Doctors asking patients to pay more of their bill up front

As health care costs rise, more patients are switching to high-deductible insurance plans.

When that deductible hasn’t been met, doctors are becoming more aggressive in asking for their payment up front.

This move entirely makes sense, since like other businesses, physician practices are also wading through the difficult economic times.

According to the LA Times, 13 percent of a practice’s revenue comes from patients, and by becoming more proactive at collections, it “may be the only way they can stay open and continue to see patients.”

So, the next time you visit your doctor, and have a high-deductible insurance plan, bringing $10 or $15 for a co-pay may not be enough.

email

Comments are moderated before they are published. Please read the comment policy.

  • Tndoc-to-be

    As a medical student with a high-deductible health policy that covers myself and my three children, I have no real problem with this practice, so long as I am asked to pay my portion of the usual and customary charge that the provider has negotiated with my health plan. I am concerned that some practices might instead ask me to pay a much larger amount than the insurance company would pay. If the insurance company pays $40 for a service, I shouldn’t have to pay $80 for it.

  • Anonymous

    If one pays more than the insurance carrier, maybe that’s a sign the insurance carrier is not doing well. And if the economy gets progressively worse, I suspect that some insurance carriers, especially the small ones, may file for bankruptcies and then no one gets paid.

    The question is how do you find out the financial status of these insurance carriers?

  • Anonymous

    Tndoc-to-be:
    Your sentiments are understandable.
    However, the insurance plans, being completely non-transparent entities, obscure their usual and customary fees, making accurate upfront billing a challenge. This makes the concept of “consumer-driven” healthcare all the more hypocritical, and therefore, a sham. My usual and customary fees are clear; it is what insurance will thinks it should be that is not.

    A family practitioner

  • John

    Most practices have policies that require payment of their stated charges at the time services are provided unless prior arrangements are made–like your insurance being accepted at par and their having to pay the charge. If you have a high deductible plan, you have some leverage to negotiate, but it isn’t reasonable to expect rates below costs or even at the “negotiated” rate by the insurer. If I as a practice owner know a high deductible plan will never be sending me a check (part of the idea) I may be accepting that plan even with an unrealistically low schedule provided I am allowed to apply my charges at my rates to that deductible. If I am prohibited from that, then there may be little reason to want to see any patients under that plan, they would be potential money-losers, even if they are paying cash.

    That isn’t to say you have no power to negotiate–you do, but don’t expect the doctor to accept what the insurer has in its schedule; that may not be workable. Oh, and best negotiate in advance, at least a “not-to-exceed” charge for your visit, and be prepared to pay on the spot.

  • Christine

    There have been women who have whinned in the public that her choice of family first would thrust us back into the image and era of June Cleaver. In my opinion that is not true. It is not difficult to imagine that if June Cleaver had to work a job she would put effort into making sure her family was all right first.

  • Anonymous

    Anonymous 11:35:

    You could seek an agency rating, from A.M. Best, or the like. But many thought AIG was pretty good, so you can’t always be sure how well they really are doing.

  • Anonymous

    Tndoc-to-be still another family practitioner here. Consumer-directed healthcare is hardly a sham, it is growing rapidly and without the aid of the government. Unless you call not killing the program to be “help”.

    As opposed to HMO’s which received a lot of government help in the 1970′s. Otherwsie, no one would have wanted it.

    Consumer-directed healthcare (CDHC) is growing because it works. To the extent that we get any price transparency, it is precisely becuase of CDHC.

    I can’t speak for anybody else, but I set my fees by what the better insurances pay anyway. I doubt I’m unique in that regard.

    So you probably are paying UCR for medical services, at least primary care. I’m starting to look out for labs and imaging facilities that price aggresively for the CDHC market. And I make sure to let the hospital know they are losing that business and offer them the chance to get it in the future.

    So no, it’s not a sham by any stretch of the imagination. I have a HSA for myself, my family, my employees, and I encourage my patients to get them if they’re in a position to choose their insurance.

    I wish HSA’s had existed when I was a medical student. By now, I’d have accumulated enough savings that my HSA would be self-funding, and my family’s high-deductible health plan (HDHP) would be less than $300 a month.

    Personally, when picking the HDHP, I tend to prefer plans that have a network in my area. So the repricing is easily done if needed.

