US20120232936A1

US20120232936A1 - Reference Pricing of Health Care Deliverables

Info

Publication number: US20120232936A1
Application number: US13/225,430
Authority: US
Inventors: Dena Bravata; Anastasia Toles; Maeve O'Meara; Matthew Vanderzee; Rina Horiuchi; Naveen Saxena
Original assignee: Castlight Health Inc
Current assignee: Castlight Health Inc
Priority date: 2011-03-11
Filing date: 2011-09-03
Publication date: 2012-09-13
Also published as: US8768867B1

Abstract

Embodiments of methods and systems for providing a payer with a platform for reference pricing of health care deliverables are disclosed. One method includes identifying a set of one or more health care deliverables to which reference pricing is to be applied, and setting a reference price for each health care deliverable of the set. For this embodiment, setting the reference price includes providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence, and allowing the payer to set the reference price for each health care deliverable based on the provided analysis. The method further includes receiving a health care deliverable request from a user who is covered by the payer, retrieving the set reference price corresponding to the health care deliverable request, and providing the set reference price or out-of-pocket cost to the user.

Description

RELATED APPLICATIONS

This patent application claims priority to U.S. Provisional Patent Application No. 61/452,062 filed on Mar. 11, 2011 which is herein incorporated by reference.

FIELD OF THE DESCRIBED EMBODIMENTS

The described embodiments relate generally to health care. More specifically, the described embodiments relate to reference pricing of health care deliverables.

BACKGROUND

Payers of healthcare services such as employers and governmental agencies have been seeking innovative benefit designs that can help curb the skyrocketing costs of care, the enormous variation in the negotiated rates for the same service within a geographic area, and the lack of sensitivity on the part of many patients to the costs of their care (who often lack financial incentive to be cost-conscious when making healthcare decisions).
One promising strategy that can address these factors is reference pricing: applying a fair cap (the reference price) to the amount that payers of health care services will pay. If a patient obtains a service from a provider who charges above the reference price, the payer may require the patient to pay the full amount above the reference price.
Reference pricing is not health care rationing: the services covered by the health benefit/plan remain unchanged and health care providers retain the freedom to set their own prices and negotiate rates. However, it reduces health care costs for the payer and increases the price sensitivity of patients who now may be faced with considerable costs if they obtain care at providers above the reference price.
In the US, the principal target of reference pricing has been the pharmaceutical industry—applying reference prices to drugs with generic equivalents (that is, providing benefits only up to the cost of the generic for brand-name drugs).
The failure of reference pricing to be adopted for healthcare services, equipment, and other deliverables is due in large part to the lack of transparency tools that enable patients to know both the reference prices for services and the prices of health care services for individual providers. Without this information, patients cannot select providers below the reference price. Additionally, setting the reference price at a level that maximizes potential savings for the employer while still ensuring patients adequate access to providers below the reference price requires up-to-date information about providers, their rates, and the location of affected patient populations. Moreover, it requires tools that can compute the price based on simultaneously maximizing these parameters.
A method and system for enabling healthcare payers to set a reference pricing policy customized for their purposes and provides their patient populations with the transparency tools required to shop for care that has been reference priced is needed.

SUMMARY

One embodiment includes a computer-method of providing a payer with a platform for reference pricing of health care deliverables. The method includes identifying a set of one or more health care deliverables to which reference pricing is to be applied, and setting a reference price for each health care deliverable of the set. For this embodiment, setting the reference price includes providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence, and allowing the payer to set the reference price for each health care deliverable based on the provided analysis. The method further includes receiving a health care deliverable request from a patient for whom the payer is responsible for covering health care costs (i.e. a member of the payer and hereinafter referred to as a “user”), retrieving the set reference price corresponding to the health care deliverable request, and providing the set reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.
Another embodiment includes a computer method of a platform for displaying prices of health care deliverables. The method includes receiving, by a platform server, a search request from a user for prices of a health care deliverable, informing the user of the reference price for the health care deliverable, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics, and providing the health care deliverable reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price.
Another embodiment includes a computer-method of providing a payer with a platform for reference pricing of one or more health care deliverables. The method includes receiving a reference price for each of the health care deliverables. The payer is then provided with a total cost of the reference pricing of the health care deliverables, which is determined by estimating a number of health care deliverables to be utilized by members of the payer over a period of time, and calculating the total cost based on the estimated number of health care deliverables and the reference price of each health care deliverable. The members include persons for whom the payer provides health care benefits.
Other aspects and advantages of the described embodiments will become apparent from the following detailed description, taken in conjunction with the accompanying drawings, illustrating by way of example the principles of the described embodiments.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows an embodiment of a health care platform that allows a payer to set reference prices for health care deliverables, and then provide the reference prices and/or out-of-pocket costs to users.

FIG. 2 shows an embodiment of a health care platform that allows a payer to set reference prices for each health care deliverable.

FIG. 3 shows an example of a plot that can be included within a potential saving report, that depicts projected savings (using the reference based pricing) and distances users would have to travel to obtain a health care deliverable at or below the reference based price of the health care deliverable.

FIG. 4 shows an embodiment of a health care platform that allows a user to electronically submit a health care deliverable request to a health care platform, and electronically receive a set price from the health care platform.

