The Comedy Show of Patient Payment (Price Transparency in Healthcare: A Stand-Up Comedy Special)
This week I am talking to Ryne Natzke, Chief Revenue Officer, at TrustCommerce, a Sphere company (@SphereCommerce), a cloud-based, software and payments technology company. Ryne and I met some years back and he was kind enough to share some of the details of that meeting, and the fact I was talking about future technology, much of which has come to fruition since.
Ryne highlights the challenges of handling patient payments in the healthcare industry and the need for transparency and security in financial transactions while acknowledging the complexity of estimating patient payments due to the variability in insurance plans and unplanned medical expenses. As he points out making financial conversations a standard part of healthcare discussions would be a positive step toward improving transparency and patient understanding.
We dive into the issue of discussing money, something I had real trouble doing when I worked in Australia as a doctor, and Ryne’s personal experience where billing was not discussed upfront during a medical procedure, leading to surprise charges later.
Listen in as we discuss the changing landscape of healthcare payments and the need for price transparency and while we both agree that the industry is moving towards more personalized and digital payment options to improve patient experience your mileage may vary. As Ryne points out providing patients with tailored payment options and proactively setting up payment plans can make the process less daunting. The future of healthcare payments is one where patients have more choices and can shop for healthcare services as they do for other goods and services online. Change in healthcare may be slow, although it doesn’t have to be even though it is incremental but expect generational shifts as younger patients become more connected to their own health.
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Raw Transcript
Nick van Terheyden
And today, I’m delighted to be joined by Ryan Netsky. He’s the chief revenue officer for trust commerce. Brian, thanks for joining me today.
Ryne Natzke
It’s great to be here and talk to you now.
Nick van Terheyden
As I do always, I think it’s important to get a little bit of context. Tell us a little bit about your background, how you arrived at this, we share a little bit of common history. Tell us tell us about your journey.
Ryne Natzke
Sure thing, I’ll start kind of current and maybe work backwards a little bit. So I’ve been with trustcommerce for about five and a half years. And we are we do integrated payments, and we work with healthcare providers to help with the patient payments, I don’t come from a payments background, I come more from the Health IT side of things. So my staff before this, I was at Health X ventures, which is an early stage venture capital fund focused on digital health technology. And before that, I spent a little over six years at Epic and a lot of my time there was managing the vendor relationships between the different groups that epic interacts with and, and you and I actually had a meeting together in Verona, and one of the conference rooms at the epic campus when you were at nuance and talking about where things were going. It’s interesting, if I remember right, many of the things that we talked about their stuff that nuances, sharing now with the ambient voice and listening in and using it to help fill out the chart. So it’s been cool to see some of that stuff happen over the last decade or so.
Nick van Terheyden
I’m just gonna say I’m really glad that you said that. Because I keep telling people I was talking about this stuff. We were doing it. And it was all about me talking and generating and you just validated. So just for everybody listening, it’s really true. I was involved in the generation of this stuff. You’re right, it was it was a very exciting time, I think we’re seeing the results of it. I obviously was a little bit ahead of my skis, because we didn’t quite get there as quickly as we thought and there was a lot of bumps in the road. But I think there’s lots of excitement now. So very cool to reconnect. Thank you for sharing that story. So tell us a little bit about trust commerce, and you know, some of the things that you do, and you know, your thoughts around where that’s going.
Ryne Natzke
Yeah, so what trustcommerce does is we do integrated payments, and there are payments companies in all sorts of industries and verticals. And really where we try to focus is on the house is within healthcare. And the interesting thing about the intersection of payments and healthcare is, unlike other industries, you pay your bill as a patient, a ton of different ways you pay before your visit, you pay at the front desk, you pay over the phone, you might call an IVR, you’ve got payment plans, you might use an ACH. So supporting payments and healthcare, you have to do a whole lot. And that’s really what we do. And the other thing that is important with healthcare is it’s not just having that credit card machine on the countertop or a place to pay. A lot of times when you send a bill or you’re trying to collect a medical bill, there’s a lot of questions. Why do I owe that or what’s the context or what’s going on here. So we want to make sure that we’re integrated and really transparent to that user. So when you log into my chart to pay your bill, it never looks like you leave my chart it but also we want to help make sure that that data is secure compliant to help make sure that the provider companies like epic and paradigm that they minimize their security risk and compliance risks and handle those transactions. They got enough on their plate with medical data. And everything that goes on with that credit card data brings a whole nother area in there. So we kind of sit in that sweet spot of FinTech and health tech to help with the patient payments.
