PBGH ANALYSIS. Highlights: Cigna Strengths and Weaknesses

Methods Description: Health Plan

Shopping Services Evaluation

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Executive Summary: Cigna

„ use benefits wisely, „ _{save money, and}

„ _{find higher-value doctor and hospitals.}

Cigna offerings are compared to third-party benchmarks and to comparable services from Aetna, Anthem, Kaiser Permanente, HealthNet, and United Healthcare.

Highlights: Cigna Strengths and Weaknesses

Overall Rating

Compared to other health plans, Cigna shopping services rated MEDIUM-HIGH.

Strengths

ÛOut-of-pocket estimates are customized to user’s coverage, including accumulated deductible and Health Reimbursement Account (HRA) limits.

ÛOut-of-pocket estimates are integrated into searchable provider directory, exposing all users to cost variations.

ÛDisplay is tailored to availability of out-of-pocket estimates based on allowed fees; if provider does not allow fee disclosure, the fact is explicitly noted.

Users can compare coverage-specific costs across medication types and delivery methods.

Weaknesses

Ü_{Out-of-pocket estimates for procedures in alternative settings cannot be compared side by side,} although the display defaults to lower-cost options.

Ü_{No alternative settings or alternatives for treatments and interventions are provided.}

Table 1. Summary of Cigna member shopping services

SERVICE COMPONENT VALUE PROVIDED

Shop and/or budget for medical service

HIGH: Out-of-pocket allowed fee estimates are coverage-specific and include accumulation towards deductible, HSA funds available, and other information customized to the user.

Compare allowed physician fees MEDIUM: Coverage-specific physician allowed fees cannot by compared side by side.

Compare allowed inpatient fees HIGH: Coverage-specific comparisons provide allowed fees for components of the inpatient episode of care.

Compare allowed procedure fees across settings

Not available Compare allowed fees for

treatment or setting alternatives

Purposes and Methods

The purpose of the shopping services evaluation is to help purchasers with their employee decision support planning by: a) helping the workforce use health plan shopping tools to search for and purchase provider and medical services, and b) advocating with contracted health plans to improve these services. We assessed health plan decision support tools to help members:

„ Shop and/or budget for medical care

„ Compare physician fees for common medical services „ Compare hospital/facility fees for common medical services „ Compare fees for alternative treatments and settings, and „ Shop for medications

To compare plans, we developed nine Use Cases spanning a variety of health care needs. They assessed how the tools handled different queries, bundled episodes of care, provided patient education, and linked with other data, such as users’ benefits, demographic information, and personalized risk assessments. Benchmark performance for each Use Case was set by a third-party cost calculator.

Benchmarks for cost calculator tools

Use Case number 1: Alternative and equally effective treatments and services

Users can:

„ _{Identify treatment and service options and supporting evidence.}

„ _{Learn about evidence-based care guidelines, such as recommended frequency of mammography.} „ _{Compare coverage-specific allowed fees for alternative treatment and service settings (e.g.,}

doctor’s office, hospital, imaging facility). „ _{Compare options and allowed fees side-by-side.}

„ _{Identify medical services that comprise an episode of care.} „ _{Learn about self-care options.}

Use Case number 2: Diagnostic testing

Users can:

„ Compare coverage-specific allowed fees for local providers’ diagnostic services (e.g., independent lab vs. hospital-affiliated lab).

„ View related coverage-specific allowed fees, such as radiology report.

„ Identify in-network options with lowest allowed fees (e.g., instructions, sorting and search functions).

Use Case number 3: Elective or planned surgery requiring inpatient admission

Users can:

„ _{Compare coverage-specific allowed fees for the surgical episode of care, including costs that span} settings and providers.

„ _{Identify the cost for each element in an episode of care (e.g., pre-admission testing and services,} hospital admission, professional services, and follow-up care).

„ _{View quality information for the hospital provider}

„ _{Readily identify the option with highest quality and lowest allowed fees (e.g., instructions, sorting} and search functions).

Use Case number 4: Services performed in alternative settings

Users can:

„ Compare coverage-specific allowed fees across settings.

„ Identify coverage-specific allowed fees by element for the entire episode of care, including doctor visits, surgical center, hospital, and follow-up care.

„ Learn about options including in- and out-of-network providers and service settings (e.g., hospital vs. ambulatory surgical center).

„ View quality information for providers and settings.

„ Readily identify the option with highest quality and lowest allowed fees (e.g., instructions, sorting and search functions).

Use Case number 5: Cost comparisons across settings

Users can:

„ _{Compare coverage-specific allowed fees for providers and services across settings (e.g., emergency} department, urgent care, office visit).

Use Case number 6: Chronic care management

Users can:

„ Identify coverage-specific allowed fees for annualized cost of care for a chronic condition. „ Identify savings opportunities such as mail-order pharmacy.

