See all the latest news about MyMedicalShopper, from traditional news media, to healthcare industry trade journals and benefits professional publications, to TV and radio segments.

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Innovation Conversations with NFP – Taking Control of Health Care Costs with Mark Galvin from MyMedicalShopper

Innovation Conversations with NFP Podcast | February 14, 2019

Host: Dave Kerrigan, Founder & Managing Director of Sante Nasc, LLC

 

Shopping for the right medical tests and procedures at the right price isn’t easy—until now. Mark Galvin from MyMedicalShopper joins the Innovation Conversations with NFP podcast to talk about how a chance meeting he had with his doctor led to the creation of a better way to shop for medical procedures. Hear how Mark started in New Hampshire and expanded to all 50 states—and how putting information into the hands of health consumers really does make a difference.

 

Listen to the podcast now.

Innovation Conversations with NFP logo

Mark Galvin joins the Innovation Conversations with NFP podcast with Dave Kerrigan

A NH company’s medical shopping tool for transparency of costs

Published originally on WMUR at: https://www.wmur.com/article/a-nh-company-s-medical-shopping-tool-for-transparency-of-costs/26270708

Know Before You Go: Website posts prices of medical procedures in Arkansas

By: Jessi Turnure, KARK | Posted: Feb 06, 2019 | Updated: Feb 07, 2019

 

 

LITTLE ROCK, Ark. – In his State of the Union address Tuesday night, President Trump called for more affordable and transparent health care costs.

Arkansas is one step ahead of him.

“It’s a small step, but I think it’s an important first step toward unlocking the black box and having us all be able to understand how the health care system works and what it’s going to cost us both in the short term and the long term,” said Dr. Joe Thompson, the president and CEO of the Arkansas Center for Health Improvement (ACHI).

The federal government required hospitals to start posting their charges online Jan. 1.

“The information itself is not that useful for most consumers because what’s charged is usually not what’s paid,” Thomspson said.

The actual payment depends on a negotiation between the hospital and the insurance carrier, and also the design of the patient’s health plan.

Another website recently started to break down the average payment rates for different procedures in hospitals across the state.

“It will stimulate a conversation between the patient and their physician about what procedures are needed, how important they are and where to go to get the best procedure done,” Thompson said.

State lawmakers approved the Arkansas Health Care Transparency Initiative three years ago. Under the insurance commissioner’s authority, ACHI developed the state’s all-payer claims database. It tracks paid claims by insurance carriers.

A company based in New Hampshire, My Medical Shopper, applied to use the data.

“There has been anxiety about putting new, real information out on what health care costs, to actually shine the light inside the black box,” Thompson said. “Health insurance carriers are concerned, hospitals and providers are concerned.”

Hospitals in the area told KARK they plan to continue to “provide quality, compassionate care to all our patients in the most cost efficient manner possible.” They also said patients can call the hospital’s financial counselors for specific and personalized information.

To register for free to access the data on My Medical Shopper, click here.

“Users of our platform, which is accessible through our website as well as easy-to-use mobile applications, can find price estimates that reflect the insurance-negotiated discounts for thousands of medical tests and procedures before they seek care, rather than falling victim to surprise medical bills weeks or months after the care has already been received,” said Christopher Matrumalo, My Medical Shopper’s VP of Marketing. “We sought to work with ACHI because their Transparency Initiative’s stated goal is ‘to empower Arkansans to drive, deliver, and seek out value in the health system.’ We have found ACHI to be committed to this goal in practice, and we believe that our collaboration has introduced a powerful new dynamic to the healthcare marketplace in Arkansas.”

The website is the first of many that could make data like this available to Arkansas consumers. Thompson said other commercial entities and researchers have applied to gain access to the state’s all-payer claims database.

An advisory board reviews the applications to make sure there would be a benefit to Arkansans. The insurance commissioner ultimately approves the use, and ACHI provides the data to them.

According to the All-Payer Claims Database Council, 21 states have an existing database, 15 of them, including Arkansas, require submissions. Five other states are in the process of implementing one, and others are strongly considering it.

 

This article and news video originally appeared on February 6, 2019 on the NBC KARK.com website here: https://www.kark.com/news/local-news/know-before-you-go-website-posts-prices-of-medical-procedures-in-arkansas/1760252094

Portsmouth business offers medical cost-comparison tool

 

Updated

 

PORTSMOUTH — A Portsmouth business owner is hoping to drive down the price of outpatient medical procedures with his cost comparison tool.

Mark Galvin is president and CEO of MMS Analytics, the creator of MyMedicalShopper. He came up with the concept five years ago while he was at the helm of Whaleback Systems at Pease International Tradeport.

Galvin, who helped launch RAScom and Cedar Point Communications, calls himself a serial entrepreneur and said he began to get frustrated with the lack of transparency in costs for health care, both as an employer and consumer.

Mark Galvin, CEO of MyMedicalShopper

Mark Galvin, president of MMS Analytics, Inc.

“What I found was, every time I started a company, as computers and servers were getting cheaper, the health benefits were getting more expensive — rapidly,” Galvin said.

