Terry Hush: I think that providers are going to have to really bite the bullet on this one so that patients can properly be financially responsible for their treatment decisions.
Erika Grotto: The provider conversation behind the patient information, today on HFMA’s Voices in Healthcare Finance podcast, sponsored by Red Dot.
Hello, and welcome to the podcast. I’m your host, Erika Grotto. The Information Blocking Final Rule from the 21st Century Cures Act and federal transparency initiatives like the No Surprises Act have given patients access to more information than they’ve ever had before. On today’s episode, I’m talking with Terry Hush, CEO of Roji Health Intelligence, about how that access should change the conversations providers are having with their patients. But first, let’s go to our Beyond the News segment. Our policy director, Shawn Stack, is unable to join us today, but don’t worry: HFMA senior editor Nick Hut is here with your headlines. Hey, Nick.
Nick Hut: Hey, Erika.
Grotto: There’s a new drug for Alzheimer’s disease that’s been getting a lot of attention in the media the last few months, much of that being around the high cost of it. So, what’s happening now with this drug, and what is the relevance here to our audience?
Hut: Yeah, thanks Erika. I find this story interesting because it highlights the tension between advances in medicine and coverage policies for new products. This Alzheimer’s drug is called Aduhelm, and it’s being touted as the first drug that halts the progression of Alzheimer’s disease. It’s a monoclonal antibody treatment, which is the same type of treatment that is used in many cases to treat Covid-19. Some in the clinical community are skeptical of Aduhelm’s effectiveness. I remember that before the FDA approved the drug in June 2021, an outside advisory panel recommended against approval, saying the clinical benefits needed to be studied more. So in a preliminary coverage determination in January, CMS said it would cover Aduhelm only when used in approved clinical trials. And it’s very hard for me to envision commercial payers covering Aduhelm when Medicare is not doing so. So assuming no change in CMS’s stance, it’s safe to say the drug is probably not going to get much traction in healthcare settings in the foreseeable future—unless and until its efficacy is further proven in clinical trials. Now, there is a 90-day comment period that began in mid-January, so there’s at least the potential that CMS will change its position.
Grotto: So, it’s my understanding this drug already has impacted costs in Medicare. Is that right?
Hut: It has. Specifically, the manufacturer, Biogen, initially priced Aduhelm at $56,000 per treatment, which quite frankly is an astounding figure. And in December, it did bring that price down by half in response to pushback. But the prospect of covering Aduhelm at its initial price tag factored into the biggest year-over-year increase in Medicare premiums on record. It was a $22 increase, and CMS said about half of that stemmed from the potential cost of covering Aduhelm. Honestly, I’m not clear on why CMS couldn’t have found a way to make its coverage determination for Aduhelm ahead of setting premiums. Regardless, the agency now says there could be a reassessment of that premium increase with the possibility of a retrospective adjustment given that the price has come down, and obviously they might end up hardly covering it at all, but that won’t be known until after the 90-day comment period ends. So we’ll be keeping everybody up to date on future developments. You can follow our coverage of this story and all other noteworthy healthcare finance topics at hfma.org/news and hfma.org/blog.
Grotto: Under the federal initiative of transparency with the new No Surprises Act provisions, patients have better access to information than before about what their healthcare will cost. But pricing information is not the only thing patients have at their fingertips these days. They’re also receiving more information about their actual care. Last April, the Interoperability and Information Blocking Rule, part of the 21st Century Cures Act, went into effect. There are a few aspects to this rule, but from a patient’s perspective, what it means is that test results, notes and other information from their encounters with healthcare providers is made available, with few exceptions, in the patient’s electronic health record as soon as it’s ready to view. I wanted to talk through what it means for providers when patients have so much access to information, so I invited Terry Hush, CEO of Roji Health Intelligence, to discuss with me how the conversation between the patient and the provider needs to change.
I’d like to start this interview with a brief story. I tend to experience the healthcare system through my kids, as anybody who’s listened to basically any of this podcast knows. You know, they’re young, they get sick fairly often, and because I have three of them, I usually end up with at least two of them sick at a time, which is what happened to me very recently. I had an experience where I was at the doctor with one child on Monday and another on Friday, and both times, I knew things before anybody came to talk to us. I knew about test results. So, the first time was when I got a notification from the pharmacy because when we went in, it was like, well, it could be this thing or this other thing, but the thing that we would have a prescription for was obvious what the test results had been. And the second time, I got a MyChart notification about a test result while we were sitting in the room, before the nurse had made it back to talk to us, and it was about 30 minutes in between. In both of those cases, having the knowledge was a good thing for me because the results were what I wanted and I understood them, but had the reverse been true, I would have been sitting in a room with a sick child, learning about a scary diagnosis from my phone, which is not necessarily a great thing. Not to mention, a lot of the tests we get as patients, we don’t get results the same day, but when we do get them, it’s typically electronically rather than from a provider. So what do you think providers need to be aware of here? It seems like there’s some good. Patients don’t have to wait until their provider has a free minute to talk to them. But this information can also lead to a lot of confusion, especially if a test is not a positive or negative, or a patient receives a result that they don’t understand or know how to read. So what are your thoughts about all this?
