How digital health expansion has shined a light in the opaque system of healthcare
Healthcare is complicated, how do we make the system easier to understand?
Emma Wellington
Imagine a healthcare system where prices are transparent, insurance plans do not rapidly change, and free resources are accessible to anyone in need. While this idea may seem far-fetched, there are organizations working to reduce the burden of hidden costs and non-transparent healthcare billing. Digital tools may be a solution to navigating the billing of fee-for-service and ACO (Accountable Care Organization) care for Medicaid and Medicare users. In addition to federal programs, creating platforms for private insurance that tackle the lack of cost consistency could transform the healthcare experience for many. By reviewing the gaps in billing for Medicaid, Medicare, Private Insurers, and High-Risk payors, researchers can determine areas that would benefit from app development and create a comprehensive solution.
Medicaid
Medicaid has experienced a massive shift in coverage since the beginning of the COVID-19 pandemic, and these changes add to the pre-existing confusion that plagues patients. The Institute for Family Health implemented a patient portal that connected MyChart with MedlinePlus Connect, offering patients hyperlinks that took them from complex medical terminology to language that was more accessible. By monitoring the use of these hyperlinks, researchers found that Medicaid patients utilized this resource frequently, signaling the crucial importance of tools such as these and room for growth with app development.
The lack of consistency between Medicaid fee-for-service and Medicaid managed care organization plans is another key issue for patients with Medicaid. Researchers reveal that identical telehealth visits carried out in the same state may vary in coverage depending on whether the patient is visiting a Medicaid fee-for-service or managed care organization. Without developing platforms that increase billing transparency, we continue to send patients through a confusing and frustrating maze of billing. The process of selecting care needs to be streamlined in a way that provides patients with prices that they can choose from, like those found in FH Healthcare Cost Estimator.
Medicare
Digital health measures implemented by Medicare have also transformed rapidly since the beginning of the pandemic, thereby decreasing the simplicity of billing. Before the COVID-19 pandemic, Medicare targeted their telehealth efforts to patients within rural areas, reaching demographic populations at an elevated risk for experiencing barriers to care. This structure changed on March 17, 2020, due to the COVID-19 pandemic, and this past year Medicare Advantage began to broaden their telehealth services accordingly. Due to the pandemic, it is no longer necessary for patients to meet their virtual providers at “originating sites”. Instead, home visits are the standard and make telehealth utilization simpler.
While telehealth operated in “originating sites” for fee-for-service organizations before the pandemic called for vast expansion, digital modes of treatment were less common for ACOs (accountable care organizations), regardless of Medicare’s previous attempts to increase telemedicine. Not only were ACO telemedicine visits uncommon overall, but this resource was more frequently used by non-ACO providers. Researchers hypothesize that this could be a direct result of the cost sharing risk of the organization. For example, if ACOs are taking part in one-sided risk structures, then the cost savings of telemedicine are not a large incentive when overspending suffers no penalty. Further, adding lack of reimbursement, due to strict requirements, combined with the low occurrence of established ACOs in rural communities appeared to make telehealth visits before COVID-19 more hassle than benefit for providers.
Private Insurance
Although the growth of digital health is frequently associated with changes in Medicare and Medicaid coverage, there is also a space within the medical field to learn about how private insurance coverage is related to digital healthcare. According to one report by Regence on BlueCross BlueShield, it is possible to save $100 per visit in a telehealth appointment compared to seeing a physician in their office, when clinically appropriate. In a comparison between the 25th and 75th percentile of income for adult patients, anywhere from $14-$39 can be saved through decreased car mileage, travel time, and wait time. When compounded with a decreased $75 cost for out-of-pocket (OOP) prices from the physician’s office, there is the potential for significant cost benefit. Other insurance companies, such as Aetna, also offer low-cost telehealth solutions due to the COVID-19 pandemic. Teladoc® visits are offered for a maximum of $45 when a patient is covered by any of their full insurance plans. The insurance company also provides a toll-free, 24-hour hotline for nurse consultations, showing how digital care billing can truly be transparent and accessible.
Information on private insurance coverage is available on individual company websites, but there is not enough academic literature on this topic. This lack of data signals a gap in knowledge surrounding different private insurance plans in relation to digital health and is a scary reality that represents the variability between plans and the confusion that digital health can cause both providers and their patients. Insurance plans vary, billing codes are ever-changing, and certain coverage laws fluctuate by state. For example, telehealth parity laws only cover 31 states and Washington, D.C. while teleradiology is covered by all 50. Alas, coverage for services rendered is unique to the private insurance provider, as well as their state, and are constantly in flux.
Uninsured/Hard-to-Reach Populations
A payor population that is commonly overlooked in healthcare is the uninsured. Uninsured patients are a hard-to-reach population that may benefit from digital healthcare. Unfortunately, digital health may have a negligible effect if not properly utilized, and patients can be further separated from their care due to the digital divide. One issue that needs to be overcome is the lack of “online health-management tools” that are used by uninsured populations. Researchers predict that older populations using these online tools are the same patients that are able to receive preventive services in the first place, emphasizing that it is critical to brainstorm ways to increase access to free online tools for patients who are not regularly seen by a provider.
When implementing a digital health solution, providers must focus on how to overcome barriers to access for the use of online tools in high-risk populations. A platform is needed to provide educational materials to the uninsured. While FH Healthcare Cost Estimator is a start to teaching app users the basics of insurance and health definitions, providers should also use applications to distribute educational sources regarding diagnostic information. The remaining barrier is finding how to do so in a means that reaches more than just those patients already receiving care.
Conclusion
Healthcare is not one-size-fits-all, but there is the potential that one app could solve questions of billing, keep patients up to date on policy changes and options, and increase access to healthcare materials. By creating applications for hard-to-reach populations and teaching those patients how best to utilize these resources, providers have the potential to determine gaps in digital outreach and how to address them.
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