Healthcare Price Transparency Initiative Begins

May 20, 2018 at 05:46 pm by Staff

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MediXall Group, of Fort Lauderdale Tackles Healthcare Cost Transparency

FORT LAUDERDALE - MediXall Group Inc., (OTCQB: MDXL), a technology and innovation-driven organization structured to bring effective change to the U.S. Healthcare Industry, is pleased to announce that the company has initiated a controlled launch of its Healthcare Marketplace in South Florida, specifically in the counties of Palm Beach, Broward, and Miami Dade. This controlled launch consists of a select group of MediXall early adopters who completed the onboarding process and were approved by the credentialing committee.

With MediXall's registered healthcare providers continuing to complete their legal agreements and the subsequent process of credentialing, the full launch with all medical services available is on track for the second quarter of 2018.

Michael Swartz, President of MediXall Group said, "The controlled launch of the MediXall Platform is an important step towards our objective of providing a better solution to connect consumers with high-quality healthcare providers and wellness services at a lower cost."

Michael Swartz on Rising Healthcare Costs

Healthcare spending, taken as a whole, is very high in the United States, and growing. From 2005 to 2016, health care spending in the United States tripled. In 2016 reached nearly $3.4 trillion, up 4.8 percent from 2015. That makes health care one of the country's largest industries, equaling to 17.8 percent of gross domestic product. In comparison, health care cost $27.2 billion in 1960, just 5 percent of GDP. That translates to an annual health care cost of $10,348 per person in 2016 versus just $146 per person in 1960. Health care costs have risen faster than the annual income. According to The Centers for Medicare and Medicaid Services (CMS), U.S. health care spending is projected to reach nearly $5.5 trillion by 2025, a full 20 percent of GDP.

Furthermore, the average premium for consumers has risen 19% over the past five years, to $7,000 for single coverage in 2017, and to nearly $19,000 for family coverage, according to the Kaiser Family Foundation. However, only 80% of health insurance premiums go towards paying for service, while the other 20% is lost in administrative overhead. Oftentimes healthcare providers go unpaid for months, or longer--causing ever increasing costs.

Despite employers paying about three quarters of their workers' premiums, according to the Society for Human Resource Management, individual workers' health costs have gone up as well. In addition to premium increases, their out-of-pocket costs, which include what they shell out for deductibles, co-pays and co-insurance, have risen too. Between 2005 and 2015 average out-of-pocket costs grew 66%, or more than twice the growth rate in wages during that period, according to Kaiser.

The Patient's Perspective

Patients struggle to bear the high costs of health care in the United States by paying increasingly expensive insurance premiums, which can only serve as a cap on a family's exposure to ?nancial ruin. Because of high annual deductibles, most patient's day to day care is still paid out of pocket.

Since costs such as a doctor's visits and many other routine visits are paid out of pocket, price comparison is increasingly important. Currently, consumers su?er from a lack of transparency, trust, and a general inability to systematically access the best health care at the most a?ordable price.

While the internet has increased the amount of information available to health care consumers, many self-pay consumer purchases are a result of chance, haphazard decision making, procrastination, and poorly information.

Moreover, many Healthcare Providers have not thought about what they would charge a cash-pay patient who pays up-front at the time of service. As a result, many times the self-pay consumer pays the health care provider at the provider's 'Usual and Customary Rate', which on average is 40% more than what insurance companies pay for their insured members. This discount represents one of the largest advantages of the insurance model.

Prices for a given procedure vary widely, however, within a town, state, country--without necessarily any real di?erence in the quality of outcomes as well. Researchers for a Health Care Cost Institute study found the national average price for 242 common services--everything from lab tests and X-rays to more extensive procedures like hip replacements and angioplasties--varied extensively across states as well as within metropolitan areas. For example, in Cleveland, the average price paid for a pregnancy ultrasound was $522. But just 60 miles away in Canton, Ohio, the average price was $183, according to the study.

An Amino Study of MRI prices found that the price of an MRI can be thousands of dollars more if you go to a hospital than if you go to an imaging center, depending on your state. Although many qualify for subsidized insurance premiums, they are still required to pay their deductible up front. In 2015, the A?ordable Care Act capped this at $6,500 for an individual and $13,200 for a family-potentially ruinous costs for many low to middle income Americans.