FIG. 5 is a flow chart that includes the steps of an example of a computer-method of providing a payer with a platform for reference pricing of health care deliverables.

FIG. 6 is a flow chart that includes the steps of an example of a computer-method for displaying pricing of health care deliverables.

FIG. 7 is a flow chart that includes the steps of another example of a computer-method of providing a payer with a platform for reference pricing of one or more health care deliverables.

DETAILED DESCRIPTION OF INVENTION

The described embodiments provide a platform that enables healthcare payers to set a reference pricing policy customized for their purposes and provides their patient populations with the transparency tools needed to shop for care. Briefly, an embodiment of the platform enables healthcare payers to select specific healthcare services, therapeutics, equipment, and/or episodes of care to reference price; to select the specific populations to whom the reference pricing policy (note that this can be applied for each service, each therapeutic, each equipment or each episode of care) should apply; to evaluate the tradeoffs in setting reference prices at various levels (for example, the lower the price, the greater the potential savings but the farther that patients will likely have to travel to have access to services below the reference price); and that shows users the reference price for a service, the expected out-of-pocket costs and/or other relevant information such as lists of providers designated as being above or below the reference price. The platform can additionally communicate exclusions to the reference pricing policy that may apply to each of the users. At least some embodiments include one reference price per deliverable, and out-of-pocket prices per provider. The user (a patient) is typically a member of a payer (such as, an employer).
Generally speaking, reference pricing includes applying a fair cap (the reference price) to the amount that payers of health care services pay. If a patient obtains a service from a provider who charges above the reference price, the payer may require the patient to pay the full amount (can be referred to as out-of-pocket cost) above the reference price.
FIG. 1 shows an embodiment of a reference pricing platform 110 that allows a payer 112 to set reference prices for health care deliverables, and then provide the reference prices and/or out-of-pocket costs to users 114. For embodiments, the out-of-pockets costs can be determined based on the reference prices. That is, for example, the out-of-pocket cost can in some cases be determined by determining how much the actual price of a health care deliverable is greater than the reference price for the health care deliverable. Additionally, or alternatively, users 114 are provided with, for example, a list of providers that are priced above the references price or priced below the reference price.
Embodiments of the reference pricing platform 110 include one or more networked servers that at a high-level aid a health care payer in setting reference prices for health care deliverables. Embodiments of the setting or selection of the reference prices includes an analysis of negotiated rates for the health care deliverables across at least one of geographies, demographics, and centers of excellence. For at least some embodiments, the analysis further includes negotiated rates for the health care deliverables across age. For embodiments, the payer 112 sets the reference prices based on the provided analysis. The payer 112 can include one or more computing devices that can be networked to servers of the reference pricing platform 110.
At least some embodiments further include receiving, by the reference pricing platform 110, a health care deliverable request from a user 114 who is covered by the payer 112. The platform 110 retrieves the set reference price corresponding to the health care deliverable request, and provides the set reference price or an out-of-pocket cost to the user. The user 114 can include any one of a number of computing devices (for example, a personal computer or a laptop, and/or a mobile device such as a mobile phone, a mobile smart phone or a tablet) which is/are connected through a wired or wireless network to the servers of the reference pricing platform 110. For embodiments, the platform performs a bulk transfer of reference prices to, for example, other platforms.
A health care deliverables data base 120 maintains, for example, the negotiated rates for the health care deliverables. Examples of health care deliverables include health care services, therapeutics, health care equipment, and episodes of care. These health care deliverables can more specifically include surgery, office visits, lab tests, imaging services, inpatient and outpatient procedures. Clearly, this is a non-exhaustive list. The negotiated rates of the health care deliverables include the negotiated rates over, for example, geographies, demographics, and centers of excellence.
After the reference pricing analysis has been provided to the payer 112, and the payer has set the reference prices for one or more of the health care deliverables, the references prices can be stored, for example, in a selected reference price database 130. The reference prices are then available, for example, for access by a user, or for cost-savings estimations by the reference pricing platform.
An identified population data base 140 includes populations of, for example, users or health care plan member to whom reference pricing of the health care deliverables should not be applied. That is, for example, some members or users may have special considerations that a payer may decide should exempt the member from being restricted to a reference price.
An embodiment of the reference pricing platform 110 includes a reference pricing server. This embodiment includes the reference pricing server being operative to identify a set of one or more health care deliverables to which reference pricing is to be applied. Further, the reference pricing server is operative to set a reference price for each health care deliverable of the set, including providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence, allowing the payer to set the reference price for each health care deliverable based on the provided analysis. Further, the reference pricing server is operative to receive a health care deliverable request from a user who is covered by the payer, retrieve the set reference price corresponding to the health care deliverable request, and provide the set reference price and/or an out-of-pocket cost to the user.
FIG. 2 shows an embodiment of a health care platform 210 that allows a payer to set reference prices for each health care deliverable. For embodiments, the payer can adaptively select reference prices and obtain feedback of how the reference pricing may affect the users. For example, the selection can include the payer adaptively adjusting, for example, a “dial” that provides information of how the reference price affects the geoaccess of the users. The dial can be displayed to the payer, allowing the payer to adjust a setting of the dial, and obtain real-time feedback on how the selected reference price affects the users.
As shown, the health care platform 210 receives claims information from a claims database 222, procedure codes such as CPT/HCPCs information from a procedure code data base 224, and grouping for episodes of care information from an episode of care data base 226. From the data bases 222, 224, 226 the health care platform 210 is able to determine provider negotiated rates 212.
