Thanks ACA!

There are certainly ways to decrease healthcare costs but people won’t like them.

In general, you have to promote preventative care over reactionary. You have to spend a lot of effort in making sure people are compliant with their medications. They need to have regular check-ups, etc. The key is to keep the person out of the hospital. There is a need for realistic reimbursements for health care providers. Reimbursements for specialists should go down and for primary care providers it should go up. In pharmacy, a $1 profit isn’t going to cut it. It is not uncommon for generic drugs to see that the profit margin is less than $3. Pharmacies need to make $10 per rx to break even. It isn’t uncommon for practices to double book Medicaid patients due to their high no show rate and low reimbursement.

The true cost savings comes from healthcare limitations. You can significantly decrease costs by having a closed drug formulary That means in each drug class; only one drug is preferred. All the others require a PA. You see this in the VA. For certain procedures, you shouldn’t cover them if the individual has a poor prognosis i.e. no more hip/knee replacements for 90 year olds. Also, for end of life care, we need to be more realistic about it. One of the most expensive medical period’s of a person’s life is his/her last 6 months. In short, you need people to accept less.

Since all this is rolled out by state, complain to your own state about the plan choices and their regulation of policy costs and doctor options. Whether insurance companies are truly held in check and/or held to certain standards is a matter of that regulation. And be careful of generalizing based on you own state issues.

My cost in early 2013 was already $9600 for a very good employer plan for four of us. A family change raised it to $13300 on private, before ACA took effect. Cobra would have been 21k+.

I had to find a plan last year. Now that plan won’t be offered in 2016 so I’ll have to search out a new one again. The cost increase last year (for my 2015 plan) took me by surprise. I expected the cost to go up but not as dramatically as it did. I now have a high deductible yet pay quite a bit more. Unfortunately, I have a feeling I’ll be paying more yet again. I like my new doctors and don’t want to search for different ones.

Cost and inability to just settle into a plan and keep it for more than a year makes me lean to the side of those who say something’s not working.

Back in 1990, my mom was diagnosed with breast cancer. She’d switched insurance as small business owners tended to do after a few years with a company (low rates for the first 2-3 years, then major hikes). The switch was about 6 months prior to her DX. The new company denied her claim because they said it was a pre-existing condition. Never mind that the previous year’s mammogram didn’t show anything, they were certain the cancer was there before the switch.
It took some amazing doctors to get that turned around.

3 of 5 of us + mom have had cancer. We’d all be basically uninsurable today.

My insurance is through my employer. There are expanded choices, most of which benefit the younger or healthier employee. I’ve been able to keep my plan pretty much as-is. There are some things I don’t like - can’t use Walgreens, vision is going to some peculiar company that I won’t use, but premiums are flat. No change next year.

I can go to the ER and my records are immediately pulled up, including prescriptions. This was fantastic when my mom was taken there and we didn’t have the list with us. They had all her records from her many doctors, which kept communication errors down.

The biggest issue I have is with the consolidation in medical practices. Instead of private group practices, the doctors have been “encouraged” or pushed into medical center affiliated practices. Due to the hassle the medical center put her clinic through, my dr changed affiliation and moved a few more miles down the road. I like her, but the hospital isn’t convenient, so I can’t move to a cheaper plan. (The new thing is no copay & low premium if everyone I see is part of the same hospital system.)

I understand the enonomies of scale, but unless we can get to a single payer system, there are going to be problems and cost growth.

@Nova10 - I agree with you that our culture of consumption is contributing greatly to the rise in medical costs. Who wants to wait a week for an MRI? Or forego it completely for some good old fashioned diagnostic skills? We tend to think that more procedures = better care. It’s not absolutely true, but it feels like it’s true because we’re doing all that we can. It’s an expensive perspective to take.

I have MS but have been stable for a while. My neurologist still wanted me to have an MRI this year, and to include the brain, cervical spine, and thoracic spine. I got hit with three separate co-pays for that and nothing I paid counted towards my deductible. Damn her curiosity, I knew it wasn’t really necessary. But it’s there, isn’t it, and that makes it hard to resist.

