Lesson Learned from "A Bill You Can Understand" Design Challenge - HXR 2016 - Paul Kahn
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Launched at Mad*Pow's annual HXR conference, The ‘A Bill You Can Understand’ design and innovation challenge demonstrates that ‘collaboration is the new innovation.’ Public and private players leveraged their respective platforms, expertise, and perspective to accelerate progress toward solving a key consumer pain point with our health care system. Two challenge winners were selected from 84 submissions and were announced at the Health 2.0 conference on September 28, 2016. There were also 10 submissions who received an honorable mention. A big thanks goes out to all who were involved in the challenge. This webinar shares lessons learned from the challenge from Mad*Pow's Paul Kahn.
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Lesson Learned from "A Bill You Can Understand" Design Challenge - HXR 2016 - Paul Kahn
- 1. PREPARED BYPREPARED BY Lessons Learned from A Bill You Can Understand DATE Paul Kahn, Experience Design Director November 9, 2016
- 3. Project Timeline February Concept collaboration with Health and Human Services March Pilot Partners & AARP sponsorship April Announcement at HxR Research Report and Website May 10: Launch at Health Datapalooza June-July: Webinar + Social Media campaign Aug 10: Competition Deadline Aug 22: Advisory panel review Sept 7: Patient focus group review Sept 15: Federal panel review Sept 21: Winners/Honorable Mentions chosen Sept 28: Winners/Honorable Mentions announced at Health 2.0
- 5. Mad*Pow Research Report • Identify major issues in the current medical billing system facing patients today from the point of view of • Healthcare systems • Insurance companies • Patients Seven Top Concerns: • Patients Don’t Know What They Don’t Know • Volume of Communication • Understandability • Terminology • Timing • Financial Planning • Trust
- 6. Patients Don’t Know What They Don’t Know • Providers don’t inform Patients about how their medical care and related costs are distributed among providers. • Patients don’t know when and where to ask questions about decisions that affect their medical care and related costs. • Patients don’t know when a denied claim will be resubmitted, processed and accepted.
- 7. Volume of Communication • Patient typically receive a large number of documents from payers, multiple providers and third-party benefits manager for a single medical event. • “Going paperless” can result in a large volume of emails from multiple sources with links to multiple patient portals, each requiring its own credentials, containing PDF copies of the same documents that arrived in the mail.
- 8. Understandability • These diverse documents do not provide a clear indication of how they relate to one another or how they define the patient’s healthcare costs. • The same charge may be described differently in a bill and in a benefit statement. • The name the physician treating the patient may not appear on the bill, while the name of physicians’ unknown to the patient do appear. • Hospitalization charges are divided into categories incomprehensible to the patient, professional and facility services defined by the provider’s contract with the payer.
- 9. Terminology • Treatments are described in unfamiliar terms. • Payment options are difficult to find and written in legal jargon.
- 10. Timing • The time needed to reconcile claims to determine actual patient charges separates the patient’s experience of care from their experience of cost. • The unpredictability and distance in time makes the entire experience unreal, followed by bad surprises.
- 11. Financial Planning • The lack of awareness of cost before and during care leads to patients unprepared for managing final cost. • Faced with bills that far exceed their available resource to pay, patients don’t know their options for managing long-term payments.
- 12. Trust Many factors undermine patient trust of the charges on the bill • The contentious provider-payer relationship that generates denial and resubmission of claims • The enormous difference between charge master and allowed charges. • The patients’ experiences of duplicate bills and unrecognizable charges.
- 13. Problems Are Closely Inter-related • Providers struggle to manage their revenue flow. • Negotiating payment contracts with a variety of payers makes it challenging to estimate the cost for a patient at the point of care. • Large payers operating in multiple states are faced with enormous variations in data reporting practices. • A significant amount of communication in the healthcare business is done by fax and copies of paper forms, then re-entered into data processing systems. • Inter-system communication in the healthcare billing world between providers, insurers and pharmacies is one of the last bastion of non-digital communication.