Further, the health care platform 210 further evaluates geoaccess information 214, along with interactions with payers in selecting reference prices 216. The health care platform 210 additionally uses characteristics of select populations 218 of users (members) in the application of the reference pricing. A diagnostic codes (such as, for example, diagnostic codes ICD9s or ICD10) data base 232 maintains information about the characteristics of the select populations.
Inputs to the health care platform 210 received from the data bases 222, 224, 226 include, for example, the past 1-2 years (clearly, the described embodiments are not limited to this time duration) of claims (for example, medical, pharmaceutical, dental, vision), lists of the relevant codes that identify the health care deliverables to be reference priced (for example, CPT codes for services, HCPC codes for durable medical equipment/contrast materials, DRG codes, revenue codes), lists of grouped codes and claim line items that describe episodes/bundles of care, and lists of codes that describe the populations to be excluded (for example, ICD9 codes that describe users with selected conditions, location codes that describe care provided in selected settings).
For at least some of the described embodiments, for each of the health care deliverables to be reference priced, a negotiated rate either is obtained through direct partnerships with the health plan, from the provider, a warehouse system of a payer, or derived from the claims. To derive the negotiated rates, embodiments include a pricing analytics program that analyzes data (including claim data, provider data, and others) to deduce providers' negotiated rates. The pricing analytics program is operable, for example, on a hosted server or servers, and utilizes a number of databases to store and process the information.
For an embodiment, the pricing analytics program imports the raw claim data. Every data source in the health care industry has their own format for representing the data, and so the system (platform) must normalize this into a standard format. Each claim is matched to the correct provider. Due to the error-prone nature of health care claim data, the system identifies incomplete or erroneous entries, and rejects or repairs them, such that they do not negatively impact the results. Additionally, medical claims are sometimes reversed or adjusted, and so the system must identify these instances and either remove the claim from the system, or alter how the claim is handled. Once the importing is done, the resultant database holds sanitized, normalized, and valid claim data.
The claim data can be incrementally updated on a regular basis, possibly as often as new claims are available. Claims can be imported via any number of formats—CSV, TSC, XML, PDF, Postscript, etc. One example of how this importing process can work is raw claims are loaded into a raw claim database. The normalization and error correction process takes these raw claims as an input, and outputs normalized claims to the normalized claim database.
For an embodiment, the claims data are parsed. This involves grouping the claims into priceable units. Priceable units are either singleton claims or groups of claims that represent a price that can be used for an out-of-pocket calculation. Because a medical service that a patient receives may be represented by a number of claim line items (CLIs), the system must collect the CLIs that are relevant for a particular service into a priceable unit. A single CLI may end up in multiple priceable units, due to the fact that different medical services may use the same ‘building block’ billing codes. The notion of a priceable unit helps bridge the chasm between how the health care industry bills for services, and how patients understand the care they get.
An example of a priceable unit includes, for example, an electrocardiogram. This would be a ‘singleton priceable unit’, as it is typically represented by a single CLI in the data. Another example of a priceable unit is the facility charge for an endoscopy. This charge sometimes is represented by a single CLI, and at other times is billed with multiple CLIs (such as for the professional charge for the endoscopy and the facility charge for the endoscopy). Another example of a priceable unit includes a 30-minute office visit. This is also typically a singleton priceable unit.
Embodiments further include synthesis of priceable units. In certain cases, the data the system has to work with may be sparse—for example, rural geographies, or regions where an insurance company has fewer policy holders. Because of this sparsity of data, the system tries to synthesize priceable units for in-network providers.
Decisions to be made by the payer include, for example, evaluating geoaccess (that is, determine the maximum distance in both urban and rural geographies that users should be expected to travel to be able to access a provider of health care deliverables below the reference price), and setting the reference price for each health care deliverable. This may require setting just one price for all geographies per deliverable or much more complex pricing such as setting the reference price for components of a service (for example, setting individual prices for technical and professional components of an imaging service), selecting the populations to whom reference pricing will/not apply (for example, typically, payers exclude patients who are hospitalized, undergoing chemotherapy, very young children, persons with other medical conditions that severely limit their ability to travel for care).
A key output of at least some embodiment of the health care platform 210 is a potential savings report (242) that describes the expected savings to the payer based on the inputs described above. For embodiments, this savings report assumes that the same number of health care deliverables will be obtained in the future year as have been obtained in the past year(s) at the same negotiated rates as in the past year(s). For another embodiment, the savings report implements predictive modeling, trending analysis, scaling methodologies, to further anticipate savings. For an embodiment, the savings are calculated as (number of health care deliverables×negotiated rates) minus (health care deliverables×negotiated rates-reference prices). For embodiments, this formula is further adjusted according to whether the payer selects to share savings with the user (for example, if the user obtains a health care deliverable below the reference price, the payer may elect to share a portion of the difference with the user) or selects to have the user pay only a proportion of the price for health care deliverables above the reference price.
FIG. 3 shows an example of a plot that can be included within a potential saving report (such as, the potential savings report 242), that depicts projected savings (using the reference based pricing) and distances users would have to travel to obtain a health care deliverable at or below the reference based price of the health care deliverable. This plot provides an illustration to the payer of the tradeoffs between distances traveled by users to obtain a health care deliverable below the reference price, and savings for the payer realized for various reference prices. Based on this knowledge, the payer can make more informed reference price selections.
Embodiments of the health care platform 210 provide the payer with estimates of cost savings to the payer due to reference pricing of health care deliverables. Embodiments includes reports that provide, for example, actual utilization of reference pricing based services, the percentage of users getting those services below the reference based price, and changes in both of these over time. Embodiments additionally include these broken down by populations (for diabetics, or people with other medical conditions; for people who work in a certain department/which would be associated with a certain paygrade; or for people who live in certain geographies).