  • Anonymous

    The patients responsiblility for services rendered by the physician depends on the contract with the insurance company. If the doctor is a in-network provider for that insurance plan, the patient pays 100% copay until they reach the deductable. If the doctor is not a network provider, the patient pays the providers fees and the insurance company will reduce the deductable by a “usual and customary” amount-which ultimately costs the patient more.

    “My usual and customary fees are clear”

    I have yet to see a doctor whose prices were transparent. The last time I saw a doctor that practiced at a big hospital based medical center, I was charged $1,200 extra “hospital charge” for a quick in-office procedure. If I had known of this cost, I would not have had the procedure done. Ultimately, I decided I could not afford treatment and decided not to return for follow-up.

    My value in the medical system is that of a “money maker.” I can no longer trust my doctor’s recommendations for making money is more important than my health.

  • Anonymous

    I am not sure if people understand how a “consumer driven” plan works.

    The level of reimbursement is set by the insurance company, not the physician. The physician still has to send a claim to the insurance company just so the company can keep track of the patient’s deductible. The physician can wait for the denial and then bill the patient or try to get payment upfront.

    However, the physician has to charge the patient what the insurance plan says the patient can be charged, in accordance with their fee schedules. And we all know that insurance companies are far from forthcoming when it comes to revealing their fee schedules. Many insurance companies had to be sued to make their fee schedules readily available!

    The article cited in the post comments on software programs needed for physicians to navigate through these plans. So much for simplification. Plus I’m sure this software is not cheap, add that to overhead. I doubt the plans are going to offer to pay for this.

    So what exactly is consumer driven, if not the cost of the service? Simply whether to obtain the service or not. And that’s why it is a sham.

    In my practice, I have seen increased reluctance from patients to come in for services, citing a high deductible. They simply expect more over the phone, free of charge. Of course, I stand my ground but it adds the stress and aggravation of a day.

    And, although this may be hard to believe, the fees in my office are completely transparent for my self pay patients, or for anyone who ask. For example, a 99213 costs 80 dollars and a 99214 costs 100 dollars.

    Again, I am transparent, the insurance companies are not. It is a sham.

    Now, this is how these plans work in my neck of the woods; they may work differently where you are. Also, I think HSA’s are fine if you know how to utilize them.

    A family practitioner

  • Anonymous

    “For example, a 99213 costs 80 dollars and a 99214 costs 100 dollars.”

    I once tried to find out how much my care would cost. Of course I needed a code. The only way to get the code is to for a doctor to give me one. So how do I get up front charges before I see the doctor? At least with my automobilbe, I get an estimate.

  • Anonymous

    Anon 5:31 PM: “…..I have yet to see a doctor whose prices were transparent. The last time I saw a doctor that practiced at a big hospital based medical center, I was charged $1,200 extra “hospital charge” for a quick in-office procedure……”

    You went to a hospital-based clinic. The hospitals do that all the time. They get the clinic space called a “hospital”, and they charge hospital fees.

    I wouldn’t be able to do that, I’m a solo family practitioner. That’s how hospital-based practices compete with truly independent physicians. They find ways to extract more payment from insurers.

    In the past, it made little difference, as the individual was insulated from these goings-on. Now that they see the cost, and are affected by it, they will choose differently. I’d be glad to help them, I do it all the time, with labs, imaging facilities, etc. Always looking for surgi-centers and other places looking to provide price transparency and generate more business.

    Anon 10:03 PM “….I think HSA’s are fine if you know how to utilize them…..”

    You’d be amazed how smart people get when it’s their own money at stake.

    Anon 11:41 PM: 99213, 99214 and all that….

    “….I once tried to find out how much my care would cost. Of course I needed a code. The only way to get the code is to for a doctor to give me one. So how do I get up front charges before I see the doctor? At least with my automobilbe, I get an estimate…..”

    You’re right, you should be able to get an estimate. The codes, by the way, are proprietary to the American Medical Association. They’re copyrighted. People using the codes have to pay to use them. This includes big business and….pay attention now…..government. As in, Medicare, Medicaid, Tricare, etc.

    The AMA gets more revenue from leasing use of the CPT codes than they get from physician dues. I’ll leave it to you to speculate who the AMA is more motivated to please.

    Someone tried to do on-line price comparison a while ago. To do so required use of CPT codes, to make sure you’re comparing apples with apples. The AMA sued them for using the CPT codes. I think the bad publicity caused the AMA to back down on that one.

