Wednesday, June 27, 2012

The Discussion I Wish We'd Had About Healthcare...


The Supreme court is about to rule on the constitutionality of the Affordable Healthcare Act, otherwise known as Obamacare. I just want to put my two cents in as a person who is self insured. My cousin sent me an article about the stress and difficulty of dealing with medical bills. I know this first hand as, unlike many people, I see every one of my medical bills and have to pay a lot of them myself, while also having to pay insurance premiums to cover my family. In this article they profile a woman whose business is to help people wade through their medical bills. Why do they need this service? Here's why: (I encourage everyone to read the whole article)

Hospital care tends to be the most confounding, and experts say the charges you see on your bill are usually completely unrelated to the cost of providing the services...“The charges have no rhyme or reason at all,” Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health. “Why is 30 minutes in the operating room $2,000 and not $1,500? There is absolutely no basis for setting that charge. It is not based upon the cost, and it's not based upon the market forces, other than the whim of the C.F.O. of the hospital.”
And those charges don't really have any connection to what a hospital or medical provider will accept for payment, either. “If you line up five patients in their beds and they all have gall bladders removed and they get the same exact medication and services, if they have insurance or if they don't have insurance, the hospital will get five different reimbursements, and none of it is based on cost,” said Holly Wallack, a medical billing advocate in Miami Beach. “The insurers negotiate a different rate, and if you are uninsured, underinsured or out of network, you are asked to pay full fare.”
With the exception of Medicare and Medicaid, experts say, the amount paid for services — or the price your insurers pay — is based on the market power of the insurance company on the one side and the hospitals and providers on the other, and the reimbursement agreements they ultimately reach. So large insurers that command a lot of market power may be able to negotiate lower rates than smaller companies with less influence. Or, insurers can place hospitals or providers on a preferred list, which may help bolster their business, in exchange for a lower reimbursement rate. On the other hand, well-regarded hospitals may command higher prices from insurers.
So let's say you have coverage through a high-deductible plan, where you're responsible for, say, the first $5,000 or $10,000. It's possible that you may have to pay more out of pocket for your medical services than your friend, also in a high-deductible plan, but one with an insurer that has greater negotiating power. “The ones that are affiliated with the larger insurers do best,” Mr. Anderson said, adding that the uninsured have virtually no bargaining power, which is why they are expected to pay much more.

So let's put this into context. When my daughter had multiple ear infections, and I mean like five in a six month period, she was recommended for ear tube surgery. The surgery literally takes fifteen minutes. They put a tiny slit in the ear drum, put a small tube in so the infection can easily drain out; thats it. To give a little background info, my daughter had so many issues this particular year that I wanted to pay more for my insurance so I could get more coverage as I was I paying so much more money out of pocket.  My insurance premium was about $500 a month (by the end of my time with MEGA Life and Health, I was paying over $800 a month due to bi-yearly increases, along with thousands of dollars of medical bills which were not covered by my insurance. I had to pay for all care of my second child because when she came out of my uterus, she had no insurance, therefore the baby had to pay full price for her care. TRUE STORY). I was rejected because she had recurrent Otitis Media and abnormal gait (ear infections and difficulty walking both due to normal kid infections). I was not allowed to PAY MORE FOR MORE COVERAGE because they were worried she would cost them more.  But to continue…

I was trying to figure out how much the ear tube surgery would cost. Since most of it would probably be under my $3500 deductible, I wanted to see the actual cost of the surgery so I would know how much I would have to pay out of pocket. I called the hospital. I talked to two or three people. No one could tell me how much the procedure was! I was given excuse after excuse about not knowing what was going to happen in the operating room, if there might be a problem that adds to the cost, the doctor's cost was unknown…you name it, they had an excuse for it.  The doctor I was using only did surgery in this hospital (which shall go nameless because they SUCK. I checked my daughter in myself because there was no one at the desk to check her in when I got there). I have limited money. My daughter could possibly eventually sustain hearing loss due to these multiple infections. My insurance would only cover a small part of the surgery and I wanted to find out how much the service would be and NO ONE could tell me how much the surgery costs!  But I have to get the surgery done.  Reading this article shed a lot of light on my situation.

Those of you who have insurance through your employer rarely have to go through what I have gone through as a self insured person. Your coverage is better than mine because your companies have more clout to negotiate with the hospitals. The hospital that housed my daughter's surgery didn't want to tell me the price because they didn't know how much my insurance would pay.  They could jack up the price at will depending on which insurance I was with. 

Understand, if everyone in the country is insured, the price premiums go down. If everyone is in the same insurance pool, there is the possibility that prices are more stable. This is part of the law:

But one of the overarching ideas behind the law, according to Mike Hash, acting director of the Center for Consumer Information and Insurance Oversight, is to eventually encourage insurance plans to provide detailed information on, say, the quality of care and how much your share of the costs will be if you choose to have your knee surgery, for instance, at one provider versus another. He also expects more clarity on out-of-pocket costs, which will be capped at reduced amounts for people who buy insurance through the state-run insurance exchanges and meet certain income requirements. But other out-of-pocket limits will apply to other people who buy plans inside and many plans outside the exchanges, experts said.

People go bankrupt because of medical bills! It's awfully difficult to shop around for the best cost when you have stage 4 cancer, time factors such as prognosis for survivability and needing medicine right now and all…. When you have a broken leg, you need it set immediately. It's not a good time to price check.  Clarity in pricing means a little more certainty as to what is coming: I had found the best doctor to do my daughter's surgery.  Shouldn't I be able to know how much I have to pay before hand??!  I hope this part of the AFA is not struck down.  I wished that America had had a real discussion about health care rather than a political one.  It took me YEARS to pay down my medical bills, switch insurances, and understand how to negotiate my way through the morass that is the current health care system. Obamacare my not be the entire solution, but it's at least a start.

1 comment:

  1. Hello,

    My name is John and I have a quick question about your blog! Could you please email me?

    Thank you,

    John

    ReplyDelete