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To Be an Informed Healthcare Consumer
I cannot imagine how it is even remotely possible to be an informed healthcare consumer under the current system. With some effort and a helpful provider, one can accumulate useful knowledge about diet and exercise, the effectiveness of various treatments, etc., all of which is well and good. But when it comes to being a consumer in a supposedly capitalist system, one cannot operate as an informed consumer. Throw in government regulation, and all bets are off.
My recent travails with obstructive sleep apnea provide a perfect example of this. I’ve had the study done because I must in order to remain employed but — were this merely a matter of personal health — I would be lost in a raging sea of costs on a night darkened by ignorance. Though I have tried to determine the out-of-pocket costs for this simple procedure, the data is simply not available. In short, I could not (and cannot) use cost as a determining factor. Allow me to explain.
As with pretty much any medical procedure these days, I needed a specialist — in this case, a pulmonologist — to conduct the test and interpret the results. I met with him a few weeks ago for about half an hour. He asked all the same questions I’d already answered in a questionnaire and took a peak in my throat to see exactly what two other doctors had already seen and documented. This short chat was billed for $558. Of course, this is not what the interaction costs or what the doctor expects to be paid for services rendered. No, the actual price of this consultation is $255.51; at least this is the price negotiated between the insurance network and the provider. The baffling part is that I can only discover this actual cost when I receive the explanation of benefits from my insurance carrier.
Where the real challenge comes in is with the actual test. I’ve seen what the clinic billed my insurance, and I know that I’m on the hook for 15 percent. But, until it was billed, I could not get anyone — not from the doctor’s office, nor the hospital — to tell me how much the billed amount would be. Moreover, I am not allowed to know what the negotiated price actually is, which will surely differ from the billed amount, until the insurance company settles accounts and sends me an explanation of benefits form.
If I had to decide whether or not this non-life saving test — which is being performed solely at the behest of the Departments of the Navy and Transportation — was worth the actual out-of-pocket cost to me, I would have no data on which to base my decision, nor any way of acquiring it. There is no way for me, or anyone else, to be an informed consumer of healthcare if we can only know the real dollar amount until after the fact.
Oh, and the five minutes where a technician showed me how to hook up the contraption so as to perform the test on myself at home? That was billed at $166.
Published in Culture, Healthcare
She shouldn’t. I’ve noticed that it improves both job and consumer satisfaction. Doctors feel they are being justly compensated for their education and skills and the patients feel as if they are getting personalized health care. My parents are extremely content with their PCP concierge service.
Concierge medicine is a win-win and not dissimilar to plastic surgery that used to be restricted to the wealthy. Competition always results in affordable pricing!
DocJay had some interesting stories to tell about his “concierge” patients. They pay him for his practice, but they can be high-maintenance.
My doctor is a sole practitioner, and she has a “membership” practice, where we pay her a monthly retainer, and get much better service for it (same or next-day appointments, email access, house calls if needed). She does accept my insurance, but she said if I lose insurance she’d still keep me on, on a cash basis. She does earn extra (no-insurance-accepted) money-she has a laser hair-removal side business, which is pretty profitable.
Concierge patients are high maintenance, but that is why doctors limit the number they take on, at least initially, and charge what they do. Frankly, medicine is as demanding a business as any other profession; the difference now is that doctors are paid accordingly for their hard work.
And that is a good thing for all parties involved.
Concierge medicine is just another word for how family practice used to be practiced.
But with retainers, like lawyers get. Not sure what that says about it.
KP, it might be worth getting your Vitamin D and B12 levels tested. It seems like getting these blood levels up helps get rid of sleep apnea for some people. I use to stop breathing for short periods of time often. Now, my wife hasn’t told me she noticed it for a year or more.
There’s no evidence that I stop breathing in my sleep. My wife assures me it is not happening, but government regulation demands I be tested in spite of contrary evidence.
Oh! Well, glad to hear it.
What is also interesting is that the hospitals will not tell you what the cost will be, but they will insist that you sign a clause agreeing you are responsible for all payments, including(and especially) those not covered by your insurance company. So essentially, they demand a blank check before service.
I just had major surgery, a hip replacement. The hospital bill alone was over $150K. The negotiated cost was $22K (this does not include Dr’s, anesthesiologists, etc). It amazes me that my insurance paid the bulk of this, but never asked me to review the bill or questioned what services I actually received. In fact, they had paid the hospital before I even saw a bill. Hard to imagine a bill this size being paid without some level of audit and verification.
Price discovery is key component of capitalism and allocation of resources. Yet the medical industry works very hard to prevent this. Combine this with third party payers, and of course the costs go up faster than inflation. Increased government intervention only muddies this even further.
