Cost estimates for doctors

Methodology #11

Overview

We believe everyone deserves to know how much their healthcare will cost. In July 2016, Amino launched tools that can help you estimate healthcare costs for many common procedures and services, compare costs for doctors in your region, and calculate what you might pay out-of-pocket for a specific doctor based on your insurance. Our cost estimates can help you prepare for the financial impact of medical care and help you make more confident decisions about where to get treated.

Amino’s cost estimates are estimates of the total amount that you and your health insurance company might pay for a procedure—this is what we call the “network rate.” You’ll see the network rate across Amino’s individual doctor profiles, as well as on our new regional cost comparison maps. The network rate will vary based on whether or not you’ve specified your insurance.

The network rate is based on Amino’s analysis and data modeling of de-identified data from millions of health insurance claims from 129 health insurance companies—including the largest insurers in the United States like UnitedHealth Group, Aetna, Humana, Cigna, Blue Cross, Blue Shield, and more. The data comes from $860 billion in insurance claims dating between June 2015 and April 2016, which means we are able to show cost estimates for millions of combinations of medical procedures, doctors, insurance companies, and regions.

The analysis behind our cost estimates

Our cost estimates are built around an “episode of care”—a set of related services that a patient may need as they get treated. For example, in the case of an ACL surgery, a patient may receive anesthesia, radiological services, and medical devices, as well as the procedure itself, as part of their episode of care. The costs of these related services sometimes vary from doctor to doctor (and from facility to facility) and are reflected in the cost estimates you see on Amino’s doctor profiles.

To determine the episode of care for each procedure of interest, we first look at all of the services that patients experience within a specified window of time. For simple procedures (like a vaccination), the window is one day (the day the procedure was done). For more complicated procedures (like Mohs surgery) the window can be up to 7 days after the procedure was done in order to account for lab tests and other related services. The specific time window for any given procedure was determined through extensive research by Amino’s data science team.

For some procedures, multiple doctors of the same clinically relevant specialty may attend to a patient during an episode of care. We label the doctor who had the most encounters with the patient during the episode of care as the “primary doctor.” The primary doctor is established as the provider ultimately responsible for a patient’s episode of care.

For each primary doctor represented in our data, we calculate the proportion of patients who received each service within the episode of care—this is the service’s relative frequency. We look at the actual dollar amounts that health insurance companies have negotiated with providers for select services, and we weight them by their relative frequency. We do this by multiplying the service price with its relative frequency to produce a weighted price of the service.

For example, if 50% of patients who received a colonoscopy also received a biopsy as part of the procedure, then the relative frequency of a biopsy during a colonoscopy is 50%. If the price of a biopsy is $100, the weighted price of the biopsy is $50.

We sum the weighted prices of all services and procedures in our episode of care to produce an estimate for the network rate. We repeat this process of looking up prices and weighting them by their relative frequency for every insurance company that our data indicates the doctor accepts.

Example episode of care

Episode of care for a colonoscopy Relative frequency Price Weighted price
Colonoscopy procedure 100% $1,000 $1,000
Anesthesia 100% $500 $500
Biopsy 50% $100 $50
Estimate for network rate $1,550

Why do we do weight prices by their relative frequency? An episode of care represents a typical patient’s experience. However, healthcare is very personal, and it is difficult to capture every possible outcome of a healthcare encounter without producing a potentially long list of cost estimates for each outcome. We weight prices by their relative frequencies in the patient population as a way to capture this variation while also producing a single cost estimate per episode of care.

We conducted checks and validations on our estimates wherever possible by reviewing external research and in some cases calling up doctors offices, reviewing “Explanations of Benefits” from real patients, and working with medical coding experts. If you’ve made it this far in our methodology, tweet @AminoHealth “Hot biopsy forceps!” and we’ll send you a sticker as a reward for your perseverance.

Cost estimates on Amino’s doctor profiles

We currently show cost estimates for more than half of the 893,000 doctors on Amino: essentially all doctors who have performed the procedures for which we have estimates. If you have selected your insurance during your search for a doctor on Amino, you will see the network rate that we’ve determined for the doctor specific to that insurance company presented along with other filters and facts—the doctor’s experience, location, insurance accepted, decision factors, and more. We believe that showing cost estimates alongside other information about the doctor will help you get a more complete picture of the doctor’s cost and experience.