Nick van Terheyden
So let’s talk a little bit about this. Before we get into the sort of details of the billing and transparency. I mean, I think you bring up a just a I mean, I think everybody understands this point, but can’t understand why it doesn’t apply in healthcare, which is I can literally go almost anywhere. I think the one exception I feel is buying a plane ticket, you know, I don’t know that we always know how much it’s gotten better. But you know, there are so many additional fees that seem to appear and you know, Congress has gotten involved, but it’s gotten a lot better. You have some sense of what it is. And by the way, it’s an awful lot easier to get to it. It’s it’s really a hey, I want to book X or buy such and such I can do it, but we just don’t seem to get there in healthcare. Why do you think that Here’s what’s going on that sort of preventing this.
Ryne Natzke
Well, a big piece of it is that it’s it’s super duper hard for one because your, your visit to the same doctor for the same appointment type, you probably going to pay different than me if we have different insurance. So it isn’t like a plane ticket in that, alright, here’s the cost today, maybe it’s gonna change tomorrow, maybe it might change in a couple hours. But generally, if somebody’s buying the same plane ticket, they’re offered the same price for it. Where healthcare, that’s just not the case. I think you mentioned it, we’re getting better. And Congress is getting involved with posting the pricing, really requiring groups to provide an estimate. But a lot of that is reactionary. Now, you’ve got to call in, you’ve got to ask, and I don’t think patients really know that yet. I think we we hear about it, we live it every day. But the patient, the average typical patient probably doesn’t. So maybe when they do call in, I don’t know if we your experiences last time I called them to a doctor’s office or hospital, I’m on hold for a while and bounced around, do I want to go through all that to get an estimate, even if I know that I can get it? So I think that’s kind of where we are today. And in scaling that up and taking that next? How are we going to be more proactive? How do we just deliver that up front, when you make your appointment take this as how much you’re going to how much you need to expect to pay once this is all said and done. We’re not quite there yet. We’ve got it in some areas. And the other piece of it is not all healthcare is planned. You might schedule an appointment, but you might have a skiing accident, you’re in the emergency room, nobody can estimate how much that’s going to cost because you don’t have any sort of diagnosis or knowing what kind of care is given. So there’s kind of there’s there’s that side of it to where we can predict what we scheduled, but we can’t really estimate what we don’t know what’s gonna happen. And that’s a big portion of healthcare as well. Yeah, so
Nick van Terheyden
hot, embarrassing incremental tip for listeners, I don’t communicate by phone, because to prove that you’ve had the phone call, you have to record it, I live in a dual party recording states, you have to say it and nobody gets all worked up about it. So I’m going to declare this and embarrass myself and say that I will only communicate by fax with all of these medical. True story. I fax everything and you know, I spend my time actually the hardest thing sometimes is getting the fax number. It’s almost like it’s a secret. Anyway, that aside, you know, you’re right. And I made light of you know, it’s a complex area, I think part of the reason that I react that way is that we see all of these organizations jumping in and go, Oh, my God, we can fix that we’ve done that. Interestingly, let’s, you know, put it out there, Amazon is one, you know that clearly making a play, has expanded their sort of access. And you know, it’s retail, it’s supposed to be easy, but they’re not really solving the problem. They’re just they’re not even accepting insurance, because that’s where a lot of this comes down to. And one of my other guests talked about this, and it was very, it was a very eloquent way of explaining this, this multi list of pricing that you see. And he talked about it. This was in fact, in the case of drugs, but it’s true for all of healthcare, for the military, and even individual, you know, the army will see different pricing, depending on the specifics of the insurance. So it’s it’s this sort of massive spreadsheet model that says, Oh, you’re x by y by z. This is your price for, you know, and it’s another diamond. I mean, it’s just extraordinarily confusing. I’m gonna pause it there. So I want to I’m interested in what you think. Is it deliberate? Do you think?