For an embodiment, the health care platform 210 includes a platform server. Further, the platform server is operative to receive a reference price for each of the health care deliverables, and provide the payer with a total cost of the reference pricing of the health care deliverables.
FIG. 4 shows an embodiment of a health care platform 410 that allows a user to electronically submit a health care deliverable request to a health care platform, and electronically receive a set reference based price from the health care platform. Data bases available to the health care platform 410 include, for example, a provider prices database 422, a benefits/plan design database 424, an accumulator data base 426 and an educational content data base 428. For embodiments, the provider prices database 422 includes information about the negotiated rates for each deliverable from each provider. For embodiments, the benefits/plan design database 424 includes information about the benefits for each user. For example, $X deductible, $Y out of pocket maximum, given % coinsurance rates for in- and out-of-network claims, and the specific benefit rules that apply for each user's health plan for each deliverable, for example, 80% coinsurance for specific lab test. For embodiments, the accumulator data base 426 includes information about the current status where each user is in their health plan based on the care they have received, for example, a deductible phase with $X spent)]. For embodiments, the educational content data base 428 includes information about each deliverable and how the user can best shop for it.
Inputs to the health care platform 410 from the data bases 422, 424, 426, 428 include, for example, the negotiated prices for each health care deliverable subject to reference pricing, the user's specific plan design describing the health care benefits and coverage for the health care deliverables subject to reference pricing, and the user's accumulators which describe how much care they have received, and which phase of their plan they are in.
For each of the health care deliverables to be reference priced, the health care platform 410 presents to the user their personalized, out-of-pocket cost and/or a list of providers that are denoted/flagged as above or below the reference price (412) to obtain each health care deliverable subject to reference pricing with proprietary educational content that helps the user to understand the factors that affect the cost of the health care deliverables, the reference pricing program, and other key factors that typically affect shopping decisions for that deliverable.
For other embodiments, the out-of-pocket cost (412) does not have to be provided to the user. That is, for example, a simpler health care platform 410 might only provide negotiated rates. That is, this simpler health care platform 410 simply displays the reference price, and displays the negotiated rates, and the user can compares the numbers. Another embodiment may additionally or alternatively display only a designation of whether the provider is above or below the reference price.
Users may chose to shop for the health care deliverable (414) and to then obtain care/purchase the deliverable (416). Embodiments of the health care platform 410 presents a summary report (432) to the user that includes the total amount spent on deliverables subject to reference pricing, the amount saved by going below the reference price and the amount that could have been saved if they had not gone above the reference price.
For an embodiment, the health care platform 410 includes a platform server, such as, a reference pricing server. Further, the reference pricing server is operative to display pricing of health care deliverables. For this embodiment, the reference pricing server is operative to receive a search request from a user for pricing of a health care deliverable. Further, the reference pricing server is operative to inform the user regarding the reference pricing for the health care deliverable. Additionally, the reference pricing server is operative to retrieve a health care deliverable reference price, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics. The reference pricing server is further operative to provide the health care deliverable reference price to the user.
FIG. 5 is a flow chart that includes the steps of an example of a computer-method of providing a payer with a platform for reference pricing of health care deliverables. A first step 510 includes identifying a set of one or more health care deliverables to which reference pricing is to be applied. A second step 520 includes setting a reference price for each health care deliverable of the set. A third step 530 includes providing (for example to a computing device of the payer that is networked to the platform server), by a platform server, the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence. A fourth step 540 includes allowing the payer to set the reference price for each health care deliverable based on the provided analysis. A fifth step 550 includes receiving, by the platform server, a health care deliverable request from a user (for example from a computing device of the user that is networked to the platform server) who is covered by the payer. A sixth step 560 includes retrieving the set reference price corresponding to the health care deliverable request. A seventh step 570 includes providing the set reference price to the user, and/or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price. The out-of-pocket cost can additionally be based on the negotiated rate, and/or a current accumulator status of the user. For embodiments, the accumulator status determines where the user is at in using their deductable or co-insurance status. The seventh step 570 can additionally or alternatively include a list of providers flagged as above/below the reference price.
For an embodiment, the platform server provides a list of available providers for providing the health care deliverable request. The list can additionally or alternatively include providers within a variety of geographic areas. The list can additionally or alternatively include providers that have negotiated rates above and/or below the set reference price, and the users' out-of-pocket costs. For a simplified embodiment, an indicator is provided to indicate whether a rate of a particular provider is above or below the reference price.
For an embodiment, the platform server identifies one or more populations of users having identified characteristics, and providing the reference pricing to the populations of users having the identified characteristics. For another embodiment, the platform server identifies one or more populations of users having identified characteristics, wherein the populations of users having the identified characteristics are excluded from the reference pricing. Examples of the identified characteristics include at least one of a qualification based on age, diagnoses, prior health care utilization, locations of care, geoaccess. For example, payers may not want to reference price deliverables for very young children or the elderly, patients with certain conditions such as cancer or pregnancy, have received certain medical services such as chronic hemodialysis, be hospitalized, or live in areas where access to deliverables is limited.
For embodiments, the health care deliverables include a health care service, one or more therapeutics, equipment, or an episode of care, wherein the episode of care includes a plurality of health care deliverable components. A health care deliverable component is generally at least one of the defined health care deliverables. An episode of care generally includes multiple pre-defined health care deliverables for example, the deliverable included in the annual care of a patient with diabetes or all the deliverables included in the care of a patient requiring repair of a hip fracture. Embodiments include applying the reference price to components of a health care deliverable or to combinations of health care deliverables.