    I’ll say it again, maybe eventually it will sink in. To the wxtent that we’re getting any move toward price transparency at all, it’s 100% completely BECAUSE of consumer-directed healthcare. The insurance companies had their own price transparency all along, the news is the price transparency is finally making it to the individual patient.

  • Anonymous

    “…..The level of reimbursement is set by the insurance company, not the physician………”

    Well, I guess so, at least for me, in that I set my fee by the best payors in the insurance market in my area. I get pretty much the same numbers when I look at the fee surveys that you pay through the nose for.

    “….The physician still has to send a claim to the insurance company just so the company can keep track of the patient’s deductible. The physician can wait for the denial and then bill the patient or try to get payment upfront…..”

    Yep, the repricing step remains a problem. If that’s the worst problem, we’re in good shape. Some insurers now have real-time claims adjudication. Since many practices discount for full payment at the time of service, the insurers have all the motivation in the world to do this.

    “…..And we all know that insurance companies are far from forthcoming when it comes to revealing their fee schedules….”

    Not following you. As a contracted physician, of course you know what their fee schedule is, you agreed to it. I do agree, the insurers are notorious for giving you a contract that references a fee schedule, but doesn’t give you the fee schedule itself.

    So….uh….ask for it. I always do. And I specifically give then the most commonly used fees in my practice, E+M, lab, etc., to make sure these concerns are specifically addressed.

    Nevertheless, the fact remains, if you performed a service for a patient, under an insurance you’re contracted with, and you don’t know what that insurance allows, you’ve got a problem in your office.

    And if you’re not contracted with the insurer, than this is irrelevant. Your fee is your fee. If your set fee is well out of range compared to what other docs charge or insurers pay, again, you’ve got a problem in your office.

    When I get fee disputes from patients, or more often from claims adjusters, car insurance, property liability, worker’s comp, usually companies that may have a large presence in other states but not in mine. They dispute a particular fee, and I’m not contracted. I can easily shoot back a letter that my fee is within one dollar of the best insurers, within five dollars of others, how can you claim my fee is excessive for UCR in my area? They back down.

    ….also a family practitioner

  • Anonymous

    While it is scary for patients to be directly paying for much of their care for the first time in many decades (ever, for most of them), this is a good thing.

    Third party payment has all but destroyed the doctor physician relationship and primary care. If the insurers and the government were to stop paying for most outpatient visits, that’d be the best hope yet for saving primary care.

  • Anonymous

    Anon 7:46 AM “…..If the insurers and the government were to stop paying for most outpatient visits, that’d be the best hope yet for saving primary care……”

    EXACTLY !!

    As a primary care physician, I look forward to seeing HSA’s grab a higher share of the market. Growing rapidly as it is already.

    I’ve been in specialty clinics during training days. Dermatologists seeing ordinary seborrheic keratoses. Cardiologists treating simple hypertension. Even they would say, there is no reason this sort of work needs to to their subspecialty clinics.

    When patients are insulated from cost, no they don’t care if they go to the derm for the SK or the cardiologist for the HTN. Or more likely these days, they see the cardiologist’s nurse practitioner and the dermatologist’s PA.

    When the patients come to realize they can see me for both. Even if a high level office visit, I will address both and they will still save compared to the two specialty visits, especially if they get called “consultations” as they so often are called…..and billed.

    That’s where the patient self-refers to the derm for the ordinary SK I could have handled in the office, and the dermatologist uses my name to call it a “referral” where I had no desire to refer. Patient either did not tell me, or pressures the office to retroactively refer if they get caught by the insurance company.

    Or, as alluded to by a previous poster, the hospital-affiliated specialist visit gets a hospital fee tacked on because they are inside a hospital complex.

    Status quo ante was the patient was insulated from these costs, though they paid with hassle factor; the biggest losers, of course, were those who paid cash or had high-deductible insurance. So, self-refer and make the primary care doc’s life miserable by making the primary care doc the bad guy by denying the visits….back in the days of mangled care in the 1990′s.

    Now the patient has the opportunity to save money, ultimately profit, by being prudent with his/her own care.

    They get sophisticated real fast when they come to understand it’s their money.

  • Anonymous

    “Now the patient has the opportunity to save money, ultimately profit, by being prudent with his/her own care.”