I remember the very first time I had bloodwork done. I was 28 years old and pregnant. My kids’ pediatrician ordered it for them, geez, I can’t even remember how young they were. Did they have any troubling symptoms that would indicate a need for bloodwork? No. But that’s how it’s done now.

In some ways our ultra-medicalization is good. Many more people get flu shots nowadays and they are relatively cheap and efficient.

I am going to disagree with this a bit, because the ACA not only described who could get insurance and how, it also set standards for that insurance. Many people upset about drastic rate increases were previously getting insurance that didn’t really insure anything important, or that could be cancelled on a whim, or that omitted things that they were certain they would never need. So yes, the type of insurance has changed for many people, from cheap garbage to more expensive but functional.

One huge change vs. 40 years ago is the cost of drugs. Back then, most plans didn’t cover drugs at all, and typical prescriptions were a dollar or three. We lived around the corner from the drugstore, and as the oldest I was charged with getting them and paying for them. Many were around a dollar.

Prescription drugs today in the US are tremendously expensive, and as we’ve seen in the past months, even some relatively lower-priced drugs have had their prices jacked up enormously. It used to be that when the generic came out the price dropped tremendously – now the generic is likely to come in not far below the original drug’s price. Given the limitations Congress has placed on negotiating drug prices, it is the most poorly managed component of our healthcare costs, and the numbers are huge.

Those major medical plans of yore also didn’t cover doctor visits. Or maternity care. Or childhood immunizations. Even 25 years ago we paid out-of-pocket for all D’s well baby visits and immunizations because the insurance policies through our employers didn’t cover well-baby care. (And, we were thankful to have a well baby.) And those birth control pills were strictly my cost.

They also didn’t cover much of anything in the way of psychiatric/mental health/habilitative care. I completely support those being required services, but it certainly isn’t cheap.

The good old days weren’t so good, IMO. Even in the days when we had dual coverage (which ended up being first dollar coverage) there were lots and lots of uncovered costs.

I still find that most people do not have any idea how much health insurance really costs today because when you get it through your employer the vast majority of the premium costs are paid directly by the employer. Luckily, your W-2, box 12DD shows the total of your employer’s cost for your health insurance plus your premium contribution.

I see lots of tax returns and W-2 forms. At mid and larger size companies, box 12DD usually has numbers in the $14,000 - $20,000 per year for family coverage. You may only be paying $4000 a year for your share of the premium, but the employer is paying the vast majority. Presumably, your wages are depressed relative to what they would have been because of these costs.

Back in 2012, here’s how the numbers shook out for a family of four: “According to the MMI, this year employers will on average contribute $12,144 of the $20,728 total cost while employees— through payroll deductions (an average of $5,114) and out-of-pocket expenditures ($3,470) — will pay the remaining $8,584.” http://www.insurancejournal.com/news/national/2012/05/15/247598.htm

That’s $17,258 in premium cost for family coverage through an employer-sponsored plan three years ago.

If you’re comparing privately purchased insurance with the amount employees pay as premiums in an employer-sponsored plan, privately purchased insurance looks really, really expensive.

If you’re comparing costs against the total premium costs (employer plus employee) then monthly premiums look more on track.

Part of the problem with all this is people are not fully aware of the costs, and they also compare apples and oranges. When we were growing up, going to the doctors office was not expensive, and drug costs were relatively low, too. The range of lab tests were pretty small, the amount of care available by today’s standards was small, it was a different world. The major med most companies offered (including the one I had when I was first working 30 years ago) didn’t cover office visits, and was basically an 80% kind of deal, so if you got sick, you ended up paying a lot more. The managed care networks came about in part to encourage people to get preventative care and also came about because the old style plans costs were already soaring (in a managed network, doctors agree for a fee structure, in return for gaining access to a pool of people in that plan on a semi exclusive basis).

