Mark Whiting told an ER doctor “no thanks” to an overnight hospital stay and an MRI.
Lori Johnson Apgar worries that out-of-pocket medical costs will push her Papillion family out of the middle class.
Note that treatment for most conditions found during screening are subject to cost-sharing with patients. Some of the conditions for which screening is available:
>> For adults: Alcohol and drug abuse, aortic aneurysm, blood pressure, cholesterol, colorectal cancer, depression, diabetes, immunizations, obesity, sexually transmitted diseases, tobacco use.
>> For women: Anemia, breast cancer genetic testing and mammography, breast-feeding support, cervical cancer, contraception, domestic and interpersonal violence, need for folic acid supplements, gestational diabetes, human papillomavirus, osteoporosis, Rh incompatibility, urinary tract infections and well-woman checkups.
>> For children: Autism, behavioral assessment, blood pressure, cervical dysplasia, depression, developmental problems, dyslipidemia, fluoride, hearing, height and weight and body mass index, hematocrit or hemoglobin, hemoglobinopathies or sickle cell, HIV, hypothyroidism, immunizations, lead, medical history, obesity, phenylketonuria, sexually transmitted infection, tuberculin, vision.
John Boldt figures some of his clients will avoid getting the prosthetics that he makes and just, well, limp along.
Mike Berlin fears that instead of getting the help they need, some of his Excel Physical Therapy patients will “just deal with their ache and pain, hoping it'll go away.”
Facebook comments include this: “If it doesn't require an ambulance, I'm not going.”
The biggest culprit in each of these situations is the deductible, which is basically the amount of money an individual pays before the insurer starts paying. Deductibles have been on the rise for years but now are an increasing focus of health consumers' pocketbook concerns.
Try on some sticker shock: $6,350 for an individual, $12,700 for a family, numbers guaranteed to bring a reaction, even though they're higher than most people will face.
Those are the limits for out-of-pocket expenses under the Affordable Care Act, counting deductibles, copayments and coinsurance. At the same time, the law requires insurance to cover basic preventive care at no cost to consumers.
But deductible creep predates the law. In the past five years, the average deductible in a typical group insurance plan rose 74 percent to $2,821 for families, according to the Kaiser Family Foundation.
Experts say deductibles will continue to rise for most people, including the 150 million Americans who are covered by employer group insurance, as well as the individually insured.
As the main component of out-of-pocket spending, high-dollar deductibles put the cost crunch onto the consumer, forcing many into considering money when they make health care decisions.
“With health insurance, up until now this might not have been something that people would have thought about all that much,” said Bankrate.com insurance analyst Doug Whiteman of North Palm Beach, Fla. “You check a box during open enrollment time and go on your merry way.”
Today's reality is that the person who doesn't bother to check health care costs can end up spending a lot more.
Even within the same ZIP code, one provider might charge twice as much as another for the same service, said Martin Rosen, co-founder of Health Advocate Inc.
“We as Americans shop around for saving a nickel on gas or 2 cents on a gallon of milk, but we're not attuned to doing that when it comes to health care,” Rosen said.
Yet it's difficult to change people's behavior, said Tom Gilsdorf, director of product development for Blue Cross Blue Shield of Nebraska.
“It has been ingrained in us that you go to the doctor, they tell you what to do, and that's what you do,” Gilsdorf said. “Everybody should find a doctor they listen to. But there's more we can do as consumers, to say, 'What's that going to cost?'
“You should always trust in the advice of your doctor, but that doesn't mean you shouldn't ask questions.”
That's exactly what Mark Whiting did last summer. His deductibles have risen substantially, even though he's a principal with Mercer Group, a Kansas City, Mo., company that advises businesses nationwide on health insurance benefits.
Whiting turned his head quickly while playing tennis, suddenly losing his balance and falling. It happened more than once, and he couldn't figure out why.
His regular doctor recommended a CT scan, but the office's scanner staff had left for the day, and the doctor sent him to an emergency room. There, the CT scan showed nothing amiss. The ER doctor suggested having an MRI and checking into the hospital overnight for observation.
Whiting stopped to consider: I'm going to have to pay most of this myself. Is it worth it, since the CT scan didn't show a problem such as a brain tumor? Was the ER doctor just covering himself because of potential malpractice concerns, in case the problem turned out to be serious?
It even occurred to Whiting that the ER doctor might be thinking about revenue for the hospital. He decided against the MRI and the hospital stay. The problem turned out to be with his inner ear, and less-expensive treatments were effective.
“I would have spent all that money and it would have had absolutely no impact,” Whiting said. “It's the probability thing that I wrestled with. I had to make that assessment on my own.
“That's one where you have to understand that the doctor's trying to do the best thing for you, but also some protection for him. And I pushed back on him. That's part of that consumer thing.”
Such decisions can be risky, however. “If people wait until it's too late or until things are bigger problems, it would be more expensive,” Bankrate's Whiteman said.
