COVER STORY


decisions. Educate them on a) reasonable costs of procedures, because patients don’t know how much procedures cost; b) the ele- ments that affect the cost of a pro- cedure (obviously, getting care in a lower-cost setting, such as an ASC, would affect the cost of a procedure); and c) how to find the lower-cost setting.


2. Create benefit designs that en- courage patients to use ASCs and/ or cost-effective facilities, like diagnostic centers that offer bet- ter value. Value-based benefit de- signs can waive co-pays or exempt members from using their deduct- ible when they use cost-effective, high-quality providers.


3. Incentivize the provider. The pro- vider has the biggest influence on the patient, Kampine says. Many providers, however, don’t know the cost differential between facilities for their own procedures, or when they are making referrals to ex- pensive locations for diagnostics. One approach is to increase the pay for providers with cost-effec- tive referral patterns, or when they use the most cost-effective venue for care. Implementing incentives like those, however, could prove problematic because carriers are often reluctant to pay differently based on the site of service.


“Effective strategies should offer something for all stakeholders, includ- ing


the payers, the providers, the


employers and members, when they take steps to migrate procedures into the lower-cost setting,” Kampine says.


Influencing Site of Service One of the companies that Health- care Bluebook works closely with is HealthSmart in Irving, Texas, a national TPA that provides compre- hensive third-party administrative ser- vices for self-funded employers. The organizations have partnered to deliver


14 ASC FOCUS MARCH 2016


Effective strategies should offer something for all stakeholders, including the payers, the providers, the employers and members, when they take steps to migrate procedures into the lower-cost setting.”


— Bill Kampine Healthcare Bluebook


price and quality transparency tools to HealthSmart members and to deliver plan designs and payment vehicles that encourage or incentivize its members to use higher value providers, such as ASCs, Kampine says. “The fastest growing cost seg- ment for most health plans is in out- patient


surgeries,” says Jake Frost,


vice president and general manager of HealthSmart. “Facility expenses, phy- sician services and lab costs comprise up to 40 percent of employer health plan expenses. In many cases, this seg- ment now exceeds inpatient expenses. There are numerous opportunities to save money, improve outcomes and limit exposure to stop-loss entities.” HealthSmart offers a program called MyDecision to contain self-


funded employer’s medical spend, Frost says. “Our solution is a three-tiered approach: patient advocacy, transpar- ency and redirection to lower cost, high-quality providers. This approach is based on HealthSmart’s belief that engaging members and helping them navigate their health care experience will lead to savings. “This proprietary program is designed to solve the significant increases in outpatient medical costs, which are now approaching 45 percent of all medical spend and are subject to a 300 percent to 1,200 percent cost vari- ance in almost any national network,” he adds. “Our program uses price transpar- ency, employee incentives, active redi- rection and bundled pricing in partner- ship with high quality providers around the country. This approach brings real, free-market principles to health care purchases and eliminates the secretive pricing, billing and discount practices of hospitals and insurers.” The program provides one consoli-


dated bill for services that includes the facility, the surgeon and the anesthe- sia costs, all at a reduced rate. It uses a simple and transparent pricing that eliminates the difficulties and surprises involved with the traditional preferred provider organization (PPO) environ- ment. And it provides access to a large enough number of outpatient proce- dures to generate significant savings for clients and members by actively redirecting care, Frost explains.


ASCA’s Role ASCA, Healthcare Bluebook and


HealthSmart are currently partnering on a research project to explore the dif- ference in price between services deliv- ered in the ASC and hospital outpatient department (HOPD) environments and quantify the value created by ASCs in the commercial insurance market. Stay tuned and watch ASCA’s web site, www. ascassociation.org, for more informa- tion as it becomes available.


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