Opinion

opinion | Mark Pothier

Out-of-pocket costs put health care out of reach

Peter and Maria Hoey for the Boston Globe

Soon after a recent minor surgery, I began suffering from a painful complication — it hurt to open the mail. Within weeks, I had accumulated a stack of envelopes related to the operation. Not a “get well” card in the bunch. Only demands for money. Now that I’d been stitched up, it was time to pay up.

“It is your responsibility to see that this bill is paid in full within 60 days,” the anesthesia company wrote.

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“We are now accepting payment by credit card,” the pathology lab trumpeted, as if it were introducing an innovation to rival the Internet.

“If you are unable to pay in full, please contact a financial counselor,” the hospital advised.

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My health care “providers” were hounding me for “out-of-pocket” expenses, a benign phrase that evokes a few quarters tangled in lint.

If only.

Going under the knife was, thank God, my first major patient experience. The health care part was easy — skilled doctors and nurses, preheated blankets, a fuzzy pillow of sedation, no overnight stay, and a scar that fell well short of Frankenstein proportions. But the blitz of invoices that followed made me question whether my UnitedHealthcare insurance was worth it.

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Anyone who’s been treated at a hospital or had an imaging scan in the last few years knows that out-of-pocket costs have spun out of control. Patients are being held liable for ever-higher deductibles, more out-of-network charges, and something called coinsurance — which should be called “no insurance.” Even gold-standard policies have coverage gaps that don’t fill in until patients reach the level of care needed for a “catastrophic” illness. In my case, the final out-of-pocket tally was about $2,000, or 8,000 quarters.

With so much attention focused on boosting health insurance enrollment numbers nationwide, the out-of-pocket issue has been underplayed. But rising expenses for individuals could undermine the primary reason behind universal coverage — healthier people. Many are being squeezed into choosing between two bad outcomes: taking on debt or forgoing treatment.

A Commonwealth Fund survey last fall found Americans “are paying more out-of-pocket for health care now than they did in the past decade.” About one in five adults spent at least 5 percent of their income on out-of-pocket costs — excluding premiums — the Commonwealth Fund said, and 13 percent forked over 10 percent or more. Those with lower incomes had higher out-of-pocket charges, mainly because their coverage was lousy.

This year, the average US employee will pay $2,487 in out-of-pocket fees, based on a projection by the benefits consultancy Aon. Over the last five years, Aon said, a worker’s share of health care costs — including premiums and out-of-pockets — will have gone up by more than 52 percent.

Depending on your insurance plan, there’s plenty of headroom for heftier obligations going forward. Under the Affordable Care Act, 2015 out-of-pocket costs for an individual max out at $6,600. The family plan ceiling is $13,200.

Directing more expenses to patients is one way health insurers have been able to ease off from the eye-popping double-digit annual premium increases that were long the norm. The industry has fashioned this trend into something of a public relations coup. Most businesses highlight a price change only when it’s a decrease; health insurance executives get to crow about jacking up the cost of their products at a slower rate than before. What a deal!

Insurers also argue that out-of-pockets make subscribers sensitive to the real cost of care. Instead of hightailing it to the emergency room for a splinter, a patient might visit a walk-in clinic or see a nurse practitioner to save money.

Taking a more ‘active role’ in their health care often involves patients making medical decisions based on their finances, not their well-being.

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“Consumers are being asked to take a more active role in their health care,” says Maria Gordon Shydlo, a spokeswoman for UnitedHealthcare. It’s a line I heard frequently during nine years as an editor overseeing coverage of the health insurance and medical industries. The problem is that an “active role” too often involves patients making medical decisions based on their finances, not their well-being.

Healthy people aren’t forced into those kinds of choices. As long as they don’t need serious or regular medical care, and their premiums come straight from a paycheck, coverage can seem almost invisible. Insurance is something that’s there, just in case. But it’s an illusion of affordability, perhaps an unintended consequence of the Affordable Care Act. The law, for good reason, exempts certain preventive services from copays, deductibles, and coinsurance. It’s a way to encourage people to seek routine care now that might head off serious problems later. The side effect is that for those whose only encounter with the health care system is a yearly wellness exam, out-of-pocket expenses can appear to be going down instead of up.

This deep into a story about health insurance, your eyes are likely glazing over. Do not seek medical treatment — the feeling will pass once you resume normal activities. My vision, too, blurred as I tried to decipher all the bills I received. Impenetrable math detailed “plan discounts” negotiated between the insurer and providers. Dense language like “surgical path level IV gross & micro” may as well have been in code. It took months to sort everything out, despite a steady stream of UnitedHealthcare EOBs. That’s an “explanation of benefits” to us lay folk. They’re identifiable by the “this is not a bill” label.

“EOBs are chock-full of information,” Shydlo told me. “People kind of toss those aside.”

I tried to harvest something useful from mine, but the “total amount you owe” often didn’t sync with statements from the hospital, doctors, and labs. I decided to write checks only after the “30 days past due” notices arrived. By then, I theorized, any contractual price cuts and unapplied credits for deductibles had been sorted out. Who knows for sure?

Maybe I should have hired Adria Goldman Gross. Her New York company, MedWise Insurance Advocacy, helps people navigate insurance claims and medical bills. MedWise has saved clients about $3.5 million in the last three years, according to Gross.

“Insurance companies are ripping people off,” she says.

To minimize out-of-pocket expenses, Gross advises, “Always ask in advance, ‘What am I going to be charged for this procedure and who is going to be taking care of me?’ ” Another tip: Insist on an in-network provider whenever possible.

Insurers and providers have long sparred over who’s to blame for escalating prices. The medical industry is in the throes of major changes that are supposed to make a difference — they include Obamacare, a shift from fee-for-service to pay-for-performance care, electronic medical records, and a tidal wave of consolidation. In the latest mammoth move, CVS Health this month said it would pay $1.9 billion to take over Target’s clinic and pharmacy operations. Such mergers give companies more leverage with insurers and allegedly yield “efficiencies” that reduce costs. It’s too early to offer a prognosis on whether any of this will save consumers money and improve health on a grand scale. Meantime, we’re getting our pockets picked clean, one X-ray at a time.

Health insurance isn’t much of a benefit if you can’t afford to use it.

Mark Pothier can be reached at mark.pothier@globe.com. Follow him on Twitter @markpothier.

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