Clinic Price Check

Due to COVID-19, the United States will face a dramatically altered healthcare landscape, but with an essentially unchanged system for insurance or cost-sharing. Many Americans will need healthcare, but will have lost their employment and in many cases their insurance at the same time. Many underinsured and uninsured individuals will see their savings wiped out, face garnished wages or bankruptcy. 

Our solution is price transparency of American health providers, including list (‘sticker prices’), cash-pay and Charity Care rates, which will allow consumers to minimize their cost exposure while also putting downward pressure on providers with inappropriate cost structures, which will be critical as we attempt to emerge from this pandemic. Many Americans avoid visiting the doctor, due to fear of the financial repercussions. Helping consumers access the cost information prior to receiving care can mitigate unnecessary spread of COVID-19 and save lives.

The problem that we address is the lack of price transparency in the American health system. The proposed project could have a high-impact, because the healthcare industry has largely eschewed efforts at greater price transparency, with deleterious effects for American consumers. According to the American Cancer Association, 56% of Americans suffer from hardships related to the cost of healthcare. In 2019, 67% of bankruptcies were due to medical costs. American's healthcare costs are some of the highest in the world, averaging two and a half times other developed countries.

Due to COVID-19 over the next six months, the U.S. will face a dramatically altered healthcare landscape, but with an essentially unchanged system for insurance and cost-sharing. Many individuals will have their savings wiped out, and have lost their employment and insurance. Uninsured and underinsured Americans are wary of receiving testing and/or treatment from health providers because of the cost of care, resulting in further spread of the virus. According to a CNN interview of a doctor, one of the most jarring experiences in the pandemic was a patient that eventually died from COVID-19’s worrying in his last minutes about who would pay for his care.

Our solution providers consumers with prices for medical services at local health providers, particularly list ('sticker prices'), cash-pay (opt-out of insurance), and Charity Care (below a certain income threshold) prices. 

On January 1st, 2019, Centers for Medicare and Medicaid Services (CMS) rule (CMS-1696-F) required hospitals to post Chargemasters, a list of all goods and services with prices, to their websites. The core innovation is to use machine learning to extract, cleanse and collate Chargemaster and other data sources into an aggregated, easy-to-compare format to help consumers make more informed decisions about their healthcare spending.  In comparison to a human expert, the machine learning methods pioneered in this project had a much higher rate of accuracy and are easily scalable. 

We offer a number of novel elements to help consumers comparison shop for health services:

1. Easy comparison of the pricing of medical services at local providers. We have over 100 times the provider density compared to other services like MDSave and ClearHealthCosts.
2. Estimation of cash-pay rates and Charity Care rates. Cash-pay and Charity Care rates are often substantially cheaper than commercial insurer negotiated rates for health services.
3. Comparison of quality information such as CMS quality ratings, national awards of excellence and technological sophistication.

Two groups of healthcare consumers will benefit from this project, the uninsured and underinsured, particularly those in High Deductible Health Plans (HDHP) members, or about 60% of the American population under 65. 

Many uninsured or low-income patients do not realize that they qualify for substantial Charity Care discounts. Health providers are at no obligation to share this information with them. Billions of dollars in health provider Charity Care goes unused yearly, even though it could potentially allow many consumers to avoid deleterious financial consequences like wage garnishment and bankruptcy. 

Many underinsured individuals in High Deductible Health Plans (HDHP) can save by paying cash-pay rates (or the rates for those who do not have insurance or opt-out of using their insurance). Cash-pay rates are on average 20% less in California, but can be as high as 95% less than insurer negotiated rates at some health providers. One user's insurance adjusted rate to see a cardiologist was $435. His provider, has a 55% self-pay discount, the cash-pay rate for the same service was $250, saving himself $185.

Having an affordable and well-functioning healthcare system is integral to fighting the spread of COVID-19 and future pandemics. Healthcare in the U.S. is tied to employment meaning large swarths of the population are vulnerable to losing their healthcare in any major economic disruption. The lack of federal paid sick leave and ballooning healthcare costs means that many front-line workers might skip seeing the doctor and continue to work furthering spread. As prices for the same medical service can vary by 600%, our goal is to help consumers find low-cost, high quality providers and alleviating fears they cannot afford care.

