Healthcare Cost Management Tools and Resources

Cost of Care Tools and Resources What is available for physicians and Patients? Circle with left arrow Support for this work was provided by the New York State Health Foundation (NYSHealth). The mission of NYSHealth is to expand health insurance coverage, increase access to high-quality health care services, and improve public and community health. The views presented here are those of the authors and not necessarily those of the New York State Health Foundation or its directors, officers, and staff.

Learners will: 1. 1. Identify the types of information Identify the types of information needed to support out needed to support out- -of cost conversations cost conversations 2. 2. Choose Tools to support Cost of Choose Tools to support Cost of Care Conversations Care Conversations 3. 3. Identify Resources to support Identify Resources to support Cost of Care Conversations Cost of Care Conversations OBJECTIVES of- -pocket pocket Circle with left arrow 2

Instructions for this Course In order to ensure that learners are able to fully interact with this course module, please: Play this as a slide show by clicking the slideshow icon Play this as a slide show by clicking the slideshow icon Turn the computer sound on Turn the computer sound on Use the green arrows to advance through the slides Use the green arrows to advance through the slides Circle with left arrow 3

Common tools already used: GoodRx.com Knowledge Check EHR Formulary Pharmacists What Tools have you used? What Tools have you used? Google Searches Before we begin, take a moment to think about the Before we begin, take a moment to think about the tools and resources you have used that relate to cost. tools and resources you have used that relate to cost. Insurance Websites Click Next to see a list of some common tools used by Click Next to see a list of some common tools used by physicians. You are most likely using them too! physicians. You are most likely using them too! Handouts about Medicare Preventive Care Coverage . . NEXT Circle with left arrow 4

The Information We Need Before we get started with specific tools, it s important to consider what we need to know! Click on the icons to learn more. Shared Knowledge/ Communication Medication Costs/Formulary Insurance Coverage Know where to send patients or who to ask. Patients will get help in accessing affordable care and insurance options. Understand cost variations and average costs. While the costs are not exact, they are helpful for planning and decision making. Helpful to Have: Helpful to Have: CPT code(s) CPT code(s) Understand formulary terms, cost variations and discount programs available to patients. There are formulary programs available to help you find cost/coverage information. Must Have s: Plan name Have s: Plan name Utilize the skills and knowledge of staff, physicians and other departments. Ask them and share what you have learned, too! Understand insurance basics and where patients can go for coverage information. Some insurance plans will provide a cost estimate specific to the patient. Must Have s: CPT, Must Have s: CPT, NPI , Plan name NPI , Plan name Medical Cost Estimates Must Patient Assistance Circle with left arrow 5

When will you use this knowledge? In each column, choose the scenario(s) where you would most likely use that type of knowledge. Click on the scenario to receive feedback on how it will be helpful. Shared Shared Knowledge/ Knowledge/ Communication Communication Medication Costs/ Medication Costs/ Formulary Formulary Insurance Insurance Coverage Coverage Medical Cost Medical Cost Estimates Estimates Patient Patient Assistance Assistance Discussing risks and benefits for each treatment option. coverage will help! Discussing risks and benefits for each treatment option. copay assistance. Discussing risks and benefits for each treatment option. coverage will help! Discussing risks and benefits for each treatment option. help inform a decision Discussing risks and benefits for each treatment option. cost/quality. Knowing about deductible and plan Knowing medication costs/coverage could Knowing about deductible and plan Share tips for cost saving and discuss Find DME, transportation or Understand what different insurance types cover. Asking the patient to get the recommended vaccinations. coverage will help! Asking the patient to get the recommended vaccinations. Asking the patient to get the recommended vaccinations. Asking the patient to get the recommended vaccinations. coverage will help! Asking the patient to get the recommended vaccinations. Knowing about deductible and plan Knowing about deductible and plan Most likely this will not be used. Share information on cost savings! Help the patient access assistance Understand the Medicare Donut Hole Find/use the formulary to prevent Share information on cost savings! Most likely this will not be used. Prescribing a medication. Prescribing a medication. programs Prescribing a medication. and Deductibles. Prescribing a medication. calls later. Prescribing a medication. Have a practice-wide list of common A general idea of price ranges and/or relative Understand the significance of in/out Ordering labs, test or imaging for a patient. costs is great! Ordering labs, test or imaging for a patient. costs with assistance Ordering labs, test or imaging for a patient. of network. Ordering labs, test or imaging for a patient. not be used. Ordering labs, test or imaging for a patient. networks. Alleviate indirect Most likely this will The patient brings up a billing issue. The patient brings up a billing issue. not be used. The patient brings up a billing issue. coverage. The patient brings up a billing issue. out-of-pocket costs. The patient brings up a billing issue. not be used. Get them help with understanding their Share cost saving tips! Most likely this will Circle with left arrow Understand types of Most likely this will 6