When Galvin’s doctor told him he needed to go for a nuclear stress test, he shopped around and noticed a $5,400 savings if he chose a facility in Derry over one of the hospitals in Manchester. After Galvin told his doctor it was going to cost him at least $1,400 out of pocket to have the test performed, his doctor said he did not need to go ahead with the test because it was being ordered simply to set a target heart rate.

“This is the power of having the information available to you and your primary care physician,” Galvin said.

From there, Galvin set out to create a cost comparison tool for typical outpatient procedures. He used public information reported by medical facilities throughout the state to create MyMedicalShopper, which launched in New Hampshire in March 2015. Galvin was part of a group that started the New England Innovation Center in 2013, which helped 15 seed-stage companies get started, including MyMedicalShopper.

Recently, the tool became available nationwide.

MyMedicalShopper is purchased by employers for employees’ use. The data engine leverages more than 3.4 billion medical claims annually to power its platform.

Officials at the company say their analysis has determined the average U.S. employer can save at least 41 percent on their annual health care costs per year when employees have this information at their fingertips and choose to compare prices for procedures.

“It’s been hard because the industry does not want this information to be known. They consider it proprietary,” Galvin said.

Robert Cummings is CEO and founder of American Benefits Group in Northampton, Mass. The national benefits service and solution provider recently partnered with MyMedicalShopper to help employer clients and employees control health care spending.

Cummings said ABG provides flexible spending accounts, health savings accounts, health reimbursement arrangements and commuter benefits for 1,500 employers. He said as more and more employers move to high-deductible health plans, employees want to maximize how far their money goes, and a tool like MyMedicalShopper benefits both parties.

“We think it’s a very dynamic, cutting edge and disruptive solution,” Cummings said.

MyMedicalShopper’s employer dashboard provides chief executives, financial officers and human resources leaders direct visibility into their group’s claims experience and how much money they are saving.

Employees can use a MyMedicalShopper app from their cellphone and use their health insurance plan to compare prices for outpatient procedures before making a medical appointment or visiting a lab.

If employers purchase MyMedicalMetrics, they receive an analytics package that shows exactly how their employees are inadvertently driving up their own costs and overall claims for the group.

“The model is to incentivize the consumer to be engaged in how they’re making a decision on spending,” Cummings said.

Galvin said MMS expanded into other New England states in October 2017 and went national in September of last year.

The company has 14 full-time employees and two-part time contractors working in Portsmouth, and is hiring data analysts and engineers.

According to National Health Expenditure Accounts, U.S. health care spending grew 3.9 percent in 2017, reaching $3.5 trillion, or $10,739 per person.

Health spending accounted for 17.9 percent of the nation’s Gross Domestic Product in 2017, according to cms.gov.

This article originally appeared in the February 2, 2019 issue of the New Hampshire Union Leader: https://www.unionleader.com/news/business/portsmouth-business-offers-medical-cost-comparison-tool/article_e06994ea-c0c8-5ced-90f4-640414de8f03.html

A tale of healthcare transparency

The long, confusing journey to find the actual cost of a medical procedure

Bob Sanders’ Pedaling for Payson ride to raise funds for Concord Hospital Trust landed him in the hospital’s emergency room.

Bob Sanders’ Pedaling for Payson ride to raise funds for Concord Hospital Trust landed him in the hospital’s emergency room.

PHOTO BY JAMES WANG

Blood in my urine. 

That’s what I saw on Sept. 15 while inside the portable toilet in Warner at a rest stop some 65 miles into my 77-mile ride to raise money for the Concord Hospital Trust to help cancer patients.

It was not the first time my urine was red on a long bicycle ride, but this time I would not panic. This time, I would not walk blindly into the Concord Hospital emergency room for no good reason and exit with a bill that I was still paying off. 

This time, I would know what the heck I was getting into and how much it would cost me.

It took a month to find out that, in order to save thousands of dollars, I had to put off a medical procedure until next year, thus risking landing in an emergency room, which could cost the health system more than I was trying to save myself.

But that’s the trade-off patients now have to make in the new world of high-deductible health insurance.

High deductibles used to be the exception. Now they are the norm, particularly in New Hampshire, where high-deductible plans are held by the highest percentage of policyholders in the country.

Nationwide, the total amount of deductibles paid by employees tripled from 2008 to 2017. The average individual deductible doubled to $1,500 in that time and the number of those with plans including deductibles rose from 60 to 81 percent, according to a 2018 Kaiser Institute study.

In New Hampshire, 69.3 percent of employees had high-deductible plans (more than the $1,300 individual threshold used for health savings account eligibility) in 2017, according to data from the University of Minnesota’s State Health Access Data Assistance Center. It was the highest percentage in the country. 

The state also has the highest average family deductible ($4,381) and the second-highest individual deductible ($2,303), just $2 below Maine. In 2016 New Hampshire was ranked first in the average individual deductible as well. 

(The prevalence of small businesses here might be a contributing factor: The smaller the company, the chances are the larger deductible an employee has to pay.)

The good thing about high deductibles is that they force the consumer to care about cost. But it also has a negative side as well.

