FAIR Health
    • President's Corner
      In this series of posts, FAIR Health President Robin Gelburd presents thoughts on healthcare transparency and related issues.

        • A Window Into Lyme Disease Using Private Claims Data - July 2017
          Lyme disease is becoming an increasingly widespread and serious public health concern. According to the CDC reported cases rose markedly from 1995 to 2015, and approximately 300,000 people are diagnosed with Lyme disease each year in the United States. To advance the state of knowledge about Lyme disease, we delved into FAIR Health’s database of over 23 billion private healthcare claims. We found evidence of how the disease is affecting the nation’s rural and urban areas differently, how different age cohorts are impacted, where it is spreading and how it correlates with autoimmune disease.

          Click here to read the full post
        • Health Insurance For College Students: What You Need To Know - July 2017
          As you prepare to go to college, don’t forget to pack health coverage. Most colleges require students to have health insurance. And, if you don’t have health coverage, and you earn enough to afford it, you may have to pay a tax penalty. There are several ways of getting covered.

          Click here to read the full post
        • Analysis: Peering Into the Nation’s Opioid Crisis Through a Regional Lens - June 2017
          The opioid crisis is national in scale, but it varies greatly at the regional level. Drawing on our national database of 23 billion private health care claims, we recently explored the regional variation in the opioid crisis during the ten-year period 2007-2016 in a new white paper. Preceded by reports on national trends in opioid-related diagnoses and on the epidemic’s impact on the health care system, this report is important because it suggests the need for policy flexibility in dealing with the varying regional manifestations of the opioid crisis.

          Click here to read the full post
        • Dental Coverage for Retirees - June 2017
          Getting dental care is at least as important when you’re older as when you’re younger, and maybe more so. Past dental problems may require additional treatment over time, such as when a filling becomes broken or chipped. Risks for tooth loss as a result of tooth decay and gum disease grow with age, because of many factors. For example, you may have decreased saliva production (dry mouth) from medications taken to treat medical conditions. And, chronic diseases such as diabetes may increase the risk of gum disease. Cognitive or physical limits may make routine brushing and flossing harder, which can get in the way of keeping your teeth healthy. Dental insurance can help make sure you can afford the dental care you need as you get older. If you’re working, you may get dental coverage through your employer. But, once you retire, getting dental coverage may not be as easy.

          Click here to read the full post
        • How Can Data Help Us Understand the Growing Opioid Crisis in Ohio? - May 2017
          From 2007 to 2014, private insurance claim lines with opioid-related diagnoses increased 770 percent in Ohio. The diagnoses were opioid abuse, opioid dependence, heroin overdose and overdose of opioids excluding heroin. Of five of the major cities in the state — Cincinnati, Cleveland, Columbus, Dayton and Toledo — Toledo had the largest increase, at 1,022 percent.

          Click here to read the full post
        • Unlocking Medicare Data Can Enlist Needed Foot Soldiers In The March To Sound Health Care Reform - April 2017
          As debate over the Affordable Care Act (ACA) and reforming federal health insurance law feverishly continues in Washington, one thing both sides of the aisle should agree on is the need for greater transparency about health care costs, quality and outcomes. A distinctive private-public partnership is poised to shine a spotlight on what sometimes can seem like a “black box” to patients, providers and insurers working within the system. Through the Qualified Entity Certification Program (QECP), the innovative spirit of the private sector can be brought to bear on questions of intense national importance at this crucial moment.

          Click here to read the full post
        • The Growing Opioid Crisis: Spotlight on New York Private Claims Data - April 2017
          From 2007 to 2014, private insurance claim lines with opioid abuse and dependence diagnoses increased 487 percent in New York State. The greatest increase occurred in the New York City suburbs (Nassau, Rockland, Suffolk and Westchester), where the rise was 1,459 percent—compared to 324 percent for New York City and 310 percent for the rest of the state.

