How employers are creating incentives for lower-cost sites of care

Ingrid Stiver Senior Manager, Health Research Institute, PwC US January 28, 2020

For a long time, doctors directed where patients went for care and site options were limited. Now employers are having more of a hand in guiding patients, creating preferred channels for care delivery that align employee preferences with a growing continuum of care options to achieve the most value. In 2020, employers will begin to join the ranks of payers already encouraging their members to choose lower-cost options outside the hospital such as free-standing imaging centers and ambulatory surgery centers. Some employers will use their worksite health clinics to encourage the use of high-quality, lower-cost care.

Some employers may persuade employees to choose the lowest-cost, most appropriate site of care through their care advocacy programs, which were offered by 74% of employers in 2019. For example, care advocates may help employees understand if a specialty care visit is needed or if a primary care visit would be appropriate for a specific health concern.

Some may use benefit design to encourage employees to use the most appropriate site of care like one multi-state health insurer does for its members. In 2017, the health insurer announced it would stop paying for outpatient MRI studies and CT scans conducted in a hospital setting, and instead send its members in nine states to lower-cost, free-standing imaging centers for these services.

Others may use lower copays or coinsurance to reach a similar outcome. Starting Jan. 1, 2019, for most of its small group plans, one single-state health insurer began covering imaging services at free-standing imaging centers so employees pay less than if they were to get images in a hospital setting.

After discovering high error rates in diagnostic imaging for its employees, a large retailer began encouraging employees in March 2019 to seek imaging services at centers the company has “identified as providing high-quality care.” Employees seeking these services elsewhere are subject to higher cost sharing. With national average hospital charges for imaging services running anywhere from 170% to 308% of what is charged by free-standing imaging providers, HRI expects to see employers and payers encourage the use of free-standing imaging centers in place of hospital imaging.

With national average hospital charges for imaging services running anywhere from 170% to 308% of what is charged by free-standing imaging providers, HRI expects to see employers and payers encourage the use of free-standing imaging centers in place of hospital imaging.