During her presentation at NH Business Review’s Oct. 10 Healthcare Confronting Disparities event in Concord, Dr. Joanne Conroy, CEO and president of the Dartmouth-Hitchcock health system, said that people with high-deductible plans “aren’t getting the care they need. They are coming to the emergency for acute care that could have been cared for early on.”

Indeed, a study by the American Diabetes Association indicated that while large deductibles do save medical costs, they also resulted in lower-income patients going to the emergency room.

Bladder stones

My individual deductible is $5,000. Even after my employer chips in $2,500 via a health reimbursement account, I have a high-deductible plan.

I found this out the hard way in 2016, that time on a 100-mile ride to benefit the Concord Hospital Trust. Back then, when I saw my bloody urine, I cut the ride short, went into urgent care at the Hitchcock Clinic. I was sent to the emergency room.

A doctor, who said I was slightly dehydrated, wanted to hook me to an intravenous bag. Way too costly, I said. I just drank a lot of water and was given a CAT scan with negative results because it wasn’t done correctly. When my urologist redid the scan, he found that stones in my bladder knocked about during the long ride, causing the bleeding. He sucked them out though the urethra, laser-blasting those too big to fit. I had no idea how much that cost, nor did I care, since I had already blown though my deductible in the ER.

This time, I figured they could just do it again. Sure enough, my urologist eventually confirmed, I had a “ton” of bladder stones again, and I should have them removed again, or they could block up the urethra, resulting in extreme pain and another ER trip.

But, he added, this is a recurring problem because my enlarged prostate prevents me from totally emptying out my bladder. The solution? Drill a pathway though the prostate.

The procedure — known as transurethral resection of the prostate (TURP) — would require an overnight stay in Concord Hospital (which owned the urology practice), though it would be less than 24 hours, so it would qualify as day surgery.

He had no idea, nor much concern, about how much this would cost me.

‘Sticker price’

I tentatively signed up for the procedure, scheduled in two weeks, the Friday before Columbus Day. Then, armed with procedure codes, I proceeded to do my homework.

First, I called the cost information number on the urologist’s pre-op literature. I got a message inviting me to leave a voicemail with my procedure number and other information to get a cost estimate in 48 hours.

While waiting I called Anthem, my insurer, which confirmed that I had hardly touched my deductible, so I was on the hook for almost $2,500 after my employer reimbursement. Anthem told me the surgeon’s negotiated fee: $1,949 for the TURP and $812 for the bladder removal. But didn’t tell me the combined fee, nor the cost of the hospital and anesthesiologist because they vary so much.

The anesthesiology cost depended on the method, which — the urologist’s office told me — would only be revealed at the hospital before I was rolled into the operating room. 

Concord Hospital (which called back more than four working days later after repeated messages) could only give me its “sticker price” — $28,000 to $41,500 — not the negotiated price with Anthem.

Anthem couldn’t tell me what that was either, but I was told that, since it would probably blow through my deductible anyway, what difference would it make?

It was only after I contacted Concord Hospital later on as a reporter that the hospital told me the negotiated price, including surgery but not anesthesia, was between $19,000 and $26,000 but “as a general practice we don’t disclose that,” said Tom Antinerella, director of patient access, explaining that contracts with the insurers were “proprietary” and besides, “it’s kind of a moot point, because if it’s more than your deductible it’s irrelevant.”

But I was still trying to make a decision, so I went on the state Insurance Department’s transparency website, nhhealthcost.nh.gov, which gives the negotiated rate on over 100 common procedures, including 22 surgical ones, but not mine.

Then I called Vitals SmartShopper, a company that works with my employer and Anthem and actually sends you a check if you go to the cheaper provider. However, my procedures were not included in our contract, so they couldn’t give me any cost figures. 

Anthem later told me as a reporter that SmartShopper would have helped me with another operation — kidney stone removal — which has a different procedure code. The public information office also referred me as a journalist (but not when I called as a patient) to check out a tab section of Anthem’s website, called “Estimate Your Cost,” which allows you to compare the cost of a number of procedures, like kidney stone removal, but not bladder stone removal or TURP, so it wouldn’t have done me any good in any case.

Ambulatory surgical center

Time was ticking by. I called back the Center for Concord Urology practice and asked how urgent it was for me to get the bladder stones removed right away. Not very, I was told. So I canceled the procedure and continued my search.

I vaguely remembered during an employee health meeting that it would be much cheaper if I went to an ambulatory surgical center. My urologist did say the procedure required an overnight stay at the hospital, and Anthem didn’t suggest it, but I figured I’d give it a try. After numerous phone calls, I learned Manchester Urology Associates performs these procedures at Elliot Health System’s ambulatory surgical center, Elliot at River’s Edge in Manchester.

Manchester Urology said its negotiated fee was $3,800. The River’s Edge’s sticker price was $3,650 for the bladder removal and $9,105 for the TURP. Amoskeag Anesthesia’s sticker price was $1,500, negotiated down to $1,300, based on the average number of hours the procedure takes.

But all this was irrelevant after I called Anthem, which told me that all I would have to fork over was a $250 co-pay. That would cover the doctor, the facility, the anesthesiologist and even some lab work.

But as a new patient, I wouldn’t get to see anyone in Manchester Urology until early next year. 