          Click here to read the full post
        • The Opioid Crisis in Illinois: The View from Private Claims Data - April 2017
          Abuse of opioids is on the rise. The widespread abuse of heroin and opioid prescription painkillers over the years is often dubbed “The Opioid Crisis.” The epidemic is disproportionately affecting white, middle-class people in non-urban settings, but are we seeing a rise in the abuse of these drugs in U.S. cities?

          Click here to read the full post
        • Health Care Reform on Hold: Now What? - April 2017
          The American Health Care Act (AHCA) was pulled from the House floor before an expected vote and efforts to repeal or reform the Affordable Care Act, or “Obamacare,” could be suspended for some time. The future of health care law reform efforts remains uncertain—but confusion is nothing new to Americans navigating the complexities of health care delivery and payment. No matter the outcome last month, Americans were still going to wake up this morning with complicated decisions to make about their health care. As we move forward, continuing to make these difficult decisions, individuals and policymakers will grapple with managing and navigating intricate inter-related health care delivery and payment systems. These policy decisions should be taken seriously as they affect individuals, families, and the health and wealth of our nation.

          Click here to read the full post
        • Alternative Places of Service: An Era of Rapid Growth - April 2017
          Where once consumers would have gone to a doctor’s offce or hospital, they are increasingly seeking healthcare from alternative places of service. They may visit a retail clinic, an urgent care center or an ambulatory surgery center (ASC), or they may receive care at home or via telehealth. Understanding the growth in consumer choices in settings for care and the trends in costs associated with them can inform nearly every aspect of the design of health coverage, including the structure of benefts plans, formation and selection of networks and the use of communications to drive member behavior. As organizations that carry the risks of their members’ healthcare, self-insurers may want to explore how these alternative places of service can keep costs down while ensuring that members get the care they need.

          Click here to read the full post
        • Hospital Impact: Benchmarks for episodes of care create opportunities for providers - March 2017
          For years, people have talked about defining medical treatments as comprehensive episodes of care as a way to base reimbursement on value rather than on volume. As long ago as the early 1990s, Medicare sponsored (PDF) a pilot program in which it paid a single, negotiated amount for an episode of coronary artery bypass graft surgery (CABG). Yet episodes of care remain somewhat underused by medical administrators and practice managers—despite the benefits they may offer.

          Click here to read the full post
        • 5 Quick Tips on How to Budget for Healthcare Costs - February 2017
          It always makes sense to plan for the costs that may be coming your way — and how to pay for them. Why not make a budget to plan for your healthcare costs?
          One reason people may hesitate is that healthcare is less predictable than other costs, such as groceries and utilities. You can’t know ahead of time whether someone in your family will break a leg or whether a chronic illness will worsen. But, if you have health insurance, the costs can be somewhat more predictable.

          Click here to read the full post
        • Want to stretch your healthcare dollars? Learn about flexible spending plans - February 2017
          Saving money for healthcare expenses is a simple idea. But, there are ways to save money that, although a little more complex, give you more money to save. That’s the idea behind flexible spending plans.

          Click here to read the full post
        • CT Viewpoints: ‘Driver’s Ed’ needed for understanding Connecticut health insurance - January 2017
          Before receiving a driver’s license, those who undergo this rite of passage must first receive driver’s education that prepares them for the challenges of the road. Yet there is no similar educational prerequisite that prepares healthcare consumers for using health coverage before receiving their health insurance ID cards.

          Click here to read the full post
        • Experimental treatments and clinical trials — how to get accepted into one - January 2017
          Most health plans only cover treatments they think are medically proven to work. But, medicine is always changing. Opinions can differ about whether there is enough evidence to support a treatment. In such a case, an insurer may say no to paying for a treatment that it calls “experimental,” even though your doctor thinks the treatment is well supported. That can leave you with a big bill — unless you successfully appeal the insurer’s decision.

          Click here to read the full post
        • How to avoid and handle surprise medical bills - December 2016
          Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from a doctor and a hospital that were both in your health plan’s network, but then you were unexpectedly treated by one or more other providers who, unbeknownst to you, were outside that network.