- 14. Real Estate is based on Location Location Location Medical Billing is based on Surprise Confusion Delay
- 15. What we heard from Patients RATED THEIR MEDICAL BILLS AS CONFUSING OR VERY CONFUSING. DIDN’T DO ANY RESEARCH ABOUT COST PRIOR TO THEIR MEDICAL VISIT
- 16. What we heard from Providers
- 17. Bills and Benefit Statements
- 18. Bills and Benefit Statements
- 26. Patient Journey Map (3-7) Being presented with enormous differences between Charge master fees and adjusted fees challenges understandability of charges and undermines trust in Providers (5) Timing delays for medical bills are unlike any other retail or service experience (7) Incomplete or inaccurate cost estimates undermines trust in both Insurer and Provider PAIN POINTS Medical Billing Top Concerns: (1) Patients Don’t Know What They Don’t Know (2) Volume of Communication (3) Understandability (4) Terminology (5) Timing (6) Financial Planning (7) Trust (3-5-7) Introducing Third Party payers complicates the process and further undermines trust (2) Maintaining accounts on multiple Patient Portals for access and payment of bills from different Providers Multiple sites makes it difficult to keep track of what has been paid
- 27. Patient Journey Map (6) Insurer could estimate the total cost of procedure at the time it is recommended and prepare Patient for total cost. Hospital could estimate when costs will be due and explain payment options OPPORTUNITIES Medical Billing Top Concerns: (1) Patients Don’t Know What They Don’t Know (2) Volume of Communication (3) Understandability (4) Terminology (5) Timing (6) Financial Planning (7) Trust(2) Coordinated statements or a unified portal to review Provider claims to Insurer, bills from all providers, and the Patient’s FSA/ HRA/ Deductible status would reduce concern about volume of communication (5-6-7) Patient will be able to pay the bill and plan for the financial consequences knowing that all pending claims have been resolved, that the bills all agree with expected cost estimates, that no further adjustments will change their cost.
- 28. Who submitted entries? • Healthcare organizations • Non-profits working in the healthcare sector • Doctors and healthcare workers • Interaction design companies • Health information and financial services software companies • Graduate student teams from public health and design schools • Ad hoc groups of people passionate about the topic
- 29. Prize 1: Easiest Bill to Understand • Winner • RadNet • Honorable Mentions • A Better Health System • Change Healthcare • Renown Health • Up To 11
- 30. Prize 1 Winner:
- 31. Prize 2: Transformational Approach • Winner • Sequence • Honorable Mentions • Business Innovation Factory • EveryBill • FAIR Health • gravitytank • Health Payment Systems • iVinci
- 32. Prize 2 Winner:
- 33. What about the EoB? Charlotte UX
- 34. Offer multiple payment options
- 35. Include patient’s insurance status
- 36. Omit un-discounted charges from statement
- 37. Cost estimate before the bill
- 38. Separate amount owed from detail of charges
- 39. Image of provider or institution
- 40. Three Approaches Entries demonstrated three approaches for unifying the billing experience • Provider Network becomes the single source managing all charges from in-network and out-of-network providers • Insurer becomes the single source of payments to be redistributed to all providers • A new Third-Party Service Platform manages claims and payment between providers, payers and patients
- 41. Current Medical Billing System
- 42. Provider Model
- 43. Insurer Model
- 44. Service Model
- 45. Conclusion: Shore Up the Fragments • Alleviate the current fragmentation of financial relationships • Transform the stream of invoices from unrelated providers and interpretations of unconnected payer benefits into a single financial relationship • Create a coherent service for managing patient’s experience of healthcare providers and their associated cost
Editor's Notes
- The true origin of the “A Bill You Can Understand” Design and Innovation Challenge is everyone’s experience with medical bills in the United States. The medical bill is an integral part of the healthcare system and a patient’s most common interface with healthcare organizations. The way the cost of medical care is communicated directly affects our health. A patient’s experience of these bills is capable of invoking illness, rage, confusion and bankruptcy. We all asks ourselves: Why are medical bills so different from all the other bills I get? Why are they so confusing?
