My name is Brett Plotzker and I am the founder and CEO of Patch, a software solution that creates real-time transparency and seamless adjudication of ancillary healthcare benefits at the point of sale. Our goal is to take all of the friction away from individuals who seek to understand and pay for healthcare services, especially where cash-pay is (and will become) more prevalent. We want a world where paying for healthcare is as easy as paying for a t-shirt with a credit card. It shouldn't be so difficult. We are industry experts and thought leaders in this area.
We started our mission by targeting the vision care space. Our aim was to make out-of-network benefits (i.e. the benefits consumers would use in cash-pay practices) easy to understand and use. After all, out-of-network is becoming the new norm of ancillary healthcare services. We eagerly and optimistically thought we'd be able to make a difference in the market — helping drive down the cost of time spent on the phone by healthcare providers and individuals seeking benefits information, easing the burden of filing paper claims, and making healthcare benefits easier for consumers to understand.
What we've encountered during our time dealing with insurers has flown in the face of our optimism, as we’ve experienced repeated blatant efforts to block the availability of this crucial information. Vision insurers have taken proactive steps to prevent eligibility information from being easily accessed when it doesn't directly fit the interests of their business model. The largest vision insurer in the country has even threatened us (hoping we will stop making benefits transparent), as we make it easier for their customers to access benefits information — which allows them to more easily use their benefits. Imagine that…helping consumers easily get access to (and understand) their benefits would be something worth making threats to prevent.
While I can give you numerous examples of these practices (and would be happy to share specifics), I feel that the worst effect of these narrow-minded practices is the long tail negatives that they create. Not only do Americans care about healthcare costs, they actually make (or do not make) healthcare decisions based on the ability to understand and use their benefits. They are NOT making decisions based on what’s best for them, but instead, choosing what’s theoretically cheapest. Under the present schema, they aren’t even getting that.
This hits particularly close to home for me, as I have a family member who was left completely helpless when trying to find a mental health professional. The majority of mental health professionals where they live don't accept insurance, and these care providers could not tell them exactly what their benefits would cover or help them understand reimbursements. Left confused, they felt prices were too high, especially when they had benefits to use. They (foolishly) never went, and a few weeks later, had to check into a facility for a (mild) suicide attempt.
Now, my family was lucky, as the attempt was mild — more of a cry for help than an actual suicide attempt. They were fortunately in a position where they could afford to pay for their care out-of-pocket, once they decided to bite the bullet. However, most Americans aren't so lucky. This is why transparency of insurance and other financial benefits are incredibly important. When people don’t get the preventative services they need, it costs the healthcare system unquantified sums of money.
Imagine if my family member hadn't paid for a psychiatrist and received the medication they needed ... How much would they have cost the system if they had been institutionalized for two months? What if their attempt had led to an extended hospitalization? What if they had injured themself in a way that required expensive, ongoing care for the rest of their life?
Now, what if, instead of a mental disorder, their condition had been chest pain or shortness of breath — and they opted not to get it checked out, because their primary care physician wasn’t readily available and they didn't understand how to utilize out-of-network benefits? What if this person only had $50 their bank account and had to choose between health care that they weren’t sure if they could afford (thanks to opaque insurance benefits) and buying food for their kids? And what if this situation wasn’t just hypothetical — but something that affects thousands of Americans every day.
You can probably see my point. Benefit transparency can lead to lower long tail costs and healthier Americans in the long run.
As someone that works in the healthcare space every day, I propose that you focus on three critical policy proposals.
First, as we aim to make things more transparent, the most crucial step is mandated open API access from siloed providers and health plans of any type of healthcare benefits with strong accountability and penalties for failure to make such data available without special effort. When data is readily available, innovative companies will design tools that provide healthcare providers and patients with cost transparency while minimizing cost and friction. Health plans and health care providers should not be able to set up obstacles for consumers that want to access cost and benefit information, as this interferes with patients’ abilities to make informed decisions about their health care. Strong accountability and enforcement for transparency is critical. The financial benefit to companies for limiting availability of pricing and benefit information is significant, particularly in the vision benefits market, where insurance companies are often vertically integrated with the manufacturer of glasses covered by these plans.
Second, I strongly encourage you to consider FSA/HSA benefits and HRAs in any price or cost transparency policy. Patch would have integrated HSA/FSA eligibility checks long ago, had the integration process not been so arduous. Most people don't know the difference between an HSA, FSA, or HRA, but they are expected to decipher the benefits themselves. Administrators of these plans are not required to easily share eligibility data with third party software companies, even though these companies are offering a tax-advantaged vehicle. These administrators are making money off of breakage models. They don't want consumers to use the benefits they have because they profit more when benefits are not used. (More Assets Under Management means better returns). This should not be allowed. Until all aspects of a transaction are made easy to integrate, consumers will never have true transparency of their out-of-pocket costs and prices. If any entity is making a profit by offering something that can be construed to be subsidized by a government tax benefit, they should be mandated to share information easily and electronically.
Third, price transparency policy should address assignment of benefits — that is, where a patient requests that their health benefit payments be made directly to a health care provider, even if out-of-network. If payers aren't mandated, always, to accept assignment, then pricing information is only half useful and individuals can't seek care from out-of-network providers — despite having insurance coverage for these services. Rules vary by state, and, at every turn, payers will not allow non-network providers to accept assignment for patients. Many patients look to their healthcare provider to figure out and accept benefits for them. If providers cannot be sure when they file a claim for a patient that they will be reimbursed for their services, it dissuades providers from helping patients, because the burden of losing the reimbursement is too great. When the patient owns the entire burden, it's free license for a payer to not meet its obligations, such as not paying the full amount, “losing” a claim, or deciding a claim is ineligible for a false reason. Assignment of benefits creates accountability.
I appreciate your interest and focus on this issue as it is critical for patients to have information to make informed decisions about important health care services. Innovative companies (like ours) are working to provide patients with access to important price and cost information in an easy to use way. But that can only happen if data is made available. I encourage you to consider bold action to improve price and cost transparency by liberating the healthcare data and providing for accountability.
I welcome the opportunity to further discuss these policy issues with you — as well as share the experiences and obstacles my company has faced in helping patients understand their benefits and the true costs of care.