Anyone who has received a statement in the mail from a health insurance company has come across these words: THIS IS NOT A BILL. The sentence usually appear in bold, uppercase letters at the top of a page that looks like…well, a bill. The problem is, it’s not a bill. It’s something called an explanation of benefits or EOB.
On this episode of HealthChangers, we spoke with two people who have been trying to tackle the confusion around EOBs and medical bills:
Dee and Randy were both involved in the 2016 Health and Human Services’ “A Bill You Can Understand” challenge that invited people to create a medical bill that was easier for real people to use. Dee served as a judge for the challenge and has also worked with Cambia’s regional health plans to redesign our regional health plans’ EOBs. Randy led the design team at RadNet, who submitted the winning design for the HHS challenge.
In this episode, we talk about how to design with empathy, what it’s like to be a consumer receiving everything in the mail, and ultimately, how different players in the industry can come together to create a more person-focused experience.
Jeremy Solly (JS): Welcome to the HealthChangers podcast presented by Cambia Health Solutions, where we share real stories of health care transformation from those experiencing it and those helping to make health care more personalized. I’m your host Jeremy, and on today’s episode, we’ll hear from two people who have been trying to tackle the confusion around medical bills.
"This bill-that’s-not-a-bill causes confusion and frustration."
Anyone who has received a statement in the mail from a health insurance company has come across these words: THIS IS NOT A BILL. The sentence usually appear in bold, uppercase letters at the top of a page that looks like … well, a bill. The problem is, it’s not a bill. It’s something called an explanation of benefits or EOB.
Dee Cruz (DC): It is technically a legal document that we must produce whenever any of our members seeks services with a provider.
JS: That’s Dee Cruz, Vice President of Operations for Cambia’s regional health plans.
DC: What the explanation of benefits does is it says, “For these dates, you saw Dr. Joe. Dr. Joe did an annual check up and ran these lab tests. This is the amount your insurance company covers and then this is what’s left that you should be billed by your provider.”
JS: This bill-that’s-not-a-bill causes confusion and frustration. I asked Dee why these forms are so hard to understand.
"Assuming we know what a consumer wants and needs is the biggest pitfall we can fall into, and precludes real progress."
DC: I think the complexity has grown just as the complexity of health care in general—the consolidation of service providers that then outsource to other service providers. When you go in to see your doctor and they send your labs somewhere, that’s a different entity potentially altogether than the doctor that is your primary care physician. And aggregating all of that information is what we’re trying to sort through and sift through.
JS: Dee and several teams inside Cambia decided to come up with designs for a new form that might better distill all that information. She says they were certain one of the forms in particular—a scaled back, minimalist design—would most appeal to consumers.
DC: When we convened a member panel to test all four of those designs the one we were convinced would score the best, consistently scored the lowest. I cannot stress enough that assuming we know what a consumer wants and needs is the biggest pitfall we can fall into, and precludes real progress.
"The difficulty is that the information is often itself a barrier to the people that need it most."
JS: Interestingly enough, at the same time Dee was working on a better EOB design, the federal government was looking to design a better medical bill, like the one you get from your doctor or other service providers. Turns out those are often confusing, too, for some of the same reasons. So in 2016, the Department of Health and Human Services issued the “A Bill You Can Understand” challenge.
The winning bill came from a team at RadNet, one of the nation’s largest medical imaging providers. RadNet’s Director of Web Presence, Randy Ziegler, headed up the team. I called him to get his thoughts on how to make a bill you can understand.
Randy Ziegler (RZ): Hi there.
JS: Tell us in your own words, what was the challenge HHS presented? What was the history of it and what were they asking you guys to do?
RZ: I thought they did a really good job of really expressing the state of the industry in that we have access to all this medical information and it often gets constituted in a deliverable called a medical bill. And the difficulty is that the information is often itself a barrier to the people that need it most to understand what has occurred in their health care journey.
So looking broadly across many organization at the medical bills they were producing, they realized that there was a real disconnect between the bills the patients were seeing and the way that the patient viewed their own medical journey.
And so I think the competition, as we understood it and as we interpreted it, was how to bridge that gap between information that we have access to and the way that it was presented to the patient. With understanding of this information, it allows the patient to become more engaged in the health care process. It allows them to make better decisions about their health care. And the medical bill was just a part of that, but it was a great place to start.
"I had a lot of questions, things that just didn’t add up for me."
JS: So Randy, you’re a person. And you’ve engaged in the health care system. Have you personally ever kind of run across those barriers as you say in using this health information?
RZ: Yeah, it’s interesting that you ask that, because just prior to the competition coming across as an opportunity, I actually had a very interesting engagement with the health care system.
My teenage son went through a kind of a health issue where I had to engage with many parts of the health care system, including his primary care provider, we did some outpatient imagining, the emergency room and we also had a stay in the hospital. So we were receiving a whole bunch of medical bills and documentations. And it was overwhelming.
