When Chris Raymond called her insurance company recently to get the price of a brain scan, she came prepared. Or so she thought.
Raymond’s experience as a former medical reporter for the Journal of the American Medical Association gives her an edge over the typical patient trying to navigate the fractured health care system. As an active middle-aged woman who still plays recreational basketball, Raymond has also suffered enough injuries to understand the system from the patient perspective.
Still, she encountered hurdles.
With a $3,000 deductible, Raymond has “skin in the game.” High-deductible health plans supposedly encourage consumers to compare prices for nonemergency procedures, since more often than not they’ll foot much if not all of the bill. But figuring out that price is hardly easy.
Raymond called her insurer armed with diagnostic codes for the condition she was having evaluated. But the company needed procedure codes instead, a customer service representative told her.
She dutifully hung up and called her hospital’s billing office, where a representative informed her the department lacked that information and transferred her to a separate finance division. The woman on the other end of the phone appeared just as lost as Raymond, she said. There were 12 separate billing codes for that type of scan, the woman told Raymond.
“Literally, I could hear her on the phone rifling through a stack of paper,” Raymond recalled.
The representative eventually guessed which code Raymond would need, and Raymond called her insurance company back.
“That doesn’t make sense,” the insurance representative told her. The code, which turned out to be inaccurate, amounted to a charge of just $9.
Raymond then deployed her sleuthing skills and Googled the procedure. According to the code she found on the internet, the procedure would cost her $400. She ended up paying around $300, she said.
Health savings accounts, or HSAs, are a pet issue among Republicans who claim the accounts can turn an average consumer into a sophisticated health care shopper. Despite the increasing prevalence of high-deductible health plans that pair with HSAs, consumers often lack the information necessary for even the most basic cost analysis.
As millions of Americans debate their insurance options for next year, experts are urging consumers to shop around. But without additional price transparency in a fractured and confusing delivery system, many Americans are simply rolling the dice. And the ability to shop is limited since many doctors, such as Raymond’s, typically have admitting procedures at specific hospitals.
The number of high-deductible plans has steadily increased since 2005, according to data from the insurance industry’s main interest group, America’s Health Insurance Plans, or AHIP. In 2016, approximately 20.2 million people were enrolled in high-deductible plans, an increase of nearly half a million consumers from the previous year.
In 2017, the number of people with high-deductible plans reached 42.9 percent of all privately insured consumers under age 65, according to new numbers from the Centers for Disease Control and Prevention. Only about 25 percent of consumers were enrolled in high-deductible plans seven years ago in 2010.
A study published last month in JAMA found that just a quarter of respondents with a high-deductible plan consulted a doctor about the price of a service, while only 14 percent actively compared prices.
Republicans are pushing separate legislative and regulatory efforts to spur even greater use of HSA-like accounts and high-deductible plans. President Donald Trump ordered three federal agencies in October to write rules within six months to simplify health reimbursement accounts, which are employer-funded, tax-advantaged accounts similar to HSAs provided by employers to workers. Trump’s executive order also aims to extend the accounts beyond the workplace, potentially including the health care marketplaces created by President Barack Obama’s legislative overhaul.
Congressional Republicans sought to expand HSAs in their health care bills that stalled earlier this year. Those efforts would continue the push for more consumer-driven care, but experts say patients still do not have enough cost data to make informed choices.
While efforts to increase transparency have helped, the market still has a long way to go.
“It’s an illusion that it’s a market like you would go out and buy auto insurance,” Raymond said. “It doesn’t work that way.”
Raymond works as a web designer for a startup company based in Rockville, Maryland. She pays around $400 in monthly premiums in addition to her deductible and contributes $100 each month to a health savings account, an amount that her employer matches.
Because her plan doesn’t cover prescriptions, Raymond pays the full price of her two generic medications until she hits a $4,750 out-of-pocket limit. Even with a prescription discount card, her efforts to save money can be limited by e-prescribing procedures that can restrict her to a single pharmacy. If another pharmacy has a better deal, she’s stuck, unless she wants to pick up a paper prescription.
The amount of work required to negotiate the system is exasperating, Raymond said. She can’t imagine how a patient with less experience decodes the system.
“How they would ever navigate this kind of stuff is beyond me,” Raymond said, speaking in particular of her parents, both blue-collar high school graduates. “It’s just impossible.”
Gambling on costs
AHIP says high-deductible plans are an “attractive, consumer-friendly” savings option for Americans seeking to reduce increasingly high prices.
The plans do help some consumers save, but often those people are low utilizers of medical services with a firm grasp of their health care costs. Premiums can be much lower in high-deductible plans, translating to overall savings for consumers who can afford to redirect a significant chunk of income into pretax HSAs. Those accounts accrue interest and roll over each year.
While insurance companies are starting to incorporate price transparency tools for consumers to help with this problem, the tools are limited at best, according to Nick Moriello, vice chairman of the National Association of Health Underwriters’ Legislative Council. After consumers parse the different options and settle on a high-deductible plan, many don’t know where to start with pricing, he said.
“The next thought that comes into their mind is, how much are my medical bills going to be because I can’t predict the future?” Moriello said. “And the next issue is, how do I find out prices?”
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Insurer pricing tools often don’t include contracted rates with the patient’s physician or estimates of the consumer’s specific out-of-pocket costs. Transparency tools of any kind are uncommon, Moriello said.
“That’s not the norm. That’s the exception to the rule,” he said.
Those problems persist in the face of the industry’s transition to value-based care, which requires the insurer, the doctor and the patient to be more engaged.
