Proactive Cost Control: Reference Based Pricing

President Trump just signed an executive order to increase the transparency of hospital charges and the ability to know and negotiate prices before treatment. The order directs agencies to develop rules to require hospitals and insurers to provide information “based on negotiated rates” to the public. Also, hospitals and insurers would have to give estimates on out-of-pocket costs to patients before they go in for non-emergency medical care. Currently, such rates are hard to get until after medical care is provided. That’s when insured patients get an “explanation of benefits,” which shows how much the hospital charged, how much of a discount their insurer received and the amount a patient may owe. In addition to consumers being unable to get price information upfront in many cases, hospital list prices and negotiated discount rates vary widely by hospital and insurer, even within the same region. Uninsured patients often are charged the full amounts.

This lack of pricing transparency is one of the major factors behind healthcare inflation in the US. Up until now there was no way to know what a provider would charge and what an insurance carrier would pay. An attempt to solve this problem emerged under the rubric of Reference Based Pricing. The insurance provider has staff engaged in finding the prices of every procedure and directing members to the lowest cost alternative. Thus a higher upfront cost in determining where to receive care results in savings in the cost of claims.

The basic structure is a self insured plan, so the employer has access to all claims data & processing. On top of this is a reinsurance plan to pay for catastrophic claims, and a Third Party Administer to monitor and proactively affect the claims. Wellnet is one such TPA, offering an aggressive wellness management program called Population Health Management.

Health coaches work both telephonically, electronically, and onsite. WellNet has fully integrated the Johns Hopkins ACG predictive modeler into our technology to provide a holistic assessment of all member data, to expedite referrals of the high and moderate risk members to our health coaching team, and to provide reporting on group-wide health risks, enabling targeted programming and campaigns. The full array of wellness services includes a Health Risk Assessment, Digital Coaching Modules, Wellness Screenings, access to Registered Nurses, and additional online resources and tools that members can access through their own health portal or our mobile application.

An even more aggressive strategy called Reference Based Pricing uses cost sharing incentives to steer members to lower cost alternatives.

• Wrap PPO Network for face to face visits with PCP’s, Specialists, and Lab Network

• Telemedicine with virtual visits to PCP’s and Specialists: unlimited access / no copay for member

• Steerage to outpatient complex imaging centers (non-compliance = no coverage for member)

• Medicare Plus 50% reimbursements for facility and surgical claims

• Medical Advocacy Program – Precertification hotline answered by Registered Nurses (RN’s). RN’s provide quality research for members to show the quality metrics for several facilities and surgeons, including the facility and surgeon that the member initially wanted to go to. If members follow our steerage (facilities and surgeons that have already agreed to 50% over Medicare), their deductible and coinsurance is waived. If members go wherever they want, they are told their deductible and coinsurance will apply and they may also be balance billed. THIS PROCESS INCREASES MEMBER SATISFACTION WHILE DECREASING BALANCE BILLING DRAMATICALLY.

• Balance bill indemnity protection for members

• Rx Offered through WellNet’s Caremark contract with the following available add-on services: ScriptSourcing – proactive service targeting certain members that allows many maintenance and some specialty meds to be sourced from A-Rated international pharmacies o US Rx Care – outsourced (away from Caremark) specialty medication prior authorization process

• Medical Bill Review and Auditing for all facility / surgical claims that are not negotiated in advance (E.G. Emergency Room claims)

• Hospital and surgical care is free to members if they follow steerage.

• All plans include WellNet’s proprietary technology, allowing for the identification of medium and high risk members and the implementation of advanced population health management programs

This insurance structure may seem invasive and expensive, but it may be the only way to realize the potential of cost sharing in health insurance: with the insurance provider itself, the TPA, doing the ‘shopping’ for healthcare services that the consumer driven model presupposes. WellNet speaks of controlling the supply chain, a big ambition for any company. When your supply is doctors the research, competition, and purchasing decisions seem overwhelmingly complex.