Hush: Those are such interesting questions given where we are with the pandemic, where we’ve just been inundated with information about healthcare and lab results, testing information and delays in services and so on. But the fact is, we have technology and data that’s surpassing the ability of both providers and patients to manage that data. And the volume of that with genomics coming online and other sources of data just exponentially increasing is it is going to complicate this scenario for all patients and providers as well. So while we have this data, we’re still stuck in this delivery model that we’ve been using forever and ever, driven by providers who are gatekeepers to testing and treatment services and the information that’s going to patients. But they have less time to be the primary communicators with their patients. So we’re asking more providers to be available for timely interpretation of results really isn’t realistic anymore. We have to rethink how we’re actually delivering both information and treatment and testing services and what are the actual information points that we need to be aware of with all this data coming online?
Grotto: What, then, should providers be telling their patients about the information they’ll have access to? Should they come out and say, “If it says this, it means that” or “I’ll give you a call to discuss it” or maybe even “Don’t bother looking at this because you won’t understand it”? What do you think that conversation should look like?
Hush: Well, it definitely shouldn’t be the last, because that would be really dissing their patients, telling them that they couldn’t possibly understand healthcare data. What we should be concentrating on is the reverse. We should be pushing information up to the front of the line. By the time the test results come through, the patient should already know what the possible tree of scenarios might be. So they should know what they’re being tested for, what the outcome would be, so that is all predictable information for them before they get their results. And if they happen to get their results before the provider tells them about it, then it’s OK because they’ve now been forewarned about that information, and they know what to expect. The other thing we need to think about is, in looking at that end-to-end process about providing information and learning for the patient, is how we integrate that information in a way that’s not casual but intentional. And I mean, the provider alone cannot provide information on everything to a patient. There’s got to be an actual thought-out process for teaching the patient what they need to know in advance. Even upgrading health literacy. We’ve got these massive megasystems of healthcare right now, but where in those systems the same model of delivery is operating. So patients are showing up, they don’t really know any information, they may be Googling information about their symptoms and so on, but they don’t know anything from the providers on what they’re likely to get, what is the process they’ll be subjected to, how they’ll be getting information from their providers or others in the system. And all of that needs to be part of explaining the process to the patient in advance. So that’s--the conversation you’re talking about is the time when the tests are ordered. When the tests are ordered, the patient should know what the likely range of possibilities are and what will happen as a result of that. The other issue that you’re raising is that when you start to get a prescription drug and the window is closed for you to actually ask questions about alternative treatments, then the patient or the parent, in your case, is caught in this kind of odd information gap where suddenly you have the prescription, which may not be exactly what you were really thinking about. You may want treatment, but you may also want to ask questions about the alternatives related to that treatment. I think that’s the problem that we have right now, is that we don’t have a really good integration of the care regimen with all this information and how it’s being presented to the patient, not so much whether the provider him or herself is interpreting those results for the patient. Most patients are getting so much information right now and have access to so much information that they can figure out what’s really going on with them and whether something is serious or not before they’re actually in an exam room. But the connection of that with how they’re actually getting care, how they’re actually getting tests and the ability to change that on the fly is simply not there. So I think we really need to invest in learning systems for patients so they can feel more comfortable and trusting of the process that they’re in for their general care: how to interpret basic lab results, what do particular labs do, what are they likely to find, what—even data—I mean, if you’re undergoing a particular kind of test that has a certain likelihood of result, what is the range of data and when should you be concerned, and then, of course, that would be followed up by some intentional conversation or scheduled telemedicine to go over those results. But we don’t think enough about how we’re going to educate patients about healthcare, even though they’re more financially responsible, they’re more driven to change providers continually, and we need to have better systems of keeping them in the loop with all this rapidly evolving data that they’re getting.
Grotto: That feels like a good segue into price transparency—speaking of higher financial responsibility—because that’s another area where patients have a lot of access, or they have access to a lot of information that they probably won’t be able to sift through. It’s become sort of a pet peeve of mine—and I almost hesitate to say it on the podcast because it’s said all the time—that people want their healthcare to be like ordering something on Amazon. But it’s not, because on Amazon, if I want to buy a lamp, I go and look at the page with all the lamps, I pick the one I like for the price I like, and it comes to me from wherever it comes to me from.