          Click here to read the full post
        • Understanding your explanation of benefits - December 2016
          If like millions of Americans, you have a health plan, you have probably received an Explanation of Benefits (EOB) from your insurer. Many people do not understand this form, and because it includes a notice that it is not a bill, they discard it. But if you do not pay attention to your EOBs, you may not get the maximum value of the health benefits you are entitled to receive.

          Click here to read the full post
        • 5 enduring healthcare insurance tips for consumers - December 2016
          In a time of flux in healthcare policy at the federal and state levels, consumers need guidance in steering through the complexities of the healthcare system.

          The new presidential administration may bring changes in the new year, but changes also may come from your own healthcare plan as the new plan year begins. It is important to check your plan documents for changes in your copays, deductibles and network participation of doctors and hospitals.

          Click here to read the full post
        • The ins and outs of free preventive care - November 2016
          Although the law may change as a result of the recent presidential election, for right now a tremendous health benefit is available: free preventive care services.

          The Affordable Care Act (ACA) requires most health plans to cover certain preventive services at no cost to you. (The exceptions are older plans that predated the ACA and have not changed since).

          Click here to read the full post
        • How to make the most of open enrollment - November 2016
          It’s fall again, and that means it’s open enrollment time. Employers can help employees with the challenges of selecting a health plan by giving them a how-to guide with questions and answers.

          The basics
          This is the season when many employers give employees a chance to pick a health insurance plan for the coming year, or reconsider the plan you already have. It’s also the time when the federal and state health insurance exchanges allow employees to select a private plan, an option that can be especially attractive if your employer doesn’t offer health coverage.

          Click here to read the full post
        • Steer Your Patients to Clear, Unbiased Data and Resources - November 2016
          Dental costs and insurance are a mystery to many consumers. You can help demystify them by making your patients aware of our free, award-winning consumer website, fairhealthconsumer.org, which can play a useful role in your own communications with your patients.

          Click here to read the full post
        • Rising Claims Reflect a Need for Better Oral Cancer Detection - October 2016
          Oral cancer is on the rise. Claim lines with an oral cancer diagnosis increased 61% from 2011 to 2015, according to data from the FAIR Health repository of over 21 billion privately billed medical and dental claims. The greatest increase occurred in throat cancer (malignant neoplasm of the nasopharynx, hypopharynx, and oropharynx) and the second greatest in tongue cancer (malignant neoplasm of the tongue).

          Click here to read the full post
        • Survey unveils strong appetite for health insurance information—As early as high school - October 2016
          Most people learn what they know about health insurance on the job, when they use their employers' health plans. But, in a nationwide consumer survey conducted this year for FAIR Health by ORC International,1 76 percent of respondents felt that was too late. In their view, people should begin understanding health insurance plans before or during high school or college. Forty-one percent thought the skill should begin to be acquired in high school or earlier. The full survey report, Healthcare and Health Insurance Choices: How Consumers Decide, is being released this month, along with the infographic below.

          Click here to read the full post
        • The Impact of the Opioid Crisis on the Privately Insured - August 2016
          The current opioid crisis in the United States is one issue that unites Americans across the political spectrum. On July 22, the bipartisan Comprehensive Addiction and Recovery Act of 2016 (CARA) was enacted. The law authorizes the federal government to strengthen opioid addiction prevention, treatment and recovery and expand access to the opioid overdose-reversal drug naloxone. The Washington Post reported on July 26 that the opioid abuse epidemic, which involves abuse of prescription opioid pain relievers and heroin use, was addressed at both the Democratic and Republican national conventions.

          Click here to read the full post
        • Telehealth: Insights from Claims Data - July 2016
          Telehealth is rapidly emerging as an acceptable venue of care for many consumers and a cost-effective option for employers and insurers. For consumers, it offers the convenience of not having to leave the home (or the clinic where telehealth is being conducted) while still receiving the healthcare they need. For employers and insurers, it is often less costly than other forms of care delivery.