I can tell you that with employer plans, the costs have been skyrocketing, and while employers have shifted some of it to employees, a lot more of it, they still are bearing huge increases. ACA has been the excuse, but if you look at the cost of insurance coverage, it has been going up as huge multiples of inflation, when inflation was roughly 3%, premiums were going up 12% a year or more.

I have had older people on Medicare tell me that the rise in healthcare costs are greed, that medicare is so cost efficient, that it isn’t responsible for the increase in costs, without of course realizing that medicare is a kind of shell game, where the real cost of medicare is assumed by the broader pool of the insured, but not in an efficient way. It is socialized medicine where much of the cost in a sense is not paid by the medicare taxes we all pay, but rather in the form of a double tax by our premiums being increased because of cost shifting from hospitals and doctors to make up for the relatively little medicare pays.

Another thing I routinely hear is how it is no big deal that people aren’t insured, that a lot of them are younger people who don’t want it, people who don’t want it or don’t want to pay for it…the problem with that is they also don’t realize if that person gets sick, how much it will cost that system. That 20 something skateboard dude they used in some ads I saw for a health exchange if he fell and cracked his head (because he wasn’t wearing a helmet, naturally) will end up in the hospital, and someone pays for that, and it is mostly through cost shifting. That person who didn’t want to buy health insurance, thought it was a waste, when a family member gets sick, would be like the idiot who refused to pay his fire tax, then when his barn caught fire wanted them to put it out…

I agree with what others have said, it also is going to have to come down to costs and figuring out what medical care is appropriate. Funny one thing I haven’t heard mentioned, in the ‘good old days’, you never saw ads for prescription medicines, when you got sick your doctor decided what the best medicine was, and prescribed it. Now the airwaves are flooded with ads (and I am leaving out ‘lifestyle’ drugs like viagra and cialis, they already are rationed). Whether it is blood thinners, immune suppresants, arthritis drugs, drugs to cure hep C, cancer drugs, we are inundated with ads, whose whole purpose is to get people to use those drugs , even if they may not be needed, someone who has athritis who might be better treated with a low level anti inflammatory goes in wanting an expensive drug like Celebrex, because they saw the ads. I don’t know why prescription meds are allowed to be advertised like that, if we keep saying health care should be between a patient and a doctor, why are they allowed to do that? It ads to the cost of medical care, and it isn’t chump change.

There also have been plenty of studies that say that some ridiculous percent of health care is spent on maintaining the last month of life. It raises ethical questions and tough ones, but for example, is it good use of healthcare dollars when you have someone who is 85 years old with a late stage cancer, trying every procedure there is to put it in remission? If someone is in the hospital, and is constantly crashing and being revived with little hope of them every recovering, is keeping them alive like that good policy? Obviously, to the loved ones, it is, and it is a horrible choice to have to make, but if we are extending so much of our resources keeping someone alive the last month, should we be doing that? And yes, it is horrible, because who decides? If a parent has a premature child who has so many things wrong with them they are unlikely to live more than a couple of months, they will want to try and keep the child alive, for obvious reasons, how do you handle that, when the cost of keeping that child alive might be in the millions of dollars? These are issues our current system being so fragmented doesn’t handle, and what happens is these costs mount up, the bill goes to the person receiving care,they go belly up, then the provider recoups that by charging everyone else extra, which in turn drives up rates.

The real problem is people want easy answers when they don’t exist, and most of the solutions I hear are slogans. Saying “people need to be more responsible for their health care decisions” is a slogan, and one that is mostly untrue, given that when people are sick, they depend on doctors to give them appropriate treatement, saying “people should shop around for medical care” makes it sound like geting treated for medicine is like getting a car painted or getting your house renovated (and actually, unless people are foolish, taking the low bid on those kind of services is often not wise, you have to look at quality and such as well), would you go to the Earl Schieb cancer center, advertising “We can cure any cancer, 1995.99, guaranteed” or would you want to go to a place with an established reputation for beating cancer? I hear that people don’t realize the cost of medical care, it is too insulated from them, that they want ‘too much’, but the reality in this country is people find out the cost of medical care the hard way, when something bad happens…despite all the claims to the contrary, the single biggest category for financial distress and filing for bankruptcy is not credit cards, it is medical bills, and they learn about the cost in the school of hard knocks. One of the things ACA was trying to prevent was that, that people couldn’t be fooled that their supposed health insurance covered things and it didn’t through a bunch of exclusions. Health plans routinely were dropping people who got a catastrophic illness, and got away with it, ACA doesn’t allow that and other abuses, and with ACA, you know what the plans cover, they cannot for example suddenly refuse to cover liver cancer or leukemia because those are now required. In a sense, maybe ACA is now letting people know the real costs and the real issues of medicine.

