Blog

Some policy analysts previously suggested high-deductible health insurance plans, where, in exchange for lower monthly premiums, patients would end up paying more when medical care becomes necessary. On one level, these plans are an incentive for patients to get healthy and stay healthy -- by not requiring less medical care, those patients can pocket the savings from the reduced insurance premiums. Another aspect of this idea is that patients with these plans will have a strong incentive to shop for care. If enough patients exercised choice,, the providers would feel pressure to provide higher quality and/or lower cost care. KFF Health News reported on some drawbacks of these high-deductible plans.

One problem with these plans is that medical care can be very expensive: "The average price of a knee replacement, for example, increased 74% from 2003 to 2016, more than double the rate of overall inflation." If the cost of a single procedure exceeds the out-of-pocket maximum, then patients lose the incentives to shop for lower-quality care because insurances are generally responsible for paying for costs in excess of the out-of-pocket maximum.

Another problem is the lack of patient choice: "Although these plans are supposed to encourage patients to shop around for medical care to find the lowest prices, Monroe found this impractical when she had a complex pregnancy and heart troubles." When faced with a potentially life-threatening condition, patients will frequently take the option that is perceived to be the safest (for example, a well-known large hospital system in the area). Asking those patients to select a different provider to save on costs seems unlikely to succeed, and probably rightly so.

Additionally, "Researchers at the nonprofit Health Care Cost Institute, for example, estimated that just 7% of total health care spending for Americans with job-based coverage was for services that realistically could be shopped for." The cited paper indicates that in 2011, 43% of money spent on health care that was examined by the study was considered shoppable, while 15% of spending in the same year was paid by consumers. The paper points out that the intersection of shoppable services that are paid by the patients is actually quite small (7%).

High-deductible health insurance plans can be a good fit for generally healthy patients. However, these plans appear to fall short of their intended policy goals.

For years now, this site has incorporated procedure volume and pricing data from Medicare. Recently, we launched a new feature to give additional context on the search results page, by providing local and state averages. This feature is available for many different procedures (for example, x-ray in San Jose).

There are already ideas underway to improve this feature, but if you have any thoughts, please let us know through our contact form.

The team at DocSpot wishes you a Happy Thanksgiving!

May your holidays be filled with meaningful connections with family and friends.

Health insurers are expected to pay for medical care, but it can be unclear whether they should be obligated to pay for promising, but unproven, procedures. KFF Health News profiled one patient whose doctor recommended a newer type of treatment. Initially, the insurer refused to cover the treatment, "claiming the treatment was not medically necessary." Soon after media became involved, the insurer changed course. Unfortunately, the patient started different treatment, precluding the recommended procedure.

To some extent, it is in the interest of insurers and those who pay premiums that unproven treatments are not automatically approved. At some point, however, a treatment shows enough promise that it should be considered. Given the advancements in medicine, it is impractical for patients to review an annual list of covered treatment options, and even if they could, there are probably not enough insurance plans for patients to reliably find a suitable option. This scenario raises the question of who should get to decide whether the insurer is obligated to pay for less proven treatments. Currently, the insurer does, but that poses a conflict of interest (similar to giving that power to patients). Theoretically, that decision could be left with physicians, but there is enough variation in the practice of medicine that patients could essentially "shop" for a doctor that would approve an experimental treatment. There could be a role for a panel of physicians to make such decisions for the coverage of experimental treatments.

KFF Health News published an article speculating about new scenarios in which patients might find themselves facing higher prices because of consolidation within the healthcare industry. This country has already seen consolidation among provider practices, but the article highlights that new mergers and acquisitions are more complex. One example would be insurers buying medical practices, and another would be health systems merging with others in different geographic areas of the country. The nature of some of these more recent mergers make it more difficult to determine whether they are anti-competitive. For example, an insurer bought a specialty pharmacy, and now customers of that insurer might have to buy injectable prescriptions through that pharmacy, even though the medication might be available elsewhere for less. The article also notes that the current administration is less eager to prosecute anti-competitive behavior than the previous one.

Unfortunately, "studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had raised prices by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%." Widespread consolidation undermines a free market, but stopping that trend in this country relies on an administration willing to combat it and judges who agree.