So betting to save $2,250 that my bladder stones will stay put for another three months, I set up the appointment. If I lose the bet, and wind up in the ER, I’ll only pay the same amount if I scheduled it at Concord Hospital. But the insurer would pay a lot more in dollars, and I could pay a lot more in terms of my health. Wish me and the health system luck. 

Another tool

It turns out I missed one important resource when trying to determine medical cost: MyMedicalShopper, started by Mark Galvin, a Portsmouth entrepreneur. I had even done a story about the company the year after it started up in 2014. 

MyMedicalShopper has since gone national. Galvin has even been invited to the White House twice to talk about how price transparency can save the healthcare system, and Medicare in particular, billions of dollars. 

It started up in 2013 when Galvin finally got a CD-ROM of actual claims data from the state. That data has since been updated every three months and augmented by the company’s customers, both businesses and individuals. 

Like the state and Anthem sites, the data revealed a vast disparity of prices for some common procedures. Anthem, for instance, pays one provider $22 for an x-ray and another $327, with payments ranging from $335 to $4,221 for an MRI of the lower joint. 

But MyMedicalShopper has information for a lot more procedures, including mine. Bladder stone removal prices range from $388 (at River’s Edge) to $6,112. And TURP costs range from $1,565 to $8,424. (The combined high estimates are actually $4,000 lower than the price provided by Concord Hospital, underscoring that the results were either off the mark, or not up to date, or that the hospital’s estimate was too high.)

But if MyMedicalShopper gets its data from the New Hampshire Comprehensive Health Information System — a result of a law mandating such transparency — why doesn’t the system website include the hundreds of other procedures included on MyMedicalShopper?

Most likely it’s “due to the relatively low frequency of the services in the commercially insured population and/or a high amount of variation among patients receiving the services,” explained Tyler Brannen, director of health economics at the NH Insurance Department, thus the state could not vouch for its accuracy.

But Galvin blames it on restrictions that the carriers put on use of the data. Brannen, however, said there are no restrictions on which procedures would be included on the database.

According to Galvin, however, carriers may say they want the transparency that will send consumers to low-cost providers, “but they really don’t. Carriers want to keep it a secret.”

He said that’s because of a rule that, in most circumstances, limits an insurer’s surplus to 20 percent of medical losses. The greater the medical losses, the greater their profit, argued Galvin.

When asked to respond to this, Anthem issued the following statement:

“Consumers rely on Anthem Blue Cross and Blue Shield to provide broad access to affordable, quality healthcare services. Prices for the same service can vary greatly from provider to provider, even those in the same area, which is why we work with consumers by providing them information and tools so they can be better informed about selecting the right care provider based on quality and possible out-of-pocket costs.”

The tools listed were the Estimate Your Cost website, the SmartShopper program, live customer support and benefit design. The first three tools failed to inform me of the cheaper alternative that was available under the latter. I had to come up with the information myself.

In some ways, this story has a happy ending. I was eventually able to get a rough idea of the negotiated costs and was — albeit with some delay and risk — able to find a cheaper alternative. But is this evidence of price transparency? Or is it an example of how difficult it can be to find out the cost of your very own healthcare? 

MyMedicalShopper CEO heads to White House to aid health cost-comparison effort

Administration said to eye ‘big bold transparency initiative’

BY BOB SANDERS 

Published: October 16, 2018 

Seacoast entrepreneur Mark Galvin meets Tuesday with two U.S. Department of Health and Human Services officials at the White House.

 

Mark Galvin, the CEO of Portsmouth-based MMS Analytics Inc., developer of MyMedicalShopper, a fast-growing medical cost comparison application that is closing in on million users, is scheduled to meet with top health officials in the White House Tuesday morning.

 

Galvin, who claims the spread of MyMedicalShopper will enable “the entire broken U.S. healthcare system to self heal,” said he is going to help the Trump administration with a transparency initiative that could save Medicare more than $100 billion.
Mark Galvin, CEO of MyMedicalShopper

Seacoast entrepreneur Mark Galvin meets Tuesday with two U.S. Department of Health and Human Services officials at the White House.

Galvin, who first visited the White House on Oct. 3, said he was invited back by Katy Talento, a healthcare adviser to the White House policy team, who was trying to start a “big bold transparency initiative.” Galvin said “the secrecy about pricing must end,” and that the administration “didn’t care who we pissed off.”

Galvin has already met with with James Parker, senior advisor to the secretary of Health and Human Services and director of the Office of Health Reform. On Tuesday, he plans to meet with Randy Pate, director of the Center for Consumer Information and Insurance Oversight and deputy administrator of the Centers for Medicare and Medicaid.

 

Galvin, a serial entrepreneur, co-founded MMS in 2013 with the help of Matt Robinson, a recent computer science graduate from the University of New Hampshire. At first, the app was seen as a way to help those in the Granite State navigate the bewildering cost of medical procedures.

 

Armed with a CD-ROM of states’ claims data, the company developed an app that would tell you the average real cost of most medical procedures. Those costs can vary by more than a thousand percent.

 

Since then, the app’s features, and its reach, has mushroomed.

