NEW YORK, N.Y. — Visit to New York City orthopedist: US$223. One X-ray: US$50. One follow-up magnetic resonance imaging test: US$766. Total bill for checking out that aching shoulder: US$1,039 – all to be paid by the patient, rather than the insurer.
Health care has gone retail.
Over the next 18 months, between one-quarter and one-half of Americans who get insurance coverage through their employers will pay more of their doctor bills themselves as companies roll out health-care plans with higher deductibles, benefits consultants say. The result: sticker shock.
“They have huge out-of-pocket costs before they get any insurance coverage, it’s a real slap in the face,” said Ron Pollack, the executive director of Families USA, a health-care advocacy group.
High-deductible plans set a threshold for medical expenses that an individual must pay for, often in the thousands of dollars, before insurance kicks in. Studies show people on these plans are three times more likely to delay or skip care than people on traditional plans, where doctor or emergency room visits are covered by a relatively low co-payment.
These plans have been around for years, pushed by employers, insurers and industry experts who believe that consumers with “skin in the game” will drive demand for better quality care at a lower cost. It is a rationale also backed by President Barack Obama’s Republican challenger Mitt Romney.
But now corporate America’s adoption of high-deductible plans is accelerating, partly because of Obama’s health-care reform, which requires insurance plans to provide more expansive coverage such as preventive care.
Several industry surveys forecast a two-percentage-point increase in the number of companies offering only high-deductible plans in 2013 to about 19 per cent, and a larger jump of anywhere from five to 25 percentage points in 2014.
“2013 is almost a calm period before a period of intense change in 2014,” according to Randall Abbott of Towers Watson & Co, a Boston-based senior consulting leader at the human resources firm.
The shift means consumers will have to spend many more hours researching their treatment options and managing costs on websites like Healthcarebluebook.com, which helped budget the cost of examining the shoulder pain mentioned above.
It could also spur lawsuits against doctors whom patients may blame for not making clear whether a test or procedure would spare them future harm, legal experts say.
Skin in the game
About 170 million people were covered by employer-based insurance in 2011, according to the U.S. Census Bureau.
Companies with workers enrolled in high-deductible plans in 2012 include General Electric Co., Wells Fargo & Co., Whole Foods Market Inc., Chrysler Group and American Express Co.
In 2013, Bank of America Corp. will offer some employees high-deductible health plans. Smokers who work at the bank will also have to pay higher health-care premiums than non-smokers.
Wal-Mart Stores Inc., which has 1.1 million people covered by health-care plans and pays 75 per cent of the premium cost for workers, is trimming the number of insurance plans that it offers. It has added “health-care advisors” who counsel employees on care, and has struck a deal with a group of hospitals that could save money on costly procedures.
Employees are going to pay more at Microsoft Corp. as well. The world’s largest software company, which covers 100 per cent of insurance premium costs for employees, will next year ask workers to pay for some portion of doctor bills and other services. It has offered high-deductible health plans since 2006 and also funds employees’ health savings accounts.
Deductibles on high-deductible plans start at US$1,250 for singles and run up to US$12,500 for families. Once that threshold has been reached, consumers then typically make co-insurance payments, usually a percentage of the service fee.
Insurers such as UnitedHealth Group Inc., Aetna Inc. and Cigna Corp. are putting prices online to help customers manage their spending.
Cigna, where two million of its 12 million members are enrolled in high-deductible plans, is upgrading a software application for mobile devices that can be used in the doctor’s office, hospital or other provider location to help decide where to go for a lab test or cheaper prescription.
“The other thing is, and this is really hard, is to figure out what stuff is necessary and what stuff isn’t,” said Nancy Metcalf, senior program editor at Consumer Reports.
For her, that choice meant that during a check-up she passed on an electrocardiogram, which measures the electric activity or your heart and is not a routinely covered test.
From doctor's office to court
Critics of this shift say it leaves consumers at the mercy of providers when it comes to medical costs. While insurers have been able to leverage their scale to negotiate rates down, ordinary individuals do not have that clout.
That gap may prove fertile ground to patients waging legal challenges against doctor bills.
Haavi Morreim, a lawyer and professor in the College of Medicine at the University of Tennessee, notes that individuals have the legal rights of any customer covered by U.S. contract law, which assumes that there will be a “reasonable charge” for the service.
Two cases based on this notion — one in Indiana filed by a patient against a hospital and another filed in Missouri by a hospital seeking payment from a patient — have reached appeals courts in the past year.
Laws dealing with “informed consent” may also play a role in putting the onus on doctors to clearly disclose costs when explaining treatment options. Doctors may be liable for a breach of fiduciary duty if their health care recommendations turn out to be too aligned with their financial interest, Morreim said.
“Courts are beginning to pay increased attention to this because more people are in high-deductible plans and more people are beginning to ask, ‘What does this cost?’” said Morreim, who has written several articles on the issue for law journals.