Price Transparency Paramount in Providing Quality, Value to Patients

Price transparency and communication can be valuable in helping patients understand their options while also providing them with quality care, according to panelists from the American Oncology Network (AON), 1 of the 4 community oncology groups invited to highlight initiatives during Patient Centered Oncology Care.

Panelists Discuss Quality and Value in Health Care
The panelists began by defining what quality and value in health care mean from a patient’s perspective, with each offering insights based on their experiences.

Brian Mulherin, MD | Image credit: LinkedIn

Brian P. Mulherin, MD, medical director at AON, defined quality as “the degree to which a service intervention is [going to] increase the likelihood of the outcome that you’re looking for.”

To achieve this, a service must have a mixture of safety and efficacy, and it must be accessible, Mulherin said. Guidelines offer one method to measure quality across multiple practices, both within the United States and around the world. For example, he referenced the National Comprehensive Cancer Network (NCCN) guidelines1 that can be found online and offer treatment recommendations for almost every form of cancer.

Value is a different kind of measure, one that evaluates the outcome based on the cost it took to achieve that result, Mulherin said. “But how are you measuring that? Are you looking at quality-adjusted life years? Are you looking at incremental cost-effectiveness ratios from a clinical perspective?… I think there are a lot of cases where this is not clear.”

Anne Marie F. Rainey, MSN, RN, CHC, CPHQ | Image credit: LinkedIn

Anne Marie F. Rainey, MSN, RN, CHC, CPHQ, director of value-based care at AON, said her own definitions of quality and value might be rigid and defined by metrics, due to her experience in community oncology and at CMS.

Patients, by contrast, take a different approach to their own definitions of quality and value. “From the patient perspective, their definitions of quality and value would really be defined by what they’re able to do outside the walls of that treatment center based on what happened inside the walls of that treatment center, right?” she said. “When my team is thinking through new initiatives and new implementation and how to make things work in a clinic, we’re really thinking about what is going to be the impact for that patient, even when they leave the facility.”

Chris O'Dell | Image credit: LinkedIn

Chris O’Dell, senior vice president of market solutions at Turquoise Health, pointed out that value is more of an industry term that may not translate well to a patient. For someone outside health care, it can be confusing to hear terms such as price, cost, reimbursement, margin, and value, which may seem interchangeable on the surface.

“I think there’s an ability for us then to take [defining these terms] one step further and say, ‘and your out of pocket is less, and you get to see the doctor you want,’” O’Dell said. This is breaking down value to what matters to the patient, he said.

Price Transparency in Health Care: How It Helps Patients
The discussion shifted to price transparency, with O’Dell discussing the origins of Turquoise Health. According to Fierce Healthcare,2 Turquoise Health launched in December 2020 to help patients know the price of health care services before they begin treatment. The company uses a search engine to help patients compare costs of care to make their health care decisions simpler. This isn’t as easy as it might seem, O’Dell said.

“One of the biggest challenges is that the data is incredibly complex,” O’Dell said, and patients might be exhausted working their way through this system. Although data can tell patients what UnitedHealthcare pays the Mayo Clinic vs AON, this information might not mean much to the patient looking at that data.

CMS now mandates transparency in pricing, and O’Dell said this boils down to 2 basic requirements: Hospitals must tell patients what they’ll be paying before they get the service, and insurance companies must give patients an explanation of benefits before charging for the service. “Those 2 things are much easier said than done. They’re really, really hard to execute but there’s some really positive progress being made by all the companies.”

However, when it comes to these tools, it can make communicating with patients about costs just as challenging as it was previously. Mulherin explained that most clinicians who prescribe treatments may not even understand all of the terms related to the cost of those treatments, which can be a barrier should a patient come to them with data on costs. “Many medical schools are starting to include that. You can say, ‘That’s not why I went into medicine.’ But this is the world that we live in now. So, there’s education on that side of it too,” he said.

Mulherin emphasized that knowing the patient’s goal for treatment, whether it be to receive a cure or to maintain the life that they’re living, is important in making decisions. However, physicians often can’t tell what the out-of-pocket costs will be for that treatment, which is often very different from the overall cost of care. Mulherin said that most physicians will prioritize giving patients the best treatment for their goals and customize the treatment from there. Patients can also let a doctor know if the treatment has become too expensive fo them to continue, which can lead to a consultation with a financial counselor. Ultimately, he said, the responsibility lies on the physician prescribing treatment.

Alti Rahman, MBA, MHA | Image credit: LinkedIn

Alti Rahman, MBA, MHA, chief strategy and innovation officer at AON and moderator of the panel, said the network has used price transparency warehouses to look at markets and understand access, quality, and cost variables. “It’s been a very fascinating discussion to have with payers when you’re no longer quoting a study that was done maybe a year or 2 ago on cost differences and quality differences but you’re looking at real [data],” he said.

The future of this data might be in simply introducing conversations between patients and physicians, said O’Dell. “The idea that you build tools behind the scenes that are using this data in an innovative way so that the physician can have a better conversation with the patient is how I predict this goes,” he said.

How Value-Based Care Plays a Role
As patients become more aware of prices in health care, especially with new tools introduced online, value-based care can have a role in designing solutions that marry both quality and value in the treatment of patients without breaking their bank accounts.

Rainey highlighted 2 goals for what value-based care could be. Scalability and sustainability should be a focus in the future, as there are currently multiple programs that help patients with different payers or have different criteria. “In thinking about developing these models, alternative payment models, a value-based care arrangement, however you want to word that, I would love to see situations where we have more inclusive diagnoses,” said Rainey. “I also think that when we think about sustainability, we do have to think about reimbursement very differently because patients have so many needs and those needs can only be addressed by a strong infrastructure within a practice or within a partnership that a practice forms.”

Mulherin also noted that cost effective often comes with a negative connotation as being a cheap treatment. “You have to be careful [about] the language that you’re using,” he said. “We may think it’s cost effective. Explaining all that to the patient, especially in the confines of a 15-minute clinic visit—that’s complicated.”

Looking to the Future
In the future, quality and cost-effective care may be a dream that can be achieved through collaborations between multiple organizations. Mulherin believes that releasing the data and making it more accessible can help to hold different services accountable for providing different services to patients. Shining light on these areas could help in harmonizing the operations and forcing this information into broad daylight.

Rainey pointed out that future generations are more technologically knowledgeable and can become key stakeholders in their own care, including being proactive in understanding the costs of their health care. This can lead to the patient being far more involved in the delivery of care, which makes price transparency an important factor in future clinical visits.

“Any program that takes the complexity and figures out the complexity and lets it be simple for the patient while they figure out the incredibly complex system, I think is a great model,” concluded O’Dell. “You let the really complex accounting stuff stay within the value-based arrangement, and then you keep it simple for the patient.”

References
1. NCCN Guidelines. National Comprehensive Cancer Network. 2024. Accessed October 29, 2024. https://www.nccn.org/guidelines/category_1
2. Landi H. Price transparency startup Turquoise Health picks up $30M series B funding. Fierce Healthcare. January 23, 2024. Accessed October 29, 2024. https://www.fiercehealthcare.com/health-tech/price-transparency-startup-turquoise-health-picks-30m-series-b-funding