          Click here to read the full post
        • Youth Concussions: A Matter of National Concern - July 2016
          A widely publicized new study in the journal Pediatrics has reignited concern about concussions in children and young adults. According to what the study authors call “the most accurate and precise estimate to date,” between 1 and 2 million concussions related to sports and recreation occur annually in Americans 18 or younger, and between 500,000 and 1 million of those concussions go untreated. That this form of traumatic brain injury, which can have long-term clinical repercussions, is so common in our youth raises many questions for anyone concerned with the nation’s health. We at FAIR Health decided to answer some of those questions by researching our database of over 20 billion privately billed healthcare claims, the largest such repository in the country.

          Click here to read the full post
        • Immigrants and Health Insurance: A Challenging Journey - July 2016
          Immigration has been much in the news lately, with the Supreme Court deadlock blocking President Obama’s immigration reform program, California’s move to try to extend participation in their state health exchange to undocumented immigrants and the continuing prominence of immigration as both a presidential election issue and a source of international turmoil. One aspect rarely addressed by the media is just how challenging it can be for immigrants, both documented and undocumented, to get health insurance in the United States. In an earlier post, I wrote about how daunting the complexity of the nation’s healthcare system can be for consumers in general. The complexity is magnified for immigrants—many of whom have difficulty communicating in English, work for low wages at jobs that do not offer health coverage and may face a welter of legal obstacles to acquire it on their own.

          Click here to read the full post
        • Embracing Complexity: Maximizing the Potential of Cost Transparency - June 2016
          The New York Times recently reported that online tools to help consumers shop for healthcare are not yet attaining usage levels or affecting costs to the degree some had hoped, underscoring the complexity of the healthcare system and the challenges involved in attempting to change consumers’ relationship to this daunting system.

          Click here to read the full post
        • Five Reasons Why Healthcare Cost Transparency Is Needed - May 2016
          Healthcare cost transparency has been a hot topic for a number of years, but the time may be right to step back and remember where the heat—and widespread interest—are coming from. This subject is especially topical because some stakeholders have questioned the value of transparency even as New York State has successfully enacted transparency into law and other states are following suit or considering doing so. Here are five reasons why healthcare cost transparency deserves to be more than a hot topic—and why it is becoming a national reality.

          Click here to read the full post


    Fresh Perspectives on Consumer Healthcare and Health Insurance Shopping Habits

    FAIR Health’s ongoing consumer research, presented in a series of survey reports, illuminates how consumers make decisions regarding healthcare and health insurance. The reports provide useful insights that help inform marketing strategies, consumer education and policy making.

    Healthcare and Health Insurance Choices: How Consumers Decide
    This survey, funded by the New York State Health Foundation, investigates consumer attitudes and practices related to choosing healthcare and health insurance. Among the findings:
  • Seventy-six percent of respondents feel the best life stage for consumers to gain an understanding of health insurance is before or during high school or college;
  • Nearly 60 percent of respondents are willing to travel great distances—50 or more miles—to save at least 50 percent on the cost of their treatment for a serious health condition; and
  • Men spend more time researching health options than women—by a two to one margin.

  • Download the report to view the full results and read our analysis.

    Consumer Attitudes: Dental Treatment and Insurance
    This survey explores dental treatment utilization patterns and dental insurance preferences.
    The findings include:
  • Total out-of-pocket cost is the primary consideration for consumers when selecting their dental coverage;
  • Only 15 percent of respondents know that a child’s first dental visit should occur when the first tooth appears, as recommended by the American Dental Association; and
  • African-Americans and Latinos are more likely to say that they or someone in their household have received dental care in a hospital emergency department.

  • Download the report to view the full results and read our analysis.