My husband’s group has also explored a membership plan, but so far, it seems like a rather exotic, untested idea for this exburb/rural area.
BTW, he is also boarded in sleep medicine. I’d be surprised if he gets that much out it here.
Our health plan is a high deductible plan and has a very helpful website where I can get a lot of information about cost to me up front. I haven’t pushed that very far, because the most intensive health care our family has needed is asthma related or some fairly standard testing. It is very helpful though, for shopping drug prices.
Finally, this point may have been made, but as confusing as the billing and final cost is to us as consumers, the way the providers have to negotiate with the payers to get a percentage of billing and then figure out what they can bill to get only a percentage, both in terms of the market and what is legally allowable, is c-r-a-z-y. The docs in his group used to have a bit of office space. Now that’s all filled with people who get paid to code and bill.
Back in the day, my father in law sometimes got paid in buckets of freshly caught fish or freshly butchered chickens. I’ll bet he didn’t have as many stress related maladies to treat either!
It’s not for your health or anyone’s safety. It’s a jobs program.
Well the results are in and apparently I have mild sleep apnea (O2 drops to 84%, for those who can interpret how bad that is) and get to sleep with an octopus attached to my face until I lose 20 pounds. Lovely.
Going in for a hip replacement next month. I was trying to find out how much out-of-pocket I was really going to have. The prices for the surgery ranged from $13,000 to $250,000! I finally spent about an hour on the phone with our insurer. As best I can tell, it will cost a max of $4500 from my checking account. We’ll see…
Sorry KP!
Being the owner of a startup, we haven’t had health insurance since last year. The only exception is a couple months of catastrophic coverage (which obviously doesn’t comply with the dictates of our benevolent government, to whom all praise and adoration is due) to cover our oldest son through football season.
It’s been an eye-opening experience. And a money-saving experience. Every doctor we’ve gone to has a cash price (we must not be unusual). We’ve been through two concussions, one on each boy, with all the follow-up testing and a suspected broken foot, yet we’ve paid a fraction of what an Obamacare plan would have cost us.
The entire economics of healthcare got turned on its head when the co-pay showed up, and until we get back to a more simple system of paying for only the services we use with insurance for catastrophic situations, nothing will improve.
The reason they guard the negotiated price (often referred to as the “allowed” amount) like a trade secret is because it is. United Healthcare and Anthem are rivals, and will do everything they can to make sure one another don’t have access to that kind of info in a publicly available database.
Some Medicaid websites will publish the fee schedule online. Typically you’ll have to search by the 5 digit procedure code.
In reference to a previous comment, if an internal medicine doctor evaluates you for 15 minutes, he will bill code 99213. If he sees you for 25 minutes, he will bill code 99214. The reimbursement for each is different.
I just searched the state of Washingtin website and they reimburse $39.13 for code 99213, and $58.04 for code 99214. Which is obviously much lower than private payers. If you know which code your pulmonologist billed you should be able to see what Medicaid pays.
http://www.hca.wa.gov/Medicaid/rbrvs
That is true, and it was one of the rationales for “managed care.”
My 36 yr old daughter has “cadillac insurance” – no co-pay -no deductable (work group). A few weeks ago as an elderly pregnant woman the doctor recommended a genetic prenatal screen. She called the insurance company twice and was told it was included in her coverage so she got it. Two days ago she got a bill for $2,225.00.
So demoralizing. They do not have that kind of money. What should she do? I am useless because I am Canadian.
That’s pretty close to what happened to me with a broken arm years ago. And this was managed care, not the current insurance mess.
I broke my arm, and I went to the emergency room. The doctor who saw me in the hospital and set my arm scheduled the followup care at his office.
Of course he did. Orthopedics has operated that way since the first cave doctor set the first cave person’s broken tibia.
Unfortunately, he was not in my “network.” (“Networks” were the insurance companies means of strong-arming doctors into accepting their payment terms and conditions.) When I made the appointment, his office told me, “Of course it’s covered. He is the doctor who set the bone.”
I subsequently got billed $1,000 for post injury care. I fought this bill for a year–to me it was everyone else’s fault but mine. The doctor’s staff should have looked it up before telling me it was covered. And the insurance company should have covered it.
I ended up paying the bill, but I paid $25 a month forever.
It’s getting to be like the IRS these days and those stories we hear all the time–five people call the IRS to get an answer to a simple question and those people get five different answers. That’s because the IRS code is five inches thick.
That’s what’s happening with health insurance. The regulations are so contradictory, confusing, inaccurate, and vague that it is total chaos for doctors and patients.