Grotto: But you can’t do that with healthcare. It feels like, though, we’ve talked to death about good patient financial communication—and whether that’s actually had any effect I don’t know—but price transparency is here. It’s a requirement. So how can healthcare organizations use the price transparency information that they’re required to post for their benefit and to the benefit of their patients?
Hush: Well, I think that your example of how you would actually order something is the way it should actually work. When you have a procedure that you’re getting price information on—let’s say you’re going in for a scheduled screening colonoscopy—you know that there is going to be a gastroenterologist involved, there’s an anesthesiologist, there’s a facility fee. It isn’t like the organization does not have that data. They know what the prices are. They just haven’t combined them into episodes. And so price transparency should be based on episodes. They’re doable. They’re being monitored by payers. They’re being monitored by Medicare. There’s bundled payment initiatives all over the place, and there’s cost measures by Medicare that break care down into episodes that include all of the different service packages that go into one trigger event, whether that trigger event is care for diabetes or care for, you know, having the screening colonoscopy or a gall bladder surgery. So there’s no reason why we shouldn’t expect price transparency to be on a basis that patients can understand, and that understanding is based on, what is this whole procedure, this whole event going to cost me? Now, would providers want to do it that way? Probably not, and why? Well, because when they’re out there with their prices, then of course, they are in competition with other providers who have similar kind of prices, and people want to put their best foot forward. Because of the negotiated insurance arrangements and different referral arrangements, it’s more complicated than simply doing a price list. Everything is part of one system, and one system can evaluate those prices, and they can evaluate it on a covered basis too, because they know what their rates are for individual payers. But they’re not going to want to expose those prices because they’re so much clearer to patients. But there are other organizations that are now beginning to produce these things, vendors out there where you can look up the price of an all-included event like that and find out what the comparative prices are. So I think that providers are going to have to really bite the bullet on this one so that patients can properly be financially responsible for their treatment decisions.
Grotto: I have enjoyed this conversation so much. I always love talking with you. Terry Hush, thank you so much for joining me today.
Hush: Thank you, Erika. It’s been fun.
Grotto: Let’s take a moment now to get a word from our sponsor, Red Dot, and their CEO, Michael Bumann. Welcome back to the podcast.
Michael Bumann: Erika, thanks for having me.
Grotto: Today we’re continuing our conversation about how Red Dot can help a provider organization with its motor vehicle accident accounts. These accounts are incredibly difficult to work from a revenue cycle perspective. Tell me why.
Bumann: Thank you, Erika. Good to be talking with you again, and I appreciate the question. Motor vehicle accidents, or MVA accounts, are by their very nature very complex. They’re the only financial class that requires 100% manual processing, really from beginning to end. These aren’t patients that schedule their accidents. There’s no standardization between liability carriers and hospital resolution. They’re difficult for staff to deal with. You layer that on top of the typical self-pay challenges—really not a big surprise that it becomes very frustrating to deal with. When you realize that there’s, you know, 6 to 7 million car accidents every year in this country, it’s a problem that continues to grow over time. The days in AR are excessive, the FTE resources are immense, and it’s super frustrating to deal with these because they never seem to get ahead. You know, they have to deal with multiple claims adjusters. They have to negotiate with attorneys. These are stressful accounts to deal with. You layer all of that together, it really does take a big whack out of the morale for really hard-working and committed people that like to see the outcome of their work. When you work with us, we come in and take all of that away. Again, we resolve a 3-month traunch of their aged accounts. We deal with them from Day 1 moving forward, and it really allows that staff to focus on their core competencies. And when you can do that, obviously, the morale goes up, productivity goes up and a lot of things are made better simply by taking care of something that’s very, very difficult to deal with.
Grotto: Alright, well until next time, thank you again for joining me today.
Bumann: Always a pleasure.
Grotto: Red Dot is the best technology-enabled acquisition solution for hospital self-pay motor vehicle accident accounts. Hospitals can now leverage Red Dot’s solution to improve their bottom line revenue while dramatically improving their patient relationships by avoiding debt collection activities. Red Dot: Good for hospitals, good for patients. To learn more, visit reddotmgmt.com.
Voices in Healthcare Finance is produced by the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is our director of content strategy. Our president and CEO is Joe Fifer. If you haven’t yet subscribed to our podcast, we recently published our 100th episode, so there’s plenty in the archive and much, much more to come. And as always, if you want to get in touch with our team, you can reach us at email@example.com.