Cost of Care Tools The best way to encourage and support out-of-pocket cost conversations is to have tools for you and your patients to use. There are a surprising number of options available. By learning about each tool s pros and cons, you can decide which ones will work best in your practice. Click on the icons to learn more about each type of tool. PEOPLE TECHNOLOGY WEBSITES Most health plans have a provider section where you can get patient- specific cost estimates, coverage and formulary information. Many also have price tools for patients too! With limited time, these are helpful to keep the conversation moving and provide the patient with helpful information that they can review later. Use your EHR! Check the formulary, build internal pricing information into templates, use your patient portal to store tools and handouts for patients. Share knowledge! Patients, staff and physicians all find cost-saving tips through experience. Billing staff can assist with questions. Ask your IT department about EHR features. There are many free sites to help physicians and patients. They can help with planning, budgeting, and finding cost savings through discounts or assistance programs. Circle with left arrow HANDOUTS INSURANC E 7

WEBSITES Types Best Uses Roadblocks Examples Patients who are uninsured or have non- covered medications Use discount cards for medication savings Compare non-insurance prices at pharmacies in the area Using during the visit to get average prices Some have $4 generic lists and patient assistance programs Independent pharmacies in the area may not be listed All $4 generics may not be listed Patients need to compare their insurance price vs the discount price Prices may be estimates GoodRx.com GoodRx.com NeedyMeds.org NeedyMeds.org Familywize.org Familywize.org Prescription Prescription Discounts Discounts Help uninsured patients plan for procedures Compare prices for in and out of network Build knowledge of the relative costs of procedures in your area Doesn t compare prices at specific facilities It s an estimate, not a patient-specific price Searches can be tricky for the exact procedure Fairhealthconsumer.org Fairhealthconsumer.org Price Price Transparency Transparency Quick and easy search by topic Find facilities nearby General knowledge of price transparency Sites can pay to appear in searches, be sure to fully review/vet the information Google Google Search Engines Search Engines Handouts and resources for patients Great tools for physicians/staff to learn insurance and formulary basics! Prescription Assistance Program and Prior Authorization Assistance Patients have a helpline to call Help patients navigate questions about surprise bills, finding insurance and insurance coverage It will take time for the patient to get the information that will help them make informed decisions. It will take time to apply and get accepted It will take time to find the assistance program and apply. PatientAdvocate.org PatientAdvocate.org CommunityHealthAdvocates.org CommunityHealthAdvocates.org Patient Patient Assistance Assistance Circle with left arrow 8