I think the real problem is we are doing everything we can to patch together the existing system, which is held together with bailing wire and spit and chewing gum rather than coming up with comprehensive change that affects the whole system. What that is, or what is best, I certainly don’t know, I know 35 years ago this system was a mess, and most things that were done since then have turned out to be band aids. Put it this way, the health of people in the US is not a luxury IMO, health care shouldn’t be something that is a birthright of how well off you are, where you live, it is funny we talk about all the threats the US faces, whether it is economic competitiveness, the ability to defend ourselves, the threats to our quality of life, if you have a population that has poor healthcare, limited access to it, it likely is not going to be the kind of country we pride the US on being.

@musicprnt, post #48 may be the most cohesive and amazing post I’ve ever read on this issue. I think you summed it all up quite nicely.

Such a complicated issue, and no matter what solution is proposed, somebody isn’t going to like it. Everybody wants what’s best for THEIR family circumstances, everyone else be damned.

@prospect1:
That is pretty much it, and if you add in the many players who have a piece of the action, it is complicated. Employers complain about the cost of health insurance (and rightfully so), but they also hold on to health insurance as a benefit they can use to compete with other employers, and fight tooth and nail against single payer (put it this way, given how expensive health insurance is to companies, why do lobby trade groups like the US Chamber of Commerce fight alternatives to employer based healthcare?). Doctors, caught in the squeeze with the health insurers, buy diagnostic labs and treatment centers, use them for their patients, often those centers unlike the doctor are out of network, so they can bill the patient for what insurance doesn’t cover, and it can be expensive (or if in network, the doctor orders a ton of tests, which if you think about it, is a conflict of interest, but it is perfectly legal). I thought what you said was summed up best in an image from some rally, where you had an older person holding up a sign, that said on one side “No Socialized Medicine”, and on the other “Government, hands off MY Medicare” , it tells the whole story IMO.

It is actually nearly impossible to know what the cost of medical care will be, until after you have received it and been told by your insurance company.

And even then the bills and EOBs and what-not are nearly incomprehensible.

Price-shopping is virtually impossible, even if you wanted to.

Thats not true. If you are having a procedure or procedures done, the Drs office should be able to tell you what your expected copay is prior to service. As long as they know the procedure codes being used, and assuming the Dr will be billing with an accepted diagnosis code, the billing office knows what the insurance allows for that procedure code or codes. These are contracted rates.

** That said, Drs can’t discuss their rates with each other, lest they get accused of federal antitrust violations. So some Drs offices may be hesitant to discuss fees if you are not a patient.

^ Assuming you have a diagnostic code, maybe. But who the heck knows what the diagnostic code is for anything?? How would I, not being a medical professional, have any idea what code anything is?

If I need an MRI, I might want to use the cheaper location, because my OOP cost is probably a percentage of the price, or maybe I am paying 100% because I haven’t met my deductible yet. My insurance company likely pays different amounts to different providers for the same MRI, depending on location/whatever deals they’ve signed. But good luck trying to get that information.

The hospitals around here all negotiate their own reimbursement rates with the insurance companies. So the price can vary widely from one place to the next for the exact same thing. And because of the way they bill, from person to person. If you call one up and ask “how much for an acromioplasty”, to pull an example out of my past, they will laugh at you.

It’s an almost completely opaque process.

You can also check the healthcare bluebook for basic reference.