 

While some sign up for the full-service app on their own, most do so through their employer, which usually sets up a system to reward a shopper who uses the application to go to a lower-cost provider. Or the employer can use data analytics to figure out whether it would save money to offer a free blood test clinic at the workplace, rather than pay the expense of their employees going to a lab on their own to get the blood work for their annual physical.

 

Then last summer, the company took a quantum leap forward by penning a deal with Alegeus Technologies, a benefit account administrator serving some 225,000 employers, to offer the application through third-party administrators, brokers and the businesses they served. After going through a length security audit, MyMedicalShopper added some 600,000 users since March, increasing its subscriber base tenfold, Galvin said.

 

In addition, the deal now means the company now has expanded its access to more than 3 billion claims, making the company database truly national.

 

This should mean a huge revenue uptick, as the company generally charges about $100 for each subscriber, pocketing about $70, after each channel partner gets its take. It will also mean expanding the company’s workforce, which is currently at 14.

 

But more important, said Galvin, is that the company can fix the broken healthcare system by putting customers back into the loop. Comparison-shopping could drive down costs by 40 to 50 percent, he said.

This article appears in the October 26 2018 issue of New Hampshire Business Review

 

 

Leader’s Edge Magazine – Build Pricing Transparency App-titude

Q&A WITH MARK GALVIN, CEO OF MYMEDICALSHOPPER

According to a recent Reuters article, researchers at the University of Toronto contacted 120 U.S. hospitals in 2011 and then again in 2016 seeking price information on hip replacement surgery. The number that could provide price information dropped from 48% to 21%, and those that couldn’t provide any information rose from 14% to 44%. How is this happening with all the price transparency efforts?
GALVIN: If you are insured, insurers often won’t tell you what the rate is, because the carriers consider the negotiated discount proprietary information. Providers say they have complied with transparency legislation because costs are buried eight layers deep somewhere on their website. And this works because the consumer is not involved in the cost of healthcare. They have been so isolated for so long from what’s billed and what’s paid that it has become a broken market. The consumer got into the mode where you pay a co-pay and you don’t care that at one place you pay it and the underlying cost to the plan, paid for by employer, might be a $50 actual expense but at a different place it might have been $500 for the same thing.

Photo of Mark Galvin, CEO of MMS Analytics, Inc. dba MyMedicalShopper

Galvin is an advocate of improving transparency efforts to reveal healthcare pricing while implementing high-deductible health plans and health savings accounts. These steps, he says, could not only reduce employers’ and employees’ healthcare costs but could also help transform the system overall.

Is the system contributing to the lack of transparency in any way?
GALVIN: It used to be that brokers were compensated as a percent of premiums and they kind of liked the fact that they were going up because it was an automatic raise. They would come in and say, ‘Sorry employer, your premiums are going up this year 25%,’ which was not unusual. The employer would say it couldn’t handle that, so they would lower the premium but do it by imposing a deductible or bigger co-pay. The insurance carriers have pushed these things that create optics for the patient where they still never become engaged in knowing what stuff costs.

We are keeping people blind by creating co-pays or doing things like paying for every employee’s flu shots. You don’t pay anything as the patient, but those shots may have cost the plan $200. And you didn’t realize that the shot isn’t free. Instead, they could have come into the office under contract and given everyone a shot, and instead of costing $200, they would have only been $20 apiece.

You are a proponent of price transparency coupled with high-deductible health plans. How do those have the potential to change the system?
GALVIN: High-deductible health plans get rid of the fuzzy optics and expose what things really cost. Initially patients do what they always do: they do what the doctor says, and the first bill comes in and they see the real numbers they have to pay and they freak out.

But if, instead of going to the ER, you went to one of these urgent care centers, it might have cost $200 instead of $3,000. So now people are becoming educated, but they are becoming educated by getting hit over the head with a stick when they see that bill.

How would price transparency change the system if it were working properly?
GALVIN: If you shop ahead, you usually can get between 50% and 90% lower costs. We’ve done some research in Maine, New Hampshire and Massachusetts.

For the state of Maine, we looked at top-100 procedures to see how much people who went for care in Maine with commercial insurance paid last year. We discovered they paid $302 million. We then asked this question: if they had shopped and gone to the lowest-cost place that still had the highest-quality metric according to our data, how much could they have saved?

What we found is they could have saved 43%, or $131 million, on those top-100 procedures. In Massachusetts, they paid $1.5 billion for those procedures and could have saved 40%, or $578 million. In New Hampshire they did a little better; the costs were $578 million, and they could have saved $202 million, just over 39%.

We’re seeing 18% to 27% savings for the bulk of our customers. The differences are often driven by two key factors. First is whether or not the plan design has a financial alignment that drives shopping. The best is where the premium or claims cost savings are shared with the employee in the form of an employer-funded HSA. Of course, that must be paired with a high-deductible health plan, which eliminates the structures that obscure the actual costs from the employee (like co-pays). Second is employer leadership buy-in. When we see the company CEO engaged, we can often see near-perfect engagement from employees.

