Tuesday, March 25, 2014

Between Scylla and Charybdis in a hospital bed

The Commonwealth Fund is out with a report*suggesting that the ACA has the potential to reduce the substantial ranks of the nation's underinsured -- those who currently either spend a percentage of their incomes on premiums deemed unaffordable by ACA formulas or who are exposed to out-of-pocket medical expenses high enough to deter them from getting needed care. Jonathan Cohn overviews the core conclusions here.

While affirming that ACA benefits are well-targeted at those likeliest to be underinsured, the report also highlights ways in which the ACA's Qualified Health Plans  (QHPs) may also underinsure -- chiefly via the high deductibles and out-of-pocket cost limits prevalent in bronze plans, selected thus far by 19% of QHP buyers. That much was not news to me. But then the report flagged another underinsurance hazard that brought me up short -- and brought a memory flash. My emphasis below:

In addition, it is important to note that the Affordable Care Act’s limits on out-of-pocket costs for covered benefits also apply only to in-network providers. As discussed in a recent report profiling insured people with medical debt, even with the new limits, the insured may encounter high medical care costs if they receive care from out-of-network clinicians. This can happen even if the patient selects an in-network surgeon and hospital, if anesthesiologists or other clinicians involved in the hospital care are allowed to stay out-of-network.
That's right. In our insane, provider-empowering healthcare delivery system (see Elisabeth Rosenthal, (1, 2, 3), you can be admitted for care at an in-network hospital and have care inflicted on you by providers who, unbeknownst to you, are not covered by your insurance. So a narrow network potentially places you between the Scylla of refusing care for which you were admitted to the hospital (if you have the unlikely wherewithal to ask everyone who stops by your bed whether they're in your network) and the Charybdis of bottomless uncovered medical costs. The ACA did not create this legal bedside robbery, of course, but it also does nothing to forestall it.

I was brushed by the shadow of this abuse myself once -- while, paradoxically, availing myself of $20,000 worth of free (for me) but mostly unnecessary care. I got that care because I was weak and foolish. After three weeks of scaring myself with a combination of heartburn and minor chest wall symptoms, I checked myself into a local emergency room to make sure I wasn't on the brink of a heart attack.

The hospital was part of a hospital network my wife works for; the employer-sponsored insurance covers care within the hospital network. The ER team decided to keep me overnight and informed me that I would be checking out against advice if I left early. By the time I'd had two EKGs it was clear nothing was wrong with my heart, but I subjected myself to a CT-scan with stress test, an ultrasound, and a $20k tab of which we paid nothing except maybe a $100 deductible (and which the self-insured hospital network essentially paid itself, I suppose). 

So I was weak and foolish -- with one exception. At the beginning, I had to sign a release agreeing to pay for any out-of-network care I received in-hospital.  The attending doctor was at hand at the time. I asked him if he was in-network. He said he didn't know. I said, how can you not know? He said his office dealt with "hundreds" of insurance plans. He offered to check. I said please do. He came back a few minutes later and said he had confirmed that he accepted the insurance plan provided to employees of the hospital he was standing in.

Whew. I can't recall whether I checked with every subsequent attending physician. I knew that the guy who did the CT-scan was in network because I'd seen him before. But that's another story.

*  *  *

* America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to
the New Coverage Expansions. By Cathy Schoen, Susan L. Hayes, Sara R. Collins, Jacob A. Lippa, and David C. Radley. March 2014

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