Asking the Right Questions in Healthcare

In early March, Congress faces another deadline to fund critical healthcare programs, including those that support community health centers and medical education. While supporting these programs is important, lurching from one stopgap funding bill to the next leaves other healthcare priorities off the table. Lawmakers need to have a larger discussion around improving transparency, access and affordability.

The same is true in healthcare when we don’t focus on the questions and conversations that empower people to receive high-quality care with affordable costs. Under a traditional insurance plan, we are trained to ask healthcare providers: “are you in network?” That's the wrong question to ask. The right question to ask is: “what does this care cost?”

Broadening the focus beyond simply whether a doctor or hospital is in network can help lead to more holistic decisions about the healthcare people receive. It can also provide individuals more freedom to choose the best care from the best providers, instead of being limited to just a few providers picked by insurance plans.

This is a lesson I learned through personal experience. Several years ago, I needed an MRI, and even with generous insurance coverage, my out-of-pocket costs were $1,300. The MRI took two weeks and an unnecessary CT scan before I received authorization for it. When my doctor later required a second MRI, I learned that if I paid in cash, my cost would only be $330, and I could get the MRI the same day. This was for the same MRI at the same location with the same provider. It made no sense to me why my traditional insurance would cause care to be delayed and the cost to be higher.

This is the case for too many patients. Fortunately, new approaches are being developed that promise to change the trajectory of healthcare in the U.S.

Take Mark Cuban’s Cost-Plus Drug company. The company is disrupting a prescription drug market plagued by a lack of transparency and rising costs. Cost Plus Drugs charges consumers 15% more than it pays to buy the medicine, along with a flat dispensing fee and shipping fee. Patients know upfront what their costs are and why. Transparency is driving better access and lower costs for prescription drugs.

Similar disruption is possible in the insurance market. Health insurance is a math equation—the cost of a claim times the likelihood of that claim plus the margin of profit an insurance company makes. An insurance model that can lower the cost of each claim would translate immediately to lower insurance costs. That is what Sidecar Health has set out to do.

Through a user-friendly app, our insurance model allows consumers to see average local prices and benefit amounts for every healthcare service, compare options and choose what’s best for them. Members know exactly how much the plan will cover and what their portion of the cost would be, if any. If someone chooses a service that costs less than the covered amount, then the difference goes back to the patient.

We have seen an increase in setting appropriate care leading to a 60% increase in colonoscopies completed at surgery centers versus hospitals. We’ve also seen a 20% decrease in emergency department visits because members aren’t having to use emergency rooms as an access point for care that can be handled elsewhere. Depending on the size of the company, employers save an average of 20% on premiums and between $1,000 and $5000 per employee, versus a typical network-based insurance plan.

On the provider side, doctors and hospitals get paid upfront – the price they want to charge – decreasing the administrative burden of insurance claims on the back end and providing more time to deliver care to patients on the front end.

The healthcare industry needs to be shaken up. With Congress often stuck debating the same old issues, it’s up to the industry to identify new and innovative approaches that change traditional ways of thinking. People can become more engaged healthcare consumers and choose the value of care that’s best for them—we just have to ask the right questions. 

 Patrick leads Sidecar Health on its mission: to make quality healthcare affordable and accessible for everyone in the United States. Patrick has more than 20 years’ experience in product, engineering, marketing, and sales  as a senior executive with both public and private companies. Patrick holds an MBA from The Wharton School at the University of Pennsylvania and a B.S. in engineering from Duke University.