- Our report collected insights and quotes from phone interviews complimented by an online survey. One team interviewed the Pilot Partner healthcare systems, insurance companies and other experts in medical billing and health literacy. Another team conducted interviews with patients chosen for their experience dealing with medical bills in the recent past. From the insights gained from these interviews, the team designed and executed an online survey that attracted responses from 355 additional patients.
- We looked at all the touchpoints across the ecosystem. The Patient’s healthcare experience touches 8 different sources: Primary Care, Specialist, Lab, Hospital, Employer, Insurer, Third-Party Benefit Manager, and Pharmacy The Patient has to explain herself to many Receptionists and Customer Service staff
- The patient has to repeatedly present their insurance credentials. Then they receive pay directly and receive bills from even more places
- Emails and phone calls across most of the ecosystem
- The digital touchpoints proliferate even more than the printed artifacts
- The medical billing journey we chose to represent was based on an actual episode of care that took place in real time during the months the challenge was being developed and launched. We chose an episode of care – diagnosing and treating skin cancer – because it lends itself to narrative presentation. Who Does The Work (row 1) generates the Billing Process which breaks down into six separate streams. The single sequence of Medical Events (row 2) contrasts sharply with the Billing Process (row 4). The Patient Experience (row 3) shows how the billing process becomes unconnected to the Medical Events, though they are triggered by Who Does The Work.
- During the procedure and post-procedure period everything goes as planned, but the cost remains a mystery. The provider gives no cost information. The insurer tells the patient he will call her back but does not. Three weeks later the insurer calls back with the charges for facility services. Meanwhile the patient is receiving bills for lab work she doesn’t recognize. She pays one lab bill with her Flexible Spending Account and gets into trouble. The charge is from the previous year. When she gets the bill from the hospital two months later, it is for professional services, another surprise. The facility charges don’t arrive for another month.
- The hardest part of running design challenges is not being able to enter it ourselves. During the challenge period, we developed a second layer of the journey map in which we identified the touchpoints causing confusion and discomfort to the patient, then aligned potential solutions. We discussed the issues identified in the research report in an internal seminar where we enumerated the pain points associated with each concern and identified opportunities to could address them.
- AARP Announces Prize 1 – What great ideas we saw for prize 1 – some themes/insights.
- And the winner is the team from RadNet led by Randy Ziegler. The strengths of this entry include: A design that segments the page or screen for easy reading A consistent view of payment due, payment options and insurance details QR code links to online presentation for further information with progressive disclosure to reveal charge details as needed A clear explanation of charges and terms Customized presentation based on patient’s insurance status
- Back to HHS– What great ideas we saw for prize 2 - some themes/insights.
- And the winner for Prize 2 is sequence led by Cheryn Flanagan for their design of Clarify, a new service that brokers information and payment for patients Some of the outstanding features of this entry include: Establishing a consumer-centric information and payment service Integrating search for services, cost comparisons and scheduling appointments Consolidating all communication from multiple insurers and providers Innovative features for consumers to pre-paying for medical services
- Charlotte UX, a strong entry that did not make the cut for honorable mention, proposed a coordinated design for Explanation of Benefits (EoB) and bill to make it easier for patients to match them, but this was one of very few designs that included the EoB.
- Offering multiple payment options on a printed bill is current practice, with many current bills provide a URL and alphanumeric code, both of which are required to give the patient access to an online payment system. Ten of the solutions went further. Most offered access to payment plans as well as online payment by credit card or bank account. The Pay Now button appears on all the online examples. In an effort to simplify the connections between paper and web-based interaction, RadNet included QR codes linking the bill to an online payment system. Online payment was the norm in the winning Sequence Clarity entry, along with a prepayment option. All of these features support financial planning.