    I use many tools available to me (internet, nurse line, etc…) to decide if a medical issue can be self treated or needs a doctor’s care. Even with recommendations to see a doctor, I will skip the doctor’s visit, self diagnose and treat because it’s just too expensive just for advice that is readily available on the internet. I have also discovered that follow-up appointments are not valuable if treatment was successful-I used to follow doctor’s orders but now I am more prudent with my care. Preventative screening are just playing the odds…are they really worth the cost? I can check my own blood pressure, cholesterol and blood sugar for a fraction of an office visit. And if I really need medical care, I can go to Walmart and get the blue light special.

    “Or, as alluded to by a previous poster, the hospital-affiliated specialist visit gets a hospital fee tacked on because they are inside a hospital complex.”

    This was a primary care visit, one of the on-site hospital clinics this particular hospital runs. Of course, if I had chosen one of their neighborhood clinics, I would have been spared the extra charge. I guess in the long run I saved money as I ceased my donations to their foundation. I guess I just wasn’t sophisticated enough to realize that this hospital was going to rip me off.

  • Anonymous

    Nothing wrong with your sophistication in my book. You demonstrated you are capable of learning. That’s more than I can say for Congress and the vast majority of people who claim to be healthcare experts.

    You have also demonstrated you can get quite sophisticated about your healthcare when it’s your own money at stake.

    Oh, and don’t think you will necessarily be spared the hospital fee if you go to a hospital-run community clinic that is physically distant from the hospital. They have ingenious ways of getting the equivalent of my solo FP office called a “hospital”.

    Bad news for them, they are bound by a lot of hospital rules as a result. Good news for them, they get to charge fees astronomically higher than I would be able to charge in my solo practice.

    I worked in a FP/Urgent care affiliated with a hospital. It was physically ten miles away from the hospital. But they find ways to get the facility deemed part of the hospital for the purpose of billing. They became part of their ER.

    I worked there from time to time. Every time I worked there, set your watch by it. I’d stick my neck out to the reception area, see someone filling out forms. I go back to see a few patients. Some time later…….where was that guy in the blue suit, where was that lady in the pink dress, the one I saw filling out forms hlaf an hour ago?

    He/she left…..why?

    The patient was cash, or high-deductible insurance, and was told the visit would be billed as a hospital ER visit, with hospital rates, hospital copays. Patient got sticker shock and left.

    They left, of course, for another FP/Urgent care facility that on the outside looked just like ours, but they didn’t finagle ways to get them called a ER.

    Patients got cut out-of-town, sewed them up out-of-town, now back home for a suture removal, faced a multi-hundred-dollar bill to take out stitches.

    The place had price transparency because the receptionist got tired of getting yelled at, after the fact, and made sure the patient knew basic fee structure in advance. I pray it doesn’t get her in trouble to tell the truth.

  • Anonymous

    “Nothing wrong with your sophistication in my book. You demonstrated you are capable of learning.”

    I fell off his bike and ended up with 15 stitches in my knee. I removed them myself instead of getting ripped off at the doctor. I wonder if those patients you mentioned learned this lesson.

  • Anonymous

    A lot of my patients end up taking out their own stitches. I don't encourage it, but can't stop them. Most of the time, the reality is their wife or daughter or sister-in-law or son, whatever, is a nurse or EMT with some common sense and they just end up getting them out.

    I'm at least not going to DIScourage follow-up by pricing the suture removal out of sight. I charge some fairly minimal office visit fee when I'm taking out someone else's stitches. My own, it's usually in the global fee of the surgery in the first place, so no charge. They do the family member thing for convenience, getting them taken out at home.

    I did notice this book recently:

    http://www.alethospress.com/howmuch.htm

    Why health care costs so much:
    The Solution – Consumers
    Dave Racer & Greg Dattilo, CEBS

    Haven't read it myself, but it came well-recommended to me. I'm going to order a copy. Check it out. If as good as described, maybe I'll keep a few copies in the office. We'll see.

    Another FP……

  • Anonymous

    “If your set fee is well out of range compared to what other docs charge or insurers pay, again, you’ve got a problem in your office.”

    When I first went into practice as a psychiatrist in a small town, the major insurer told my patients that my fees (set deliberately by me at about 80% of the national average because of the rural area) were way in excess of UCR.

    I called them and had a very informative chat. They set UCR by area and most of the claims submitted from my area for psychotherapy were by a couple of pastoral counselors, and none by a psychiatrist as none had practiced there before.