HANDOUTS Tool Best Uses Roadblocks Learning Resources Find tools that you feel comfortable using/recommending It is an extensive list! Taking the time up front will save on the backend. Consider having staff assist when possible. ACP s list of Apps, Websites and ACP s list of Apps, Websites and Organizations Organizations ACP s list of Cost Estimator ACP s list of Cost Estimator Resources Resources Cost of Care Resources Cost of Care Resources Normalize the conversation Promote patients asking to improve relationships Patients may be hesitant because they don t want to burden you. You may need to start the conversation the first time. ACP s Patient Facts ACP s Patient Facts NYACP s Poster NYACP s Poster Talking about Costs Talking about Costs Help patients understand basic insurance terms Help patients plan for the Medicare Donut Hole Insurance plans are all different, the patient should still call their insurance to find out plan details! NYACP s Medicare Coverage Gap NYACP s Medicare Coverage Gap Handout Handout NYACP s Avoid Surprise Bills NYACP s Avoid Surprise Bills NYACP s Insurance Literacy NYACP s Insurance Literacy NYACP s Cost Saving Tips for NYACP s Cost Saving Tips for Medications Medications Insurance Information Insurance Information Circle with left arrow 9

TECHNOLOGY Tool Best Uses Roadblocks Use your EHR to check the patient s formulary. It will most likely show tiers and possibly copays and alternatives. Ask IT or put in a ticket to see if your EHR is capable of more! Ask if average prices or even your own organization s average prices can be entered in the EHR. x To use the formulary correctly, the patient s complete insurance information must be entered into the system. x You may need to persistently follow up on tickets x They may only be able to enter the charge amount and not the patient responsibility Electronic Health Record Electronic Health Record Keep a list of handouts for patients to access Follow up on Cost of Care questions from the patient visit Provide links to price transparency tools Some patient portals may be limited in functionality to store this information Patient Portal Patient Portal Circle with left arrow 10

Insurance Type Best Uses Roadblocks Examples Check patient s formulary Get patient s coverage details Get plan-specific price estimates Check network status for labs, facilities and specialists You will need to know the patient s plan type The search and estimate capability will depend on the insurance You will need the appropriate CPT Code Insurance Website Insurance Website Cost and coverage information for Medicare Part A and B Covered preventive services When and how to get covered benefits Great for patients to use Great for a better understanding of traditional Medicare coverage Patient must know if they are on Medicare or a Medicare Advantage plan Apps require a smartphone and some older patients may not have one Search can be cumbersome and require some exploring What s Covered App What s Covered App Medicare Apps Medicare Apps Circle with left arrow 11

People Tool Best Uses Roadblocks Ask and share with other physicians about what patients have done to make care more affordable. Ask for alternatives or options they have used Physicians/Clinicians/Staff Physicians/Clinicians/Staff Assist with finding formulary information Information about your patient s specific plan Contact other billing departments or the insurance for cost questions Cost information for in-house procedures Prior Authorization information This will take time until it becomes a regular conversation in the workflow There may be extra costs associated if your organization has a billing service. Billing Department Billing Department Handouts and resources for patients Great tools for physicians/staff to learn basics Prescription Assistance Program and Prior Authorization Assistance It will take time to find an assistance program and apply. It will take time to apply and get accepted Patient Advocates Patient Advocates Ask about savings in other areas (like housing or utilities) that could re-allocate resources and help make medications more affordable! They can also help to inform a care plan that needs to account for childcare and missing work. x They may not be available in your organization x They may only be available for inpatient information Social Worker/Care Social Worker/Care Coordinator Coordinator Ask what they have done to make care more affordable. Ask for other alternatives or options they have used Patients Patients Compare or look up prices Find drug alternatives Assist in checking formularies Knowledge of patient assistance programs or savings clubs You may find a difference across types of pharmacies in willingness to look up and share information Pharmacist Pharmacist Circle with left arrow 12

