Analysis: Employees to face healthcare sticker shock

NEW YORK Sun Oct 28, 2012 1:46pm EDT

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NEW YORK (Reuters) - Visit to New York City orthopedist: $223. One X-ray: $50. One follow-up magnetic resonance imaging test: $766. Total bill for checking out that aching shoulder: $1,039 - all to be paid by the patient, rather than the insurer.

Healthcare has gone retail.

Over the next 18 months, between one quarter and one half of Americans who get insurance coverage through their employers will pay more of their doctor bills themselves as companies roll out healthcare plans with higher deductibles, benefits consultants say. The result: sticker shock.

"They have huge out-of-pocket costs before they get any insurance coverage, it's a real slap in the face," said Ron Pollack, the executive director of Families USA, a healthcare advocacy group.

High-deductible plans set a threshold for medical expenses that an individual must pay for, often in the thousands of dollars, before insurance kicks in. Studies show people on these plans are three times more likely to delay or skip care than people on traditional plans, where doctor or emergency room visits are covered by a relatively low co-payment.

These plans have been around for years, pushed by employers, insurers and industry experts who believe that consumers with "skin in the game" will drive demand for better quality care at a lower cost. It is a rationale also backed by President Barack Obama's Republican challenger Mitt Romney.

But now corporate America's adoption of high-deductible plans is accelerating, partly because of Obama's healthcare reform, which requires insurance plans to provide more expansive coverage such as preventive care.

Several industry surveys forecast a two-percentage-point increase in the number of companies offering only high-deductible plans in 2013 to about 19 percent, and a larger jump of anywhere from 5 to 25 percentage points in 2014.

"2013 is almost a calm period before a period of intense change in 2014," according to Randall Abbott of Towers Watson & Co, a Boston-based senior consulting leader at the human resources firm.

The shift means consumers will have to spend many more hours researching their treatment options and managing costs on websites like Healthcarebluebook.com, which helped budget the cost of examining the shoulder pain mentioned above.

It could also spur lawsuits against doctors whom patients may blame for not making clear whether a test or procedure would spare them future harm, legal experts say.

SKIN IN THE GAME

About 170 million people were covered by employer-based insurance in 2011, according to the U.S. Census Bureau.

Companies with workers enrolled in high-deductible plans in 2012 include General Electric Co, Wells Fargo & Co, Whole Foods Market Inc, Chrysler Group and American Express Co.

In 2013, Bank of America Corp will offer some employees high-deductible health plans. Smokers who work at the bank will also have to pay higher healthcare premiums than non-smokers.

Wal-Mart Stores Inc, which has 1.1 million people covered by healthcare plans and pays 75 percent of the premium cost for workers, is trimming the number of insurance plans that it offers. It has added "healthcare advisors" who counsel employees on care, and has struck a deal with a group of hospitals that could save money on costly procedures.

Employees are going to pay more at Microsoft Corp as well. The world's largest software company, which covers 100 percent of insurance premium costs for employees, will next year ask workers to pay for some portion of doctor bills and other services. It has offered high-deductible health plans since 2006 and also funds employees' health savings accounts.

Deductibles on high-deductible plans start at $1,250 for singles and run up to $12,500 for families. Once that threshold has been reached, consumers then typically make co-insurance payments, usually a percentage of the service fee.

Insurers such as UnitedHealth Group Inc, Aetna Inc and Cigna Corp are putting prices online to help customers manage their spending.

Cigna, where 2 million of its 12 million members are enrolled in high-deductible plans, is upgrading a software application for mobile devices that can be used in the doctor's office, hospital or other provider location to help decide where to go for a lab test or cheaper prescription.

"The other thing is, and this is really hard, is to figure out what stuff is necessary and what stuff isn't," said Nancy Metcalf, senior program editor at Consumer Reports.

For her, that choice meant that during a check-up she passed on an electrocardiogram, which measures the electric activity or your heart and is not a routinely covered test.

FROM DOCTOR'S OFFICE TO COURT

Critics of this shift say it leaves consumers at the mercy of providers when it comes to medical costs. While insurers have been able to leverage their scale to negotiate rates down, ordinary individuals do not have that clout.

That gap may prove fertile ground to patients waging legal challenges against doctor bills.

Haavi Morreim, a lawyer and professor in the College of Medicine at the University of Tennessee, notes that individuals have the legal rights of any customer covered by U.S. contract law, which assumes that there will be a "reasonable charge" for the service.

Two cases based on this notion - one in Indiana filed by a patient against a hospital and another filed in Missouri by a hospital seeking payment from a patient - have reached appeals courts in the past year.

Laws dealing with "informed consent" may also play a role in putting the onus on doctors to clearly disclose costs when explaining treatment options. Doctors may be liable for a breach of fiduciary duty if their healthcare recommendations turn out to be too aligned with their financial interest, Morreim said.

"Courts are beginning to pay increased attention to this because more people are in high-deductible plans and more people are beginning to ask, 'What does this cost?'" said Morreim, who has written several articles on the issue for law journals.

(Editing by Michele Gershberg, desking by G Crosse)

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Comments (10)
I’d bet mule butts to Navy beans that most MRI’s are unnecessary, especially for an, “aching shoulder” or similar conditions. So subtract $766 bucks from the $1.039 scenario.

It’s been in the news recently that, like antibiotics, MRI’s are overly and often unnecessarily prescribed.

Oct 28, 2012 3:51pm EDT  --  Report as abuse
chandleralan wrote:
The same thing happens with medicare. Medical care just bills the govt for as much as they can and bills the patient too. I thought medicare was supposed to be free health care; boy was I surprised, they just piled on what they did and billed us both. Medicare is just a bonus for the medical industry and Obama care will probably be the same.

Oct 28, 2012 5:48pm EDT  --  Report as abuse
morbas wrote:
Utopia;
If taxation was nationalized and only touched income, collected only by the federal IRS, then equally distributed to all three government levels (federal, state, and municipality), then the individual would assume total control. On the subject of healthcare, a government allotment of lowest commoner coverage results in the individual controlling the services one wishes to use from those allotted to everyone. Each individual may choose further coverage based on needs, and conscious as can be personally afforded.
Now you say that is not possible; yet I say, Industry would love it, thus the unstoppable force is present.

Oct 28, 2012 10:15pm EDT  --  Report as abuse
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