Duncan Sibson, Krish Maypole

Mia sifts through her mail and groans as she comes across what is sure to be another outrageous hospital bill. Dealing with her knee has been a nightmare. When the pain first started, she decided she’d see a doctor. Mia didn’t know where to start. Overwhelmed by the number of options, she finally picked a provider at random. Then, when she was told she needed surgery, she was left guessing how much it would cost. Worst of all, it has been months since the operation, and her pain has not gone down as promised. She can’t help but feel defeated.

Mia isn’t alone. In fact, 79% of Americans are dissatisfied with healthcare costs and 66% are frustrated with healthcare coverage. Variable healthcare costs and quality are linked to both a lack of transparency and the inability of most patients to navigate the complexities of the system themselves. Historically, hospitals and other healthcare providers in the United States have not published their standard prices for procedures, drugs, and other services and items. However, the federal government ordered the release of this information in hopes that increased price transparency would help consumers estimate and compare the cost of care between different hospitals. Despite this effort, a lack of price transparency persists nearly a year later. Some hospitals still haven’t released any data, and while others have, many aren’t sharing all of it. What’s worse is that the data released are frequently in formats unintelligible to most people and don’t help patients make healthcare-related decisions.

Quality is also affected by the rampant lack of transparency. Many physicians may not provide appropriate or necessary care, instead ordering unnecessary tests and procedures that lead to greater costs to patients and employers. Right now, the system hides intelligible provider quality data from patients, who must play a challenging game of hide-and-seek if they want to make informed decisions. Unfortunately, most patients don’t know how to play as only 12% of U.S. adults understand how to navigate our health system, meaning that consumers do not have the tools to select a high-quality, low-cost provider on their own. 

As we’ve written previously, existing benefit solutions are either too broad with little clinical expertise or too narrow and are not able to address most MSK conditions. The fact remains that consumers are still confronted with more challenges than they should face alone. Patients need help moving through a tangled healthcare ecosystem, wrought with high hospital prices, inconsistent outcomes, and confusing data. 

MSK care requires many different types of providers and therapies which can make navigating the healthcare system challenging and frustrating for patients. There is no one-size-fits-all solution, and as others have written, a comprehensive MSK wellness approach is the only way employers can ensure that nobody gets left behind.  

How Expert Navigation Works in Practice

Let's get back to Mia. Remember her nightmare experience? Her journey would have been completely different with Icon’s support.

Mia is a 54-year-old woman from Colorado who works in construction. Her job requires that she lift heavy objects and stand for long periods of time. A few months ago, she noticed pain and swelling in her left knee and had trouble performing daily tasks.

Mia decides that it's time she sees an orthopedic surgeon about her knee. She tries searching for doctors on her insurance company’s website, but quickly becomes overwhelmed with all the options.

Mia’s search experience would have been easier if her insurance company had a searchable database of all of the healthcare providers in Colorado. Even with that level of specificity, she would have had to sift through hundreds of orthopedic surgeons across the state without knowing the relative cost and quality of each one. 

For Mia, choosing the right provider could mean avoiding unnecessary surgery: a combination of exercise and physical therapy has shown to be a slightly better and significantly less invasive alternative to surgery for middle-aged patients with common conditions like degenerative meniscus tears. For both Mia and her insurance company, avoiding surgery could also mean saving a lot of money. If Mia were to undergo a knee arthroscopy and partial meniscectomy, she would owe nearly $2,000 in out-of-pocket costs, and her plan would be on the hook for more than $4,000. If Mia were to follow a more conservative care pathway, her out-of-pocket costs would plummet to $293, while her plan’s bill would also fall to $761. We’re talking about a 600% cost reduction and a better chance at Mia getting back to work quickly and in good shape.

At this point, Mia realizes that she needs help moving through the healthcare system, so she contacts Icon Health where she has immediate access to her board-certified Icon MSK expert. Mia’s MSK navigator takes the time to understand her condition and preferences to create an evidence-based care plan that combines the most effective conservative virtual treatments with the leading in-network providers. Now, Mia has the support and guidance she needs all the way through recovery to ensure she gets the best possible clinical outcome while avoiding overly priced providers.  

After meeting with her orthopedic surgeon, Mia finds out she needs an MRI, so Icon finds her a cost-optimized MRI center, evaluating the quality of on-site diagnostic equipment and making sure that the center has low re-imaging rates. Following the MRI, Mia works with her care navigator to solidify a plan for physical therapy. With Icon’s help, Mia is on track to living and working pain-free, with no outrageous hospital bills.

Care navigation is an increasingly important part of our healthcare system. As new information becomes available, Icon Health continues to put patients first, ensuring transparency and health equity for patients just like Mia.

To learn more about Icon Health please visit www.iconhealthco.com or send us an email at hello@iconhealthco.com.