As a result, increasing numbers of patients go without insurance entirely, thinking their healthcare needs would not justify the expense of an insurance premium. Oliver Wyman found that enrollment in the healthcare exchanges decreased by 22 percent in 2016 and 2017. This population, often young and too well o? to qualify for government-funded welfare programs like Medicaid, therefore neglect going to the doctor for routine visits. This represents a loss both for patients and providers.

The Provider's Perspective

For health care providers, o?ering services to insured patients is complicated, costly and fraught with delays. As indicated above, providers customarily discount their services by an average of 40% as a result of the insurance companies' bargaining positioning. Moreover, providers often must wait for months before a claim is reviewed and approved by insurance companies and they receive payment. Finally, providers must write o? a large percentage of their billings due to unpaid co-pays, deductible, co-insurance, disputed billing, and other situations. According to many providers, the wait time for payment from an insurance provider is 27-90 days on average from the time of service. The administrative burdens and payment delays often increase when government programs like Medicare and Medicaid are involved.

Illinois, for example, has more than $5 billion dollars in unpaid state health insurance and $2 billion dollars in unpaid Medicaid bills to healthcare providers who in many cases have waited years to be reimbursed. The situation is so bad that many providers opt not to deal with Medicaid, turning away those most in need because they cannot a?ord to provide services for free. Approximately 50 percent of providers make this tough decision. The administrative mess costs providers as well as insurance companies. Only approximately 80 percent of a healthcare insurance premium goes to actual medical services, on average. The remaining 20 percent goes to administrative costs of the insurance company.

These di?culties have led to a sharp increase of providers abandoning insurance companies in favor of cash only, concierge medicine, and other alternative business models. Many providers, however, cannot a?ord to completely replace their business model, which is what is often necessary to make the shift pro?table.

The Current State of Heathcare Price Transparency

Although the number of uninsured has dropped in the wake of the Affordable Care Act (ACA), the percentage of individuals enrolled in high deductible plans has increased. In the individual market, nearly 90% of people in the ACA Marketplaces enroll in a plan that qualifies as a high deductible plan. And in the employer-sponsored insurance market, there has been a shift towards high deductible plans over the last ten years. A survey conducted by the Henry J. Kaiser Family Foundation in 2016 found that deductibles in employer-sponsored plans have increased 67% since 2010 and that, while only 4% of workers were enrolled in a high deductible plan in 2006, 29% were enrolled in such a plan in 2016. Moreover, more than half of workers were enrolled in a plan with a general annual deductible of at least $1,000 for individual coverage.

While the reasons for the movement toward high deductible plans are many, the point that should be emphasized in this is that high deductible plans are proliferating, which marks the beginning of the return of the individual health care consumer. Before a patient reaches and exceeds their insurance deductible, a patient shopping for an MRI, a strep test, or just about anything else, will act just like any other customer shopping in the market for any other good or service. Since any purchase before hitting the deductible the patient is "paying with their own money," they will be price sensitive and therefore willing to shop around among different providers of the same medical service.

Thus, just as Walmart competes with Target for customers on price, selection, and quality, health care providers, which are no longer assured of customers as a result of their negotiations with third party payers, will have to compete for patients along dimensions that matter to patients. These dimensions are likely to differ from those that defined competition over the last 40 years. The companies that innovate to serve the needs of this emerging health care consumer are the ones that will emerge and thrive, while old models of innovation, innovation focused on third party payers or on metrics that are largely irrelevant to individual consumers, will begin to fade away. Therefore, "Consumer choice" is and needs to stay at the heart of the national health care debate. This presumes access to accurate information about costs. While consumers only started feeling the pinch of out of pocket expenses and woke up to health care costs a few years ago as their share began to rise, they lack the necessary facts to make intelligent decisions about the quantity and quality of what they are purchasing. As costs continue skyward, this crucial information, especially price transparency, is what consumers are now demanding.

But health care pricing remains a mystery that can't be solved by consumers, on their own. While pricing to consumers includes insurance premiums and payments to providers, only providers have the key to correct the problem that is largely driven by provider decisions and costs.

