Improving the financial experience of patients requires an end to mafia-style price negotiations

While health care may be the most important purchase most people will make in their lifetime, it is also the one they are least informed about. Despite legislative changes such as the law without surprise and the Centers for Medicare and Medicaid Services’ price transparency rulepatients in the United States still have a terribly loose understanding of the healthcare payment process.

Lack of transparency in healthcare pricing often leads to devastating consequences for patients, forcing some into deep debt and others into avoiding doctor visits or skipping medication. This problem won’t get better until the healthcare industry gets rid of price-inflating middlemen and behind-the-scenes price negotiations held by businessmen, according to a discussion panelists had at the event. of a session at MedCity. Investing in digital health conference on Wednesday.

Panelists agreed that CMS’s price transparency rule does not work. Although this was heralded by lawmakers as a huge win for patients, many experts hold the belief that the price data published by hospitals is essentially useless to consumers. The rule is flawed in its design because it forces hospitals to publish very complex billing data that is too confusing for patients to understand, panelists said.

Furthermore, it is impossible to produce an accurate estimate of the costs of care in a fee-for-service environment, Cedar CEO Florian Otto pointed out. For example, patients often change medications or contract sepsis in hospital – true price transparency would imply a bundled payment system that takes into account the flexible nature of a patient’s entire care journey, a Otto said.

Even health system administrators can’t understand price transparency data, according to Ryan Hildebrand, audience member and innovation administrator at LCMC Health. He recalls a recent conversation he had with LCMC Health’s chief revenue officer, Suzanne Haggard, in which he sought to better understand the cost of care in the healthcare system.

“I asked him, ‘Hey, how much would knee surgery cost?’ and she said ‘Well, I don’t really know – you would need to know this and that and this and that.’ There are so many layers that are built in, there’s really no one who understands it top to bottom. he said.

This complexity and this lack of transparency are sometimes at their peak when it comes to drugs. A key reason why almost 40% of Americans are skipping or rationing their prescriptions due to price gouging by pharmacy benefits managers, said Adrian Rodriguez, vice president of quality and safety at Mark Cuban Cost Plus Drug Company.

His company seeks to eliminate these intermediaries by going directly to suppliers to obtain drugs. Bypassing pharmacy benefit managers not only often results in 85% savings for patients, it’s also a more honest and transparent way to provide people with their medications, Rodriguez pointed out.

Pharmacy benefit managers aren’t the only ones evaluating prices — providers are also very knowledgeable, according to Maria del Carmen Uceda, chief surgical sherpa at Surgical Sherpa. His company guides patients through the process of negotiating health care prices (much like a Sherpa guides a climber up a mountain). She said she often deals with surgical practices that charge patients many times the Medicare rate for procedures.

Del Carmen Uceda shared an anecdote that sums up a problem she often encounters in her work. She was speaking with a surgeon who used to lower prices for the patients she worked with, but he said his hands were completely tied once his practice was taken over by Texas Oncology.

“He said, ‘I have to code like they want to code.’ For one procedure, they wanted to charge seven times the Medicare rate. That’s not right,” del Carmen Uceda said. “I’m sorry, but there’s a mafia out there. I’m probably going to offend some hospital systems. , but they negotiate with the payers behind closed doors and the community suffers.

Photo: James Brey, Getty Images

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