WEBSITES Tool Best Uses Roadblocks Learning Resources Can help uninsured patients plan for procedures Has educational materials for health insurance literacy Compares prices for in and out of network Doesn t compare prices at specific facilities It s an estimate, not a patient-specific price Best search is with procedure code Introduction to Introduction to Fairhealth Using Using Fairhealth Fairhealth to Estimate Costs Estimate Costs Fairhealth to Fairhealthconsumer.org Fairhealthconsumer.org Get discounts on medications with just a printable card Compare non-insurance prices at pharmacies in the area Compare pricing for Medicare Find alternative medications Easy to use during the visit - even on your phone Save on Pet medications too! Independent pharmacies in the area may not be listed $4 generics are not listed Patients need to compare their insurance price vs the GoodRx discount price Using Using GoodRx GoodRx GoodRx.com GoodRx.com Searching multiple $4 generic lists Finding assistance programs Has a phone number for patients to call The website is cumbersome to navigate Not all $4 generic lists are included Price search tool gives estimates Helping Patients Save on Helping Patients Save on Healthcare Expenses Healthcare Expenses NeedyMeds.org NeedyMeds.org Get discounts on medications with just a printable card Compare non-insurance prices at pharmacies in the area Get discounts on medications that are not covered by insurance or for patients who are uninsured It is not accepted by all pharmacies $4 generics are not listed Can not be combined with insurance coverage Using Using Familywize Familywize Using Using FamilyWize FamilyWize if you already have insurance already have insurance Familywize.org Familywize.org if you Circle with left arrow 13

WEBSITES PEOPLE TECHNOLOGY Tool Review What tool category(ies) would you use in this scenario? Click on the icon to receive feedback. INSURANCE HANDOUTS A patient is concerned about a bill that they received. They didn t expect it to be so high! You notice that a patient s outcomes are not changing and find out that they haven t been taking their medications due to cost. You are ordering labs and imaging for a patient. Websites like Websites like FairHealth information to help patients learn information to help patients learn about insurance costs about insurance costs FairHealth have have Some websites may give an estimate Some websites may give an estimate of costs. Knowing the relative costs of costs. Knowing the relative costs assists informed decision making. assists informed decision making. Use medication websites to estimate Use medication websites to estimate costs, find assistance programs and costs, find assistance programs and get discount cards. get discount cards. Help patients learn about the Help patients learn about the different out different out- -of of- -pocket costs such as deductibles and copays. such as deductibles and copays. Use medication websites to estimate Use medication websites to estimate costs, find assistance programs and costs, find assistance programs and get discount cards. get discount cards. Handouts with the websites are Handouts with the websites are helpful. Consider information about helpful. Consider information about the Donut Hole too! the Donut Hole too! pocket costs Technology may not help much Technology may not help much here. It would be great to put known here. It would be great to put known prices in the EHR! prices in the EHR! Use the EHR formulary to find tier, Use the EHR formulary to find tier, cost and alternative medication cost and alternative medication information. information. Staff may check the billing Staff may check the billing software to ensure the correct software to ensure the correct information is entered. information is entered. With the NPI and CPT code, patients With the NPI and CPT code, patients can call their insurance for a cost can call their insurance for a cost estimate and network verification. estimate and network verification. Use the insurance website to check Use the insurance website to check formularies. They sometimes formularies. They sometimes change mid change mid- -year! The best place to send them so The best place to send them so that they know their plan details that they know their plan details for out for out- -of of- -pocket costs. pocket costs. year! Use medication websites to estimate Use medication websites to estimate costs, find assistance programs and costs, find assistance programs and get discount cards. get discount cards. Pharmacists, clinicians and other Pharmacists, clinicians and other patients may know about discounts patients may know about discounts and programs. and programs. Advocates can assist with Advocates can assist with surprise billing laws and surprise billing laws and understanding insurance. understanding insurance. Circle with left arrow 14

Additional Resources Learning to use the online tools: Learning to use the online tools: Introduction to Introduction to Fairhealth Fairhealth Using Using Fairhealth Fairhealth to Estimate Costs to Estimate Costs Using Using GoodRx GoodRx Using Using Familywize Familywize Using Using FamilyWize FamilyWize if you already have insurance if you already have insurance Starting the Conversation Starting the Conversation H Helping Patients Save on Healthcare Expenses elping Patients Save on Healthcare Expenses This Photo by Unknown Author is licensed under CC BY-SA 15