An embodiment includes identifying reference prices at centers of excellence (COEs). Generally, a COE can be defined as a provider with experience caring for patients with particular conditions or in need of particular services, and who has typically higher quality than non-COEs for the care of patients with that condition or requiring that procedure. For embodiments, a total cost of the episode of care is covered by the payer if the user receives the episode of care from a COE. For another embodiment, if the user receives the episode of care from a non COE, then a selected reference base price is covered by the payer for the total episode. Payers may choose to cap the amount above the reference price for the episode to be paid by the user.
Embodiments include providing, by the platform server, the payer with a total cost of the reference pricing of the health care deliverables. For one embodiment, the total cost is determined by estimating a number health care deliverables to be utilized by the users of the payer over a period of time, and calculating the total cost based on the estimated number and the set reference price of each health care deliverable. Other embodiments further include the total cost accounting for saving shared with the users, and modifications to amounts each user pays over the set reference price. Other embodiments further include the total cost accounting for liability caps of the users. For an embodiment, the payer may be some amount greater that the reference price, wherein the amount paid by the payer decrease above the reference price.
An embodiment further includes imposing (selecting) a liability cap on the user (member). That is, a reference price applies, but if the cost of the health care deliverable exceed a selected cap, the user (member) is covered (liability capped) of the actual cost exceeds the cap. For an embodiment, the out-of-pocket cost shown to the user reflects the application of such liability cap.
For some embodiments, the references prices are adaptively calculated. More specifically, the reference price for each health care deliverable is adaptively calculated based on changes to health care deliverables pricing over at least one of time, pricing information received from health care providers and centers of excellence (COE), demographics, health of population, geography of population, health benefits, health care utilization, and geoaccess, and negotiated rates at the COE. Here, utilization represents the number of deliverables obtained by the user population.
For an embodiment, the analysis and setting of the reference price for each health care deliverable of the set further includes identifying and grouping users. That is, for example, the reference price for a hip surgery may require risk adjusting the past claims of patients based on their age and comorbid conditions, before evaluating where to set the reference price. Additionally, users can be grouped by demographics, or the health of the populations.
For an embodiment, the analysis and setting of the reference price for each health care deliverable of the set further includes analyzing geoaccess of the users. Typically, payers want to minimize the distance that a user has to travel to get care from a provider of deliverable below the reference price and may set higher reference prices in geographic areas with fewer low-cost providers.
For an embodiment, the analysis and setting of the reference price for each health care deliverable of the set further includes adjudication. Typically, after a patient receives care, a claim is sent to the health plan in order for the provider to be paid. The health plan applies a set of rules as outlined in users' health benefits description for that service and determines if the claim should be allowed, and if so, what price should be paid. This process of taking the claim, applying the benefits rules, and determining the amount to be paid is adjudication. Often, health plans are incapable of properly adjudicating bundled health care deliverables or episodes of care. The reference pricing strategy can be adapted to fit within these inferior health plan processes. The reference pricing platform can perform the adjudication, or the platform can interact with, for example, a company or service that does the adjudication. Either case, the health plan would need to provide the claims for reference based pricing services.
For embodiments, adjudication can be processed or performed by either a payer's (typically an employer) third party administrator (TPA), or by a TPA that has been contracted specifically to adjudicate the health care deliverables subject to the reference pricing of the described embodiments.
For an embodiment, the analysis and setting of the reference price for each health care deliverable of the set further includes influencing the reference price based on cost saving desired by the payer—the lower the reference price is set, the more the savings for the payer. Some payers may be more proactive in yielding savings, and thus would set the reference prices lower, whereas another payer may simply want to protect against the highest cost providers. For embodiments, the savings are shared with the patient.
Embodiments include displaying an out-of-pocket cost of the health care deliverable to the user (member). This can further include (or alternatively include) displaying a negotiated rate of the health care deliverable request to the user with a designation of whether the negotiated rate is above or below the reference price. The negotiated rate is the rate for the deliverable that is contracted between the health plan and the provider. That is, the rate the payer agrees to pay for deliverables provided by health plans of the payer. An alternative embodiment can merely indicate or denote providers as above or below the reference point. This can be desirable when the user (patient) has a bandwidth-limited device (such as, a mobile device).
Embodiments include displaying an out-of-pocket cost of the health care deliverable to the user (members of payer's health plan). This can further include displaying a negotiated rate of the health care deliverable request to the user with a designation of whether the negotiated rate is above or below the reference price. Embodiments can include alerting users if they have received health care deliverables having negotiated rates above the reference price, and further, notifying users of providers in their area where users can go instead for health care deliverables below the reference price.
Further, embodiments include determining a difference between the negotiated rate for the health care deliverable request and the set reference price of the health care deliverable. Once the difference has been calculated, an embodiment includes crediting the user with the difference or a portion thereof. Another embodiment includes billing the user for the difference or portion thereof. Another embodiment includes adjusting the user's deductible and/or health reimbursement account, health savings account, flexible spending account, or other similar type account. Another embodiment includes adjusting at least one of a debit card, a credit card or other financial instrument or account by the difference. Another embodiment includes adjusting payer benefit or incentive program balances. Another embodiment includes adjusting the user's health insurance premiums. Another embodiment includes adjusting the user's payroll. Another embodiment includes applying secondary insurance to the difference.
