which_chick | (no subject)

Okay, a day late and whatever, but here's the Why Insurance Is A Rook posting. As ya'll recall, I had surgery a month or so ago to get rid of a lumpy ganglion cyst on my wrist. As it was the first (and thus far, only) doctoring I did this year, I got to run through the deductible and whatnot with many Explanations of Benefits and bills and so forth in a vacuum of experimentation. Things have finally settled down and I believe I'm done with the whole thing, bills and all.

No. I mean rook like "cheat, swindle". I'm nouning the verb, like many people verb-the-noun (for example: "I googled it.") only in reverse. Ain't English grand?

First, I had a consultation with the surgeon. Because I'm not an HMO person and because my insurance lets me do it, I called the surgeon guy's office and set up an appointment. I spake thusly to his office lady: "Hi. I have a ganglion cyst on my wrist that I'd like taken off." She gave me an appointment. The surgeon spake thusly: "You have a ganglion cyst on your wrist. It will not go away on its own. I will cut it out for you."

The bill: $220.00
Highmark Blue Shield adjusted rate: $135.00
Amount I paid: $135.00
Total cost for an uninsured person thus far: $220.00
"Highmark" total: $135.00
Total I paid thus far: $135.00

Well, that's not so bad, there. Right? I gots me some lazy damn insurance that expects me to pay assloads of money towards my own care. None of that damn ten-dollar co-pay in my world, either.

I got some pre-surgery crap done. Included were x-rays and an EKG.
The bill: $31.00
Highmark Blue Shield adjusted rate: $20.00
Amount I paid: $20.00
Total cost for an uninsured person thus far: $251.00
"Highmark" total: $155.00
Total I paid thus far: $155.00

I'm paying 61.75% of what the uninsured person pays.

At this point the bills dissolve into categories I do not understand.
I have one for "Path UPMC BEDFORD"
The bill: $122.00
Highmark Blue Shield adjusted rate: $20.00
Amount I paid: $5.00
Total cost for an uninsured person thus far: $373.00
"Highmark" total: $175.00
Total I paid thus far: $160.00

Now the insured person (me) is paying 43% of what the uninsured person pays. Yowza. Probably that's some kind of aberration, there, right? I mean, hell, that can't be right, can it?

I have one for "Forearm/wrist surgery"
The bill: $1000.00
Highmark Blue Shield amount: $400.00
Amount I paid: $245.94
Total cost for an uninsured person thus far: $1373.00
"Highmark" total: $575.00
Total I paid thus far: $405.94

At this point, I've paid about 30% of what an uninsured person would pay. Am I getting a third of the care? Should I worry about this?

I have one for "Assorted Hospital Crap"
The bill: $3000.11
Highmark Blue Shield amount: $1035.20
Amount I paid: $207.03
Total cost for an uninsured person thus far: $4373.11
"Highmark" total: $1610.20
Total I paid thus far: $612.97

Whee! Fourteen percent of what actual poor people pay. It's good to be insured. I'm a believer.

I have another one for "Anesthesia"
The bill: $605.00
Highmark Blue Shield amount: $275.00
Amount I paid: $55.00
Total cost for an uninsured person thus far: $4978.11
"Highmark" total: $1885.00
Total I paid thus far: $667.97

Thirteen and a half percent, just about. Pity it's not twelve and a half percent because that'd make a dandy damn joke. In lieu of a joke, all I can say here is that I'm damn glad I have insurance, even crappy insurance that makes me pay for care.

Okay, so comparing ME to an uninsured person isn't fair because my insurance has clearly started paying some of each claim. But what if the uninsured person got to pay the same prices as Highmark Blue Shield gets to pay? Would that still be a hideous amount of difference?

I think it might be, rabbit.

I have one for I-don't-know-what (can't find it on the EoBs I saved)
The bill: $215.00
The Blue Shield amount: $137.57
Amount I paid: $137.57
Total cost for an uninsured person thus far: $5193.11
"Highmark" total: $2022.77
Total I paid thus far: $805.54

An uninsured person pays $5193.11 to get a ganglion cyst removed from a wrist.
Highmark Blue Shield pays $2022.77 to get a ganglion cyst removed from a wrist.

If you still can't see the rook, it's here...

If you have insurance, even insurance with a great big huge deductible at the front end, it's worth it because your medical care costs are HALF (or better -- 39% for this case study) of what uninsured people pay. Insurance makes your medical care COST LESS via the magic of bargaining power... even if you never get beyond the deductible.