    Understanding Consumer Health Insurance Preferences
    This survey penetrates healthcare and health insurance shopping preferences and benefit utilization trends. Findings related to consumers’ plan enrollment decisions include:
  • Premium cost is the top concern for consumers ages 18-44 when choosing a health plan;
  • Consumers ages 45 and older are more interested in making sure their personal doctors are in network than they are about premium cost; and
  • Consumers in all age groups care more that their personal doctors are in network than they do about overall network size.

  • Download the report to view the full results and read our analysis.

Industry Trends and Consumer Insights

Medical Survey

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Dental Survey

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National Kidney Month

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Health Disparities

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Health Disparities (Spanish)

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Childbirth Trends

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Emerging Trends in Healthcare Delivery

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Episodes of Care

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Concussions in Children and Young Adults

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Opioid Dependence and Abuse

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The Opioid Crisis: Impact on Healthcare Services and Costs

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Healthcare Consumer Attitudes Consumer Survey

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Oral Cancer - A Growing Health Issue

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Obesity and Type 2 Diabetes in Young People

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Regional Variation in the Opioid Crisis

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The Opioid Crisis in Texas

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The Opioid Crisis in Pennsylvania

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The Opioid Crisis in New York State

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The Opioid Crisis in Illinois

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The Opioid Crisis in California

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Lyme Disease

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Methodologies  |  Consumers  |  Consumer Engagement  |  Business  |  Government  |  Researchers  |  Healthcare Professionals  | 

FAIR Health Overview Materials

Brochure: Be Sure of Your Source
FAIR Health Facts
Consumer Resources for Businesses
Overview of FAIR Health Data Products

Overview of FAIR Health Methodologies

Resources for Consumers

To advance its mission, FAIR Health offers a range of consumer services at www.fairhealthconsumer.org. This Website, features educational articles and videos, online cost estimation tools, glossaries and links to other helpful resources.

Download our free materials or explore customized options to make FAIR Health tools available to your employees, members, health plan participants or other constituents.

Resources for Consumer Engagement

FAIR Health consumer resources are a great way to connect health plan members to data that inform their medical and dental plan benefits. In addition to the materials above, learn about the many ways in which FAIR Health tools can be shared with consumers.

Business Resources

Download information about FAIR Health data solutions. 

Government Resources

Resources for Healthcare Professionals

Resources for Researchers

    • Published Articles on Transparency
        • Telehealth: Insights from Claims Data
          July 26, 2016
          Telehealth is rapidly emerging as an acceptable venue of care for many consumers and a cost-effective option for employers and insurers. For consumers, it offers the convenience of not having to leave the home (or the clinic where telehealth is being conducted) while still receiving the health care they need. For employers and insurers, it is often less costly than other forms of care delivery.

          An analysis of recent claims information uncovers valuable insights into the latest trends in telehealth benefits utilization -- insights that can help inform almost every aspect of the way health coverage is designed and health care is administered today. By peering into our database of over 20 billion privately billed health care claims -- the nation’s largest such repository -- FAIR Health is able to open a window into telehealth utilization that is useful for employers, insurers, brokers and other professionals concerned with health care trends.

          Read full article here.
        • Embracing Complexity: Maximizing the Potential of Cost Transparency
          June 28, 2016
          The New York Times recently reported that online tools to help consumers shop for health care are not yet attaining usage levels or affecting costs to the degree some had hoped, underscoring the complexity of the health care system and the challenges involved in attempting to change consumers’ relationship to this daunting system.

          From its inception, FAIR Health has recognized that, although cost and insurance reimbursement understanding is essential to empower consumers to manage their health care expenditures, price transparency tools alone cannot fulfill all their informational needs. Consumers also require lucid and accurate information about health care insurance and the health care system overall. Beyond transparency, they need context and clarity.

          Read full article here.
        • Five Factors That Influence Health Plan Selection
          July 21, 2015
          A recent survey by FAIR Health, an independent, not-for-profit dedicated to healthcare cost and insurance transparency, indicates the top factors that influence consumers' health plan selection. The survey, of more than 1,000 adults, was conducted in March, 2015.

