctor, first, I try to find out background history, education history of this doctor. The years of experience in medical field are very important to me. (participant 4)

- First, I try to find a good doctor by reading reviews, doctor’s background and ratings. After that, I try to check their prices and compare them with average prices for the same procedure. I use free online tools to check the price. (participant 5)

What actions do you take after the doctor has prescribed lab tests, procedures or treatment?

- Make sure they are in-network and try to find out the price. (participant 1)

- I call my insurance company to find out the price out of pocket (participant 2)

- I do them if they are required. (participant 3)

- When doctor has prescribed me to do testing and treatment, I double check if he is correct (participant 4)

- Try to find out how much it will cost to me, then I decide whether I can afford them. (participant 5)

How do you know what price will you get and how much will be covered by your insurance?

- The doctor will let me know, but there are often “surprises”. Sometimes, my insurance has a website that shows the price. If not, I will call the provider or pharmacy to find out the price. Often the price comes out more than they say in the beginning (but never less, for some reason). (participant 1)

- I will find the answer (cost to me) from insurance company first before moving forward with any other suggested or recommended treatment from doctor. (participant 2)

- I ask receptionist to print paper with all calculations (participant 3)

- If I’m not sure about how much I have to pay, I usually call the insurance (participant 4)

- I don’t. The doctor’s prices and bill prices are different. Sometimes hospitals include some additional fees which insurance company refuses to cover. In my case, the insurance covered some part of medical procedures, but didn’t pay for hospital fee. (participant 5)

If you ask your healthcare provider for the price, how do you know that you’ve been offered a fair price?

- It’s hard to compare since prices are not published (yet). (participant 1)

- Since we already have health/medical insurance, I don’t research this. I really don’t. I just accept their answer (or copay) and move forward if our finances allow it. Otherwise, if it may be life threatening (I.e. cancer of some sort) then, sadly we will charge this expense on a credit card. (participant 2)

- I don’t know, just trust them (participant 3)

- I call my insurance to make sure my doctor’s services are covered by insurance (participant 4)

- I try check the price on online resources and compare it with the hospital price (participant 5)

How do you avoid a surprise bill?

- It’s hard; even if you use an in-network provider. (participant 1)

- I really don’t. I guess I just accept their answer and move forward if our finances allow it. (participant 2)

- I didn’t have one (participant 3)

- I will get the second opinion and the second price from another doctor. (participant 4)

- I never know for sure what I will have to pay in the end. (participant 5)

Takeaways from user interviews and my research:

· People are vulnerable and cannot control the situation if it comes to medical services.

· The majority of respondents have overall good health and the insurance from their work with good insurance plan terms, thus they are less concerned about prices. However, those of them who are self-employed or had to get more comprehensive treatment than regular physical, are faced with the issue of uncertain and high prices for medical services.

· There is no point in asking the price of a health care provider or pharmacy. You will pay a negotiated price anyway (the price your insurance company has negotiated with health care provider).

· Cost estimates on the insurance web sites are averages based on claims data, so the actual costs will be different depending on factors such as member’s health plan design, deductibles/co-insurance and out-of-pocket limits. To get a price that takes into account all patient’s plan benefits you have to request a price estimate from the provider.

· If the procedure is done before the insurance plan approves it, you could be responsible for the full cost, with the insurer paying nothing. Health insurance companies use the prior authorization or pre-approval process to verify that a certain drug, procedure, or service is medically necessary before it is done (or the prescription is filled).

· You may be more likely to get out-of-network services (often for a lower price) covered if your plan does not offer a medically necessary service.

· The price of procedures is just one small portion of what a patient is expected to pay to the hospital. For most procedures, other services are included in the final bill including “facility fees,” medical supplies, physician’s fee, etc.

· Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors. Very often patients end up with big bills because they went to an in-network hospital but were seen by an out-of-network doctor.

· More than one-third of the health care services did not help patients get better.

