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.

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.

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?

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.

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.

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

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.

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.

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.

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.