Thank you for saying that. I am amazed at how so many people don't see and understand this. It is not just about Cost which is insane alright. It is about the BS we have to go through after a visit to a doctor or hospital. I am scared about the type of bills and claim fights I have to do if I visit a doc. Not because I cannot afford it necessarily. But because I have to spend may be like 5 hours calling doctor's offices, insurance admins, billing departments and what not.
Regular rank and file workers use to have HMOs but those plans have given way to HSAs and PPOs. PPOs were advertised as doctor choice but that's really misleading, all they really do is increase your out of pocket. For a condition that can't be handled in network within a reasonable distance of your house then the HMO insurer has to allow out of network access. HSAs are a great deal if you don't get sick, are rich or can put money in them... but if you need health care they aren't so good since the out of pocket is high.
If we don't get a public option or Medicare for all then I think HSAs will be the future, basically pushing insurance as catastrophic care with some legally mandated primary care covered by default (with a copay).
At least with a $25k deductible you generally won't go bankrupt and you just have to imagine paying off that imaginary new car for 5 years.
In practice, it was less expensive out of pocket for the intensive surgery (a bit over $1000) than it was two months ago for the low-intensity local anesthesia surgery ($1300), even though the initial bill was over twice as high.
At any rate, because of my chronic condition, I'm very sensitive to costs. I'll take the good insurance, thank you!
For my condition that requires regular surgeries (like 3x/year), there are two levels of surgery - one local anesthetic, one general anesthetic. The first time I got the general one done, the bill to my insurance was $35k. This time, with the new insurance, the bill was $19k. So I think the PPO relationship is making a huge difference in how the internal billing works.
At a higher level, the full hospital general anesthetic surgery in January on new insurance cost me less out of pocket than the much less complex local anesthetic surgery cost me in December, on previous insurance.
I was very careful. The doctor was in network, the hospital was in network, and my copay was, I believe, $30 for each visit, covered under my insurance. One day I showed up for my appointment, they led me to a room where I waited 10 minutes. Then the doctor came in, and it wasn't the guy I had been seeing for the last three months. He told me my doctor had taken ill and he was covering the appointments. He asked me how I was doing, and had the nurse redo the dressing on the wound vac. Then we were done.
A month later I received a bill from this doctor for $1900 because he was out-of-network, and while my insurance covered out of network at 80%, they covered it at 80% of the in-network rate. The doctor billed out of network patients at about twice the negotiated in-network rate (a fairly common occurrence), so the 80% coverage was actually 40% coverage, and I owed the other 60% which came to about $1900 for 5 minutes of work (the nurse who changed the dressing worked for the hospital so her work and materials were covered in network.) And the kicker was that I didn't know a different doctor was going to be attending me until he walked in the door.
If you think that maybe your "max out of pocket" will save you, it won't. If the insurance lists a "out of network max out of pocket" it only covers expenses at a negotiated in network rate. Any amount your out-of-network doctor bills that is over the insurance company's in network rate is effectively unlimited. Despite having a $2500 in network max, ad a $5000 out of network max, and a very good health plan. I left that accident with about $35k in medical debt.
(An interesting side note, when it came time to remove the hardware, I went back to the same hospital/trauma center and doctor who had installed it--though a different hospital from above. A day before the surgery I went to the hospital for the pre-op stuff. At the end of the process, the hospital admin met with me to take my payment. I was expecting a $30 copay or similar, but I found out that while the hospital was in network six months before, they had dropped their contract with my insurance company a month prior and the pre-op was going to cost me $800. So of course I cancelled the surgery, but I was still on the hook for the pre-op work. Today every time I visit a medical professional of any kind, no matter how many times I've visited them before, I ask about in network coverage.)
can you think of any other role where a professional interfacing directly with customers wouldn't be expected to at least estimate how much the service will cost them?
However, a car body shop can estimate how much it will cost to fix up my vehicle after a collision with a deer. Those professionals can provide an estimate based on the amount of effort and materials they believe are required. But they don't sit there and try and tell me how much my insurance will pay and how much I will have to pay out of pocket or if my insurance will cover any of the bill.
Obviously in the situation above, time isn't of the essence as much as it might potentially be for a medical issue.
Knowing the "hourly" rates and what treatments may be needed can allow a doctor to estimate the total cost range from a low end to the high end (might be $200 for simple diagnostic and we find nothing more to treat to $2,000,000 if as we progress done the rabbit trail we find evidence that leads up to more tests and it turns out to be cancer). Medical issues are like software development. You don't know what you don't know so God only knows how much effort (cost) will be involved. We can give estimates but the doctor and the software developer shouldn't be trying to figure out if the work involved is covered by external requirements (what and how much will medical insurance cover or does this development qualify for some tax credit or is considered sufficient to fall under some contractual constraint/requirement higher up). Should we expect software developers to know and understand tax laws? Should we expect doctors to know everyone's insurance plans and coverages?
I'll rephrase my statement. medical insurance/billing is too complicated to reasonably expect a doctor or patient to fully understand. this being the case, there should be someone working at the hospital/practice whose job it is to actually understand this shit and give me an estimate at each step of the process. doesn't really fix the underlying problem, but at least then I could make an educated choice between receiving care and being able to afford retirement.
I'd argue though that those best adept at handling the complexity are actually winning in this model. If you are reasonably healthy already and can navigate HDHP/HSA rules, you can have a much higher take-home income + savings than in other countries with government run healthcare systems.
Ironically, the whole point of HDHPs was to put downward pricing pressure on the medical system by encouraging people to price-shop. Alas, due to a variety of market/regulatory factors, that hasn't happened.
We have a pretty pricey insurance plan: family of 4, 36k/year. When my wife had a gall bladder attack and had to get it removed, the insurance company quickly paid the surgeon's bill, and followup doctor visits.
But the insurance company denied the anesthesiologist bill, the hospital surgery room rental bill, and the hospital recovery room bill all as "medically unnecessary", also known as: they won't be covering it.
We tried talking to the original doctor and surgeon but of course they got paid and their offices said the rest of this wasn't their concern. We weren't really sure who we should be talking to to help us show the insurance company that anesthesia is fucking necessary when someone cuts you open.
After about 8 months of stress it was all eventually resolved for a fraction of the original price. In those 8 months though everyone who wasn't getting paid were sending us notices about how we didn't pay yet and how we could set up a payment plan. We talked to hospital billing and they said they usually just drop bills insurance doesn't cover. Usually. And that we shouldn't worry since this happens all the time and that it usually isn't resolved until lawyers get involved.
the usual "gotcha" that people mention is going in for a planned procedure and accidentally receiving care from an out-of-network physician. this makes your out of pocket max irrelevant. I've never had this happen to me and I have no idea how often it actually occurs (outliers are always the loudest on the internet), but it still worries me.
They’ll put a note in your file.
If someone else gets swapped in when your in the table, call back and bitch to them. I’ve had that eliminate the out of network charge.
Is it still a massive pain in the ass we shouldn’t have to deal with? Yes.
I've never been to a doctor without a ridiculous "outlier" scenario following the visit for months.
But the fact that the people with money and good insurance are suffering from the system as well as the poor seems to be lost on Democrats, and the Republicans are just paralyzed by the whole idea of fixing health care. It's a massive political failure for both parties.