Our competitors, Castlight health, Clear Health Costs, and Healthcare Bluebook, are focused on using either claims data or shared bills to create price transparency. However, these companies have not been very effective because of the sheer number of prices in the system. A conservative estimate of the number of prices is 1.25 billion prices (15 insurer groups* 15,000 services * 5,500 hospitals). This is 4X’s as great as the number of people in the U.S. 

Clinic Price Check takes a different approach in two key ways: 

1. Use of Chargemaster and other provider pricing data for services
2. Focus on different patient populations, particularly cash-pay and the uninsured

This project relies on recent release of health provider Chargemasters, per the CMS disclosure rules. We then use machine learning to extract, clean and collate Chargemaster and other health provider pricing data into a consumer-friendly, comparative format. By removing the complexity of insurers, we are able to eliminate a large amount of pricing variation and offer our users comparable baselines, i.e. the cost if they opt-out of insurance or qualify for Charity Care. 

By fostering greater price transparency, even consumers in Cadillac health plans have the ability to compare cash-pay prices to their insurer negotiated prices, which in the long-run will reduce costs for commercial health plans. 

The core innovation of the proposed project is to use machine learning to extract, cleanse and collate data from a large number of web sources, in a variety of formats into a clean, easy-to-compare format that allows customers to price compare health providers. In comparison to a human expert, the machine learning methods pioneered in this proposed work had a higher rate of accuracy and are easily scalable to hundreds of millions of provider services. 

Once we are able to aggregate pricing data, we then can estimate cash-pay, Charity Care and Medicare rates. If insurer negotiated rates are released as expected on Jan 1, 2021, we will estimate insurer negotiated rates for most services. 

We are also working on the next stage which is to start to build an intelligent pricing system. Many consumers do not understand health provider billing codes. We're working on developing machine learning models to predict pricing for service bundles based on a consumer's symptoms or diagnoses. 

The proposed technology has been implemented for about 5,000 services for almost all hospitals in California at ClinicPriceCheck.com. Clinic Price Check has been validated by the users of the site, who have used it in the San Francisco Bay Area to find cheaper prices. At this time, Clinic Price Check has about 3,000 monthly active users, with user growth up 200% month-over-month. After the shelter-in-place order is lifted, we are scheduled to hold over 20 library seminars in the Santa Clara county to help users learn about and use the product. 

We have been featured on NBC Bay Area, Health 2.0, The HealthCare Blog and Georgetown Entrepreneurial Alliance. We are also part of the Tech Futures Group (an organization part of the California Small Business Administration) and the University of California Berkeley SkyDeck incubator program.

Here's an example of how we helped a user money on their health costs. One user’s insurer suggested a health provider with a negotiated rate of $1,225 for a MRI of her back. She found a provider on Clinic Price Check that charged $375 for the same procedure. If she had gone with the first provider, she would have paid her $500 deductible, plus 20% coinsurance on the remaining amount, or $645 and her insurer would have covered the remaining $580. By going with the cheaper provider, she saved herself $270 dollars on this one procedure and her employer $580 in increasing premiums.

The activities that will drive change for healthcare consumers is having a easy-to-use, real-time pricing application that will allow consumers to estimate healthcare costs at local providers, choosing the lowest-cost, highest-quality healthcare provider. 

Comparison shopping will start with cash-pay consumers. This process has already started in cities with greater hospital competition like Los Angeles. Cash-pay consumers used to pay list prices, but cash-pay rates at many LA hospitals have fallen to the Medicare Reimbursement rate, due to the Afordable Care Ave and consumers shopping around. The Medicare Reimbursement rate is the only price in the healthcare system related to the cost of providing care. Currently, consumers in commercial health plans at the same Los Angeles hospitals pay 5-20 times the Medicare Reimbursement rate for the same service. 

In regions, where there has been greater health provider concentration, like in the Bay Area, we assume that better price comparison among providers will lead to similar dynamics in the cash-pay market, with some providers dropping their cash-pay rates to the Medicare reimbursement rate. 