          Read full article here.
        • Consumer Preferences: Spotlight on Health Insurance Cost, Physician Access and Network Size
          July 9, 2015
          As health plans and benefits advisors plan for this fall’s enrollment period, the results of a recent FAIR Health consumer survey shed light on what is most important to plan members when they select health insurance or choose a doctor.

          The survey results are particularly timely because insurers, employers and public/private exchanges increasingly offer health plans that require greater cost-sharing and benefits management responsibilities on the part of plan members, thereby making plan and provider selection decisions potentially more complicated.

          Read full article here.
        • The Rise of Health Care Consumerism - and the Informed Consumer
          June 18, 2015
          The Institute for Healthcare Consumerism Blog
          According to 2015 FAIR Health survey estimates, half of U.S. consumers consider their out-of-pocket medical costs higher than they expected. A third of those surveyed felt that costs were much higher than anticipated.

          Unexpected medical expenses are particularly troubling when consumers make good faith efforts to minimize costs by obtaining services within their insurance plans’ networks – only to receive “surprise bills” from providers they did not realize were out-of-network. Concern over the disparity between anticipated and actual costs is helping lead the way to a national dialogue, and, in some instances, to state-based legislative reform.

          Questions about unexpected medical bills are not new, so what is driving the momentum today for consumer protections? Changes in how and where health care is delivered, the increase in access to private insurance through public exchanges, the expansion of members’ responsibilities for managing their coverage and the lack of health care literacy among consumers are among the many factors combining to create a need to set ground rules for a new era of health care consumerism.

          Addressing this need, New York State recently enacted a law providing some of the nation’s most comprehensive health care cost transparency protections to help consumers avoid surprise medical bills and better manage their out-of-pocket medical expenses. Other states, including Texas, California, New Jersey, Connecticut, Oregon and Colorado are considering legislative proposals to address these consumer concerns.

          Read the full article here.
        • Millennial Engagement A Cornerstone for Health Care Consumerism
          June 4, 2015
          Significant changes in health insurance enrollment, such as public and private exchanges, and new benefit designs, including high-deductible plans and narrow networks, are requiring individuals to take on greater personal responsibility for selecting the most suitable plan and managing their own benefits and costs – often through Internet portals. Individuals must become better informed health care consumers who are skilled at using the latest technology to navigate the system and get the most out of their health coverage.

          The size, diversity and buying power of the population segment known as Millennials or Generation Y (ages 18-34) make them an important group to study. According to the Pew Center, this generation constitutes the largest segment of the U.S. workforce and later in 2015 will pass Baby Boomers as the largest living generation. By engaging Millennials, health care sector leaders can plan a future when individual consumers can manage their own health insurance purchases, provider choices, benefits and expenditures simply and cost-effectively.

          Read full article here.
        • Survey Reveals Consumer Dependence on ER Services for Non-Emergent Care
          May 26, 2015
          More than 14.1 million people nationwide have signed up for health insurance since enrollment under the Affordable Care Act opened in October 2013, and, in the same period, an additional 2.3 million young people have gained insurance through their parents’ health care coverage. Overall, the national uninsured rate is estimated to have dropped 7.1 percent in a year and a half.

          It is critically important that these newly-insured individuals, as well as those already insured, understand their insurance benefits and their own payment responsibilities. Informed and careful use of health care services will benefit not only consumers’ own wallets, it also will support effectiveness and efficiency in the national health care sector to the benefit of all.

          Read full article here.
        • New York Law Sets Standard for Transparency
          May 22, 2015
          A new healthcare cost transparency law in New York State aims to protect consumers from health plan cost issues that have challenged even the savviest consumers. The law, which other states are watching closely, requires insurers to publish clear information about plan rules for apples-to-apples comparsions.

          Plan documents must provide detailed explanations and examples of reimbursement calculations that will enable consumers to compare the benefits of various plan options and, once enrolled, make better informed treatment decisions.

