Feb, 13, 2015

Decision Support Tools for Marketplace Coverage

This week, I had the pleasure of serving on a panel at AcademyHealth’s National Health Policy Conference on the topic of Marketplaces. I was privileged to join Dr. Mandy Cohen from CCIIO and Professor Mark Hall of Wake Forest University in a discussion of trends moving forward in Marketplace competition, moderated by Dr. John McDonough of Harvard. The key takeaway was that the theme of the next open enrollment will be decision support tools for consumers to choose the best plan for them.

Mark’s presentation focused on recent research of how insurers compete in a Marketplace environment. He posits that since carriers no longer compete by working to select the least risky population, they now compete on premium, plan design and network. Often the carriers will create multiple plans in order to broaden their appeal to a Marketplace consumer base. This results in a bevy of plan designs and choices, even within the same carrier. Add to that the often-times opaque nature of narrowing networks, and consumers can be left navigating a very important and expensive purchase in the dark.

When asked about the types of decision support that Marketplace consumers might see in the next open enrollment, Mandy laid out three major areas: out-of-pocket cost calculators, drug formulary search tools and provider network searching. In fact, many State-Based Marketplaces are working on precisely these tools for their consumers as upcoming additions to their websites. However, as has been the case with so much of ACA implementation, these tools sound easier to implement than they prove to be in Marketplace environments.

Out-of-Pocket Cost Calculators: The complexity of plan designs and out-of-pocket costs policies among carriers and plans can make these calculators a feat to construct. Additionally, a lack of price transparency can present a challenge in estimating costs. If a plan’s co-pay is 20%, but there is no reference price upon which to calculate the 20%, the information is not helpful to consumers. One solution to this challenge is using data from an All-Payer Claims Database to construct a price list for carriers and providers.

Drug Formulary Search Tool: A formulary search tool is the most simple decision support tool to build. Generally, the formularies are in similar formats, drug names are standardized and the cost structures are easy to understand. But there can be complexities around step-therapy drugs and the tool requires frequent updating with new drugs and new generics changing formularies regularly.

Provider Network Search Tools: A robust tool that can narrow plan options by participating providers is very complicated since generally, the information on participating providers is held by the carriers and not in a standard form. One carrier may list Robert A. Smith M.D. at University Medical while another lists Dr. Robert Smith. While a human can sort through these differences, an IT system has more difficulty. One option to move toward a true provider network search tool is a common provider directory, used by carriers and by the Marketplace.

The State Network will be releasing an issue brief on consumer decision support tools in the coming weeks. Stay tuned for more insights.