    So I have to differ with you—an insurance companies idea of UCR is baloney. The insurance companies fees are only relevant for in-network service by insurance company contracted providers who accept those fees.

    My fees are my fees and I sign no contracts to favor one group over another. They are set fairly with consideration of the value of the service, what other physicians of the same and other specialties charge as well as an eye to other learned professionals for reasonableness. They are collected upfront based on the planned service. Some people don’t like that. Others do, because they know that they have already payed for the scheduled appointment and know what they are out. If there is substantial extra service for that day, a quick glance at ones watch tells them exactly what it is costing them.

  • Anonymous

    “http://www.alethospress.com/howmuch.htm”

    More marketplace health care.

    Perhaps it’s ok that I remove my own stitches to save the minimal office fee since I am an experienced quilter.

    What if I decide it’s too expensive to be evaluated for chest pain? Perhaps my internet search indicates it’s heartburn and don’t want to pay the thousands of dollars for an evaluation. Or I decide to skip those screenings, like mammography, because my risk is only 1% in the next 5 years and with a 10% false positive rate…it could cost me even more money.

    Do I get any sort of guarantee with my health care purchase? After I pay thousands of dollars for years of treatment-only to find I was misdiagnosed-are you going to give me my money back?

  • Anonymous

    I think this discussion is valuable. However, I apologize for my skepticism. If I see a patient with a “consumer directed” high deductible plan, from a plan I participate with, I get paid the contracted right. I do not see how this results in lower healthcare costs and, also, benefits primary care.

    Colleagues: be careful what you wish for. Be suspicious of anything that seems so readily endorsed by the health insurance industry. And, be prepared, for a patient to say, “Why do I have to come in for a refill? It’s going to come out of my deductible” or “Why are you billing 99214? All you did was a 99213!” or “You didn;t tell me I was going to have to pay extra for that urinalysis.”

    A family practitioner

  • Anonymous

    Sigh, so much rhetoric. So many spoon-fed talking points. So little time. 11:11 has legitimate skepticism, fine. But 11:09, spare me the talking points already. It’s getting old……Well, here we go again.

    HSA’s have been in effect since early 2005, and before that, MSA’s. The old Medical Savings Accounts were considered experimental, had a ceiling on the number of participants, and was expected to sunset. It would take an act of Congress to extend the program, and you can’t predict the future with politics like that.

    The Bush administration created HSA’s in 2004. Don’t know how government managed to screw up and do the right thing, but it passed with little meddling. I think it was because everyone was paying attention to Medicare Part D. Not to mention wars in Iraq and Afghanistan.

    But they DID THE RIGHT THING and the bill passed. HSA’s became the law of the land, now requiring the opposite….it takes and act of Congress to make the thing disappear. Only then did you see them take off. Prior to that, it was small, specialty carriers that had them. When HSA’s became the law of the land and I could get group HSA’s for the practice, only then did the big players pay attention to them. Why invest in them if Congress could let the whole thing die by failing to renew?

    The agents tell me I was the first in my little county to get a HSA, for myself and my employees.

    Well, sigh….let’s start.

    If you don’t get your chest pain worked up, that’s your problem. Don’t blame the insurance for your stupidity. HSA’s now have a track record of several years, and the datais coming back. There is no difference in utilization for preventive services between HSA holders and those with traditional insurance.

    You have the HSA, you’ve funded it, don’t come crying to me you don’t have the money. It’s OK if you force someone else to spend money on your behalf, but it’s bad if you have saved money on HDHP premium and you didn’t put aside the money saved?

    You don’t get the chest pain worked up, because you wanted to save your own money, I have as much sympathy as I would if you ruined your car engine because you wouldn’t spend money for oil changes.

    Nor do you have to shop around for price for emergency services and the big services often chosen under stress, like the person just told he/she has cancer. Sheesh, that’s the oldest and most ignorant of them all. Talking point number 1.

    No, you don’t shop price. Listen very carefully, maybe it will eventually sink in……the insurance company shops price. It’s called a network. That’s why I, personally, prefer to pay a little more (and it really is a little), to get a HDHP with a company that has a strong network in the area.

    You want a guarantee with your health care? Tell me where you get that anywhere on the planet. But hey, let me know. When I have to guarantee my patients won’t die, I’ll drop my nursing home practice.