          Read full article here.
        • Strategy for a Transparent, Accessible, and Sustainable National Claims Database
          April 15, 2015
          A recent American Journal of Managed Care article1identifying “barriers” to creating a national health-care claims database offered an unduly discouraging perspective. Focusing on a selective research organization, it overlooked, and to some extent mistakenly portrayed, what has already been accomplished in “Big Data” for the healthcare sector. The experience of FAIR Health, Inc, in creating, operating, and expanding its national health-care claims database offers a more positive account. FAIR Health’s database already provides data to researchers as well as to payers, providers, government agencies, and policy makers. It also offers significant ongoing service to consumers in the form of a free online search tool to find the estimated cost of healthcare services and procedures in their own area using ordinary, consumer-friendly language, both in English and Spanish (and not solely arcane codes, as was mistakenly referenced in the recent article). In estab-lishing its database and making it broadly available, FAIR Health has found solutions to problematic barriers and has identified operational requirements and features essential to a successful database.

          Read full article here.
        • Taking Advantage of Health Care Transparency Trends
          April 2, 2015
          Advisors work hard helping their business clients to deal with the complexity and expense of health care insurance benefits as well as with the needs and expectations of their employees. They recognize that their clients’ satisfaction with advisory services will be greatly influenced by employees’ experience with the plan chosen by their employer.

          When a plan exposes employees to unexpected out-of-pocket health care costs, the surprise bills can color employees’ perception about their benefits and lead to complaints that may impact the brokers’ relationships with their clients. By keeping up with, and taking advantage of, developments in transparency in health care costs and insurance, advisors can better serve their clients, improve enrollee experience and promote greater member satisfaction.

          Read full article here.
        • The Transparency Train Is Leaving the Station
          March 31, 2015
          The national health care cost transparency movement is well underway. A proactive approach to helping employers and their workforce board the transparency train can help brokers and other advisers differentiate their practice and ensure that their business will move forward as new consumer-focused health care cost transparency initiatives unfold.

          We are already seeing the ripple effect of the cost transparency transformation. Health care utilization is changing, with more consumers deciding to receive care at alternative facilities such as urgent care centers, retail health clinics and ambulatory surgery centers. More employers are selecting narrow and tiered networks and high-deductible plans that require employees to roll up their sleeves to try and understand the implications of these new plan designs.

          Read full article here.
        • State’s Health Bill Will End Surprises on April Fools’ Day
          March 26, 2015
          There will be fewer surprises on April Fools’ Day. The New York State Budget Bill that generally takes effect April 1 and creates new consumer protections includes some of the nation’s most comprehensive health care cost transparency requirements. The law addresses surprise balance bills, emergency care costs, dispute resolution and network adequacy. Several states are monitoring the New York bill and considering similar legislation.

          The health care reimbursement system can be difficult to understand. Prior to the implementation of this law, even the most diligent patients who do their homework and check to see if their providers are in-network often face surprise expenses.

          Read full article here.
        • From Transparency to Clarity
          March 12, 2015
          Everywhere we turn, we hear about the importance of transparency in healthcare. In light of the Affordable Care Act’s (ACA) disclosure rules and with the spotlight squarely placed on the industry, health plans and hospital systems, clinicians, policymakers, industry leaders and media outlets are all touting the benefits of accessible, reliable healthcare data. But while transparency is an important goal, it is only the first step toward driving improvement in our healthcare system. To see real change, we also need clarity.

          What is the difference between transparency and clarity? Think of the pile of dirty dishes in your kitchen after a holiday meal. You can see that they need to be cleaned, dried and put away, but how do you start to make sense out of the chaotic mess? Now, picture those same dishes clean, with the glasses and silverware neatly arrayed on a beautifully set table. That’s clarity. Clarity means taking data elements and making them actionable by adding the context necessary to inform sound decision-making for all stakeholders—payors, plan sponsors, purchasers, researchers, practitioners and consumers.