The confusion is intentional on the part of the insurance companies. Without clear language, they always have an out. And they are bigger and stronger than any individual doctor or patient.
Somehow the answer ends up always being the same: the insurance company is right, the patient is wrong.
ObamaCare was more stupid upon existing stupid.
I don’t know how else to say that. Managed care benefited no one except the insurance companies. Health care was in a financial mess before ObamaCare came along. Now it is a million times worse.
So the latest bit of the adventure was “the doctor ordered you a machine.” Really? He knows what fits both medical necessity and my budget? Of course, this is yet another thing I’ll just get a bill for and have no say in. Apparently I’ll need to be trained in its use which will incur more costs because obviously a person trained to use procedures to work on our nation’s most sensitive weapons can’t read the manual and figure it out. I don’t plan on being unbearable, but stumbling around in the dark like this really gets me going. Even if the machine is super quiet I may still end up sleeping on the couch because I’ll be insufferable.
Years ago, my sister-in-law with four kids, one of whom had multiple orthopedic problems requiring several surgeries (he is now a career Air Force guy, by the way), ended up with a lot of medical bills even though she had top-of-the-line health insurance. (Her husband was a high muckety muck at John Hancock.)
She made us all laugh one day when she said, “Hey, when these bill collectors call me, I just say, ‘I put everyone in the hat each month. If you don’t stop giving me a hard time, I’m not going to put you in the hat.'”
If a plan representative assures you a procedure will be covered and the bill says it isn’t, the problem could be a coding problem. That is, sometimes procedure X fits both in Category A and Category B, with A being covered and B not covered.
If the doctor’s office or lab put X into Category B, X will not be covered, even though X fits into Category A equally well. In that case, persuading the doctor’s office to give the insurer new paperwork with procedure X classified as Category A may solve the problem.
Other times, it’s a prior authorization problem. To keep costs down, many pricier treatments “covered” by a plan aren’t unconditionally covered. They are covered only if some doctor’s office petitions the plan for an authorization before the treatment is done. For example, the doctor’s office may have to testify that cheaper treatments Y and Z are unlikely to work in your case, or were already tried and failed.
In my experience, knowing who to talk to can sometimes lead to a retroactive prior authorization. Logically, if your treatment history shows you were eligible for prior authorization, it’s just a paperwork snafu. Usually, though, you will be stonewalled with, “What part of ‘prior’ don’t you understand?”
Pilli – My max out of pocket would have been $4500 but I knew it was coming so I paid an extra $40 a month for the plan with a $3500 out of pocket. Easy math in that decision. Just be aware that the fact you have hit your max will not be communicated quickly, so you may wind up paying people you shouldn’t. Keep careful track of your receipts. I called my insurer about 3 weeks post surgery and they helped me figure out who I should pay and who they were paying in full. Good luck with the surgery, best thing I ever did. 2 months out and I am already walking over 3 miles a day. So nice to be pain free.
Im having a procedure next week. I also have a high deductible (after losing my original insurance and Dr.).
I called the hospital to ensure my insurance would cover the procedure. Insurance considers this “diagnostic” not preventative, even though if they find something concerning they can try to prevent it from getting worse. Therefore, I am on the hook for the procedure ($1200). I asked the surgery group for the cash price: $600.
Insurance companies co-wrote Obamacare. They are as much a culprit in this financially corrupt system as the politicians.
My dad, an old time family doctor, recommends sleeping in a snug t-shirt with a tennis ball in the back. Said it was the standard Navy approach when he was a flight surgeon back in the 60’s.
I’ve heard that one too but there was no way in h*** I was getting my husband to do that. :)
Exactly. Every time you get an ugly, pointless, paperwork requirement in this stuff, the correct response is to screw up your face into an ugly, angry, expression, pound your fist into your palm and quietly curse “Newt!”
I’m an individual contractor, and when my health insurance became “ACA-Compliant” two years ago, the premium more than doubled and the deductible rose to $15,000 per individual and $30,000 for the family! Bottom line is that I basically pay out of pocket for anything that isn’t “catastrophic”.
My daughter went to the ER earlier this year for something mild, my wife gave them the insurance information and we received a bill for $3500. With a $15k deductible I would have had to pay the entire thing. I never pay medical bills immediately and instead wait for them to go through insurance just in case. Two weeks later, the hospital makes a clerical mistake and sends me a letter saying, “because you don’t have health insurance, here is your adjusted bill, $600.” I saved $2900 because they thought I didn’t have insurance!
Which raises the question…is it moral to tell the hospital you do not have health insurance if in fact you do?