Even Patients Are Shocked by the Prices Their Insurers Will Pay -- And It Costs All of Us

[erronis]

https://kffhealthnews.org/news/article/insurers-pay-high-prices-premiums-coinsurance-cost-control-inflation-patients/
Elisabeth Rosenthal

Samantha Smith of Harrisburg, Pennsylvania, went into the operating room for emergency removal of an ectopic pregnancy. "I'm grateful I didn't die," she said, but she was shocked to see that the outpatient surgery was billed to her insurer for about $100,000.
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Jamie Estrada of Albuquerque, New Mexico, twice received injections of lidocaine in his upper spine to test if a permanent nerve ablation would treat his chronic neck pain. His pain vanished -- until the numbing agent wore off about six hours later. The real zinger: His insurer was billed $28,000 for each 10-minute procedure.

Mark McCullick of Longmont, Colorado, was sent for a whole-body PET scan to find out whether his prostate cancer was back. The two-hour scan showed no evidence of cancer, but the $77,000 bill sent to the company that administered his insurance alarmed him.

Medical inflation has steadily outpaced general inflation for years, with bills for many brief, routine procedures reaching tens of thousands of dollars.

These cases highlight the questions that haunt the American health system and the patients caught in its grip: What is a reasonable price for any health care visit or procedure, and how is it determined? How hard do insurers, the purported stewards of the patient's hard-earned health dollars, fight to lower charges, and how closely do they scrutinize bills for accuracy?

Smith, Estrada, and McCullick's cases are all "chargemaster" bills, calculated from the master price list that health providers place on services. Patients who have insurance don't generally pay them. But they matter because they are often the starting point for the negotiated price the insurer agrees is reasonable to pay for the services. Patients are typically responsible for 10% to 20% of the negotiated price, their coinsurance -- and when prices are this high, that can be a big number. What's more, those negotiated rates are difficult for patients to access (until they get the bill) and seemingly arbitrary.

Also, because health insurers can offset high outlays one year by raising premiums and deductibles the next, they have little incentive to bargain hard for good deals for the patients they cover. So patients all pay unknowingly, indirectly.

. . .

Elisabeth Rosenthal, senior contributing editor for health news analysis, joined KFF Health News in 2016 as editor-in-chief after 22 years as a correspondent with The New York Times. She had covered a variety of beats for the newspaper, from health care to the environment, and did a stint in the Beijing bureau. While in China, she covered SARS, bird flu, and the emergence of HIV/AIDS in rural areas. Her 2013-14 series, "Paying Till It Hurts," won many prizes for both health reporting and its creative use of digital tools. Her book, "An American Sickness: How Healthcare Became Big Business and How You Can Take It Back," was a New York Times bestseller. She is a graduate of Stanford University and Harvard Medical School and briefly practiced medicine in a New York City emergency room before converting to journalism.

[area51]

1. And it doesn't have to be this way.

pnhp.org

[erronis]

2. I was in Vermont when they started down the Single Payer path

and started working for the Vermont health care board that would have been central to its functioning. Unfortunately they chickened out because of industry (insurance) pressures and a lot of misinformation on how it would save the state money.