The Catalyst for Payment Reform, which tracks value-based initiatives, estimated that 97 percent of value-based health plans included some type of cost calculator in 2014. More than 80 percent of value-based plans included member-specific considerations like copays and coverage limits, the group reported.
But only 40 percent of commercial health payments were tied to value in some way, according to the group. The shift toward value-based care has been a “slow-moving process,” Moriello said.
“I would wonder what percentage of traditional fee-for-service plans have cost calculators of any sort,” he said. “That number would be very low.”
Republicans have long championed the use of HSAs to engage patients and encourage them to take control of their health care dollars. But recent efforts have focused on expanding HSAs without doing much to give patients more information about pricing.
A bill to roll back the Democrats’ health care law that the House passed in May would have repealed a tax on HSAs and increased the maximum contribution to cover an individual’s deductible and out-of-pocket maximum. (The limit for HSA contributions in 2017 is $3,400 for an individual and $6,750 for a family.)
The repeal effort faltered in the Senate, but that chamber’s legislation also would have allowed consumers in the individual market to use HSAs for monthly premiums. That proposal would have essentially extended a popular tax break for employer plans — one reason employer plans are such a good deal — to people purchasing plans in the individual market.
The tax break for employer-sponsored plans was worth a collective $260 billion in income and payroll taxes in 2017, according to the Tax Policy Center, making it the federal government’s priciest tax expenditure.
Republicans have sought to free that benefit from the constraints of corporate America. HSAs are a core component of House Ways and Means Chairman Kevin Brady’s concept of the health care “backpack” — the idea being that consumers could take health care tax incentives with them from a corporate job to an entrepreneurial job.
“You decide what to put in the backpack,” the Texas Republican wrote in a USA Today opinion piece. “You control it. And you take it with you throughout your life.”
“You shouldn’t have to buy what the federal government mandates you must buy,” Texas Republican Sen. Ted Cruz said in a July floor speech in support of measures that would have expanded HSAs, among other things. “You should choose what meets the needs for you and your family.”
Congress expanded and overhauled the accounts — which under a previous system were known as medical savings accounts — in 2003 as part of the law to create the Medicare Part D prescription drug program. Medical savings accounts were limited to 750,000 people but attracted few customers because of their restrictive and complex structure.
President George W. Bush consistently lobbied for expanded HSAs but received pushback from Democrats and consumer advocates worried in part about how the expansion would affect low-income people. While the concept of tax-free savings are great, they said, it’s an idea that mostly benefits the wealthy.
Congress was also concerned about the budgetary impacts of offering universal HSAs, considering the hefty price tag that the prescription drug bill already carried. The end result limited the scope and availability of the accounts by capping the amount that could be contributed, preventing people from using them for premiums and requiring that they be coupled with high-deductible plans, among other restrictions.
Democrats still worry about the effects of high-deductible plans on low-income consumers. Reports have shown that low-income enrollees in high-deductible plans forgo medical care, including preventive services not subject to their deductible. A 2016 study from the Employee Benefit Research Institute found a decline in services like flu vaccines and breast cancer screenings among low-income workers.
The multilayered health care industry is confusing enough for the average American. Faced with higher upfront costs, patients may find it easier to simply skip the doctor altogether instead of spending hours or days trying to calculate actual costs of coverage, like Raymond does.
“What these high-deductible health plans are doing, in my opinion, is they’re putting most of the onus on people to pay for everything and just shifting the cost away from employers,” said Raymond, who supports a single-payer system, “[They’re] just throwing us out into the wild: ‘You figure it all out.’”
High-deductible plans paired with HSAs, also sometimes referred to as consumer-directed plans, are only a “partial solution,” argue conservative health scholars Joe Antos and James Capretta.
“Advocates of market-based incentives in health care have to be realistic about the barriers to achieving a fully functioning marketplace,” the two wrote in a September brief for the right-leaning American Enterprise Institute. “In the health care market, customers have inadequate information about treatment options, provider quality, and prices of services. The imbalance in information between the patients and the suppliers of services makes it difficult for patients to make independent decisions about their care.”
Millions of Americans are currently weighing their options for 2018 in both the exchanges, where open enrollment began Nov. 1, and in employer plans. Many in Congress, Republicans included, support additional pricing transparency, but the issue receives little attention.
Most pricing proposals that do make it into legislative text target the most egregious practices, such as surprise out-of-network bills, excessive emergency care charges or the practice of balance billing, when a doctor bills the patient the rest of his or her fee that the insurer’s rate did not cover.
Moriello suggests requiring insurers to share their network pricing, but that in and of itself is just a “baby step,” he said, because consumers still wouldn’t be able to compare prices for services under potential plans when they’re shopping for next year.
Jodi Ray, who helps consumers choose and enroll in exchange plans at the University of South Florida, said she starts by asking people how often they need medical care, then helps them map out hypothetical scenarios such as having a baby or breaking a bone.
“It’s not simple. It’s complex,” she said. “I have seen people with very high degrees come in here. They get overwhelmed.”
Moriello often gives consumers general rules for saving money, such as switching to generic drugs, using a mail-order pharmacy or seeking care at outpatient facilities whenever possible.
“But short of those tips, there’s no real transparency in terms of actually crunching numbers and proactively shopping as a consumer,” he said.
If Republicans really want the free-market utopia they envision for HSA owners, they might have to agree to a little regulation.
“There can’t be a free market if I don’t know what the prices are,” Raymond said.