Considering all of the above, I decided to focus on Blue Cross Blue Shield (BCBS) company and improve their attempt to provide comprehensive information about quality and cost of medical procedures and services to their members because:

1) BCBS is the second-largest medical insurance provider by total members with over 40 million lives covered, so more people could benefit from using customized cost calculator. If only the top 5 largest health insurance companies implement cost estimator, 145,4 million people will get access to it (almost a half of US population).

2) Another reason to choose large insurance company’s platform is that they already have information about real prices because before joining a health insurance plan’s network, all doctors and hospitals negotiate prices for their services, including everything from a routine physical to a complex surgery.

3) Needless to say, looking for the procedure price through a member’s health insurance account with all his/her plan benefits (co-payments, deductibles, etc.) makes it easy to calculate the final price the person would pay in the end based on his/her actual benefits.

To better envision a prospective user, I created User Persona.

After gathering all the information about users, creating user personas based on gathered information, I made User Flow to represent the entire paths that the user goes through to complete the tasks.

Low-fidelity wireframes were created to illustrate where the major navigation and content elements of the site are going to appear on the page and to show paths between pages.

High-fidelity prototype is intended to illustrate the overall design concept more accurately. The possibility to click through the prototype is much more effective in collecting true human performance data. Needless to say, that it’s cheaper to make iterations with prototype than to change code after it’s complete implementation.

I added Find Treatment Cost option to the member’s account home screen for easy access.

Search options are intended to look by facility or doctor’s name, as well as by procedure, service, lab test name or medical code. If the user has the list of procedures, tests, services from his doctor, he can scan or download it and the system will find medical facilities which can provide all or most of them.

1. Shows the percentage of how many procedures from your treatment plan the hospital provides.
2. Treatment Cost is a total price for the services from user’s treatment list that facility provides. Your Price indicates the total cost of the treatment the user is responsible to pay for the services. The system takes into account user’s personal health plan benefits (e.g. co-payments, coinsurance, deductible etc.) when calculating total treatment price users should pay.
3. Medicare Prices are averages based on actual amounts that have been paid on claims and reflect the discounts that the health plan has negotiated with the facility. Comparing facility price with Medicare price users can see how the provider’s price differentiates from real, market price of the services.

The price of procedures listed in the facility price list is just one small portion of what a patient is expected to pay to the hospital. For most procedures, other services are included in the final bill including “facility fees,” medical supplies, pharmaceuticals and drugs, patient dietary and laundry services, and other support services like financial counseling and social services.

To know upfront what exactly is included in the facility price the user can See Treatment Plan Details.

There is also an option to compare treatment plan prices in different facilities or compare procedures, lab tests or services prices from different providers. The user can replace some too expensive services from the list by less expensive ones from other providers.

To make sure your treatment will be covered by the insurance plan, you will need to hit Pre-Authorize button and fill out the form. This will also help to validate the price.

Sometimes to get a better cost and quality of the services it’s more useful to search by procedure names, than add best options to your treatment list, group them and compare.

As for quality assessment of the services, I would allow patient’s reviews at BCBS website. Besides, it would be better to add Treatment Effectiveness or Helped to Recover parameter to existing rating parameters, such as Recommend this provider, Communication, Courtesy, Environment, Promptness because, as a matter of fact, we go to the doctor not only for having a pleasant and polite chat, but above all to receive an adequate treatment that will help us to get better. According to statistics, currently, more than one-third of the health care services that medical providers deliver do not help patients get better. Therefore, patient’s reviews and rating parameters that reflect the treatment result will help to eliminate wasteful practices, i.e., those that provide little clinical benefit.

Summary

With rising deductibles, high undisclosed medical prices, more out-of-pocket spendings, more out-of-network providers, the importance of the upfront information regarding medical prices and covered services are very high.

When you have insurance, you have to deal with things like: Have you met your deductible? Do you need a pre-approval? Is your provider in network or out? How much will the facility charge for their services? It can be complicated to get the answers. Therefore, health insurers should support their members by helping them to solve issues in an easy and more convenient way. Moreover, they will benefit from it as well.