Many experts argue that one of the largest impediments to true pricing transparency is that with the initial stages of diagnosis and treatment, the future costs are unknown. After looking into this matter further, this is a big understatement of the problem for consumers.

The first issue facing consumers is not the prediction of future cost, but basic pricing facts and principals that drive the costs are essentially unknown. The reality is that even though there is a "schedule of fees," for services, those fees are not the truth as it relates to consumers. Real fees are the ones negotiated with each individual insurance company or health plan. Those prices don't create a schedule of prices for "knee replacement surgery," for instance; they only indicate what the health plan will pay Provider A for the physician charges for that service. Provider B in another network has a different negotiated fee.

The amount that the provider puts on the bill to the health plan is in fact the Charges; the real price is what the health plan will allow for payment, or the reimbursement rate. That is why a consumer can get an initial estimated bill from a hospital for a $33,000 CT scan, yet an Explanation of Benefits (EOB) from the health plan that shows the allowed charge as $5,000, and "a write-off" for the difference. The $5,000 is the price that was negotiated with the health insurance plan. However, one of the pitfalls is that the consumer doesn't know those prices, which vary widely across carriers and markets.

In today's market, almost all prices are negotiated between providers and health plans. The only exception is that some providers refuse to participate in certain health plans, and do not accept insurance company assignment, which is the willingness to accept their payment in full for covered charges. With the transition to Managed Care HMOs and PPOs, the idea of real fees were radically altered, when health plans realized they could take money out of payments to providers by negotiating prices.

Without confirmed prices, it is difficult, if-not next to impossible for patients to know their costs in advance. To bring us back to reality, even if a physician, who wanted to be responsive to a consumer, could estimate his or her own fee, the estimated amount would not reflect the consumer's total costs, since the majority of the time there are additional fees layered in. For example, there would also be hospital inpatient or outpatient charges (diagnostics or procedures), plus other physicians and services (anesthesiology, pathology, and assistants or consultants). For the consumer, making a health care purchasing decision is as risky as writing a blank check, since in Healthcare's current state the consumer's medical bill in the mail could vary significantly than what they were expecting.

Even if consumers complete full due diligence on their health coverage, which implies that they have verified that the provider they are going to participates in the plan before purchasing, they still get caught in a pricing issue in most cases. This can be attributed to that under the same system negotiation that dictates fees that health plans will reimburse providers, there are usually separate negotiated agreements for physicians and hospitals. This makes it more than likely for patients to be able to see their physicians under their plan, and at the same time be out of network for diagnostic tests or procedures at that physician's practice/institution.

Furthermore, effective January 1st of each year health plans often change or modify benefit plans. On the contrary, contracts between health plans and providers do not follow this same schedule. As a result, they're many cases where Consumers can sign up for a plan with their services from a specific provider being covered, but find their provider, which was covered when they started the plan, go out of network at some point in the life of their plan. As a result, consumers are forced to change providers because the rules prevent them from changing coverage during the enrollment year.

Exacerbating the problem even further, market negotiation of provider prices may give payers greater leverage than the previous "Usual and Customary" charge calculations, but the outcome is still simply to push existing cost problems to employers and consumers.

Without any relief to the consumers, higher regional costs translate to higher fee negotiations. Under the high-deductible benefit plans being purchased today, consumers are paying a larger and larger share of actual payments, in addition to a larger share of premiums. Even with consumers taking on a larger share of the healthcare costs, they still have no power to directly challenge prices to either health plans or providers. In addition, complex billing practices, secretive insurer-provider contracts, the sheer number of third party payers, and major quality variances in delivery of healthcare may mean that it will be difficult for price transparency initiatives to achieve economic efficiency.

Healthcare's Roadmap to True Price Transparency

While many experts believe state directives and legislation are necessary for true price transparency, I believe that elaborate, many times complex schemes and claims databases are really not required to foster the conditions needed for sustainable price transparency. To clarify what is driving this contrary position, each provider already holds a centralized source of information for their own tangled network of health plan agreements and in turn, the prices for each of their services. Not only that, they also are in command of efforts to reduce their costs.