If you are a cash-on-the-barrel sort of person, you can't get the "Highmark Blue Shield" prices even though you'd pay at the time of service and there would be no dumb-ass paperwork involved in them getting paid. Hospitals are not allowed to give individual human beings the "Highmark Blue Shield" prices because they claim that those prices are negotiated based on guaranteed payment by Highmark Blue Shield yadda yadda yadda. Hospitals charge more to treat people without insurance because so few of the people without insurance manage to pay their expensive hospital bills. Uhm, who can see the positive feedback loop, here? Anyone? Bueller? Bueller?

Seems like a rook to me, anyway.

Flat | Top-Level Comments Only

I had a 3 and a half week hospital stay in 2002, plus assorted doctor's visits and test etc. Earlier that year my husband had outpatient surgery to get his wisdom teeth removed.

End of year totals (approximate b/c I am too lazy to dig through the old medical files)

Uninsured person cost - $90,000
Insurance cost - $32000
My cost - around $3500

I totally am behind medical insurance. Most people (you are not most people,

which_chick do not have the financial discipline to save the money in an emergency fund or a dedicated medical fund. Most people with insurance have the premiums deducted from their paychecks where they never see it, so never miss it. I would like to get the negotiated rates without paying the premiums; I could put aside the money I pay already in premiums (just add it on to the amount I already put aside on a monthly basis for non monthly bills like car insurance and our house repair fund). That way I could earn interest on the money instead of Blue Cross/Blue Shield earning the interest and be able to pay the bills upon receipt. The way our health system is set up prevents that.

You know, I need to remember to preview (or at least re-read) comments before posting to catch typos such as not closing the () after

which_chick and changing the first sentence to read "I am totally behind medical insurance." I suck.

Let's see what I can dig up for the kidney stone removal I had recently:

Uninsured person cost - $14,615.60
Insurance cost - $4,284.22
My cost - $300

So, yeah, I'd be in a whole lot of trouble if I didn't have insurance.

one element to also consider:
if any insurance premium costs are taken from your paycheck, they are pre-tax dollars, so you also get the lower tax bracket benefit.
In the posistion I have, I see the whole premiums being paid, and believe me, it ain't pretty.
I refuse to run the type figures you quoted, but let's just say, that the time DH had the flu, and got an emergency heart cath procedure as part of his treatment, I really appreciated the low deductible on the insurance he had at the time.

As I understand it, the inflated "real people" charges are based on the following:

1) a lot of it goes straight to Medicare or one of the other state/federal programs. These had a history of only paying a percentage of such bills, the last time I looked into the matter. Because the medical providers obviously wanted to be paid *all* their money, not just the bureaucratically-determined fraction, they started a long, long process of inflating the base number to up their marginal return.

2) "real people" without insurance are infamous for just blowing off medical bills. The billing people usually just settle for fractional payments. This, too, causes an inflationary pressure on "real people" bills, as the nominal price goes up to increase the marginal return on whatever's left after the long, painful billing process has its way with the payment process.

I don't know, I've laid out exactly $150 in the last eight years in health care expenses, which really ought to have been paid by my insurance, but I couldn't be bothered to straighten out the issue, since the money came out of an old, unused MSA which is slowly eating its seed corn due to the unadvantageous fee structure & relatively low interest rate.

Highmark is not my favorite company right now... The way they pay from what I understand is a decreasing percentage per "code". So they'll pay, say, 50% of the first "code," 40% of the second, and so on. When Linda had her spinal fusion, the spine doctors refused to take the insurance. Apparently the way Highmark has things set up, the guys who spend 3 hours cutting you open, carefully scraping bone growths away from your spinal column, drilling holes in the bone and screwing you all back together again get paid less for that than the leg guy does for spending 15 minutes setting a bone and putting it in a cast.

(Our insurance co at the time was Carefirst BCBS out of MD, which makes this a "Blue Card" claim, and Highmark has the blue card contract for all of PA, even though they aren't the local insurance company in the philly area)

When the "negotiated price" is about 20% of total, the total naturally hyper-inflates.

In our case, the doctors wanted approx $8k in payment for services rendered. They billed $23k. Highmark paid $3.7k. We paid $4k. The dr office sends a letter saying that they will "accept as payment in full" $X, which is substantially lower than the $18k you owe on paper.

Presumably if we were uninsured, we'd be billed $23k and $X~=$8k.

Presumably, if drs weren't wasting so much time and effort negotiating with insurance companies, they could same many hundreds of thousands of dollars both in clerical staff wages and of their own time (shall we talk about the iterative guessing game necessary to discover which antacid script the insurance company would actually cover?). Above all, the insurance company game is one that extracts money from patients and non-patients alike while paying sub-reasonable rates to drs and pharmacies, in order to become fabulously wealthy and powerful. The sum total of monies being paid for health-related services in this country (lumping insurance in with that) is way too high, with a diminishing amount of that money going to the people who actually provide health services, and we STILL can't figure out a way to actually provide reasonable health services to everybody.