After it becomes common knowledge that consumers can cash-pay at lower rates for health services. Informed health consumers in Cadillac health plans will see the lower cash-pay rates and start paying cash. This will grow the cash-pay market and force more health providers to offer competitive cash-pay rates. A growing cash-pay market will in turn create pressure for commercial insurer rates to fall because more employers will try to become self-insured to take advantage of the lower cash-rates. With a declining employer market, insurers will be forced to lower commercial rates. 

We're also hoping that greater price transparency will lead to more pressure on elected officials to put in more regulations on de facto price discrimination. De facto price discrimination means that consumers can pay vastly different amounts for the same service at the same health provider. If the federal government implemented price control measures in line with the cost of providing care like in many other developed countries, American healthcare would become much more affordable in short measure. 

Over the last four months that we have been operational, we've helped over 12,000 users search health prices in California. Currently, we're in the process of expanding to the entire United States. In one year, we're hoping to reach a 500,000 people, by adding pricing data for the entire US, specialized COVID-19 pricing tools to help consumers determine if they qualify for government or financial assistance and with a marketing campaign to increase awareness. 

The size of the uninsured and underinsured population in the US is about 161 million people. We hope to serve the majority of these users in the next five years, through either our consumer or enterprise product. 

Our goals are in the next year are:

• Display list, cash-pay, Charity Care and Medicare prices for the top 5,000 medical services at the vast majority of healthcare providers in all states
• Create quality video content on health plan and health provider pricing topics
• Grow our user base from 12,000 to 500,000 users
• Document over $10,000 of user healthcare savings due to the website

Our goals for the next five years:

• Add insurer negotiated rates if they are released
• Release an enterprise product with health plan details like deductibles, co-pays and out-of-pocket maximums
• Grow the user base to over 10 million users 
• Become a profitable social venture

There are a number of key barriers that would prevent us from accomplishing our goals of complete price transparency:

1. Centers for Medicare and Medicaid (CMS) revokes the Prospective Payment Services (PPS) rules to release Chargemasters CMS-1696-F. Even if these rules are not revoked, but not enforced, providers might not comply with the guidelines. About 5% of providers are currently not in compliance with CMS-1696-F. 

2. The difficulty of educating consumers on how health provider pricing works. Through internal surveys, we have estimated that approximately  90% of health consumers do not understand health provider pricing. 

3. Similar to pharmacy pricing, a minority of hospitals offer substantially lower cash-pay rates, then the rates they charge commercially insured patients. Providers make it clear in their written policies that patients must not have insurance to get their substantially lower cash-pay rates. For instance, at one hospital in Los Angeles, they charged commercially insured patients $350 for a Metabolic Panel and charged cash-pay patients $30. In California, must allow any consumer to cash-pay. However, health providers are not required to share lower cash-pay rates with consumers. It's unclear if consumers with insurance can cash-pay in other states and if health providers have any obligation to share cash prices with them if they ask. 

4. Hospital final bills are often bundled meaning that services are grouped together without informing patients. Bundling makes estimating medical costs difficult for consumers and for us, because there are hundreds of thousands of medical services and supplies and each provider bundles these differently. 

This is how we plan to overcome these barriers: 

1. If disclosure rules are reversed, we will develop a method to estimate the annual provider price increases, which are generally relatively consistent. 

2. The proposed effort will work on ways to make pricing untethered to the abstract and archaic current billing system, by linking pricing to diagnoses to help consumers better understand healthcare pricing.  

3. We partnered with NBC Bay Area to call the California Managed Care Department to determine if consumers with health insurance can pay lower cash-pay rates. In a similar way to determining California's policies, we are planning to hire summer interns to contact Managed Care Departments in each state to determine the answer to this particular question. 

4. We are working to develop a method to address health provider bundling, including accessing the feasibility of using predictive models to predict bundling and subsequent pricing of those bundles by different providers.

Joanne Rodrigues - Full-time, Neveena Ferrao - Part-time

Joanne Rodrigues, is the founder and principal investigator on this project. She is an experienced data scientist with master degrees in mathematics (London School of Economics), political science (U.C. Berkeley) and demography (U.C. Berkeley) and a bachelor’s degree in international economics (Georgetown University). She has a forthcoming book in Addison-Wesley’s Data and Analytics Series, Product Analytics: Applied Data Science Techniques for Actionable Consumer Insights and six years of experience applying machine learning/statistical algorithms to derive business insights (in healthcare, gaming). She managed analytics teams at Sony and led MeYou Health’s data science efforts. For this proposed work, she built the data pipeline, the machine learning algorithms to collate pricing data and the backend for the web application for Clinic Price Check.