Another pillar of this position is that market competition, as well as economic sense, will ensure that providers paint a picture of pricing that is neither too good to be true nor too harsh for the consumer. By introducing increased market competition, providers will be pushed to reexamine and adjust their pricing to the benefit of consumers. As the consumer's share of their healthcare costs continue to increase, consumers will demand realistic and more transparent prices from these providers, that if not provided will lead to the consumer choosing a provider that is responsive to these demands.

This is what brings me to believe that providers are the logical first responders to consumers' need for coherent pricing. To remain in business as it becomes heavily consumer-financed, providers will need to pivot their approach to pricing to better help patients make wise choices. It is in the provider's best interest to help consumers make affordable and cost-effective choices for their care.

Another factor contributing to the need for providers to make a change if we ever want true price transparency, is that the current health care payment system, including Medicare, Medicaid and private insurance, has up until recently sheltered providers from the effects of their own internal actions that increase costs. For much of the time providers were insulated from the costs that patients will pay for the treatments they prescribe, compounded by the drive to purchase the latest technology and equipment, invest in new buildings, and promote growth strategies that providers assumed would be covered by ever-willing insurance and consumer payments.

This fee-for-service payment system has led to providers having no understanding of the ramifications of decisions and pricing at all levels. The only way for providers to begin addressing the consumer issues is to comprehend their own pricing and costs, and to recognize the impact on their customers.

In my opinion the overall problem stems from the traditional system of insurance companies and the large influence of Medicare establishing cost of care. Insurance companies negotiating pre-determined rates via proprietary networks for its customers is the foundation of the current value stream. Open market price competition is severely suppressed by the use of the payer-based, closed system we see today. In the current system insurance companies and government programs that function as insurance companies, have assumed the role of consumers in healthcare markets. These third parties negotiate prices, preapprove medical services, determine who can serve as a patient's physician, and provide other intermediation services, which are all functions typically associated with consumers in other markets. With these third parties acting as the true consumers in the current healthcare system, healthcare providers cater to them and not to the individuals receiving the care. This model results in the complete opposite of fundamental economic models of supply and demand by creating an artificial pricing structure.

While we hope for wide-scale change, innovation is slow to catch on, especially when it comes to the U.S. healthcare industry. That's because organizations that have the resources to revolutionize health care on a mass scale, such as Walmart or Amazon, are apprehensive due to the embedded infrastructure and the complex regulatory. We've seen some new entrants become more commonplace, such as independent labs and imaging centers. The traditional medical care delivery centers should critically look to find ways to deliver care more cost effectively to balance expense with changing revenue streams.

The future state of healthcare should include mandatory price disclosures for patients to see before or upon entering the facility. Imagine if you could book a doctor's appointment or look for a specific medical service just as easy as booking a flight or a hotel on Priceline or make a dinner reservation on OpenTable. If all healthcare providers were offering a menu of service offerings and associated prices, consumers could be empowered to shop around for their medical services. This streamlined pricing would lead to the elimination of networks and insurance price setting as providers will set market pricing. This approach promotes capitalism and consumer choice, allowing providers to compete on the basics of price and quality. This will increase consumer knowledge and openness to new forms of medical delivery that do not compromise medical care. Think about the way consumers purchase other goods and services. Someone who buys a television on Amazon, rather than at a local store, typically does so because Amazon's price is better.

And like other services we pay for, we need information on quality of the goods received. A future state, based on true economic principles, will lead to quality measurement, monitoring and communication. Through media, e.g. Consumer Reports and social media platforms, as well as user reviews, consumers will have the tools to be informed and educated. Providers will benefit from corresponding rewards and increased business or, alternatively, be affected by penalties resulting in decreased business.

The key to unlocking the affordability of health care does not lie with political recommendations around policy. Without really looking under the hood at the cost mechanisms of U.S. health care, the fundamental costs don't change from pre-Affordable Care Act times, Obamacare, or proposed changes under future healthcare proposals.

As we push toward industry changes, the solution lies in evolving the economic model to promote free market pricing and innovation. Additionally, alternative care delivery platforms, such as telemedicine and on-site employer clinics, are changing the way the traditional model works. We need to explore ways to unravel the current system that lets the entrenched industry players dictate pricing from behind the scenes and begin to shift the power back to the consumer. Consider the case of LASIK eye-correction surgery. LASIK is not covered by insurance because purchasing eyeglasses is much less expensive than LASIK. Because consumers must pay directly for LASIK services, the LASIK market has behaved just as the conventional technology sector has: over time, prices have gone down, and quality has gone up. No LASIK provider or supplier has complained that the decline in prices has led to less innovation. As we can see market forces will and certainly do work best in the areas of America's health care system where insurers play less of a role, and consumers' willingness to pay is at the center.