Ryne Natzke
I don’t know if it’s deliberate. I just don’t know if it’s always been the top priority. Because if you’re, if you’re a healthcare provider, the patient responsibility is not where the majority of your revenue actually comes from. It’s coming from the health plans and the government. So when you’re thinking about where you’re spending resources and energy to make things more efficient, or maximizing your collections, you might get a better bang for your buck by focusing on on that end of things. And I think the trends that we’ve seen over the last 1015 years or so, is that’s changing what used to be 5% of your revenue might be patient out of pocket now becoming 1520, maybe more in some cases, you can’t write off 40% of that the way you could before because now that’s a really meaningful amount towards your margins. So I think I don’t think it’s necessarily deliberate. I don’t think anybody’s out there to say I’m trying to make it so hard on my patients. But when you think about things of where else you can spend your risk Horses, it hasn’t necessarily been the top priority historically.
Nick van Terheyden
Yeah, no, I agree with you in that sense. I mean, I think I’ve always started from the position that I think people come in with the best intentions. And, you know, the incentives that exist will distort behavior, not necessarily in the way that we expect, or, you know, even one, quite frankly, and you know, that’s true. Even in the building, I think the vast majority, there is a small minority, and just put them to one side. They’re just misbehaving. And, you know, we don’t need to sort of replicate that behavior. So we’re seeing more in the way of transparency, we’ve seen lots of regulations that says, hey, you have to, I’ll tell you my own personal experience actually getting that information was I might as well as been pulling teeth. And, and it wasn’t, you know, and I had it sounded very similar to your sort of words through Well, I don’t know, was a lot of the response. Because we don’t know x and y, and, you know, insurance and this and something could happen. How do we effectively solve for that?
Ryne Natzke
I think our needs to bring in some groups are doing this. But I think making the financial conversation, just part of the care conversation with your health care provider, I think is we’re not we’re definitely not there yet. I mean, in my own experience, I had just a regular checkup procedure a couple of months ago, the provider said, Hey, I noticed this, we can do that. Do you want to just take care of that right here? And I said, Great, let’s do it. I’m here. I don’t need to schedule an appointment. I don’t want to leave work. And I knew in the back of my mind, I’m probably going to get charged for this. But it was not brought up at all. It was it. There was it was. So that bill came and I was like I knew it. All right, I’ll pay it, I get it. I’m fortunate enough that I’m in a position where it wasn’t that big of a deal. And it wasn’t a big dollar amount. But that’s not the case for everybody. And it could have been 10 times more for something else. And it just wasn’t even a part of the conversation of Do you want this treatment, it will cost that it just wasn’t there. And I think making that more normalized and giving the providers that information, so that when they’re having those kinds of conversations with their patients that they can bring that up and give them that context. It would be great, a great movement towards that.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Ryan Netsky. He’s the chief revenue officer at trust commerce, we were just talking about the transparent billing. And you know, the, I’m going to be a little bit pejorative here. And I don’t mean it fully in this respect. But you know, the upsell, which it really isn’t, I mean, I think to your point about that sequence of events, hey, we’re here, we’re doing this, we found this, why don’t we just fix it, I mean, that’s the same as the car mechanic saying, you know, your brake pads actually need fixing. Let’s do that. Now. That’s not a bad process. But you bring up a point. And I’m just going to push back a little bit because I feel this and feel completely free to push back on me. Because maybe this is my Britishness. But I will tell you, when I practice medicine in the UK, money never came up. And to be clear, it’s not free, it never was free. You know, it’s free at the point of service. I went and practice in Australia. And one of the things I had to do was to finish each consultation with and how would you like to pay? And it was the most uncomfortable part of the conversation that I had, I could have all sorts of really uncomfortable, personal conversations with people with no problem at all. But talking about money was very difficult. Is that just me? Or is that broadly part of the problem?
