Always the responsible patient, Gregg Shivers turned 60 and, like clockwork, called his doctor to schedule a colonoscopy.
Next on his list was to confirm with his insurance company that his plan would cover the preventive screening, which doctors recommend people over 50 have at least every 10 years.
What Shivers found out annoyed him to no end: His colonoscopy would be covered in full, with one exception. If the doctor found and removed a polyp for testing, the entire procedure would be reclassified as diagnostic, and Shivers would be on the hook for 20 percent of the bill. After meeting his $1,000 deductible.
But no one told him precisely how much that might be.
“This whole insurance and medical testing thing is crazy,” said Shivers, a lawyer who lives in Medford. “Nobody knows what the rules are.”
Years ago, employers and insurers covered so much of the bill that patients didn’t have to think too much about their share.
But skyrocketing health costs have pushed more people into high-deductible plans, which require thousands of dollars in out-of-pocket payments before coverage kicks in. This type of plan has made people more sensitive to health-care prices. But as Shivers’ experience shows, it’s not easy to find out in advance exactly how much a procedure will cost.
“At a time when more and more consumers have high deductibles and are being asked to manage their health spending in ways like never before, they have extremely limited information to make health decisions,” said David Grande, a physician and senior fellow at the University of Pennsylvania’s Leonard Davis Institute of Health Economics.
The price we pay for an opaque health-care system is greater than the dollar amount at the bottom of our bills. Faced with the possibility of an expense they can’t cover, some patients will forgo care. Others may stash bills out of sight and out of mind, potentially damaging their credit.
But with the number of people being covered by high-deductible plans showing no signs of slowing down, analysts say the veil will have to be lifted on prices and consumers will have to be brought into the decision-making on what’s really necessary for their care.
“It’s inevitable that health systems are going to have to be able to provide more transparency into prices, and procedures that fall under deductibles are going to have to be more relevant, meaning something consumers can pay,” said Christopher Kerns, an executive director at the Advisory Board Co., a research and consulting firm. “The pendulum is not likely to swing back.”
The number of Americans with high-deductible health plans has soared in recent years. Just under 30 percent of people with employer-sponsored health insurance had a high-deductible plan in 2016, up from 4 percent in 2006, according to the Kaiser Family Foundation’s employer benefits survey. The survey defined a high-deductible plan as one with a deductible of at least $1,000 for an individual and $2,000 for a family – though many consumers face amounts far higher.
The vast majority of plans purchased by individuals and families through Affordable Care Act health insurance exchanges also come with a high deductible.
Pennsylvania Health Access Network, which helps people enroll in these plans, often encounters people who are surprised to have to shell out so much money to see the doctor, after also paying for insurance. Rather than face a bill they can’t pay, some patients will delay care, which could be even more costly down the road, said Antoinette Kraus, director of the Philadelphia-based group.
“You can almost compare it to when folks didn’t have insurance,” Kraus said. “You’re scared of how much it’s going to cost to go figure out what’s causing you pain, so you don’t and you end up in the emergency room when it’s much worse later.”
Shivers canceled his colonoscopy appointment after learning of the potential liability to his wallet – more over principle than cost.
“My doctor tells me I ought to do it, but my insurance company discourages me from doing it,” he said. “It just makes me so angry that you can pay all that money for insurance and they can just change the rules in the middle of your surgery.”
There’s no requirement that patients be told what they could owe. Kraus thinks letting people know in advance what to expect in a bill could reduce the number of patients who lash out over costs they didn’t anticipate and could even let them budget for the expense.
Better-informed patients could be a benefit to health systems, too, some analysts say.
Hospitals are long accustomed to picking up — or writing off — part or all of the tab for uninsured and low-income patients, a cost that often is redistributed to those who can pay.
But as the number of high-deductible plans has grown, so has insured patients’ hospital debt, said Kerns. When patients don’t understand their bill or are surprised by it, they’re less likely to pay, he said.
Most hospitals have a policy to provide financial assistance to patients who can’t afford their care, and financial counselors to help them navigate the process, but patients often don’t know it. If hospitals want to drive down debt owed by insured patients, they could start by saying what kind of bill to expect, Kerns said.
“The likelihood of collecting in full goes up markedly the earlier you do it,” he said. “If patients are told up front what their obligation is going to be, they understand it.”
At Flash Sports Physical Therapy in West Chester, it’s not hard to find out how much care will cost.
Physical therapist J. Ryan Bair’s practice does not accept insurance. Patients pay upfront and are given a receipt they can submit to an insurer for possible direct reimbursement.
“What you have is full transparency. They know exactly what the costs are,” Bair said. “We sit down and say this is what we’re seeing and what our plan would be for you, and this is what it’s going to take to get there.”
Some of his patients say that policy is a selling point.
When Elizabeth Masiello, 40, suffered a running injury, she turned to Flash because she knew Bair through his training clubs for runners.
The West Chester marathon runner didn’t care that her insurance company would consider Bair an out-of-network provider – meaning that coverage could be far less than for an in-network provider — because she thought his expertise matched her needs and that he could offer more personalized care than she would get through a covered provider.
To Masiello, it was an added bonus to know upfront how much her physical therapy would cost, as opposed to having to wait until she got a bill in the mail to see how much her plan covered for an in-network provider.
“The answer is we’ll bill your insurance company and whatever they don’t cover we’ll bill you,” Masiello said. “With Ryan, it’s clear.”
Analysts say a spotlight on cost could draw more attention to broader ailments in the health-care system.
Knowing that a blood test can cost $11 or $100 depending on where you go isn’t enough to get people better, more affordable care. But once patients get a taste of access to information through more transparent pricing, their appetite may grow for more answers, such as why insurance premiums keep going up and what’s the difference between good and bad care, said Anne Weiss, a managing director at the Robert Wood Johnson Foundation. And that kind of awareness, she believes, could also draw the attention of policy makers.
Price disparity, Weiss said, is “the simplest window into the dysfunction of the health-care system.”
Just one data point – price – could empower patients to look into other aspects of their health care, she said.
“If they knew that,” she said, “they’d start asking a lot more questions.”