As healthcare consumers become increasingly price sensitive under high deductible plans, the main priority of the changes to our healthcare system should be centered around empowering consumers to choose healthcare providers and services based on convenience and personal criteria as opposed to the rules of a third-party. When consumers have real choice instead of a requirement to stay within proprietary PPO and HMO provider networks, consumers will shop for an array of competitively priced wellness and medical services offered by the ever-increasing supply of primary care providers, specialists and ancillary service providers choosing to practice healthcare via internet enabled platforms. As substantial amounts of primary and specialty care become easily accessible through Internet-enabled care, virtual care or self-care, patient satisfaction will increase, as will the amount of time physicians are able to focus on critical care needs.

The conclusion we should make is that it appears that the U.S. healthcare consumer is ready to price shop for their growing healthcare needs. However, if we truly want to see this happen, the healthcare industry needs to evolve to a patient-centered model to foster this new wave of consumerism. This is exactly the reason we created MediXall Group.

MediXall Healthcare Ecosystem - Finding the Right Solution for Patients and Providers

Since inception of the company, we have been committed to bringing effective change to the U.S. Healthcare Industry by creating a level of price transparency and digital convenience that consumers have come to expect in every other aspect of their lives. Since the creation and explosion of the World Wide Web we have seen constant innovation of price and quality available benefiting consumers going online.

The first to jump that got our attention were travel sites, hotels, and then full-blown e-commerce for anything and everything a consumer could want. However, healthcare has up to now been different. We have spent the past 2 years developing and refining our consumer-centric platform to fill this void in the market, finally launching the MediXall Healthcare Marketplace in March 2018. The MediXall Platform is a new generation healthcare marketplace platform to address the growing need of self-pay and high deductible consumers for greater transparency and price competition in their healthcare costs. This transparency shifts the power to the patient's hands, allowing them to find quality, affordable medical, dental, and wellness services, offered by quality doctors, dentists, and other health providers in their area.

We created the MediXall Healthcare Marketplace with a cash paying customer forefront in our design. The online experience was designed to mirror other e-commerce sites found in other markets, with what centered around creating an online marketplace for healthcare services in the same way retailers sell their goods on the Amazon Prime platform, providing consumers Amazon-style reviews, transparent pricing, and comparative shopping. The website enables consumers to purchase most medical services from Qualified and vetted providers that compete based on a combination of quality score, location, best all-in cash price and convenience.

Our platform offers two value-added services to consumers shopping for medical procedures. First, we work with the individual providers, so that they offer consumers a transparent all-in cash price. Second, beyond the prices, MediXall ensures that providers offer consumers details on what the listed service includes so that they pay one price and one price only, which is not always the case when dealing directly with providers. Because of the complexity and fragmentations of the industry, online marketplaces such as WebMD have seen remarkable success within the U.S. digital healthcare market. Generally accepted as a forum with potential to reduce inefficiencies and increase transparency, the online marketplace is a free-market environment, utilizing the power of competition to empower the consumer as it reduces inefficiencies and increases transparencies.

With this new healthcare platform, we are bringing a consumer-centric marketing model that has been successful in the retail industry to the healthcare market. This new online, easily accessible and understood "auction" of medical care will offer patient/consumers the opportunity to review the services offered and costs of service for desired procedures, with a large and growing number of practitioners in South Florida participating in order to compete. In addition, provider reviews on our platform can only be written by consumers who have used a service by a provider within the MediXall Network through the platform. As a result, consumers can access credible reviews that provide a basis for informed decisions. The net effect of the vendor-competitive model of the platform is it empowers consumers to control their healthcare based on a combination of quality score, location, price and convenience. In this era of rapidly increasing deductibles and healthcare costs, the MediXall Healthcare Marketplace is designed to be transformational and disruptive to traditional methods of medical care and provisioning of medical services to the consumer.