Ryne Natzke
Now, I think that that is the case, I do think that the industry and kind of the perception behind it is changing. And if I learn from my background, so when I was at the venture capital fund, we did look at a company that helped with price transparency and getting collections based off of estimates and things like that it was company called health apps. We ultimately ended up acquiring them in the last few years here, but I remember talking to the CIO at a health system and saying, Hey, I’m we’re evaluating this company. What do you think about this? And he goes, Ryan, I can’t imagine asking my patients to pay before they even show up but that’s just not gonna work. And we still ended up investing in it. And I do think that that’s different now but it also it’s a there’s a couple of ways you can do it to make it less uncomfortable because if you say, Hey, how are you going to pay for this? But by the way, it is this many dollars for this reason. And by the way, here’s why because this is off of your health plan. I think patients are going to be more used to it, if you say, Hey, this is gonna cost 500 bucks, if you don’t pay for it, we’re gonna cancel your appointment. And there’s no context, there’s no more information about it, that I think that’s a little bit of a different story. And you can do that with digital tools, right? That doesn’t have to even be a conversation that can be any text message or walking them through a portal, things like that. That makes it a little bit more natural. But also, again, going back to that same appointment I was at, I went to go check in and they said, Hey, Ryan, you have a $30 copay for this visit? Do you want to take care of that now? Or should we send you a bill after the fact? And I wanted to just be like, Why are you giving me the choice, just make me pay this right here. Because if you give me if you send me the bill, it’s gonna, I know, it’s going to cost you five, six bucks to set to send that statement, it’s going to take longer for you to collect, it’s going to sit on my counter for four weeks before I even got paid, I don’t have a bunch of stamps, I’m not going to the post office anymore. So like, just just take care of it right there. And I think training the staff making it more normalized, where patients know they have to pay, and I don’t think it’s a surprise. So I think we’re there where it’s not that big of a shock anymore. It shouldn’t necessarily need to be that uncomfortable.
Nick van Terheyden
Yeah. So I mean, I’ll, I’ll support you in the sense that, you know, so I married a an Irish woman born and bred in Dublin. And, you know, when she came across to the UK, where we were, you know, she was used to it, that was part of the natural, you know, and she was shocked when people didn’t ask her to pay when she went to see the physician. So I think you’re right, there’s some acclamation or climatization, to that sort of experience. That said, you know, I think flexibility for me is one of the key elements to this is, you know, because you’re there going, well, I’d rather just deal with it and make sure that reverse. And, you know, I know, it’s entirely personal. But that sort of brings us back to this concept of how do you personalize this so that people have choice in a way that is meaningful. And for me, it’s about just being organized, I want to be in a certain place to sort of fix that I’m, you know, I don’t use stamps, either, you know, if they don’t have a digital payment method, they’re typically not receiving a check for me, because I don’t know that I could find that. So, you know, there’s some elements there. But you know, we can do all this easily. I mean, crikey, my my children who are no longer children, you know, they go out to food, and they don’t have the cash changing hands for splitting the bill anymore. They do it all by Venmo, or whatever, there has to be a better digital way of doing that and serving it up. I mean, I think, you know, this is about choice.
Ryne Natzke
It is about choice. And I think that choice can also lead to a little bit of paralysis too, especially if you if you if you’re offered too many options. So one of the things that we’ve seen with some of our partners, and I think it’s at Georgia doing this now, too, is rather than giving everybody every single choice, it’s alright, can we how can we be smart about this? How can we get this patient these options, maybe proactively putting them on a payment plan, because we know that their propensity to put to pay isn’t quite there, but we can split it out over six months? Maybe don’t send them that $5,000 Bill right off the bat, because they’re gonna get sticker shock. They’re going, Oh, my gosh, how am I going to take care of this? Proactively say, Hey, you have a $5,000 bill, we are enrolled him in a payment plan, it’s split out over the next 10 months, let’s get your payment method on file and start going and get you $500 A month for the next 10 months take care of this. You don’t want to offer that to everybody. If somebody can pay the $5,000 get have them just take care of it right there. So it’s, I totally agree that giving choice giving some options is important. And it’s helpful because one thing that healthcare doesn’t have a demographic, there’s no, like, everybody is a patient. Everybody has this. So you kind of have to segment your patients segment your consumers the way that other businesses would, and and give them the right options that are personalized to them to make that experience better and improve outcomes and financial outcomes.