Boldt, a certified prosthesis orthotist with Advanced Prosthetics of Omaha, said he sees some patients each year who haven't visited a doctor in years, only to find out that they have conditions that should have been treated much earlier.
“I'm worried that there's a lot of people that are cost-avoiding health care,” he said. “Then you lose preventive care and you end up with catastrophic costs.”
There are no certain guidelines for what consumers should do when faced with medical choices, beyond asking questions and learning as much as possible. Besides, consumers often are missing a key fact: cost.
Medical providers are trying to address the lack of transparency, but it's not universal.
Omaha Imaging expects people will be searching for bargains and last month started publicizing discounts for cash, priced at $425 for an MRI, $250 for a CT and $150 for an ultrasound.
“We think it's going to be like car insurance, where you're going to pay out-of-pocket first,” said marketing director Blake Thompson. “We're trying to come up with more affordable costs.”
Without knowing prices in advance, it's difficult to be a savvy health care consumer, said Cliff Gold, CEO of CoOportunity Health, a Des Moines insurance coooperative that markets products in Iowa and Nebraska.
“Not many physicians are aware of the cost of the services they order, particularly if they're not doing it in their offices themselves,” Gold said. “Unless you're an inquisitive consumer and ask the questions, you're not going to find out.”
The differences can be huge: Is this a $30 copay for an office visit or a $3,000 test that's on your deductible?
“Doctors do not want to worry about cost,” Gold said. “You don't want the benefit plan to interfere with the actual practice of care and what's best for the patient.
“However, the rising cost of care and the attention that the health care system has gotten of late should give both practitioners of care and patients a reason to ask questions and consider alternatives.”
Some doctors may keep costs in mind, he said. A patient with a headache may ask for an MRI, but the doctor may suggest a pain reliever first. Some patients may prefer surgery over physical therapy because they think it's an easier fix, despite the cost, Gold said.
Once consumers have a financial stake in their medical care, he said, “It does make both the practitioner and the consumer sit back and say, 'Are there alternatives to this that don't endanger my life?', and there often are.”
Asking whether there's a cheaper generic alternative to a name-brand medicine is a relatively simple question, for example.
The future of medical costs is not entirely bleak, however, especially the Affordable Care Act's requirement that insurance cover all costs for preventive care such as age-appropriate screening for such diseases as breast and colon cancer.
It's the consumer's responsibility to use those “free” services regularly to avoid more serious medical problems later.
The law also eliminated lifetime “caps” on insurance coverage and set a limit on annual deductibles, although today's dollar amount is indexed to health care inflation. And insurers can't deny coverage to people who apply.
Many employers also are giving incentives to stay healthy through wellness programs, in many cases actually reducing employees' costs. Again, it's up to the employee to take part in the program.
One hope is that consumers, faced with paying for a big chunk of their care, will help push down costs of health care down by choosing health care at least partly according to cost.
From that standpoint, higher deductibles are not an accident.
Higher deductibles have followed higher medical costs, often because employers and insurance companies want to control monthly premiums. Generally, insurance plans with high deductibles have lower premiums than low-deductible plans.
Besides keeping premiums more affordable, higher deductibles give consumers more “skin in the game,” an incentive to control expenses that will come directly out of their pockets. Employers and insurance companies also save money when consumers pay more of the costs.
“Deductibles are just one lever of the benefits equation,” Blue Cross' Gilsdorf said. “Premiums go up when benefits expand, everything else being equal,” and that puts pressure on deductibles, too.
Having a high deductible makes sense if you don't plan to have many medical costs in a year, because such a plan keeps monthly premiums down, Gilsdorf said.
High-deductible health plans are purposely designed to have consumers pay more out-of-pocket, but also can be paired with health savings accounts that carry tax advantages and end up saving money.
High-deductible plans, also called consumer-directed plans, are becoming more common. Half of the individual health plans sold by Blue Cross of Nebraska are high-deductible plans, a share growing by 5 or 10 percentage points a year.
About one out of five Nebraska employers offer similar plans, in some cases putting company money into their employees' health savings accounts as well.
“Consumer-driven plans are meant to get people to pay more attention, to be more responsible in terms of how they go about making health care decisions,” said Health Advocate's Rosen.
“This notion that you are involved and responsible, that's the starting point,” he said. “The way the system is moving, you're responsible whether you are actively involved or not.”
Doctors usually don't have the time to run down the costs of various options, he said. That's why groups like Health Advocate have cropped up to help people navigate the health care system.
“You're paying that first $2,000, $4,000 or $5,000 out of pocket,” he said. “If you can get the work done for $750 instead of $1,500, that's significant. But you have to know to ask that question.”
The Affordable Care Act may help consumers know what to ask, Blue Cross' Gilsdorf said. “The law has shown light on the cost of care. Ultimately, health care is the consumer's responsibility. We need to help give consumers the tools to make those decisions and start asking those probing questions.”
Some questions have few answers.
Lori Apgar, the Papillion day-care operator, remembers a $35 copayment and out-of-pocket bill of $150 to have tubes put into her infant son's ears. When he had one removed three years later, she had to pay $1,500 toward her deductible.