With MediXall, consumers, starting in South Florida, now have the option to search for doctors and book appointments based on cost, distance, ratings, and availability at the click of a button. By delivering a solution that better connect consumers with high-quality healthcare providers and wellness services, MediXall enables our Provider Network members to engage consumers with the level of price transparency and digital convenience that they have come to expect in every other aspect of their lives.

The MediXall Provider Network includes pre-registered healthcare providers who have been formally credentialed and approved by the MediXall Credentialing Committee. The company's robust Provider Network of healthcare providers include:

To ensure we promote the highest level of quality care for its users, our Company requires all providers who join the MediXall Provider Network to go through a full credentialing review process and continuous monitoring, which has been modeled after the same process practitioners are required to take to become an in-network provider with an insurance company. Practitioners failing to meet the credentialing requirements of an insurance company may mean not receiving payment for out-of-network claims; with MediXall it means not being permitted to provide services through our Healthcare Marketplace Platform.

Credentialing is a lengthy, but necessary, process to ensure that consumers have access to quality healthcare providers. To make the credentialing seamless and easy for providers, MediXall entered into a unique technology partnership with a NCQA certified CVO. This partnership enables MediXall to verify that each provider on the platform meets the Company's compliance and quality assurance requirements with industry leading turnaround time and efficiency, starting with application collection and processing, all the way through verification, committee review, and ongoing monitoring.

Once a health provider has requested to join the marketplace, MediXall conducts a full credentialing process that evaluates the qualifications and practice history of a healthcare provider. Once a provider's participation application is received, the Company verifies the qualifications and practice history of a health provider. This information includes, but not limited to:

If the provider passes all of these checks, the application is then forwarded to a credentials committee for review. This committee consists of a panel of experienced and respected physicians from a variety of specialties. Providers who are approved by this committee become MediXall preferred providers and can begin providing services through the Healthcare Marketplace. Members of the committee are educated as to the Company's credentialing process and have agreed to hold a review meeting monthly to evaluate new providers for approval.

The U.S. healthcare system is experiencing a growing crisis of access, cost and quality of care due to inefficiencies in today's healthcare system and barriers between participants. Innovators in other industries have solved access, cost and quality inefficiencies through the implementation of technology platforms and business models that deliver products and services on-demand and create new economies by connecting and empowering both consumers and businesses.

We have taken the same approach to solving the pervasive access, cost and quality challenges facing the current healthcare system. Consumers' ability to access high-quality, affordable care has been limited by many factors such as physician availability, prohibitive costs, physician office hours and geographic locations. Likewise, burdensome administration, cancellations, reimbursement rates, unfilled appointment slots, geographic constraints and business hour limitations have historically impacted physician efficiency and, as a result, constrained physicians' income.

We believe we have created a platform that is uniquely positioned to bridge the supply and demand gap between physicians and consumers by fundamentally changing the way market participants access and deliver healthcare--eliminating traditional barriers and inefficiencies between participants and empowering them to engage in a healthcare marketplace on their own terms. Our platform provides consumers with access to fully-credentialed physicians, comprehensive medical services and consumer engagement strategies in an economic model that delivers multiple benefits to all participants. The unique combination of these features enables us to dynamically and efficiently match consumer demand and physician availability. We believe the confluence of consumer empowerment, emergence of broad technology solutions and focus by all constituents on providing high-quality, cost-effective healthcare creates a unique opportunity for a disruptive platform that transforms the way consumers access, providers deliver, and employers and health plans administer high-quality, cost-efficient healthcare.

Our vision for the MediXall Platform's prominence in the healthcare marketplace is to create a unified online environment that connects physicians and caregivers to patients, and payers to the caregivers, across all healthcare settings. Starting with pricing transparency and leveraging the just-in-time service delivery model, we intend to expand our service offerings to enable smarter care and empower the customer/patient at virtually every point of the healthcare continuum; whether organically, through acquisitions, or through integration with our strategic partners' solutions. As we expand the Healthcare Ecosystem, the MediXall Healthcare Marketplace will facilitate such transformation in the future of healthcare by offering community connectivity, interoperability, data analytics, and consumer engagement features and functionality.

Michael Swartz, President of MediXall Group

Sections: Business/Technology