Nick van Terheyden
Yeah, I like that. I think that’s, you know, that’s a great way of sort of encapsulating it in a single phrase healthcare does not have a demographic, there’s so much variation. And that’s not just the medical piece of it, you know, we’ve started to understand that it’s, you know, this individualized medicine is really what we’re all looking for. That’s what I know I want I want it you know, specific to me, it’s my dimensions my, you know, metabolic, whatever status. Doing that in healthcare for the back end piece has been certainly challenging. How? How are you approaching that? Where do you see this going is have we have we been helped by the regulations? Do you think that’s really sort of push things? Or do you think we were going there anyway?
Ryne Natzke
I think some of the regulations are going to help. I think like, kind of we touched on it before the posting the pricing, posting the costs. That’s a good first step. I do. And you also mentioned Amazon. I mean, what does it say that so many people are excited about the new stuff that Amazon is doing, like you said, they don’t take insurance, they’re willing to pay outside of their network outside of what they’re already paying in premiums and things like that, because they want that better experience. And I think that there’s going to be a decent dining market forces are just going to move it as well. Because if all of a sudden you’re starting to see your primary care Doc’s or your those kinds of appointments, move to Amazon, that’s not great. And now they control that top of the funnel a little bit more. So I think in order to really be competitive and continue to fight off some of the groups like the Amazons of the world, you have to adapt it. And that experience goes beyond just that experience talking to the clinician, it is the scheduling, it is the communication, it is how you’re billed it is understanding what’s going to be happening and things like that.
Nick van Terheyden
Yeah, I think great point. I mean, it’s no secret online. I’m I’m a big fan of Mark Cuban’s cost plus I think they did a an astoundingly Good job. The big difference for me when you looked at that was the price differential was so much bigger. You know, in the case of Amazon’s latest, you know, expansion of service, I don’t know that it was a real deal. At least it didn’t feel like it based on what I saw in terms of the pricing. Whereas when I looked at Cuban in, I think I posted somewhere, the differential for me was like it was a 95% reduction on the cost that I was being charged at CVS, which, you know, it was just an outrage to me, there’s a whole thing going on with, you know, PBMs, and stuff that I think is just not serving. So we’re in an exciting time, I like to believe I mean, you know, I’m sometimes a little bit despondent about healthcare, because it feels like this is deja vu. And, you know, but you know, to our original point, and where we met, and how long it took us to get to some of those things that I talked about, there’s clearly some opportunity without getting over too far over our skis. What do you think the potential is? Where do you see this going? You know, what is the future? Hold on? Hold on, what are you excited about?
Ryne Natzke
So one of the things you just mentioned is like healthcare not being, nobody’s gonna accuse healthcare of being an early adopter of breaking technology, I think we’ve all got to be a little bit of patience and have the right expectations of how things are coming in. But I do think, I think we are moving to a place where I need to schedule an appointment, I need care. Alright, I’m gonna go online, do I get this through Amazon? Do I get it through my primary care provider? Do I get it through my insurance directly, and shopping around the way I shop for cars or plane tickets or things like that, I do think that that’s people want that convenience, and they see it in other places. And that’s where I see going for your general care needs and some of those telehealth visits and things like that.
Nick van Terheyden
So providing choice, giving people the opportunity to really sort of make their own decisions about the way that they schedule, the way that they pay. You know, getting all of that, are we well positioned to be able to deliver against that. What’s that? What do you see the timeline for this?
Ryne Natzke
I mean, it’s starting now. So I do think that it’s going to be it’s going to be incremental, it’s going to it’s not, it’s not going to happen overnight. But it is going to move you were going to gradually move there. And I think as the younger generation, if they’re not used to the old way of doing things, they’re not used to necessarily having a primary care provider. So I think it’s going to be a little bit generational too, as people can kind of progress and get more connected to their own health.
Nick van Terheyden
Fantastic. Well, as we do each and every week, unfortunately, we’ve run out of time. I think I’m I’m in agreement with you. And obviously you know you pick a key word for me incremental. I think it is it’s it’s every journey starts with small steps. You know, we’re all looking for the moonshot. But the moonshot takes a small step to start with exciting times. You know, lots happening that I think is positive. Just remains for me to thank you for joining me on the short on the show. Ryan, thanks for joining me.
Ryne Natzke
Thank you so much. It’s great talking to you.
