The Hidden Costs of Health Care “Coverage”

The Hidden Costs of Health Care “Coverage”

I’m a healthy 48-year old anesthesiologist. At least I was healthy until an unintentional 20 pound weight loss over the summer, accompanied by unquenchable thirst, insatiable appetite, blurry vision, and the bathroom frequency of an elderly prostatic. My lab workup would reveal a high fasting blood sugar of 310 mg/dL, a very high hemoglobin A1C >14, positive urine ketones (showing that my body was breaking down muscle to use for energy), low levels of C-peptide (a byproduct of natural insulin production, revealing that my pancreas was making little insulin), and a glutamic acid decarboxylase (GAD-65) antibody level that was off the charts (which correlates with Type I diabetes due to autoimmune pancreatic islet cell destruction). So, today, I’m suddenly an insulin-dependent diabetic with a relatively rare case of Late Autoimmune Diabetes of the Adult (LADA). That will definitely alter your daily schedule,… as well as immediately put you in the market for a fair amount of pharmaceuticals and medical supplies.

Now that I have my diet well-controlled with careful carbohydrate intake, resulting in a relatively low insulin requirement, I’ve started to look for ways to improve the diabetic lifestyle impediments that can interfere with a busy O.R. schedule and active life. My initial daily regimen has included four glucose checks a day (involving meters, lancets, test strips, swabs, and cotton balls), and up to four insulin injections: long-lasting NPH insulin twice daily as a base, with a sliding scale of short-acting regular insulin at meals and bedtime – all with syringes and vials. That’s a lot of stuff to manage and carry.

I’m transitioning to a single daily injection of ultra-long lasting Triseba® (insulin degludec), supplemented with a once or twice daily dose of Novolog® regular insulin as needed for fine-tuning: all by easy-to-manage injection pens. The next step is to convert from all the finger stick checks to a more streamlined glucose monitoring system. After looking at the few continuous (and flash) monitoring options out there, I’ve purchased the Freestyle Libre® system. It consists of a small 14-day subcutaneous sensor which attaches to your skin, transmitting your glucose level to a hand-held scanner, or to an app on some cell phones. That can save a lot of finger sticks, as well as reduce the daily bulk and transport of required equipment.

The savvy reader might have already questioned how much all of this stuff costs. The short answer: it ain’t cheap. Goodrx.com will show you that the most basic insulin vials of regular and NPH can cost $150 each on the low end, with other types of insulin running $300 to $1000 each per vial or pen. The other necessary basic supplies can add $100 per month or more. Finding out the costs and insurance coverages, formularies and deductibles, co-pays and participating pharmacies is an exercise in frustration – and for the patient reader, that’s where this article is headed.

When I priced out the Freestyle Libre system with a recommended medical supply company, applying my private insurance coverage with the $3,000 deductible, the costs to me for Year One would have been:

 

Handheld reader –  $300 each, one for work and one for home: $600

 

14-day sensor – $193 each x 26 (12-month supply):  $5,018

 

So, of the $5,618 subtotal, insurance would pick up the remaining $2,618 after my $3,000 deductible. I believe that my co-pay for the sensors after the deductible was met was quoted around $70 each. That would leave me with another $900 or so for roughly 6-months worth of the “discounted” sensors.

That all seemed a little pricey to me for a technology that cannot be more complicated than my Android cell phone, Chromebook laptop, or Playstation 4 – any of which cost me about the price of one single, quoted glucose reader – in the neighborhood of $300. So, I started looking for direct pricing. Goodrx.com priced me readers and sensors for about $70 and $55 each, respectively. That calculates to a Year One cost of roughly $1,600 – by paying out-of-pocket at Walgreens. Hmmmm… $1,600 versus $5,600. For the exact same products. A FOUR THOUSAND DOLLAR DIFFERENCE! A 350% markup, if my math is correct.

So, it appears that I (coupled with my employer/group contribution) can pay roughly $6,000 per year in insurance premiums for health care “coverage,” then a $3,000 deductible before that coverage takes effect, at which point I may still be liable for co-payments… and then I get the privilege of being in the covered network for which I will pay a markup of unnecessary, additional thousands of dollars. A 350% tax? Again, the savvy reader might question where all that money goes, if just directly paying for a more transparently-priced medical service or supply can be had so much more affordably?

The thoughtful among us might also question:

What services are insurance corporations actually providing today?

Has the catastrophic medical insurance market morphed into an expensive, non-transparent, buyers’ club which surreptitiously raises prices for everyone while financially benefiting a potentially useless class of interlopers by skimming excess profits… perhaps to the tune of many billions of dollars per year?

What are the economic distortions in the medical market when true costs are difficult to acquire?

What is the cost of supporting the streams of third-party individuals, entities, organizations and bureaucracies that stand between a patient-consumer and a physician end-service, medical supply service or drug manufacturer?

What role is the FDA playing in encouraging or inhibiting competition, price transparency, and corporate protectionism?

