“Hynden was shocked when he got the second CT scan in January, and the listed price was $8,897 — 33 times what he paid for the first test.
Gulf Coast Medical Center is part of his Cigna insurance plan’s approved network of providers. But even with Cigna’s negotiated discount, Hynden was on the hook for $3,394.49 for the scan. The additional ER costs added $261.76 more to that bill.
The higher price from Gulf Coast and its parent company could be a result of their enormous pricing power in Fort Myers, says Gerard Anderson, a professor of health policy and management at Johns Hopkins University.
Lee Health owns the four major hospitals in the Fort Myers area, as well as a children’s hospital and a rehabilitation hospital, according to its website. It also owns several physician practices in the area. When you drive around Fort Myers, the blue-green Lee Health logo appears on buildings everywhere.
“Anybody who’s in Fort Myers is going to want to get care at these hospitals. So by having a dominant position, they have great bargaining power,” Anderson says. “So they can raise their rates, and they still do OK.”
Anderson says his research shows hospital consolidation has been driving prices higher and higher in recent years. And because more and more people, like Hynden, have high-deductible insurance plans, they’re more likely to be on the hook for huge bills.
So Lee Health and other dominant hospital systems mark up most of their services on their master price lists — the list that prices a CT scan at Lee Health at $8,897. Anderson calls those lists “fairy-tale prices” because almost no one actually pays them.
“Everybody who’s taken a look at it agrees — including the CFO of the organization — that it’s a fairy-tale thing, but it does have relevance,” Anderson says.
The relevance is that insurance companies usually negotiate what they’ll pay at discounted rates from list prices.
So from the master price of $8,897, Cigna negotiated Hynden’s bill down to $5,516.14 — a discount of almost 40 percent. Then Cigna paid $2,864.08, leaving Hynden to pay the rest.”
The fact that Medicare has been put on a sound financially footing – for the first time in its history – has never appeared in any official government announcement. Ditto for the fact that the disabled and the elderly may bear a heavy cost along the way.
These facts have not been in the headlines of any major newspaper. They have not been addressed in any news article. To my knowledge they have never been discussed in any opinion editorial. Even more surprising, they are repeatedly ignored by scholars and in scholarly reports at think tanks around the country (other than my own).
Here is a third thing l bet you don’t know. Although Republicans have criticized the “Obama cuts in Medicare spending” as threatening access to care for the elderly, the GOP alternative essentially does exactly the same thing.
What no one bothered to discuss was the much bigger budget story: an enormous reduction in future Medicare spending and its impact on the health and financial well-being of the 54 million people in Medicare.
Here is a bit more detail.
Who is likely to negotiate the lowest fee with a doctor, hospital or some other health care provider? The federal government? A large employer? An insurance company? Or, a patient spending her own money? Strange as it may seem, the answer is often the patient. One of the most persistent myths on […]
Canadians coming to the United States (and paying a cash price upfront) were paying almost half as much as US employers were paying and even less than the typical payment by Medicare. Think about that. These patients not only lacked a big bureaucracy to bargain on their behalf; they were foreigners.
The other factor is third party payment. After the deductibles and copayments are exhausted (which is almost immediately in the case of a knee replacement) the only payer is the third party. The incentive of the hospital is not to lower charges, but to raise them. In fact hospitals typically try to maximize against third-party payment formulas and they have sophisticated computer programs to help them do it.
An individual patient, paying with his own money and willing to travel to another city for care, is a different kind of buyer. If the hospital wants his patronage, it has strong incentives to compete on price.
This very large insurance company, representing tens of thousands of people and their very large employer (the state of California), achieved a remarkable reduction in costs by doing nothing more than sending patients into the hospital marketplace with the knowledge that the money they had to spend totaled no more than $30,000.
Oh, I neglected to mention there is one class of customer that gets knee replacements for as little as one-fifth of what Medicare pays: the family dog. This is for a procedure that involves the same technology and requires the same basic surgical skills as knee replacements for humans.
Source: Free The Patient – Forbes
The Sessions – Cassidy bill:
There is nothing wrong with a little friendly financial heads-up advice regarding insurance. But below the surface, what does all this advice say about the inflated costs of the healthcare system in which we are obliged to navigate, specifically the role of “insurance” in driving those costs?
But there is something more telling about the underlying dysfunction of our third-party billing system based the advice many are doling out, and something you won’t find when evaluating cost-savings strategies in any other industries.
Read entire article via How to Really Stretch Your Healthcare Dollars | Robert Nelson, MD | LinkedIn.
Some things are so familiar or so close to “us” that we don’t see them for what they really are. Take the case of the famous vision impaired artist depicted above, Claude Rhinoir. His tendency to misinterpret his surroundings is a result of his inability to correctly identify something that he lives with everyday.
Such it is with our healthcare landscape, being littered for decades with misplaced oddities such that we don’t even notice them anymore, let alone question their purpose.
And here is the lesson that Claude’s repeated misinterpretation should teach us: Please understand that the concept of “out-of-pocket” expenditures in healthcare is an anomaly caused by our bizarre third-party payment system in healthcare; we call this the billing cycle and it is unique to healthcare financing. Yes they are real, just like Claude’s horn, but completely unnecessary in the picture. And these out-of-pocket costs are grossly inflated, being based on inflated billed charges to begin with; nor would they even exits in most cases if not for the intrusion of third-party payers into the arena of routine healthcare.
Read the entire article at Out-of-Pockets: What They Really Mean | Robert Nelson, MD | LinkedIn.