How was your organization able to get pricing information with such little transparency in the market?
GALVIN: I got the state to give us a version of the database that was a commercial-use version. It turns out there are about 15 states that have these databases, all modeled after the initial one in New Hampshire. We managed to get it from Maine, Massachusetts, Connecticut, Arkansas, Colorado and Utah. Many of these states have succumbed to our analytics team’s explanation of why it is the public interest to get access to the data.

As we’ve been in the marketplace, we have worked with third-party administrators that are releasing claims files for their communities under HIPAA. Under the terms of use, users give us permission to get explanations of benefits sitting in the portal, and we grab the last 12 to 15 months and de-identify it and those bits of data we combine in our database. We now have 3.3 billion claims in our database. We’ve been in New England and launched our national database in August.

How did you get involved in this industry?
GALVIN: I’m a serial tech entrepreneur. I was the first employee in companies I started and had to set up the benefits plans. What I saw was the crazy increase in the cost of these insurance plans and the percentage of the company’s budget that was being consumed by healthcare insurance.

I had been educated on these things called high-deductible health plans and health savings accounts by my physician, who was fed up with being told how to run his practice by insurers. When I started my fourth company, I decided to set up a zero out-of-pocket exposure plan. I got a high-deductible plan—$5,000 or $10,000—with a small premium deduction, and I fully funded their HSAs with the premium savings. That meant they had $5,000 in their account to keep if they didn’t spend it. If they ran out of money they were given to pay bills, they could bring their bills to HR, and they would cut them a check up to the $10,000 where insurance kicked in.

People loved it. It turned everyone instantaneously into caring healthcare consumers. Suddenly they wanted to know costs ahead of time. The company saved 32% on this generous zero-deductible plan. We surveyed the employees, and they had on average saved 75% of the money they had in their HSAs. The next year, premiums dropped by 7%.

This was when I got involved in legislation for price transparency. I discovered the state of New Hampshire had to submit every claim they paid to the insurance department quarterly, so they had this massive database. I decided to create price transparency. At the time, an app called Gas Buddy let you do a search at current location to find out gas prices nearby. We decided to create a healthcare version of Gas Buddy on mobile phones.

Why haven’t price transparency tools or healthcare “shopping” worked well so far?
GALVIN: If you Google this, all of the articles out there say these tools don’t work. And the reality is that, historically, they haven’t worked well.

The reason for that is most of the shopping has been done in a very abnormal way. You go to the doctor, and they send you for a procedure or test. They send the order out, and you are scheduled to go Thursday at 3 p.m. to another doctor or for a test. The shopping platforms in the past have said, “Call us after that, and we’ll help you find a lower-cost place and give you a financial incentive.” They still don’t show you prices, but they have experts who will tell you what to do.

That’s not a natural shopping experience. I love TVs, so how do I find a new one? I Google it or go on Amazon and get a nice clean list of the cost and what the descriptions are. There isn’t a lot of price discrepancy, because people can get that information so readily and are able to shop ahead of time. But most people won’t turn around and change their doctor’s orders; that’s not the way they shop.

How does MyMedicalShopper differ from other price transparency tools, and how do you think it can change how we choose and pay for services?
GALVIN: If you were to grab our mobile app, you pull this thing out while you are with your doctor. Say he wants to send you for a bone density study. You start typing in bone density, and it pops up and tells you everyone locally who does it, how much it’s going to cost you, your insurance discount calculated in, how much will come out of your pocket and what will be paid by the employer and the insurer. And you can say, “Doc, can you send me to this cheaper one over here?”

That’s where the opportunity is. You can make it a natural shopping experience and make it in a platform so they can bring it to their own doctors. It’s easy access at their fingertips, and that makes all of the difference.

Employers and individuals paying for their own insurance are looking for new solutions. This new round of price transparency tools brings the consumer back in. When you eliminate all of the broken optics, they can sit down with their doctor and figure out what works best for them.

What should brokers and consumers look for if they are considering using a price transparency tool?
GALVIN: You have to eliminate the thing where you can’t work with your doctor. Before you leave their office and they have made an appointment for you somewhere else, they need to able to navigate it simply and quickly, and it has to launch on their mobile device.

It has to be as intuitive as Google and give you similar information: where do I go and what am I going to pay. It’s also important to have the quality score. People misunderstand and think the highest price thing is the highest quality, and that isn’t true in healthcare. In study after study, there is no relationship between cost and quality in healthcare. It doesn’t work like other industries.

Don’t complain about the cost of care or inability to provide care for everyone if you are going to continue to be a bad consumer. My worst nightmare is when I go to an employer and they say they have a zero-deductible plan and don’t want to change it.

They could be building a retirement account and get zero out-of-pocket exposure and have a quarter of a million dollars sitting in their retirement account. The result on society in general is that healthcare costs will become a more perfected marketplace where productivity is rewarded like in other markets.

This interview was published on Leader’s Edge Magazine: https://leadersedgemagazine.com/articles/%202018/09/build-pricing-transparency-app-titude

Radio Entrepreneurs interview with Mark Galvin, MyMedicalShopper

Jeffrey Davis, host of Radio Entrepreneurs, interviews Mark Galvin about his fifth venture capital-back startup company, MMS Analytics, Inc. dba MyMedicalShopper.

