Wednesday, May 14

Who pays and who benefits from insurance under ACA?

I often hear people say that one reason that we spend so much on health care is because "patients don't care about the cost of their care because their insurance pays for everything" so I was curious if that is true under the new plans offered under the ACA.

Under a bronze plan in Washington from one of the biggest Blues (Premera) in the state - for someone with diabetes the patient will pay  99% of the expected $5400 in charges  and over $10,400 out of pocket a year. (cost of care + cost of insurance)
The example shows how this plan covers medical care when managing Type 2 Diabetes. Use this example to see the financial protection you receive if you are covered under different plans.
Because everyone's situation is unique, the actual care you receive will be different from this example and the cost of care will also be different.
Premera Blue Cross Preferred Bronze 5500Carrier Logo
Amount owed to providers:
Plan pays:
Patient Pays:

Sample care costs:

Medical Equipment and Supplies
Office Visits and Procedures
Laboratory Tests
Vaccines and other preventives

Patient Pays:

Limits of exclusions
I am a huge proponent of patient engagement (I was the national project director at ONC of Provider Adoption of Patient Centered Health IT) but that doesn't mean cost shifting to patients nor does it mean that bearing this cost will result in a healthier outcome. (Although I am healthy myself no one I know wants to live with diabetes).

Currently about 40% of all health care spending is borne by the patient and medical bills are the #1 case of bankruptcy in the US (and the majority of those had health insurance at the time they were first diagnosed).

NOTE: I also often hear people claim that patients need to be more responsible and shop for their care (very little of these charges vary by provider) so other than seeing their doctors less often or finding cheaper supplies it is difficult to see what behavior they can do to change the overall cost of care unless they no longer have diabetes (in some cases weight loss can achieve this but I would love to hear how often this actually happens).

The third thing that people often assume is that these costs could be prevented. One of my followers as tweeted and blogged last week if "people weren't lazy" our costs would be lower and congress fell for this myth as well. Even though this sounds logical every study has shown that preventive care merely delays when someone incurs medical care not if.

People simply live longer but they then suffer from higher rates of high cost illness like cancer, dementia, Parkisons or congestive heart failure). You should still be responsible, exercise, eat well, manage stress (and make a good living) but it is simplistic to think people are all going to suddenly change their behavior without education or support and very few doctors have the training or the background to coach people (thankfully new models of care can do this).

So at the end of the year the insurance company received $5300 and the doctors, Pharmacy and labs received $5400 and the patient paid for all but $50. I also wonder if after bearing nearly the entire cost is the patient any healthier?

Having everyone covered is critical but how we provide healthcare is of far more importance and until their are new models of care that patient can "pick" we are just paying for more of a broken system. 

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