What if you and your doctor have no idea what anything in the system really costs?

What if your doctor would happily provide you a service at a fraction of what your insurance “coverage” bills you?

What if your insurance company profits more in the health care transaction than does your physician? 

What if she would be happy to charge you far less in a direct transaction… rather than participate in an awkward “provider-insurance corporation-subscriber” threesome of purposefully disjointed communication and secrecy?

What does it mean that in order to essentially avoid being defrauded of large sums of money, a patient like myself must spend many hours searching for solutions outside of the accepted “system” which enables that fraud?… And how much more difficult must it be for patients without health care experience to maneuver through that system?… Especially if sick and financially disadvantaged?

This physician-patient, for one, has been awakened to the power of price transparency and interloper-reduction. Health care “coverage” is, admittedly, very expensive. In contrast, what do the actual medical services and supplies cost, absent the interference and markup? What if we could cut the price tag of our health care by 350% just by pulling the costs out into the sunlight and eliminating the unnecessary intermediaries in exchange for direct and transparent care models?

Although a minority of physicians and patients operate in a freer medical market, there are well-established and growing options in play that bypass opaque, expensive and unnecessary obstacles to affordable medical services. Direct Primary Care (DPC) practices like Atlas MD and 1,000 others around the country; transparently-priced surgery centers like Surgery Center of Oklahoma and many others; advocacy groups like the Free Market Medical Association; Liberty and other health shares; laboratory, radiology and pharmacy service companies that offer transparent and discounted prices; and comparison marketplaces like MediBid to help you find them… all are growing service providers responding to a demand for more transparent, understandable and affordable medical services. By putting in a few hours of research as I did, you may be able to save yourself thousands of dollars in unnecessary medical costs. Few would deny that health care “coverage” is expensive, but medical services do not have to be.

Dr. Rice is a private practice anesthesiologist currently in Pittsburgh, PA. He has particular interests in free market medicine, graduate medical education, and physician resident advocacy.

Would you like the $9,400 CT scan or the $450 CT scan?

Would you like the $9,400 CT scan or the $450 CT scan?

We’re not all careful. Some of us ride motorcycles on the highway,… recklessly. A nephew ended up at a Level I trauma center in Houston, Texas, in March of 2016 as a result. He was patched up and lived to ride another day. Ten months later, his dad gets the final itemized hospital bill. As doctors in the family, my wife and I opine on medical matters with some frequency. The dad texted us a picture of the bill. As you are sure to expect, the charges were for ridiculous amounts that no one really pays. Most people probably think that these matters just get handled somehow, somewhere, between insurance companies and hospitals, then the patient pays some reduced amount of that massive charge, bewildered but happy to walk away still financially solvent after the threat of a bankrupting and indecipherable hospital bill. For most people, that vague understanding (and narrow fiscal escape) seem to be enough to be able to put the experience behind them. For others, though, we want to understand what the *expletive* is going on?!

As I looked through the 44 items billed to my nephew, there were a few which I could not identify despite my proficiency in medicalese. Some charges stood out as being so excessive that I felt guilt in being associated with hospital systems (which almost without exception follow the billing practices that will be described here). For years, I have been frustrated with the opacity of medical billing, physician “reimbursements,” and the seemingly secretive third party alliances which keep doctors and patients in the dark as to costs, pricing and revenues streams. This has led me to investigate and promote the growing numbers of medical practices and facilities that choose to operate direct-to-consumer with transparent and competitive pricing. Out of curiosity, and in disbelief at the hospital charges, I decided to attempt to find a transparent retail price comparison for each billed hospital item where possible.

Using some simple online searches, I quickly found cost comparisons for radiology and lab tests, as well as some pharmaceuticals. Pricing Healthcare, Good Rx, and Health Tests Direct gave me the bulk of the comparisons. For intravenous medications, which are more difficult to find for public consumption, I found some equivalent medications at a veterinary site, Medi-vet. Before you recoil at using a dog medicine, rest assured that these are the same sterile, safe, medical grade pharmaceuticals as those used on humans – some are the same brand that I personally have administered to patients. They just happen to be transparently priced because the veterinarians typically operate outside of the constraints of government and insurance company contracts in honest pricing models.

Tallying the 24 of the 44 charges for which I could identify and find a comparison, the hospital charged over $35,000 while direct-to-consumer retail businesses offered similar services for $3,200 (a price difference of over 1000%). For example, the $9,400 CT scan of abdomen and pelvis with contrast is offered for $450 in Dallas at Southwest Diagnostic Imaging Center (a 2,000% price difference). The $6.68 generic hydrocodone with acetaminophen pain pill can be readily found at Publix or Safeway or Walmart pharmacies for about a quarter each (a 2,600% price difference). Check out the table nearby for more head-shaking and sigh-inducing comparisons.

Hospital administrators are sure to retort: “but those tests aren’t of the same quality that we offer! These tests are done in an emergency and high acuity settings, which are expensive! We have very high overhead costs to cover and have to make up for those that don’t pay their bills!”