Use Case number 7: Personalized care recommendations and treatment alternatives

Users can:

„ _{Receive age- and gender-customized preventive care and screening recommendations that are} linked to self-management tools (e.g., personal health record, health risk appraisal).

„ _{Compare screening options by coverage-specific allowed fees.}

„ _{Learn about screening, recommended frequency, and possible complications.} „ _{Link to in-network providers to make appointments.}

Whether users search costs, physicians, settings, or procedures, Cigna’s member portal, “Healthy Life,” displays similar coverage-specific out-of-pocket estimates. Users view this information throughout the shopping experience. Cigna reports that 50% of users come to the portal to search for a doctor, while only 1.5% of users are looking specifically for cost estimates. Thus, Cigna includes cost and quality transparency in nearly every physician or facility search on the member portal. Cigna notes that over 20% of users searching for basic doctor or hospital information are converted into a cost transparency searches.1

Cigna Shopping Services

Users can search providers by name or specialty, settings by name or type (e.g., urgent care, ambulance, laboratory services), and procedures by name. Search fields auto-fill, guiding users to preferred terms. Allowed fee estimates are available for approximately 250 common adult and pediatric procedures.

Shop/Budget for Medical Services

Users can view physician-specific and coverage-specific allowed fees and out-of-pocket estimates for individual physicians, but cannot compare them side-by-side across physicians. Users can filter physicians by criteria that include gender, languages spoken, availability to new patients, and Cigna Care Designation, a program recognizing physicians who meet cost and quality benchmarks. Physician search results display a “Cost Efficiency Rating” for each provider that reflects patient care and cost, compared to other in-network specialists.

Users can view coverage-specific out-of-pocket allowed fees for an individual doctor by selecting among a list of services and clicking on “Show me the math.”

Selecting “show me the math” displays user's customized deductible, co-insurance, and Health Reimbursement Account (HRA) amounts and a procedure description. In the following example, the user has not yet met the deductible.

Users can initiate the search with a doctor or with a procedure, viewing integrated, coverage-specific out-of-pocket allowed fee estimates at all steps. Costs for physicians are sorted by high performance (Cigna Care Designated) physicians first, then sorted by cost within that group. In addition, Cigna has incorporated quality distinctions even into map views – using a different colored pin to designate the Cigna Care Designated physicians.

Procedure-specific hospital searches can be sorted by out-of-pocket allowed fees, coverage-specific out-of-pocket allowed fees, alphabet, or national vendor status for common procedure types. Users may choose to display out-of-network providers early in the search process, but they are excluded by default. Dynamic search functions narrow results by location and out-of-pocket allowed fees for hospitals and physicians. In the following example, the user’s unmet deductible exceeds the total estimated allowed fee. In addition to Cigna Care designation, provider quality information available on a separate page includes only board certification.

Selecting “Show me the math” displays the calculation of estimated allowed fees by doctor, setting, and coverage, based on deductible, coinsurance, and HRA status. Remaining HRA funds are integrated into the display, but this feature may not be fully functional. In the following example, estimated allowed fees for an MRI of the lower back exclude professional fees.

Cigna ranks providers who do not disclose costs in the lowest (most expensive) tier and notes the fact explicitly.

Display if the doctor/hospital cost information is unavailable due to contract prohibition.

Display if the doctor allows costs to be displayed but not the facility where the procedure is performed.

Lack of Data

Procedures searches display results for hospitals on a separate page from results for other facilities. Users must notice the tab (in red box) and then select the option to see allowed fee information for other facilities. Users cannot compare allowed fees in alternative settings side-by-side. However, Cigna's tool points the user to the place of service with lower costs. For example, an MRI search will point the user to the freestanding facility locations, and the customer has to take action to move to the hospital tab to see the higher cost hospitals. This represents a deliberate design choice by Cigna to drive users to find the lowest cost alternative for treatments such as MRIs and CT scans.

For procedures that can be performed in a doctor’s office, in an ambulatory surgical center, or in a hospital, three separate pages contain allowed fees. Direct comparisons are not possible. Users must click through every page to find the option with lowest allowed fees. However, display tab defaults to option with lowest costs – whether Doctors, Hospitals, or

Users can find drug information three ways: using an auto-fill search field for drug names, selecting one of 11 conditions, or browsing alphabetical and drug category lists. Educational resources from Healthwise also display.

Users can view coverage-specific drug costs across drug types and delivery methods. Users are alerted to lower cost options, which display alongside the user’s requested option.

After selecting a medication, users can specify dosage and pharmacy options, aided by an integrated map display. The mail-order option is highly visible.

Searching by condition displays evidence-based medication guidelines.

After users select mail-order delivery, comparative costs for brand-name medications and any generic equivalents display. The lowest cost option is highlighted.

The tool alerts users to coverage-specific deductibles but users must return to the main estimator to obtain deductible balances.