Radio Entrepreneurs interview with Mark Galvin

Jeffrey Davis, host of Radio Entrepreneurs, interviews Mark Galvin about his fifth venture capital-back startup company, MMS Analytics, Inc. dba MyMedicalShopper.

Interview can be found here: https://radioentrepreneurs.com/mark-galvin-my-medical-shopper/

Millennials Bring Online Consumer Behaviors to Health Care

Tools and incentives can spur cost-conscious decisions

BY STEPHEN MILLER, CEBS

Millennial employees, especially, are “shopping” for nonemergency health care providers, although hurdles continue to impede cost-savvy choices for tests and procedures.

Millennial employees—who now outnumber Baby Boomers—are more comfortable with nontraditional ways of engaging with their health care providers and are more likely to apply shopping habits associated with online retail to their health care decision-making, whether in a traditional or a high-deductible health plan, a survey by the nonprofit Employee Benefit Research Institute (EBRI) found.

According to results from the survey published in EBRI’s March Issue Brief, Millennials were more likely than other generations to:

  • Check the quality or rating of a doctor or hospital—51 percent Millennial compared to 34 percent Generation X and 31 percent Baby Boomers.
  • Use an online health care cost-tracking tool—28 percent Millennial compared to 17 percent Generation X and 10 percent Baby Boomers.

Millennials were also more than twice as likely as Baby Boomers to use a walk-in clinic and more than twice as likely to consider using telemedicine.

“These findings perhaps reflect [Millennials] comfort in researching consumer decisions online, and applying the same consumer habits they use on Amazon or other retail online sites to the health care arena,” said Paul Fronstin, EBRI’s director of health research and education.

Transparency Challenges

While online tools and smartphone apps are increasing available to show price and quality ratings for health care providers, progress toward health care consumerism has been slowed by “lack of proper employee financial incentives and health insurance plans that create disincentives for people to care what the actual cost of a test or procedure is,” said Mark Galvin, CEO of MyMedicalShopper in Portsmouth, N.H., which provides data and tools for health care consumers.

He noted that transparency tools may “lack critical features that make them generally usable by Millennials and others,” such as by:

  • Not being “built first for mobile.” The moment your doctor tells you that she is sending you for a test or procedure “is not the time to pull out your laptop and navigate five levels deep into a website to try to search price and quality,” Galvin said. A better solution is to have a user-friendly app already installed on your handy smartphone, making price comparisons “as simple as searching on Google for anything else.”
  • Not providing precise insurance-negotiated rates. Some tools display “fair prices” as a benchmark to use when contacting health care providers, or a “green, yellow, red” indication of where in the market-price spectrum a particular provider or facility might be. “These are unfamiliar shopping concepts to people who have grown up with Pinterest, eBay, Amazon, Google and Yahoo,” Galvin noted.

It “would be a big step toward fixing this broken market,” he added, if plan sponsors made sure brokers are not paid based on a percentage of premiums, and if they eliminated structures like co-pays “that create scenarios where the patient pays the same out-of-pocket regardless of the wild price variations within a short travel distance.”

Hospitals and doctors also have been criticized for not making the prices on their services more readily available. While progress toward greater price transparency “at the macro level has stalled—in the sense that the industry hasn’t seemed to make much progress in the availability of transparency data—it hasn’t stalled at the employer/patient level,” said Kim Buckey, vice president of client services at Birmingham, Ala.-based DirectPath, a provider of personalized benefits education, enrollment and health care transparency services. “We’re seeing increasing interest from employers in transparency services and increased use by participants where employers offer these plans.”

As EBRI noted, Millennials are “more comfortable with consumerism—this is the generation that grew up being able to customize just about everything, from how their phones and laptops are configured to how their coffee is made,” Buckey said. Still, “the barrier for them—as for all users of health care—is lack of knowledge of price differences and that they can, indeed, shop for these services just as they shop for those laptops and lattes.”

[SHRM members-only toolkit: Managing Health Care Costs]

HSAs and Consumerism

“Consumers are empowered now to make their own decisions, but they’re horribly unprepared to make really smart decisions,” said Anna Phalen, vice president of customer insights and account management at Jellyvision, an employee communication software firm based in Chicago. “Employees are looking to employers for more options supported by tools to help them make the best choice. It’s become an expectation, like any other benefit.”

‘Consumers are … horribly unprepared to make really smart decisions.’

When communicating with employees about consumer-driven health care plans—such as high-deductible health plans coupled with a health savings account (HSA)—Phalen advised, “Remind employees how their HSA contributions will help cover costs for prescription drugs, then point them to price comparison sites like GoodRX.com to show them what they can expect to pay out-of-pocket for their medication—and where to find the best deals.”

“Enrollment levels in HSA plans are related to how employers view the plan,” said Beth Umland, director of research for consultancy Mercer’s health and business practice. “Investing in communications can make [a big difference] in driving enrollment to an HSA plan.”

“It seems that the longer a participant has had an HSA, the more we see signs of engagement, like contributing $2,000 or more annually to the account,” EBRI’s Fronstin said. “It takes participants some time to figure out how plans work.”