An embodiment includes receiving a search request from a user for pricing of a health care deliverable, retrieving a health care deliverable reference price, providing the health care deliverable reference price to the user, providing a list of providers of the requested health care deliverable across a variety of geographies. For an embodiment, this includes displaying or showing the user the out-of-pocket costs. Additionally, or alternatively, a filter can be utilized, thereby enabling the user to find and have displayed only providers that are below the reference based price.
An embodiment of the platform provides the payer with accrued saving to the payer based on utilization of the platform for reference pricing of health care deliverable.
An embodiment includes receiving or obtaining information of claims paid. Further, verification is made to determine whether a reference pricing policy has been properly applied to the claims paid. If the reference pricing policy has been erroneously applied, the user of any erroneous applications of the reference pricing policy can be alerted of the errors.
After claims have come in, embodiments of the platform include evaluating whether the reference based pricing policy of the payer has been appropriately adjudicated. This can include, for example, checking to see whether inclusion/exclusion criteria were properly applied, or that the right reference price was applied in the right geography. Embodiments include notifying the user and/or the payer if the was an error in the adjudication.
For an embodiment, the user is notified if they have gone to a provider who is above the reference price. Additionally, the user can be notified that they could have saved money by going to another provider. Further, the user can be provided with, for example, a link to a search (or a list of providers in their geography (located proximate to the user) that are below the reference price. The email can also inform the user as to how much they could have saved by going to a provider below the reference price
FIG. 6 is a flow chart that includes the steps of an example of a computer-method of providing a payer with a platform for reference pricing of one or more health care deliverables. A first step 610 includes receiving, by a platform server, a search request from a user for pricing of a health care deliverable. A second step 620 includes informing, by the platform server, the user regarding the reference pricing or out-of-pocket costs for the health care deliverable. The calculating of the total cost of the reference pricing includes a third step 630 that includes retrieving, by the platform server, a health care deliverable reference price, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics. An embodiment includes a single reference price per deliverable. A fourth step 640 that includes providing, by the platform server, the health care deliverable reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price. Alternatively, for mobile device users, a list can be provided to the users that denotes provides as either being above or below the reference price.
An embodiment further includes identifying capabilities of a user device, and adapting the displaying of the pricing of health care deliverables or out-of-pocket costs to the user based on specific capabilities of the user device. The user can be accessing the platform using anyone of many types of devices, such as, a computer, a telephone, a smart phone or a tablet. If the user is using a mobile device, for an embodiment, the platform may display to the user the closest providers below the reference price, or whether a provider is below or above the reference price. If, for example, the user is using a telephone, the platform may simply indicate those providers who are above or below the reference price without providing out of pocket costs. Further, if the user is using a telephone, an embodiment includes the user accessing a mechanized phone tree in which the user makes a call, gets authenticated, and is provided a menu for selecting the reference based pricing service for which the user wants to know the out of pocket cost or reference price, and the platform (through the user device telephone) receives the answer.
Embodiments include the platform responding to a user's search request or inquiry with advice or information on whether or not the user may qualify for exclusion based on policy design from analysis of the claims data. More generally, this can include providing information about the payer's reference based pricing policy to inform the user as to what services fall within the reference based pricing policy, what the reference prices are, and whether the user would be included or not.
Another embodiment includes a program storage device readable by a machine (of the reference pricing platform), tangibly embodying a program of instructions that when executed by the machine cause the machine to perform a method of providing a payer with a platform for reference pricing of health care deliverables. The method performed includes identifying a set of one or more health care deliverables to which reference pricing is to be applied, and setting a reference price for each health care deliverable of the set. Setting the reference price for each health care deliverable of the set includes providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence, and allowing the payer to set the reference price for each health care deliverable based on the provided analysis. The method further includes receiving, a health care deliverable request from a user who is covered by the payer, retrieving the set reference price corresponding to the health care deliverable request, and providing the set reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price.
FIG. 7 is a flow chart that includes the steps of an example of a computer-method of providing a payer with a platform for reference pricing of one or more health care deliverables. A first step 710 includes receiving, by a platform server, a reference price for each of the health care deliverables. A second step 720 includes providing, by the platform server, the payer with a total cost of the reference pricing of the health care deliverables. The calculating of the total cost of the reference pricing includes a third step 730 that includes estimating a number of health care deliverables to be utilized by members of the payer over a period of time, and a fourth step 740 that includes calculating the total cost based on the estimated number of health care deliverables and the reference price of each health care deliverable, wherein members include persons for whom the payer provides health care benefits.
As previously described, for an embodiment, the platform server identifies one or more populations of users having identified characteristics, wherein the populations of users having the identified characteristics are either included or excluded from the reference pricing.
For an embodiment, a total cost estimate is provided to the payer that accounts for saving shared with the members, and modifications to amounts each member pays over the set reference price.
As previously described, embodiments include the reference price for each health care deliverable being adaptively calculated based on changes to health care deliverables pricing over at least one of time, pricing information received from health care providers, demographics, health of population, geography of population, health benefit, utilization, geoaccess, and negotiated rates at centers of excellence.
Although specific embodiments have been described and illustrated, the embodiments are not to be limited to the specific forms or arrangements of parts so described and illustrated. The embodiments are limited only by the appended claims.