    Most of my patients that take out their own stitches, as I explained earlier, do so because they have a family member with healthcare training. Their daughter the nurse snags a suture removal kit from work and snips them for Dad so he doesn’t have to make the trip to the doctor’s office. So they’re doing it responsibly.

    I charged some minimal fee for this. I have worked in hospital-affiliated clinics that had that “hospital emergency fee” thing going on, and my patients would get sticker shock and leave, when they found out their suture removal would cost…..literally……$200. So they split, and called daughter the nurse. Don’t blame them.

    FP 11:11 I appreciate the skepticism. Fine. I have to admit, I will get patients that nickel and dime that sort of stuff. Of course, I get that under Medicare and traditional insurance, I’m sure you get those types as well. You’ll get more, I guarantee. Sometimes annoying, but hey, isan’t that what we want? Patients that ask “is this really necessary?

    “Why do I have to come in for a refill? It’s going to come out of my deductible” or “Why are you billing 99214? All you did was a 99213!”

    Surely you get that already with traditional insurance, I know I do, all the time.

    You and I will get pretty much the same pay for our services. I expect I will see patients who choose to save money by seeing me instead of three specialty visits for problems you or I can easily treat. I suspect I am, but harder to quantify. So where I think this will benefit primary care, is high-level visits for multi-problem visits that may have gone to specialists in the past. The hypertension visit with the skin tag taken off. I know it’s weird, but I’ve been in derm offices where the patients have come in directly for this without even checking with their primary care doc. Regrettably, some primary care docs refer that stuff as well.

    The competition will be over the medical work with a price tag in the $5000 range. That’s a family HSA deductible. Outpatient imaging. Endoscopy. Labs. Medications. The BID generic instead of the once a day branded drug. Suddenly they can remember to take their medicine twice a day when it’s four bucks versus a hundred. Medrol dosepack versus prednisone.

    But like with the preventive service, the data is coming out. A good four years experience with HSA’s, plus the more limited experience with MSA’s. Enough time to get more solid underwriting data.

    Anthem, just one example, raised premium for their HMO, PPO products in 2009.

    Their HDHP product, associated with their HSA…..they lowered premium.

    http://preview.tinyurl.com/ba5e7l

    Links To Anthem web site. The data is coming in, and it’s showing lower cost but preventive service is maintained.

    Although I appreciate skepticism, I have noticed in the rhetoric among some, I can see the concern.

    The fear is not that HSA’s won’t work.

    The fear is that HSA’s WILL work.

  • Anonymous

    11:11 – by the way, I offer HSA’s to my employees. I have a group HSA. From time to time, I do side-by-side comparison with traditional PPO’s.

    I fund my employee’s HSA, and of course I pay for the HDHP (=high-deductible health plan, that’s the insurance with the $2,000 individual/$5,000 family deductible.

    I fund the deductible to the same $250 deductible the employee would see with a traditional PPO. So effectively, it’s the same coverage for the employee, except the employee has the opportunity to save that money, or some of it, if prudent with healthcare purchases that year.

    It is cheaper for me to buy the HDHP, AND fund the HSA, than to buy a PPO with a $250 deductible. Not a huge savings, but it sweetens the deal.

    I’m not funding family coverage. Thing is, if you have an employee with, say, an employed husband in a trade, as I have, the employee can offer a cheap HDHP for a hundred-some dollars a month or basically convert to family. And about hald the combined HSA is funded by me already.

    If the employee leaves for any reason, that money belongs to the employee. My paperwork ends when I distribute that money to the employee. So you get that COBRA problem, I know you’ve seen it, I certainly have. Left a job and unfortunately gets sick while between jobs or new insurance hasn’t kicked in yet.

    Why don’t you COBRA your old insurance? Well, it would have cost some thousand-plus a month. Fair enough.

    But under HSA rules, if the person is between jobs, the person can pay premium out of HSA savings. That could carry someone through those bumps of a few months between jobs.

    I don’t pick insurance for social engineering purposes, but it’s nice to be able to offer healthcare coverage that helps address these problems….AND I save a couple bucks no less.

    Goodman and Musgrave, in their book “Lives at Risk”, (2004) Rowman and Littlefield publishers, make a good case for a health plan centered around HSA’s and HDHP’s, with subsidy for those with low income, and those with chronic conditions, motivating the individuals to look for the most efficient providers of the services they need.