I’ve discussed costs with my daughters’ and my docs. Sometimes, the final bill came in lower because those big bad insurers are also holding docs to negotiated caps. But the doc staff has always been able to suggest the range. One D went for a specialist procedure and the desk clerk ran it by the insurer and quoted me my exact cost while I stood there.

It does depend. For some procedures, until they start, they can’t know the extent of the “work.” They can know the initial codes, but not what else they will need to do. All my doc reps have been frank about that. They can, eg, tell you the cost of an x-ray, but not whether they will need additional angles. But I can still get an idea. Eg, for something at the hospital, I was told the incremental (time) charges for the procedure room, the doc charges for the code he expected to use and the one he might have to add… They couldn’t tell me how long I’d be in there, for certain, but expected 15 min and a max of 60 min.

This isn’t a shelf product. You don’t always want to price compare, change docs to save a few dollars. I did research my options for that procedure and learned it was less at an ambulatory…and the wait was longer.

I get that we want it easy breezy and cheap.

Again, states regulate your plan/policy options and costs. Some better than others. In mine, not only is oversight effective, the citizens are vocal.

I remember (as I am sure many of you do) when HMOs were going to solve ALL of the increasing healthcare costs. Back when my kids were little I loved our pediatrician, but he stopped taking our insurance. I was glad to pay out of pocket, as we (luckily!!) did not have to visit very often. One of my kids got a bad ear infection (our ped did not routinely give antibiotics for ear aches but this was a bad one). We ended up with several office visits and the other ped used an instrument to check his hearing. The overall bill was $250! At that point we switched practices which was fine, but not nearly the same level of love. At this point, the co-pays for many doctor visits are similar to the what it cost to visit the doctor pre-HMOs.

One concern with all of this is the unexpected charges incurred when a doctor on a procedure or in an operation is not in-network and the patient is then expected to pay out of pocket at the non-network rate. The patient is not told the other doctor is not in-network or given choice of in or out of network. The cost of medication is outrageous in many cases (the recent case of the drug company that raised the cost of a drug by thousands of percent just because they could!).

The ACA is not perfect. Certainly one positive is that our college grad kids get to stay on our plans until age 26. Hopefully, most will have their own employee-based insurance they can afford well before that. But nice to have that option.

To me, one very important aspect is that insurers cannot drop someone because they have a pre-existing condition. People used to be trapped in jobs because if they switched they or a family member would no longer be covered. Or people would simply be un-insurable.

I have a family member who was self-employed and had to be buy individual plans for many years. She said that the plans would change, not be offered, or the prices increased dramatically year after year. The ACA may not have fixed that, but certainly most people can now get insurance.

Mom, all I can say is that, for my insurer, they will all be treated as in-network, when there is a procedure your own in-net doc initiates. This applies to ED here, too, as the hospitals are in-net. We went thorough a heck of a lot of permutations on the former ACA thread and confirmed much is not as scary as some media reports. My D2 was also in-net for ED in her college area, hours away, in another state. For an office visit there (off campus,) we did have to confirm the doc was in-net and eventually just had her come home, as the wait would be longer. YMMV.

This all varies by your own area.

You tell them the procedure you are having. If you are having a colonoscopy, they know the procedure codes and likely diagnostic codes.

Maybe, but the differences are probably at best slight, and if your provider is in network, if you have met your deductible you will just pay the copay/coinsurance. If not you will pay the negotiated rate (they will be pretty close between providers, and many are not really flexible-- providers are given a contracted rate- take it or leave it. Your out of pocket will go towards your deductible.

OK, lookingforward- what is ED? All I can think of is erectile dysfunction and am guessing that’s not it! Eating disorder? Emergency Dept ? (usually its ER)

Our insurance is changing this year. My H’s company is changing to a HSA or a prohibitively expensive tradional plan. We are going to try the HSA and see how it goes. My H has an auto immune disease and is on a drug that costs $30,000/year. In the past our co pay was $240/year and now our maximum out of pocket is $6000 which we will use every year. I’m nervous how this will all work out. I am taking the max that I can in the HSA and hope that it’s enough.