All of this may be true. True and unprovable? True and irrelevant? True or not, it definitely is not the fault of the billed consumer. A few years ago in Houston, I was pleased to hear economist Tom Woods of the Mises Institute talk on this topic. In response to such arguments, he opined, “your bad business model is not my problem.”

Bad Business Models

Where did the hospitals’ bad business model come from? Why are things the way they are? How did such a convoluted, if not collusive, system ever develop? Why do insurance costs keep rising? Books and innumerable articles have been written from a multitude of perspectives to explore those questions. The short answer might be that after more than fifty years of continual intervention into medicine by third parties (insurance corporations, lucrative hospital “non-profit” corporations, legislative bodies, and innumerable government agencies), patient and physician have been removed from as much of the health care interaction as possible. The primary participants have no idea what anything costs. The numbers are decided and exchanged behind closed doors with secret contracts negotiated by teams of lawyers and high-powered executives. There is no downward pricing pressure because the costs are well obfuscated from those that incur them (the physicians ordering the tests and medication) and those that pay them (the hapless patient that pays her insurance premiums in perpetuity, then the co-pay at time of service, then the deductible, and perhaps even a residual percentage of the bill) . Who knows how much money has been spent or where it went? To make matters worse, every economic incentive is to charge more.

In business, everyone understandably desires to receive as much for their product or service as the consumer or market will pay. But by hiding true costs, it is possible to eke out more than the consumer would knowingly agree to. (Imagine buying a vehicle and driving it off of the lot without any idea what you would be billed… many months later.) Admittedly, hospitals incur costs for the uninsured, under-insured and for emergency care that may be poorly reimbursed despite the hospitals’ tax benefits, direct taxpayer funding and government grants. They have an incentive to increase prices to recoup potential revenue losses, but also to accumulate very large cash flows to buy up the competition, purchase physician practices, and to build new facilities all around town.

But who really pays those massive hospital charges? Probably few, and maybe nobody. One might think that insurance companies would balk at such extreme charges, but they don’t pay those rates, either. By listing very high base charges (which can be found in every hospital’s typically elusive chargemaster), the hospital can show a generous concession to the negotiated fees with insurance companies and government payers. The insurance company, in return, can show its supposed advocacy to customers by how much it “saved” them in inflated hospital charges, thereby justifying higher premiums and deductibles. This distorted and distorting arrangement is the foundation of the cycle and incentive structure of ever-increasing prices in health care. Although I hate to admit it, physician groups are guilty, as well. To the extent that we participate in third-party billing, we too, will and must price services very high as a starting point to a low negotiated “reimbursement” by insurers and the government. Thus, a patient will commonly get a $2,000 bill for anesthesia services in my field of medicine, while the recovered payment to the group may only be a few hundred dollars or less.

So, what’s the solution?

Some may be ready to concede that mandating health “coverage” by law has not bent the cost curve of health services – nor has any previous legislative intervention of decades past. If the incentive structures and hidden costs described above are accurate, one might determine that forcing full participation in a highly flawed system can only worsen its inefficiencies and distortions. A few years ago at a meeting of the Free Market Medicine Association in Oklahoma City, one of its founders, Dr. Keith Smith, told us, “medical services are not expensive. Health ‘coverage,’ on the other hand, is very expensive.” When one is able to distinguish between the two, it becomes evident that in order to introduce downward economic pressures to our out-of-control health care prices, honest and transparent direct-to-consumer pricing must be at the core of the solution.

Today, as patients and physicians alike seek more truthful, ethical and affordable pricing models, there is a growing trend towards Direct Primary Care and transparent pricing of medical and surgical services. While every aspect of Big Medicine and its myriad lobbyists may oppose such moves, these drives to transparency are at least part of the solution in bringing down costs, extracting expensive but low-value middlemen and bureaucracy, putting control back in the hands of consumers, providing information to patients for honest evaluations of quality and value, and re-establishing the one to one relationship between patient and physician. So, the next time you need medical services, you may not be asked the question, “would you like the $9,400 CT scan or the $450 CT scan?” but if the situation permits, you just might benefit from doing some shopping.

[*the author’s views do not represent the views of his academic or employment associations… guaranteed!]

References, accessed between Feb 8 and Feb 10, 2017

sodium chloride 1-liter bag IV fluid $2.24

lidocaine 2% $2.58

Health Test Direct:

Basic metabolic profile (panel)  $40.93; complete blood count (CBC) with differential $24.79; PT and PTT combined $41.97; red blood cell antibody screen (Coomb’s test) $36.77; blood type ABO and Rh factor combined $32.48

https://pricinghealthcare.com/prices/SouthwestDiagnosticDallas/CT%20Scan

Pricing Healthcare, Southwest Diagnostic Imaging Center:

CT scans $275-$450

Plain film diagnostic x-rays $93-$150

Hydrocodone: multiple pharmacies under $15 for sixty tablets = <$0.25 each

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