    If your HSA gets big enough, you can start setting aside enough money for immediate expenses, and put the rest in stocks, bonds, depending on your risk tolerance, within the HSA.

    Even in the presence of current economic conditions, if I had had a HSA when I was in medical school, like the first post Tndoc-to-be, by now I’d have enough saved that I would put HSA savings into conservative income-bearing funds, using the income to pay HSA deductible automatically.

    Basically, I’d have a free HSA. My HDHP insurance, for a family, middle-aged couple and a few kids, would be, runs me about $350 – $375 a month.

    Tndoc-to-be, you keep that HDHP and HSA, and save into it regularly.

  • Anonymous

    “You want a guarantee with your health care? Tell me where you get that anywhere on the planet. But hey, let me know. When I have to guarantee my patients won’t die, I’ll drop my nursing home practice.”

    Tell me where on the planet I would get quality market based health care?

    “I expect I will see patients who choose to save money by seeing me instead of three specialty visits for problems you or I can easily treat.”

    My PCP will only spend 10 minutes to deal with only one problem at a time. And as for specialists, I find appointments are longer, they are more knowlegdable than my PCP, they are more likely to “squeeze me in” during an urgent episode, and call me on the phone when things aren’t going well. All this for only $12 more than my PCP. I have to travel to my specialist and I have considered transfering my care to my PCP who practices 10 minutes from my home. But when things go wrong, my specialist will be available for appropriate treatment, while my PCP will send me to Urgent Care for a band-aid (not at all a cost saver.)

    So where is my cost savings? I find the cheapest practitioner? I refuse procedures my doctor recommends? I don’t see my doctor when I am not sure? If I see three specialists instead of seeing my PCP three times, I save $36. Yippee. Or are you going to provide me with three services and charge me twice as much? Or do I see that nurse practitioner down the street that charges half of what you do for twice the service?

    An HDHP-HSA plan for my family with a $5000 deductible would cost $4300 (if I didn’t have a pre-existing condition-I am probably no longer insurable) per year in premiums. Over the two years I pursued a diagnosis for my chest pain I spent over $20,000 (all office visits, outpatient imaging, etc.) The health plan requires I pay 20% for services after my deductible is met. So with the premiums, the deductible and the out of pocket expenses, I would have paid $20,600 for my medical care in those two years-over 15% of our income just for my health care. Of course, I don’t have prescription coverage with that so tack on another $2,000.

    Get rid of you cable TV and fancy car you say? I don’t watch TV and I commute by bicycle.

    From Wikipedia:
    1. People in these plans allocate substantial amounts of income to their health care, especially those who have poorer health or lower incomes.

    2. Adults in high-deductible health plans are far more likely to delay or avoid getting needed care, or to skip medications, because of the cost. Problems are particularly pronounced among those with poorer health or lower incomes.

    3. Few Americans in any health plan have the information they need to make decisions. Just 12 to 16 percent of insured adults have information from their health plan about the quality or cost of care provided by their doctors and hospitals.

  • Anonymous

    “…..would have paid $20,600 for my medical care in those two years-over 15% of our income just for my health care…..”

    So income annually a little less than $70K?

    I’ve changed my mind. You’re right. There is nothing on this planet that will satisfy you. For you, it won’t matter if you have a HSA or PPO or HMO or The French, Canadian, German, and NHS systems put together.

  • Anonymous

    “What most people really object to when they object to a free market is that it is so hard for them to shape it to their own will. The market gives people what the people want instead of what other people think they ought to want. At the bottom of many criticisms of the market economy is really lack of belief in freedom itself.”

    ~Milton Friedman, Wall Street Journal, May 18, 1961

  • Anonymous

    “So income annually a little less than $70K?”

    I make an median income for the area in which I live.

    And for you FP’s who complain about how much you make-$125,000 in year salary-$150,000 in loans. Make 3 years of payments at 5% interest and you still make more than my spouse and I together.

    “For you, it won’t matter if you have a HSA or PPO or HMO or The French, Canadian, German, and NHS systems put together.”

    I actually like my PPO-I pay a percentage out of pocket. Why would I want to go to a HSA-where an unpredictable illness drains my savings and I then have to chose between sending my kids to college or getting that CAT scan. My only issue with the health care industry is the quality of care I have received. The family practitioners are the worst and I avoid them whenever possible. And since you are so intent on me shelling out my own money for health care, I have begun using alternative providers-not covered by my insurance.

