Providers should be the principal source of price information for uninsured patients and patients who are seeking care from the provider on an out-of-network basis.

Price transparency for the uninsured is subject to a substantial and expanding number of laws at both the federal and state levels and it is the first responsibility of providers to ensure that that policies and practices adhere to these legal requirements. Regardless of legal requirements, however, it is in a provider’s best interest to be proactive in its approach to price transparency. A growing number of patients face significant financial responsibility for healthcare services and are becoming increasingly price sensitive. As consumer price sensitivity has intensified, so too has media attention to healthcare prices. Providers that can speak accurately and confidently about their prices will be better positioned to succeed in this environment than providers that can only refer back to their charge schedule.

Providers should develop price transparency frameworks for uninsured patients and patients receiving care out of network that reflect several basic considerations.

Clarify the limitations of the estimate. Prices in most instances will take the form of an estimate; that is, provide a price for a standard procedure without complications and make clear to the patient the services included in the price and how complications or other unforeseen circumstances may increase the price. New payment models such as bundled payment may enable providers to set firm prices for certain procedures. As noted, some providers are covering the price of care related to avoidable complications within the provider’s control so that the estimated price to the patient does not increase in these situations.

Serve as the primary price information resource for these groups. Providers should clearly communicate preservice estimates of prices to uninsured patients and patients seeking care on an out-of-network basis. Federal and state laws define basic requirements for communicating prices to patients who are eligible for financial assistance. Beyond that, the provider should, at a minimum, offer clear information on how a patient can obtain price estimates and ensure that the patient can easily reach someone who can address such requests.

Providers should consider which approaches are most useful in providing information to uninsured patients in their markets, including the possible use of web and mobile technologies to respond to queries from an uninsured patient or provide information about the price of a particular service. A national steering committee of experts including patients, hospitals, physicians, payers, and others have developed a set of patient financial communication best practices that providers should refer to when developing or reviewing their patient communication practices.

Identify inclusions and exclusions. Providers should clearly communicate to patients what services are and are not included in a price estimate. If any services that would have significant price implications for the patient are not included in the price estimate, the provider should try to provide information on where the patient could obtain this information.

Offer other relevant information. Providers should give patients other relevant information, where available. The task force notes that some states have begun to make both price and quality data available on public websites and encourages all states to furnish such information on providers. A number of public and private organizations also offer public access to data on patient outcomes, safety, and patient satisfaction or credentialing information on providers who have met certain quality benchmarks. The price estimate that a provider gives to patients can reference and provide links to various reliable websites where the provider knows relevant information is available.

Referring clinicians help patients make informed decisions about treatment plans that best fit the patient’s individual situation. They should also recognize the needs of price-sensitive patients, seeking to identify providers that offer the best price at the patient’s desired level of quality.

Most clinicians will encounter more price-sensitive patients as exposure to higher deductibles and other forms of patient cost-sharing increases. Resources such as the Choosing Wisely campaign, a collaborative effort of more than 50 specialty societies, are helping clinicians and their patients make informed decisions about appropriate treatment plans to meet the patient’s individual situation.

When a treatment plan has been decided upon, clinicians will need price information to help their patients find providers that best meet the patient’s clinical and financial needs.

  • For insured patients, the clinician will typically want to refer the patient to his or her health plan as the best source of information.
  • To address the needs of uninsured patients, clinicians should request that providers to whom they refer patients make price information available to help in referral decisions.
  • In non-emergent situations, the clinician should provide the patient with a list of providers so that the patient can obtain and compare price information from them before the referral decision is made.

Clinicians who assume some degree of financial risk for managing a patient’s total cost of care under new payment models (including shared savings models and global or capitated payment models) may need some information on the cost of care provided by others treating that patient. The specific information required will depend on the type of financial risk assumed by the clinician, the ways in which attribution is handled, and the clinician’s relationship with other providers delivering care (e.g., whether they are part of the same ACO). The relevant stakeholders should determine the best way to ensure that clinicians have the information necessary for making such decisions.

Publication Date: Tuesday, March 10, 2015