Many parts along the way, there were questions about what we thought occurred and what we were seeing documented in our medical bill, and they didn’t always seem to add up. And so I was coming off that experience of trying to sort out our own medical bills and so I felt like I was able to bring my own personal experience into the competition. Because I had a lot of questions, things that just didn’t add up for me.
"Does this make sense?” Does this communicate? Do I know what to do next?”
JS: Do you guys have any sense of why medical bills got so complicated? Did you guys glean how we got here?
RZ: Our sense was that many times, it seemed like the constraints of the software that actually produces the bill got in the way of the communication that needed to happen. And part of that is we felt like maybe not always the right constituents were at the table at that moment in time where the bill and the format of the bill were conceived.
Of course we come from a point of view that we like to use design as a business tool as a tool for effective communication and creating better experiences and we often wondered whether there was a designer participating in the development of that. Meaning that a designer typically will play the role of being the user advocate—in this case the patient advocate—to say “Does this make sense?” Does this communicate? Do I know what to do next?” You know, ask those questions that a patient would ask.
Often the reason a designer can ask those questions, if they’ve done their homework by following a user-centered design process where they’ve created personas, so they understand all the various contexts where a patient might interact with a bill.
Have they done any sort of user testing where they’ve put drafts in front of patients and listened to them and heard the challenges they face or the way they process the kind of information that’s presented on the bill? Those are the kind of things designers like to do, that they do naturally. So I guess to answer we wondered whether there was a design voice, or a user-advocate voice at the table when some of these bills were created.
"Keeping the consumer at the center requires you to have empathy for the context in which they live, the context in which they engage with you and your organization."
JS: I thought it was interesting what you said the software was getting in the way of what needs to happen for consumers. So how do we get back to that point of really keeping the consumer in the center of our thoughts and making sure this is always about them?
RZ: That’s a great question. In our design submission I think on the very first page we attempted to answer that question, and we answered it initially with a single word and that is the word “empathy.”
And what we mean by that is keeping the consumer at the center requires you to have empathy for the context in which they live, the context in which they engage with you and your organization. From a design perspective that is understanding and walking in the consumer or the patient’s shoes.
In this competition we tried to play that out by having a clear view of the various type of contexts that patients are interacting with a medical bull, whether that’s through their first time engaging with the medical system, or maybe they’re going through a long-term protracted health event. Maybe they’re in some sort of financial difficulty.
And it’s understanding the particular context that these patients are in that helps you become empathetic towards the way they want to interact with you as an organization, or want to interact with your information. In this case as it is expressed in a medical bill.
"Some were elderly and maybe not familiar with the health care system. Some of our personas were facing financial hardship."
JS: So take us to, you’re starting to design a better bill, right? Were there a couple of key insights that you guys used or that were that design voice or principle that you applied when you were designing your guy’s version?
RZ: You know the competition itself really emphasized the importance of keeping the patient in the center of the design process. And so a couple of the ways we felt like we tried to embrace this was very early we tried to create personas, which was to invent fake people, but people who could be real patients and they were patients that had a name and a personality, and more importantly they had a particular context that they were approaching the medical bill.
Some were elderly and maybe not familiar with the health care system. Some of our personas were facing financial hardship, and some might be approaching a bill with concern about their ability to pay.
So we had those personas in place, so as we were asking questions about what would be helpful we would say, “What would be helpful to Amanda who is facing financial hardship right now? What kind of information might help her process the fees here?” and things like that. So creating those personas were helpful tools to think about the various contexts that the bill would be used in.
"Things that seemed very obvious to us became a mystery to our test subjects. And you so badly wanted to point on the paper where it was."
We also did some user testing. We felt like we were pretty good users, number one, because I particularly had just gone through a health care experience and had a lot of questions of my own. When we went and did some initial drafts we wanted to put them in front of people who were unfamiliar with the competition and kind of real people that kind of matched some of our user personas. And so we put the bills in front of them, we asked them some questions, listened to them, we asked them to kind of talk out loud and listen to some of the questions they had as they tried to process our design and the communications.
And then we would put challenges to them like “when is your bill due?” or “how much do you owe for this particular service?” and just ask if they were able to come up with the right answers. That was very interesting because things that seemed very obvious to us became a mystery to our test subjects. And you so badly wanted to point on the paper where it was. But if you’re honest about your effort you realize that if your test subjects are having difficulty understanding a piece of information, you’re probably not treating it appropriately.
"Patients felt that their medical bills had little connection with where they were with their insurance."
JS: Randy that’s great. I always find user testing really interesting because there’s always great information that comes out of it. Was there any comments from your user testing that stood out to you as particularly notable?
RZ: When we were performing some user testing and patient interviews, one of the things that seemed to keep on coming up was that the patients felt that their medical bills had little connection with where they were with their insurance, with their deductible and co-pays.