  • Anonymous

    Ah, you you DO have insurance. But you say: “Over the two years I pursued a diagnosis for my chest pain I spent over $20,000″

    So you’re saying….you spent twenty thousand dollars out of pocket for medical care over two years under a PPO???

    “And since you are so intent on me shelling out my own money for health care…..” She’s shoveling it out like crazy under a PPO, more than you would spend with a HSA……?

    With the money I would have spent for a PPO, I can pay for the HDHP, fully fund my HSA, and still have money left over. The maximum out-of-pocket under my insurance is way less than the amount of money you described.

    You know, you like your PPO, fine. Keep it. I’ll keep my HSA. The numbers are the numbers. Even in four years, I’ve managed to put aside good savings for health expenses. I only wish it had existed when I was a medical student like tndoc-to-be at the top of the thread.

    You don’t like your FP, for pity’s sake go somewhere else. Or don’t use the FP at all. Let the specialist do your primary care.

    Actually with the money saved I could spend on alternative practitioners……

    But hey, suit yourself.

  • Anonymous

    “Ah, you you DO have insurance. But you say: “Over the two years I pursued a diagnosis for my chest pain I spent over $20,000″

    Health care dollars-that’s what the doctors billed-and my insurance helped me pay.

    With my PPO, premiums (I used market values-not my employers price-like I did for the HDHP), deductable and out of pocket costs $12,800 compared to the $22,600 it would cost on a HDHP for that two year work-up and I have prescription coverage. And I didn’t have to pay even more out of pocket for my family.

    “With the money I would have spent for a PPO, I can pay for the HDHP, fully fund my HSA, and still have money left over. The maximum out-of-pocket under my insurance is way less than the amount of money you described.”

    It seems kind of short-sighted of you to think that what works for you, works for everyone.

    So if I had a HDHP at the time of my chest-pain work-up I would have spent $10,000 more than I did with the PPO. So market based health care suggests that I would have been more careful with money if my insurance coverage wasn’t so comprehensive. During a very stressful time, I was supposed to shop around for the best price? What if the doctor with the best office visit price charges a lot for labs or imaging? Was I supposed to refuse that CT?

  • Anonymous

    >>During a very stressful time, I was supposed to shop around for the best price?

    Sigh…….this will be my last comment, because you obviously do not read or listen. As I have said, multiple times, and you have repeatedly ignored, you don't shop for price when you're having chest pain. The HDHP insurance shops for price.

    It's called a "network".

    You's not giving accurate figures. Whatever it is you claim you "spent" for fealthcare, didn't come out of your pocket in fact, it came out of the insurance. That was repriced to the insurance network, and was most certainly less then claimed in reality.

    When you have a HSA with HDHP insurance, I am conservative with this and use big players locally (think of a color), they have already contracted with virtually everyone in the area. If I get chest pain, I just go. The docs and hospital will be in-network. I will not get one of those clearly crazy "rack rate" prices where they charge $100K but insurance actually pays $20K.

    I will get billed $20K because I have insurance that has "shopped price" for the big ticket items.

    I will "shop price" for medical services in the $5000 or less range, consistent with my HSA deductible. The vast majority of that is elective, and any layperson can do it. Maybe not you that's your decision.

    You like your PPO….fine. It's a free country. So far. I'm working to make sure the current Administration does not take away my right to contract as I please for my own health insurance.

    I mean that, because the Massachusetts Connector is trying to define "creditable" insurance as anything with a deductible lower than current Federal law. The effect will be to make HSA's not competitive financially, and run them out of business.

  • Anonymous

    “I will “shop price” for medical services in the $5000 or less range, consistent with my HSA deductible. The vast majority of that is elective, and any layperson can do it. Maybe not you that’s your decision.”

    All the medical service I received for my chest pain were in the $5000 or less range. The vast majority of that was elective, and maybe I am not sophisticated enough to call around to all the different doctors in my network to save a few bucks. Oh yeah, my insurer already does this for me. (That hospital based PCP that ripped me off was in-network.)

    I guess I did save the health care system money by not going to the emergency room.

    “you don’t shop for price when you’re having chest pain.”

    After a two year work-up, don’t you think that a fatal heart condition was eliminated first? Although the doctors disagree with my decision, I have decided just to live it. I guess I save the health care system even more money.