          Read full article here.
        • Reforming Reimbursement
          February 9, 2015
          As the healthcare industry undergoes unprecedented change, particularly in regard to payment reform, payers recognize a growing need for more comprehensive payment methodologies that adequately represent the true market cost of health services today.

          Providers who have traditionally based their payment methodologies on a multiple of Medicare’s fee schedule are beginning to recognize inherent limitations in a Medicare-based schedule that can affect their bottom line. Luckily, many limitations can be addressed by integrating independent, market-based data into a payment schedule.

          Read full article here.
        • The Vocabulary of Change
          January 8, 2015
          HFMA Hudson Valley NY
          Seismic progress has been made in the national healthcare cost transparency movement over the past five years—akin to the evolution from the horse and buggy days to the recent news that the space probe Philae had landed on a comet 300 million miles from Earth. While the mode of transportation is critically important, the destination is what matters most. Visionary leaders today are harnessing the latest sophisticated data management technology and innovative analytic capabilities to transport stakeholders to a place where informed decisions about healthcare policy, process, risk, cost and availability can be made with the collaboration and concurrence of all affected parties.

          Kick-starting the transparency engine 
          Five years ago—and, actually, long before that—it was generally understood that the healthcare system was broken. All stakeholders, including consumers, employers and unions, government entities, insurers, practitioners and hospitals had their own wish lists and sets of expectations of what the system should deliver. Against this backdrop, healthcare expenditures continued to escalate, and the proportion of costsharing shifted to the consumer grew steadily. Questions also continued to plague policymakers as to whether increasing costs in the healthcare system yielded a concomitant improvement in treatment outcomes. It became apparent that to gain a firm understanding of healthcare trends and practice patterns and to support compromise and collaboration, there was a need for an independent, agreed-upon source of cost and utilization information that could generate clear benchmarks and “apples to apples” comparisons—a unifying healthcare data vocabulary, if you will.

          Read full article here.
        • Gain Narrow Network Buy-In
          January 7, 2015
          As health plans and purchasers struggle to keep premiums low and quality high, many are turning toward narrower networks. However, limited networks have sparked concern among consumers, plan sponsors and policy makers who worry that they will unduly limit patients’ access to care and lead to increased patient use of out-of-network providers with higher out-of-pocket costs. New York has passed a new law to protect consumers from unexpected out-of-network costs and many states are considering tougher standards for network adequacy.

          When plan members face unexpectedly high costs or receive a bill for services they thought were covered, it affects how they value their benefits and, in the case of employer-sponsored plans, the sponsor’s overall satisfaction with the plan. In addition, insurers may find themselves spending valuable time and resources dealing with frustrated members or time-consuming appeals. For narrow networks to work, they must work for everyone--plans, purchasers, plan sponsors, participants and providers. That means delivering access to timely, accurate and user-friendly information to ensure that plan members get the most out of their provider network.

          Read full article here.

Transparency Legislation and State Health Programs


Under the New York State Budget Bill FAIR Health's 80th percentile benchmark serves as an officially recognized reference point for out-of-network charges in New York State. The FAIR Health 80th percentile supports mandated disclosures by payors to help consumers estimate out-of-pocket costs for out-of-network charges.


The New York State Budget Bill contains several provisions relating to use of the 80th percentile as a standard for out-of-network care and dispute resolution. Organizations subject to the new rules, including insurers, HMOs, managed care organizations, student health plans, and similar organizations, must:


  • Describe their reimbursement methodologies and provide examples of out-of-network reimbursement calculations using 80th percentile data as a reference point.

  • Provide guidance regarding out-of-pocket costs to plan members for out-of-network services in their own geographic areas, both in writing and through a website that enables consumers to estimate their out of-pocket costs for such care. Comply with consumer protection requirements related to emergency services and “surprise bills,” i.e., – balance bills for out-of-network services which an insured reasonably believed were “in-network.”

  • Comply with new dispute resolution procedures that consider 80th percentile data in determining reasonable fees.

Click here to read more and view the official Bill Memorandum issued by the NYS Department of Financial Services.