Neveena Ferrao, an experienced designer and web developer, who designed over 30 sites in 10 countries and with bachelors and masters degrees in Computer Science. She built Clinic Price Check front-end, helped optimize the site for usability and continues to work on front-end design and development challenges.

Advisors

1. Carol D’Souza, MD, Seasoned Physician, with over 25 years of experience working in adult medicine focusing on older, high risk populations. 

2. Sam Zeigler, Serial Entrepreneur, Co-founder/VP of Engineering at Locus Labs, growing the company through three rounds of funding and substantial revenue growth, recently acquired by Acuity Labs, a predictive medicine company.

3. Nathan Cobb, MD, Physician, Georgetown Medical School Professor, Founder of health technology company, MeYou Health, which was acquired by Healthways, a health and wellness company.

Clinic Price Check currently has a few partners that have aided with business development and development of the product:

• Tech Future's Group (a California small business administration program), which has helped us with development of our accounting, IP and business strategy
• University of California Berkeley SkyDeck, the Berkeley Institute of Data Science, HAAS Start-up Squad and University of California alumni and founders networks
• Georgetown Tech Alliance and Georgetown Entrepreneurial Alliance

Clinic Price Check is a social venture and will always offer price comparison for most health services at local providers for free. We will charge for an enterprise version and premium consumer version, which will integrate plan specifics like deductibles, copays, coinsurance and out-of-pocket maximums and AI pricing tools.

Unlike anything else on the market, this novel application allows consumers to compare prices for medical procedures at local health providers. There are two customer groups that we are targeting: (1) uninsured and underinsured consumers directly and (2) employer groups, particularly self-insured employers.

The total addressable market is the cash-pay healthcare market in the United States (U.S.), which would be around $495 billion annually. Clinic Price Check will monetize the product as a low-cost employer and consumer add-on (charging a $1 per employee per month).Clinic Price Check would charge consumers the same amount charged to employer groups (without the initial start-up fees). The full Service Available Market for consumers and employer groups is $1.886 billion.The Service Available Market is not completely obtainable because some employers and consumers have high quality insurance plans or may not be interested in our service for other reasons. 

If we are able to get the majority of employees in High Deductible Health Plans, a portion of uninsured/underinsured consumers who employers do not join our service and some government employees, the Serviceable Obtainable Market is $847 million.

In the long-term, we plan to fund our mission through the development of an enterprise version, which includes insurer negotiated rates, plan details and potential integration with Health Saving Accounts (HSAs). 

Clinic Price Check, the website, is production quality(has been throughly bug-tested) and currently scaleable to millions of users. The next step for commercialization is to improve the underlying matching algorithm and complete the data extraction, cleaning and collation for the other forty-nine states. (We estimate this will cost $20,000 to complete the process to cover the entire United States.)

Once Clinic Price Check covers the entire U.S.United States, the next step is getting press for the site and improving site SEO, through thousands of entry points for each billable service. (For SEO/marketing campaigns, we estimate it would cost $20,000.) Once a sizable user base is secured, the search for ad partners will commence to support the scalability of the application to tens of millions of users. 

Concurrently while growing the free version of the site, there will be a push to find early adopters in the employer benefits space, to try our product on a free-trial basis for the first three months. One strategy for gaining employer groups is the bottom-up approach or having participants sign-up with their employer email. Once we have reached some density in smaller employers, the final stage is to convince large self-insured employer groups to try our service.

