Comparison shopping coming to Highmark

Members will be able to find out how doctors and hospitals rate, and also estimate out-of-pocket costs for various procedures and surgery

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Highmark officials want to make shopping for health care as comfortable as shopping for a car or house -- and they plan to do it by shining a brighter light on cost and quality data for local hospitals and physicians.

When the Pittsburgh insurer's program is fully in place this spring, officials say Highmark members will be able to find data online on how physicians and hospitals rate against national quality data, as well as information about a doctor's medical training and board certifications.

Most notably, the Highmark website will feature an easy-to-use "Care Cost Estimator" that will allow consumers to see their estimated out-of-pocket cost for an elective surgery or procedure based on their individual insurance coverage, from admission to discharge.

The site will not list estimated costs for emergency room visits, and it cannot track add-on costs such as facility fees or other unforeseen costs. Patients who do not have a computer will be able to get the information by calling Highmark customer service.

"It's exciting because it really goes to the core costs," said Steven C. Nelson, senior vice president for health services, strategy, product and marketing. "You will have 1,000 patients who are engaged in their care before they get care. That's moving the needle."

Highmark already has begun to survey patients about their care. By responding to five questions -- such as grading their overall experience and whether they would recommend their physician -- patients supply information that is used to give physicians a star rating. If a patient submits a complaint, a physician has an opportunity to respond and resolve the issue.

Other insurers, notably Aetna, also provide cost and quality information to members, but -- as the region's dominant carrier -- Highmark's new program will make the information more widespread locally. It also marks another milepost in the nationwide movement toward greater transparency and accountability in health care.

That is welcome news for U.S. Rep. Michael Burgess, a Republican physician from north Texas, who for the past decade has tried -- so far unsuccessfully -- to push legislation that would compel insurers to provide a statement of estimated out-of-pocket health care costs. His latest bill, introduced last summer, had bipartisan support but was not taken up in committee.

"I had no idea that 10 years later I would be in the same place," Dr. Burgess said last week.

Dr. Burgess said he was motivated by what he saw in his own obstetrics-gynecology practice, with the wide variation in medication prices and procedure costs -- cost differences that did not hit home with patients because their insurance policy covered most of the bill, if not all of it.

"As long as the insurer insulates the patient from the cost of the care, the sky's the limit," Dr. Burgess said.

But when patients fielded a bigger share of that cost, he added, "People were able to decide what's a lifestyle choice and what's going to keep them out of the hospital."

Closer to home, Rajiv Varma, a pediatric neurologist at Children's Hospital and president of the Allegheny County Medical Society, said physicians are in favor of transparency and support patients knowing more about the cost and quality of their care -- as long as the information is accurate and complete.

Still, boiling "quality" down to a handful of data points or a star rating concerns him.

"This is more information than what people have now, but it's not all the information they need," Dr. Varma said. "That's what they need to understand."

If physicians are to be rated on a star system, he said, then consumers should also have access to the specific criteria behind the ratings or else the ratings are meaningless.

Because Highmark rates are negotiated, the price variation probably will not be significant. It is not clear if UPMC physicians will still be included if the Highmark-UPMC contract is not renewed or extended in 2015 because, for now, the Care Cost Estimator will only have information on in-network providers.

Traditionally, people who need an elective surgery such as a knee replacement would follow their primary care physician's referral advice. That dynamic is already changing now that more physicians are employed by hospitals and health systems, and so are more likely to refer patients to specialists within that health system.

By drawing back the curtain on costs, Mr. Nelson said, the idea is not to necessarily direct patients to the cheapest care, but to give them information so they can judge for themselves where the best value is considering both cost and quality.

"People are led by their physician. The question is, are they also going to be led by their wallets?"

Currently, almost no one pays the full hospital and physician charges, the actual cost of which is negotiated by the insurer ahead of time. Many believe a big reason why health care costs continue to climb is because consumers have been shielded from the true cost of receiving care.

A year ago, Truven Health Analytics published a white paper that concluded greater transparency could save the U.S. $36 billion out of the $2 trillion spent on health care. Up to $850 billion of the total spent is wasted. Truven analysts found, in some cases, the cost for a single procedure can vary by 100 percent in the same market.

That is changing now that more people are opting for lower-premium-higher-deductible plans. They are more affordable, but they also place a bigger share of the health bill on the patient.

"If I'm paying 40 percent of the cost out of my pocket, it's important for me to know what I'm buying," said Christine Whipple, executive director of the Pittsburgh Business Group on Health. "As people have more skin in the game, that's going to become important."

Dr. Burgess agreed. "We have educated patients that more is better when it comes to testing, X-rays and that sort of thing. You need to get patients actively involved in what their care actually costs," he said.

"What I was trying to do is very simple: Let's just put some information out there."

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Steve Twedt: stwedt@post-gazette.com or 412-263-1963.


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