“Every year it's gotten worse,” said Apgar, whose family deductible is now $5,000 a year. “We can't afford to skip things. I'm not one to go to the doctor every time I have a headache or a sore throat. But it's kind of scary.”
For Omahan Lee Cooper, a $2,400 deductible stands in the way of getting an artificial foot and partial right leg after poor circulation resulted in an amputation last spring.
Cooper had to go on disability from his job at a rendering plant and pays $588 monthly for COBRA insurance out of his $1,600 monthly disability check. He doesn't have savings to pay the deductible toward the prosthesis.
He is being referred to a state rehabilitation program in hopes of assistance, but for now uses crutches and a wheelchair to get around. If his insurance paid more — a middle-of-the-road prosthesis may cost $10,000 — he could get back on his feet.
“Nobody seems to have answers,” Cooper said. “It's a hell of a fight, I know that.”
Decoding deductibles: how to take control
Tips for controlling deductibles and other out-of-pocket medical expenses.
>> Shop around
Compare similar terms: deductibles, copayments, coinsurance, drug coverage, first-dollar coverage, as well as monthly premiums. Consider high-deductible plans with health savings accounts, especially if your employer offers a plan and will contribute. If you're healthy and eligible, consider a “catastrophe” policy, with low premiums but a high deductible. Choose a plan that fits your needs, whether high or low medical claims each year.
>> Know your plan
Read your plan documents carefully and ask your employer or health plan administrator if you have any questions. Make sure you know: the type of plan you have; whether your doctor is in-network; the deductible amount; when the plan year begins and ends; which services are covered before you meet your deductible, like checkups and other preventive care; which services and medications are covered after you meet your deductible (is there a copay or coinsurance?).
>> Put some money aside
Ask if your employer offers a health savings account (HSA) or a health reimbursement arrangement (HRA). If not, you may be eligible to open an account with a local or online bank. Check the IRS list of “qualifying health care expenses” to see what types of health care costs you can pay for with your HSA.
>> Know before you go
If you haven't met your deductible, it's a good idea to know how much your service will cost before you visit the doctor. You can ask your doctor or his office manager how much a procedure or service will cost. Contact your insurer to find out what's covered. Keep a record of whom you talked to, when and what you learned. If you stay in your plan's network, your doctor will usually charge your plan's in-network “contracted rate” even if you are paying the whole amount out-of-pocket because you have not yet met your deductible. If you go out-of-network, the cost will usually be higher.
>> Ask about lower-cost options
Ask your doctor for alternative treatment locations, and find out the relative costs. Your doctor might be willing to negotiate a lower fee, give a discount for paying in cash or quickly, or let you pay in installments over time. You can also ask about lower cost alternatives — for instance, you will pay much less for generic drugs than brand names, or for a pill or injection that can be taken at home instead of in a doctor's office. Ask to bring along your own medication to the hospital. See if your primary doctor can care for you rather than using a specialist. Consider a minor-medical clinic instead of a hospital emergency room. For prescriptions, ask about mail-order delivery, manufacturers' discount programs, free samples or pharmacy discount cards.
>> Track the paperwork
Keep track of treatments, tests, medication and supplies and check your bill for agreement. Check your receipts with the explanation of benefits from the insurance company. They should agree. If there's an error, such as the number of days in the hospital, take charge. Call the insurance company first and, if necessary, the care provider. Sometimes the company denies coverage because of an error by the doctor's office, such as an incorrect code. The bill can be reprocessed with the correct information. Keep your medical records together in case you need to dispute a bill. If there's an incorrect coverage denial, consider an appeal through the insurance company's review process, and meet the deadline for appealing. If you can't reconcile differences, consider an outside review by the State Department of Insurance.
>> Consider timing
Most deductibles reset with each plan year so, if it's an option, arrange tests and procedures with that date in mind. If you're near the end of your deductible, for example, or close to meeting your out-of-pocket maximum, you might want to schedule medical care you've put off so your insurer will cover more of the cost. If you're facing a cap on benefits, maybe schedule part of a procedure in December and the rest in January. If you're facing a number of costly procedures, wait to do a big one early in the year to max out the deductible and have remaining procedures covered at a higher level. And, if you have a flexible-spending account, use the dollars by the deadline or lose them.
>> Take prevention seriously
The best way to keep health care costs low is to stay healthy. Of course, that's not always possible, but we can reduce our health risks by taking care of ourselves. Find out what preventive services are covered —- before and after you meet your deductible — and take advantage of recommended screenings and regular checkups. Ask your doctor about what you can do to stay healthy. Make an effort to eat a healthy diet, get regular exercise, quit smoking and manage stress.
>> Be your own advocate
Speaking up and asking questions up front can help you keep your health care costs under control.
Sources: Healthcare Survival Guide, Health Advocate Inc.; FAIR Health, a nonprofit that maintains a database of reimbursement rates; Wall Street Journal