Claims

1. A computer-method of providing a payer with a platform for reference pricing of health care deliverables, comprising:

identifying a set of one or more health care deliverables to which reference pricing is to be applied;

setting a reference price for each health care deliverable of the set, comprising;

providing, by a platform server, the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence;

allowing the payer to set the reference price for each health care deliverable based on the provided analysis;

receiving, by the platform server, a health care deliverable request from a user who is covered by the payer;

retrieving the set reference price corresponding to the health care deliverable request; and

providing the set reference price to the user, or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.

2. The computer-method of claim 1, further comprising providing, by the platform server, a list of available providers for providing the health care deliverable request.

3. The computer-method of claim 1, further comprising identifying, by the platform server, one or more populations of users having identified characteristics, and providing the reference pricing to the populations of users having the identified characteristics.

4. The computer-method of claim 1, further comprising identifying, by the platform server, one or more populations of users having identified characteristics, wherein the populations of users having the identified characteristics are excluded from the reference pricing.

5. The computer-method of claim 4, wherein the identified characteristics comprise at least one of a qualification based on age, diagnoses, prior health care utilization, locations of care, geoaccess.

6. The computer-method of claim 1, wherein the health care deliverable comprises a health care service.

7. The computer-method of claim 1, wherein the health care deliverable comprises one or more therapeutics.

8. The computer-method of claim 1, wherein the health care deliverable comprises equipment.

9. The computer-method of claim 1, wherein the health care deliverable comprises an episode of care, wherein the episode of care comprises a plurality of health care deliverables components.

10. The computer-method of claim 9, further comprising identifying reference prices at centers of excellence (COE), wherein a total cost of the episode of care is covered by the payer if the user receives the episode of care from at least one COE, and a selected base reference price is covered by the payer if the user receives the episode of care from a provider that is not a COE.

11. The computer-method of claim 1, further comprising providing, by the platform server, the payer with a total cost of the reference pricing of the health care deliverables, comprising estimating a number health care deliverables to be utilized by users of the payer over a period of time, and calculating the total cost based on the estimated number and the set reference price of each health care deliverable.

12. The computer-method of claim 11, wherein the total cost additionally accounts for saving shared with the users, and modifications to amounts each user pays over the set reference price.

13. The method of claim 12, wherein the total cost additionally accounts for liability caps of the users.

14. The computer-method of claim 1, further comprising selecting a liability cap for the user.

15. The computer-method of claim 1, wherein the reference price for each health care deliverable is adaptively calculated based on changes to health care deliverables pricing over at least one of time, pricing information received from health care providers and centers of excellence (COE), demographics, health of population, geography of population, health benefits, health care utilization, and geoaccess, and negotiated rates at the COE.

16. The computer-method of claim 1, wherein setting a reference price for each health care deliverable of the set further comprises:

identifying and grouping users;

analyzing geoaccess of the users;

factoring in adjudication capabilities of a health plan of the payer;

influencing the reference price based on cost saving desired by the payer;

analyzing an ability to obtain pricing information in advance of receipt of each of the health care deliverables.

17. The computer-method of claim 1, further comprising applying the reference price to components of a health care deliverable or to combinations of health care deliverables.

18. The computer-method of claim 1, further comprising displaying the out-of-pocket cost of the health care deliverable to the user.

19. The computer-method of claim 1, further comprising displaying a negotiated rate of the health care deliverable request to the user with a designation of whether the negotiated rate is above or below the set reference price.

20. The computer-method of claim 1, further comprising determining a difference between a negotiated rate for a health care deliverable request and the set reference price of the health care deliverable, and at least one of:

crediting the user with the difference or a portion thereof;

billing the user for the difference or portion thereof;

adjusting the user's deductible or health reimbursement or equivalent account;

adjusting at least one of a debit card, a credit card or other financial instrument or account;

adjusting payer benefit or incentive program balances;

adjusting the user's health insurance premiums;

adjusting the user's payroll;

applying secondary insurance to the difference.

21. The computer-method of claim 1, further comprising:

receiving a search request from a user for pricing of a health care deliverable;

retrieving a health care deliverable reference price;

providing the health care deliverable reference price to the user, or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price;

providing a list of providers of the requested health care deliverable across a variety of geographies.

22. The computer-method of claim 1, further comprising the platform providing the payer with accrued saving to the payer based on utilization of the platform for reference pricing of health care deliverables.