If you have not specified your insurance during your search for a doctor on Amino, you will see a range of prices instead of a single cost estimate. For example, let’s say you’re looking for a doctor to perform a colonoscopy in San Francisco. To determine the range of cost estimates we’d show, we look in our database to evaluate all of the patients with private insurance who saw doctors in the San Francisco area for colonoscopies (over the given time frame that our database covers, right now June 2015-April 2016). Then, we estimate what these patients would have been charged for a typical colonoscopy, based on the type of insurance they have and the doctor they saw. Over these patients, the 5th and 95th percentiles become the low and high cost estimates within the range we show.

Using our regional cost comparison maps

Amino currently shows cost estimates for 9,000 cities. If you have specified your insurance when looking at Amino’s regional cost comparison map, you will see a network rate for each city—the median network rate. We determine the median network rate by looking at all the doctors who perform that procedure and accept that specified insurance company in that region, and showing the 50th percentile over typical patients for those doctors.

If you have not specified your insurance when looking at our regional cost comparison map, you will still see a median network rate. That median network rate is calculated by evaluating all of the patients with private insurance who saw doctors in that region for the given procedure. Then, we estimate what these patients would have been charged, based on the type of insurance they have and the doctor they saw. Over these patients, the 50th percentile becomes the network rate we show.

Calculating your out-of-pocket cost estimates

The out-of-pocket cost calculator helps you understand what you might pay for a procedure, based on your insurance plan. If you select “Calculate What You’ll Pay” while researching cost for a specific procedure or service on Amino, you will see the calculator.

Choose a typical insurance plan design or enter your custom plan details. Within the calculator we provide two preset typical insurance plan designs you can choose from: High deductible and Low deductible. Many insurance companies have plan options that correspond to these, with Platinum usually having the lowest deductible and lowest co-insurance percentage, and Bronze having the highest deductible and highest co-insurance percentage. You can also enter in your specific plan details if you know them.

The right-hand side of the calculator shows how the three key elements of your plan design—remaining deductible, co-pay, and co-insurance—factor into your out-of-pocket cost estimate.

Final thoughts and our limitations

Wherever possible, our team conducted checks and validations of our cost estimates by reviewing external research and, in some cases, calling up doctors’ offices, reviewing “Explanations of Benefits” from real patients, and working closely with medical coding experts.

Our cost estimates are designed to help you make more informed healthcare decisions, but they are not a prediction of the price you’ll find on your next doctor bill. The data we use to power our estimates are a snapshot of the dollar amounts health insurance companies have paid care providers for select procedures and services in the recent past. They are not guaranteed prices that health insurance companies will continue to pay in the future. If a health insurance company and a doctor negotiate a new rate for a procedure that is different from what we’ve seen in the past, the change will not be immediately reflected in our cost estimates.

Additionally, we do not have a complete picture of every payment health insurance companies have made to every doctor in America. As a result, for some doctors, we do not have enough data for certain procedures. In these cases, we create cost estimates by computing the median price paid to the doctor’s practice group (if applicable), or to all doctors in the same city or state, or some other appropriate level of aggregation. These reference prices allow us to fill gaps in our data.

Your doctor might recommend testing and treatment during your episode of care that is different from the episode of care we use to produce our cost estimates, which could make your total cost significantly different from our cost estimate. Therefore, Amino cannot guarantee the price you’ll be charged by a doctor or hospital. We also don’t have cost estimates for uninsured individuals or those paying in cash, since many providers do not (or cannot) make these cost estimates public or easily accessible. Amino recognizes the importance of these cash prices and will be looking into new data sources in the future to serve this need.

Our estimates are based on an analysis of what most patients typically experience, which can provide helpful context as you plan for care. For more specific estimates based on your particular health needs, we recommend that you call your health insurance company’s customer support line or your doctor’s office to confirm what is covered and what you might pay.

Due to the nature of our insurance claims data and available resources, it is challenging to accurately and fairly take into account the complexities of individual patients’ case variation or understand every doctor’s complete patient mix. Therefore, we are currently not conducting risk adjustment for our cost estimates. We understand the importance of risk adjustment, and we will strive to incorporate risk adjustment into our analyses in a future version of our product.

For more information about our methodology, contact us at insights@amino.com.