A national survey of health plans shows that price estimator tools available to commercial plan enrollees provide price information for a variety of services at the provider level.
In an effort to slow the rising costs of healthcare, consumer groups, state governments, and health plans have called for greater price transparency in the healthcare market.1-3
Policy makers and researchers have posited that increasing price transparency will afford consumers the opportunity to comparison-shop among providers, which could result in higher-cost providers lowering their prices to improve value.4,5
As enrollment in high-deductible health plans has grown, consumers in these plans have a greater financial incentive to compare prices across providers because they have higher out-of-pocket obligations.1,6
Even consumers not in high-deductible health plans may now participate in benefit designs offering incentives and opportunities to select higher quality and lower cost (ie, high-value) providers.7
Consumers want to understand their out-of-pocket expenses for specific services for a given provider, as well as the costs for a complete episode of care.8,9
To help meet consumer needs, health plans have implemented tools that allow consumers to compare and select providers based on providers’ quality performance and prices for specific healthcare services. Using such tools can benefit consumers in terms of lowering their out-of-pocket costs and selecting higher-quality providers.
Recent evidence shows that availability of price information can impact consumer behavior and promote informed decision making. In a study of 1421 employees, researchers found that presenting easy-to-understand, high-quality information alongside pricing estimates increased the likelihood of an individual choosing a high-value provider.10
Increased likelihood of visiting a new provider, as well as lower payments for clinical care, have also been attributed to accessibility of price estimates.11,12
Much attention has been given to the topic of price transparency; however, studies to date have primarily focused on price information made available through state requirements for mandatory reporting.3,13-16
Meanwhile, in the private sector, health plans have begun to offer provider-level pricing information to their members using Web-based price estimator tools.1,8
Although some information is available, we are unaware of any studies that have systematically collected data on the characteristics of health plan price estimators.17
The purpose of this exploratory study was to describe the characteristics of price estimator tools offered by health plans to their members and to identify potential trends, challenges, and opportunities for advancing the utility of these tools.
For the purposes of this study, “price estimator tools” refer to tools that allow consumers to obtain estimates of prices associated with specific healthcare services that could be either specific to a provider or based on geography.
Data for this study were collected using a Web-based survey instrument. To develop the survey instrument, we conducted a targeted literature review of health plan price estimator tools, reviewed health plan price estimator tools that were publicly available, and conducted preliminary interviews with representatives of 4 plans to get a broad understanding of these tools. We pilot-tested the survey with these same 4 health plans and conducted telephone interviews with these plans to get additional feedback on the survey.
Final survey questions focused on the following 7 aspects of health plan price estimator tools: 1) core capabilities and characteristics taken into account, 2) data used in price estimator tools, 3) display of price estimates, 4) services for which estimates may be obtained, 5) provider information, 6) member engagement, and 7) outcomes and challenges. The questions were a mixture of open-ended and binary yes or no responses. For open-ended questions, we asked plan representatives to elaborate on characteristics pertaining to their price estimator tool that were not included as a response option on binary yes or no questions. Twenty-two binary questions had corresponding open-ended questions to which the plan representatives could respond.
We invited 106 health plans that met the following criteria: a) listed as a member of America's Health Insurance Plans in 2014, and b) offered products in the commercial insurance market. Of the 106 plans, 4 plans were not eligible to participate because they no longer offered commercial products at the time of the survey, and 2 had recently been acquired by another health plan. Using a key informant approach, we e-mailed invitations to the chief medical officers of the remaining 100 health plans, who then shared the survey with their teams, as appropriate. Data from this survey were collected in 2 phases between April 2014 and July 2015.
To be included in our analyses, plans had to have a price estimator tool available to their members. For the analyses, we characterized health plans by total size of enrollment (using quintiles), time since their price estimator tool became available (<1 year, 1-3 years, >3 years), and vendor type for their tool (health plan, third-party, or a combination of both). We examined the overall frequencies and Fisher’s exact tests for each price estimator tool characteristic, stratified by health plan characteristics (not all results are reported). Following the calculation of frequencies, we compiled and summarized all open-ended responses. Any plans that did not provide a price estimator tool were excluded from analyses.
Sample and Health Plan Characteristics
A total of 43 plans responded to the survey, resulting in a 43% response rate. The characteristics of the responding plans can be found in the eAppendix
(available at www.ajmc.com
). Of the 43 plans that responded during both phases of data collection, 11 did not provide a price estimator tool to their members, although 4 of these 11 intended to provide a tool within 12 to 24 months. One plan of the 43 had made a tool available during our second phase of data collection in 2015, but did not provide updated responses to the survey. Our final analytic sample is thus composed of the remaining 31 plans that provided price estimator tools to their members.
The 31 plans included in the analyses account for 140.8 million commercial enrollees, corresponding to 75.9% of the total national commercial enrollment for 2014.18
Thirty-nine percent of these plans launched their price estimator tools more than 3 years ago, and just under half of the 31 plans (45%) offered multiple tools to their members—both provided by the plan directly and through arrangements with third-party vendors.Key Features of Price Estimator ToolsCapabilities of health plan price estimator tools.
Our results indicated that health plan members have access to a variety of price estimator tool capabilities (Table 1
). Ninety-four percent of plans allowed for provider comparison shopping and about 58% displayed estimates for prescription drug costs. In generating price estimates, plans account for various member characteristics depending on the type of service being estimated. For instance, a member’s zip code (94%), product type (77%), and benefit design (77%) are commonly used characteristics for provider comparison shopping. In contrast, about one-third of plans account for member zip code (35%), product type (29%), and benefit design (29%) for cost estimates of prescription drugs (Table 1).Services for which estimates may be obtained.
Eighty percent of health plans choose which services to provide estimates for based on the most commonly used procedures and services. Of the most commonly used procedures, we found that nearly all of the plans provided estimates for elective outpatient surgery (97%), radiology services (eg, x-rays, computed tomography scans) (97%), and inpatient surgical services (97%) (Figure
A majority of health plans also provided estimates for physician services (71%) and services associated with select chronic conditions (61%), such as glycated hemoglobin testing for patients with diabetes. Open-ended responses revealed that many members might also obtain estimates for preventive services, including wellness visits, preventive screenings, and behavioral health services. Less common, are estimates for services at retail/convenience clinics (32%), services provided in the emergency department (26%), and telemedicine (6%).Data taken into consideration.
Data used to generate price estimates for the services primarily consisted of a health plan’s historical paid claims for a specific geographic area (55%), the health plan’s historical allowed rates (the maximum a health plan will pay an in-network provider for a service) for specific providers (52%), and a plan’s current negotiated rates (ie, the price negotiated between the health plan and the provider for a service) for specific providers (45%). These data are generally updated quarterly or semiannually (65%).
PDF is available on the last page.