23. The method of claim 1, further comprising:

receiving claims paid;

verifying that a reference pricing policy has been properly applied to the claims paid;

alerting the user of any erroneous applications of the reference pricing policy.

24. A computer-method of a platform for displaying pricing of health care deliverables, comprising:

receiving, by a platform server, a search request from a user for pricing of a health care deliverable;

informing, by the platform server, the user regarding the reference pricing or out-of-pocket costs for the health care deliverable;

retrieving, by the platform server, a health care deliverable reference price, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics;

providing, by the platform server, the health care deliverable reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price.

25. The method of claim 24, further comprising:

identifying capabilities of a user device; and

adapting the displaying of the pricing of health care deliverables or out-of-pocket costs to the user based on specific capabilities of the user device.

26. The computer-method of claim 24, further comprising the platform providing the user with accrued saving based on utilization of services with reference prices.

27. The computer-method of claim 24, further comprising informing the user regarding alternatives to the health care deliverable.

28. The computer-method of claim 24, further comprising showing the user their out-of-pocket cost after applying the health care deliverable reference price and other healthcare benefits for multiple providers of the health care deliverable.

29. The computer-method of claim 24, further comprising displaying a negotiated rate of the health care deliverable to the user with a designation of whether the negotiated rate is above or below the health care deliverable reference price.

30. The computer-method of claim 24, further comprising determining a difference between a negotiated rate for the health care deliverable and the health care deliverable reference price, and at least one of:

crediting the user with the difference or a portion thereof;

billing the user for the difference or portion thereof;

adjusting the user's deductible or health reimbursement account;

adjusting at least one of a payer benefit or incentive program balances;

applying secondary insurance to the difference;

adjusting the user's health insurance premiums;

adjusting the user's payroll;

applying secondary insurance to the difference.

31. The computer-method of claim 24, further comprising adaptively updating the health care deliverable reference price for each health care deliverable as changes occur with at least one of the time, pricing information received from health care providers, demographics, health of population, geography of population, health benefit, utilization, geoaccess, and negotiated rates at centers of excellence.

32. The computer-method of claim 24, further comprising applying the reference pricing to components of a health care deliverable or to combinations of health care deliverables.

33. The method of claim 24, further comprising:

receiving claims paid;

34. A computer-method of providing a payer with a platform for reference pricing of one or more health care deliverables, comprising:

receiving, by a platform server, a reference price for each of the health care deliverables;

providing, by the platform server, the payer with a total cost of the reference pricing of the health care deliverables, comprising;

estimating a number of health care deliverables to be utilized by users of the payer over a period of time; and

calculating the total cost based on the estimated number of health care deliverables and the reference price of each health care deliverable;

wherein members include persons for whom the payer provides health care benefits.

35. The computer-method of claim 34, further comprising identifying, by the platform server, one or more populations of users having identified characteristics, and providing the reference pricing to the populations of users having the identified characteristics.

36. The computer-method of claim 34, further comprising identifying, by the platform server, one or more populations of users having identified characteristics, wherein the population of users having the identified characteristics are excluded from the reference pricing.

37. The computer-method of claim 34, wherein a total cost estimate provided to the payer accounts for saving shared with the users, and modifications to amounts each user pays over the set reference price.

38. The computer-method of claim 34, wherein the reference price for each health care deliverable is adaptively calculated based on changes to health care deliverables pricing over at least one of time, pricing information received from health care providers, demographics, health of population, geography of population, health benefit, utilization, geoaccess, and negotiated rates at centers of excellence.

39. The computer-method of claim 34, further comprising applying the reference price to components of a health care deliverable or to combinations of health care deliverables.

40. A system for reference pricing of health care deliverables, comprising:

reference pricing server operative to identify a set of one or more health care deliverables to which reference pricing is to be applied;

reference pricing server operative to set a reference price for each health care deliverable of the set, comprising the reference pricing server operative to;

provide the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence;

allow the payer to set the reference price for each health care deliverable based on the provided analysis;

reference pricing server operative to receive a health care deliverable request from a user who is covered by the payer;

reference pricing server operative to retrieve the set reference price corresponding to the health care deliverable request; and

reference pricing server operative to provide the set reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.

41. A system for displaying pricing of health care deliverables, comprising:

a reference pricing server operative to receive a search request from a user for pricing of a health care deliverable;

the reference pricing server operative to inform the user regarding the reference pricing for the health care deliverable;

the reference pricing server operative to retrieve a health care deliverable reference price, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics;

the reference pricing server operative to provide the health care deliverable reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price.

42. A system for providing a payer with a platform for reference pricing of one or more health care deliverables, comprising:

a platform server operative to receive a reference price for each of the health care deliverables;

the platform server operative to provide the payer with a total cost of the reference pricing of the health care deliverables, comprising;

estimating a number of health care deliverables to be utilized by users of the payer over a period of time, wherein users include persons for whom the payer provides health care benefits; and

calculating the total cost based on the estimated number of health care deliverables and the reference price of each health care deliverable.

43. A program storage device readable by a machine, tangibly embodying a program of instructions that when executed by the machine cause the machine to perform a method of providing a payer with a platform for reference pricing of health care deliverables, comprising;

providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence;

receiving, a health care deliverable request from a user who is covered by the payer;

providing the set reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.