- The patient’s deductible and out of pocket status, information currently held by the insurer, can have enormous impact on the actual amount to be paid. Bring this information onto the bill supports financial planning and trust. Most of the bills displayed the patient’s deductible and out of pocket status with their insurer. A few entries integrated the patient’s HSA, HRA and FSA account status into the billing statement and permitted the patient to designate money from these accounts as payment.
- A bill can display many numbers for each charge: the “charge master” or un-discounted price, the price allowed (discounted) by the patient’s insurer, the amount paid by the patient’s insurer, any amount already paid by the patient, and the balance due. The text labels describing these numbers varies tremendously. What the healthcare provider expects to receive is called Charges while the amount allowed by the insurer goes by many names – Allowed Charge, Discount – and the amount paid by the insurer to the provider may be called Payment/Credit, Adjustments or What Insurance Covered. Most entries simplified the bill by limited this presentation to two numbers. Winning entries applied common language to label the actual provider charge (Amount That Was Billed), the payment from the insurer to the provider (Your Plan Paid) and the patient’s previous payment (You Paid). Simplification and use of common language labels improves understandability and trust.
- The best solutions included a method for presenting an estimate of the cost for a visit or procedure before sending the bill. There is a variety of approaches to this issue. The gravitytank IRIS service and the Up To 11’s entry both present this estimate at the end of the provider visit. Up To 11’s estimate is a “Maximum Estimated Cost” (the cost before insurance) at the time of a visit. Change Healthcare’s SmartBill, designed to support an Episode of Care example, is divided into an estimate and final bill. That estimate is updated during the duration of the care episode, to better prepare the patient for receiving the final bill. Better Health System’s entry starts with estimated costs associated with a Doctor and continues with Billing Progress Reports leading to a Final Bill. In Sequence’s Clarify service concept, the cost to the patient for a service appear before the service is performed.
- The model of a monthly credit card statement inspired half the entries to clearly separate the statement of the amount owed from the details of how that number was calculated. This also simplified the first page or screen of the bill. There are many fine examples among the solutions of progressive disclosure, in both print and online. These designs first communicate what should be paid and when it is due, and then provide justification for the charges on following pages or through interaction with the screen.
- Images of the people involved in medical care is another reflection of current consumer expectations. The inclusion of provider or institutional images in many of the bill designs is clearly influenced by current practice in social media (Facebook, Slack) and shared-economy applications (AirBnB, Uber). Seeing the face of the person you are paying adds a personal connection, increases trust and addresses the lack of transparency we often experience in today’s billing practices.
- Back to HHS– What great ideas we saw for prize 2 - some themes/insights.
- In the current system, patients receive bills from multiple sources. Each patient is expected to assess the accuracy of these bills by integrating information from their primary insurer and benefits manager. The patient receives sporadic information about negotiations between providers and payers, but is unaware of how claims and payments will be resolved. A common response to this cognitive overhead is to pay nothing.
- By merging the insurer’s information with the charges from in-network and out-of-network providers treating the same patient, the healthcare network can take over the role of unified medical bill provider and become the source of truth to the patient. The patient faces a single billing stream and manages resources in benefits accounts separately.
- The patient’s insurer could also be recast in this larger management role, becoming the single source of payments to be redistributed to all providers. In this case, the insurer resolves both claims and balance due with the providers, the patient faces a single billing stream from the insurer, and manages resources in benefits accounts separately.
- A third possibility is imagining a new service that monitors claims and payment between providers and insurers and manages payments between providers, benefits managers and patients. In this case the patient faces one bill stream from a third party, independent from both the provider and the insurer. Several of the entries propose that such a service would provide pre-treatment cost estimates along with cost comparisons for different provider and benefit comparisons for different insurance plans.
- Once we alleviate this problem, visual and service design improvements can address the issues related to confusion, poor financial planning and lack of trust. Undoing the current fragmentation requires significant reorganization of the information being presented to the patient. The key to unlock a patient-centered billing system is the same whether it comes from the healthcare network, the insurer or a new patient-facing service.