Solve can help us in a number of ways:

• Greater integration/growth of our network within Solve and MIT Networks
• Opening doors to companies/organizations that will join a pilot for the enterprise version of our product
• Expanding our network/building relationships with our social impact founders. 
• Funding to power further development of this web-based application
• Improvement of our pitch and general ability to describe and market the product to consumers
•  Access to MIT staff in Machine Learning/AI to aid development of our product

Clinic Price Check has a number of partnership goals:

• Branding/marketing our free consumer product
• Educating consumers about cash-pay
• Creating, selling and piloting our enterprise product
• Determining the legality around cash-pay and financial assistance if a patient has insurance
• Securing funding or grant money to continue development of the product

Clinic Price Check would like to partner with a few different groups:

• Partner with MIT Machine Learning/Artificial Intelligence facility and institutes such as the MIT Statistics and Data Science Center and Data, Systems and Society. They can help us develop our intelligent pricing agent to help consumers connect symptoms or diagnoses with health provider pricing.
• Partner with Solve Community Company or Foundation Partners. They can help us determine what aspects of our product are most interesting to employer groups and help us launch an initial enterprise product pilot.
• Partner with MIT Solve network of Social Entrepreneurship Companies and Organizations. We can learn from their experiences and form a shared network and support system. 

Health security is defined as "the activities required to minimize the danger and impact of acute public health events on the collective health of populations." Having an affordable and well-functioning healthcare system is integral to fighting the spread of COVID-19 and future pandemics in the United States and around the world. Our solution focuses on a problem that touches almost every American, the cost of healthcare. Healthcare in the U.S. is tied to employment, meaning large swarths of the population are vulnerable to losing their healthcare in any major economic disruption. The lack of federal paid sick leave and ballooning healthcare costs means that many front-line workers skip seeing the doctor and continue to work furthering spread. 

As prices for the same medical service can vary by 600%, our mission is to help consumers find low-cost, high-quality providers and alleviating fears the uninsured and underinsured cannot afford care. 

We would use the grant money to develop an intelligent pricing agent to help consumers estimate costs based on symptoms, diagnoses and chronic conditions. Many consumers do not understand healthcare billing codes or pricing bundles, so to make this application more useful to the average consumer we need to translate pricing into how consumers approach healthcare from symptoms, diagnoses and management of chronic conditions.

From COVID-19, we have learned that America is just as, if not more vulnerable, that other nations to the ravages of pandemics. We must act now  to build a sustainable and affordable health system.  

Our application, Clinic Price Check, uses Artificial Intelligence (AI) to extract, cleanse and collate health provider data into an easy-to-compare format to allow consumers make more informed decisions about their healthcare. Our goal is to use AI to lower the information asymmetries between low-income consumers and Big Healthcare.

We would use the grant money to develop an intelligent pricing agent to help consumers estimate costs based on symptoms and diagnoses. Many consumers do not understand healthcare billing codes or pricing bundles, so to make this application useful to the average consumer we need to translate pricing into how they approach healthcare from symptoms, diagnoses and management of chronic conditions. 

United Nations' 1948 Universal Declaration of Human Rights states that necessary medical care is a human right. Currently in the United States, healthcare is increasing out of reach of the middle and lower income Americans. Americans are increasing making precarious decisions between basic necessities like food, rent and visiting the doctor. Our goal is to give consumers that same access to information and tools to save money, that large health providers and insurers have access to, using AI to level the playing field. 

In the United States, in almost no industry, other than healthcare, is de facto price discrimination the norm. De fact price discrimination refers to the fact that consumers can pay vastly different amounts for the same service at the same hospital. For instance, for a metabolic panel at one hospital in San Jose, the average insured customer will pay $840, a cash-pay patient will pay $130 dollars, and a Medicare patient will pay $11 dollars. Many of the consumers forced to pay the highest prices are the ones that can least afford it, lower middle class families with High Deductible Health Plans (HDHP).

Our mission is to use AI intelligence for the betterment of humanity by using advanced analytics to recreate health providers cost-structures such that they can be made apparent to all Americans. With better information generated by advance analytics, we can touch almost all Americans and pressure health providers with inappropriate cost-structures to revise those cost-structures downward in line with market pressures. Similar solutions can be applied in other spaces with monopolistic concentration of power or information asymmetries. 

Our application is an experiment in whether grassroots Artificial Intelligence applications can be used to drive political change in industries exhibiting rent seeking behavior. We believe AI tools in the hands on consumers can be used to bring awareness and mitigate the effects of price gouging on low-income consumers. Necessary healthcare should never be unaffordable for any American. Americans should not die needlessly because of their inability to afford care. Given the rise in unemployment rates and loss of healthcare in this pandemic, the need for transparency in healthcare is even more pressing.