He noted that, “once the plan design is better understood, participants are more likely to take advantage” of an HSA’s many benefits. These include being able to contribute pretax dollars to the account and to build up or invest unspent funds to pay for future out-of-pocket health care expenses, creating an incentive to spend prudently today so that funds are still available down the road.

 

Published by HR Today here: https://www.shrm.org/ResourcesAndTools/hr-topics/benefits/Pages/millennials-bring-online-consumer-ism-to-health.aspx

Why Healthcare Pricing Stays Opaque

Summary: Why wait for special price transparency regulations before requiring medical suppliers to support a normal shopping experience?

BY MARK GALVIN, CEO OF MYMEDICALSHOPPER

In almost every industry in the U.S., consumers can easily access price information to shop. There is one glaring exception to this rule: goods and services in our nation’s healthcare system. Why do we accept the concept that it’s OK that we have no idea what the costs will be until after we have received the service?

As a result, there is no price elasticity that would normally reward vendors who don’t overcharge and reward innovators that reduce costs while improving quality. Because the market for healthcare is broken, disparate prices bear no relationship to cost and quality. Table 1 shows very common examples of how the same medical procedure can have wild price variations within short distances.

Table showing disparities in discounts for procedure prices across nearby, in-network providers.

Prices for medical tests and procedures vary wildly, even when considering the insurance-negotiated discounts.

Many believe there’s no fix without healthcare price legislation, and recently we have seen some regulations passed and additional measures discussed by our political leaders. But Americans already get consumer-based pricing models in nearly every other industry, and shopping comes naturally to most of us.

See also: Is Transparency the Answer in Healthcare?  

So why would anyone wait for the passage of special price transparency regulations before requiring their medical suppliers to support a normal shopping experience?

According to the Peterson Center on Healthcare, U.S. residents paid over $352 billion in out-of-pocket healthcare costs—along with another $3 trillion in healthcare premiums and taxes—to pay for commercial and government healthcare programs last year. This represents a staggering 10x, or 1,000% more than, what parents paid when baby boomers were teenagers. Unlike in the mid-‘70s, most medical tests and procedures vary in cost by 5–10x within a short distance of home, but very few of us recognize this. When we consider we’re just as likely to get the best care at the lowest-cost facility, you might think that we’d all take a personal interest in how we choose the providers and locations we use to receive “shoppable” medical tests and procedures. Yet most of us don’t.

The reason is that the continuing rhetoric among suppliers, legislators and payers—created by the combination of the quasi-regulated environment of healthcare with a third-party, indirect, payer system—interferes with normal market dynamics.

Most legislation aiming to mandate some sort of price transparency has simply provided plausible excuses for the industry to say “we use industry best practices” and “we complied.” This provides cover so the industry isn’t subjected to the same consumer protection laws that affect goods and services in every other market. What’s actually needed is less regulatory meddling and more free market principles to reward innovations that lead to higher-quality care at lower costs.

Graphic that highlights conflicts between carriers and members created by medical loss ratio regulations

Medical loss ratio rules may create a conflict between carriers and their members, as their profits are tied to total claims cost by state and federal regulations.

Rhetoric around “personal mandates,” “lifetime caps,” “pre-existing conditions,” “market stabilization,” “Cadillac tax” and other things that relate only to who will pay for healthcare coverage create a smokescreen that ensures that we never talk about the most basic issue in delivering services to this mass-market – price of medical procedures.

Unfortunately, severe unintended consequences were created when many of our state legislators created a set of rules known as Medical Loss Ratio (MLR) rules, and, more recently, these rules have been codified in federal law known as the 80/20 rule. The intended effect was to limit the amount a healthcare carrier could charge a customer in insurance premiums to no more than the actual medical charges plus a fixed percentage to operate the business and provide a reasonable return to shareholders. This type of rule or contract is often referred to as “cost plus.”

The unintended consequence is that carriers have no incentive to reduce medical claims, and therefore premiums and out-of-pocket expenses. Regardless of the carrier’s wish to help you, as long as there are MLR rules (a.k.a. 80/20, “cost plus”), carriers have a financial disincentive that makes them likely unable to survive if the amount of spending on medical procedures and drugs dropped substantially.

Because research has shown that medical price transparency alone (shopping) could knock more than 50% out of healthcare expense, you can see why some might want to slow the movement to consumerism by continuing to maintain secrecy on procedure prices, while beating the drums of healthcare rhetoric. This approach will keep us ignorant of the root cause of the outrageous cost of care in the U.S. – overpaying for medical procedures.

See also: The Search For True Healthcare Transparency  

The good news is that more and more individuals have high-deductible health insurance plans, with roughly 36% of all people under the age of 65 currently enrolled in an HDHP. Now there’s a grassroots movement, debunking lies and empowering patients and employers—not lobbyists—to take action.

Intuitive decision support tools continue to be adopted by those who want to be able to compare their options for healthcare based on price, in addition to quality and convenience. Eventually, as price-elasticity is restored to our broken healthcare market, we will see a full reversal of the unsustainable cost trends we’ve experienced over the last decade.

 

This article was published on Insurance Thought Leadership here: http://insurancethoughtleadership.com/why-healthcare-pricing-remains-opaque/