And so, in our solution and our design, we worked hard to try and capture that kind of information on the medical bill itself. Where the patient would be able to see at that moment in time where they were with their co-pay and deductible, and in many ways that’s probably unusual for medical bills to show that information because it really represents a type of information integration that doesn’t always exist when producing medical bills. But that was a huge gap and it was a piece of information that is very, very helpful to patients and so we attempted to show that in our medical bill design.
"Abbreviations and technical jargon became obstacles to understanding."
Other things included trying to figure out things like eliminating medical jargon and abbreviation. Where it makes perfect sense to us as health care providers, but to patients who don’t operate in this space every single day some of those abbreviations and technical jargon became obstacles to them understanding.
So we went through an audit of all the terminology and labeling that existed on the bill all of the narrative language that existed on a bill and we did a rewrite to put it in plain, everyday language. That was I think a very helpful thing to kind of normalize and tame down some of the complexity that we were finding in the medical bills.
"One of the challenges would be to have robust data system were you can be aware whether a piece of data can be labeled one way internally and one way when it is patient facing or provider facing."
JS: I want to switch gears a little bit. So I love how this challenge focused on how we keep consumers at the center and make sure this design works for the people who are going to be using it. But the other folks that would use this are providers and doctors and health systems, right? They’re the ones that will be implementing this design. Did you guys think about that in this process? Even though the focus is on how consumers and people will be able to interpret this?
RZ: Yeah, honestly we didn’t make that a chief criteria in our design. Obviously we wanted it to be tethered to this notion that it could be implemented. In a way we didn’t want to do anything that was so out there that organizations couldn’t see a way forward to produce a design that adopted some of these concepts, but that rally wasn’t a primary driver for us.
We feel like the bill we designed is something that can be implemented. I think the difficulty is that the same data that presents itself on the bill is used in other parts of the organization to serve other purposes. And so there is this challenge is to have this data both internal and useful for internal systems and controls as well as patient facing.
And so I think one of the challenges would be to have robust data system were you can be aware whether a piece of data can be labeled one way internally and one way when it is patient facing or provider facing. So I think there’s certainly a lot of work that has to be done, but we felt like, we have seen examples in isolated cases of that type of sophistication in the way you handle data and present data externally and internally.
"We want to be an industry leader in helping not only our organizations but other organizations do a better job."
JS: So the challenge is over …
JS: You guys won. Congratulations!
RZ: Thank you.
JS: What’s gonna happen next?
RZ: We’ve had a couple of conversations with some folks that were watching the competition and participating in it. And partly because our charter for RadNet is to lead radiology forward, so we want to be an industry leader in helping not only our organizations but other organizations do a better job in kind of the consumerism of health care. We know this is something that we need to do better as an industry.
So yes we’ve had some conversations, we’re still figuring out what those turn into. But even internally, obviously winning this award got some attention in our organization and we’re able to share with them that we put RadNet’s bills right alongside the other competition bills and there were some big gaps.
And that really didn’t come as a surprise, and we’ve known that. So there is now I think really an initiative in place to really take a look at our bills across all of our imaging centers and the systems that we have to embrace some of these concepts. It takes a lot of work.
I guess what I would say is our particular bill that we submitted—to be fair to these organizations—was out of context of any particular billing system or any particular health care organization. So it’s really not a matter of just lifting our design and slapping it on a bill of some other organization.
Really what I would encourage is to really follow the process of user-centered design. Where you gather the requirements of your own system and the constraints there and design something that’s responsive to the unique needs of not only your business, but more importantly your patients.
"Do you have someone who is an advocate for the consumer who continually represents their point of view, their concerns, as you build these solutions?"
JS: You learned a lot through this process. You focused a lot on how consumers interact with the health care system. Looking out—whether it’s bills or other pieces of the system—what other suggestions of advice do you have that you maybe learned along the way that can help health care innovate and keep consumer at the center?
RZ: I actually think you almost you gave the answer in the question. You have to make the consumer the center of the problem you’re trying to solve. Look around at the teams that you’re building to solve some of these health care challenges. Are all the right people at the table? Do you have, if not a patient or the consumer himself, do you have someone who is an advocate for the consumer who continually represents their point of view, their concerns, as you build these solutions? And I think from our particular point of view, the design process is a great tool to allow that to happen—to keep that consumer, the keep that patient always at the center of the solution.
JS: Randy, I just want to take a second to thank you for talking with us today. It was great to hear about your experience with the “A Bill You Can Understand Challenge.” And congratulations again on winning the award.
RadNet, Inc. is the leading national provider of free-standing, fixed-site diagnostic imaging services in the United States based on the number of locations and annual imaging revenue. RadNet has a network of 305 owned and/or operated outpatient imaging centers. RadNet’s core markets include California, Maryland, Delaware, New Jersey, New York and Rhode Island. In addition, RadNet provides radiology information technology solutions, teleradiology professional services and other related products and services to customers in the diagnostic imaging industry. Together with affiliated radiologists, and inclusive of full-time and per diem employees and technicians, RadNet has a total of approximately 7,300 employees.