High deductibles, varying costs encourage budget-based medical decisions

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PITTSFIELD — Maura Rose advises her clients to look for bargains and compare prices online before making a purchase.

It's the advice that a person might get before going car shopping. But Rose helps clients find the best medical treatment they can afford.

Most people in Massachusetts have medical insurance. But that doesn't mean people can afford to use it. Paying deductibles is becoming difficult for many people.

Berkshire Health Systems, the group that runs Berkshire Medical Center in Pittsfield and Fairview Hospital in Great Barrington, has increased the number of monthly payment plans for people trying to cover their bills by 7 percent since 2017.

Go here for a sidebar that provides links to charge lists as well as financial aid and patient care phone numbers. 

With high-deductible health insurance plans, "you've basically bought a catastrophe insurance policy," said BHS Chief Financial Officer Darlene Rodowicz.

In 2018, about one-fourth of adults in an annual survey said they went without needed medical treatment because they could not afford it. Two-thirds of them had health insurance.

Rose is a registered nurse and family nurse practitioner as well as one of the few independent patient advocates in the Berkshires. There are others, including Jill LeBar in North Adams, but most of them work for specific medical providers.

Rose started RoseCare Patient Advocacy & Elder Services in Great Barrington about six years ago. She helps people coordinate health care with doctors and medical professionals and obtain medical care at a price that won't bankrupt them.

"Right now, it's tough to be old and it's tough to be sick. You have to negotiate all this complex system," she said. "I'm saturated with work. I could work constantly."

Go here for a related article on the Roses and their experience with the helath care system.

Paying more

Shopping for good prices for medical procedures and care is more important than ever, now that more than 43 percent of Americans younger than 65 belong to high-deductible health insurance plans, according to the Centers for Disease Control and Prevention.

The IRS defines a high-deductible health plan as one with a deductible of at least $1,350 for an individual and $2,700 for a family. People pay the full deductible before benefits begin. Even when coverage does kick in, most plans don't cover everything. Insurance holders still must pay a portion of their medical bills.

In Massachusetts, people are paying more for medical care through out-of-pocket and cost-sharing plans that shift more of the burden onto the consumer, according to the Center for Health Information and Analysis.

Out-of-pocket medical expenses grew by 27 percent from 2014 to 2017 for Massachusetts residents, the most recent information available.

The Berkshires is feeling the pinch.

At Berkshire Health Systems, more patients are setting up payment plans for services instead of being billed for the entire sum at the end of treatment.

In Boston, legislators are working on prescription drug price reductions.

"It impacts everybody. We spend 40 percent of the state budget on health care, that's just one example," said state Sen. Adam Hinds, D-Pittsfield, a member of the Joint Committee on Health Care Financing. "Across the commonwealth, individuals and businesses and communities are impacted. Clearly, it's time to do something."

Prices vary

The price of medical services can vary widely among Western Massachusetts' nine hospitals. 

Go here for a chart related to this article comparing the prices per services at Western Massachusetts hospitals.

For example, according to hospital charge lists, there is about a $12,500 difference in the most- and least-expensive local hospital treatments for seizure. On average, treating these ailments cost:

- $16,333 at Cooley Dickinson Hospital in Northampton;

- $14,969 at Baystate Medical Center in Springfield;

- $13,017 at Fairview Hospital in Great Barrington or Berkshire Medical Center in Pittsfield;

- $11,557 at Mercy Medical Center in Springfield;

- $11,468 at Baystate Franklin Medical Center in Greenfield;

- $10,438 at Baystate Noble Hospital in Westfield;

- $10,079 at Baystate Wing Hospital in Palmer;

- and $3,769 at Holyoke Medical Center.

The actual amount a person will have to pay for seizure treatment might not be anywhere close to this price, depending on insurance coverage and other factors, hospital officials said.

Rose said that while she helps her clients shop for the best prices, she also guides them to make quality-of-service choices as well.

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At the end of paying for treatment, people want to be healed, after all.

"My advice to people is to ask questions," Rose said. "If you pay out of pocket, you'll get a different, usually lower, price, and I see this all the time."

To help clients, Rose spends a lot of time on the phone with medical professionals and insurance companies, making sure everyone has an individual's most up-to-date health records and getting every dime out of an insurance company. She searches for savings and quality care whenever possible.

Sometimes, getting the price of medical care down is difficult, especially with rare diseases, which limits patient options. Other times, Rose has found simple ways to trim costs. Once, she saved a client thousands of dollars with a Google search.

Rose had a client who required regular bandage dressings a couple of times per week. The pharmacy charged $242 for the new bandage. Medicare was reimbursing Rose's client $90 per bandage, meaning he had to pay the remaining $152 out of pocket. Rose looked up the bandages online and found them available for $60 each. By not billing Medicare and buying the bandages online, the client's dressing bill was cut by more than half.

"I'm like, 'Are you kidding me?'" Rose said, remembering the find. "It just gets so complicated."

Rose also knows how to work with the health care system's quirks.

For example, she had a client who needed an MRI. The hospital told her client it would cost $5,000 through Medicare, but $1,500 if paid out of pocket. She also knows that, in many instances, Medicare will pay for a person's rehabilitation, but only if that person recuperated at a hospital for three days. Anything less than that and the person's condition is considered by Medicare to be not that serious. Follow-up services must be paid out of pocket. Rose has seen this happen to people before. Patients end up paying thousands of dollars for the visit and follow-up treatment.

"Now, they're paying, I'm talking about $4,000 to $5,000 per week. The bills are staggering," she said. "It's a tough system to figure out."

Area hospital officials said they do all they can to keep down prices for the community, but it's a challenge.

Between Medicare and Medicaid reimbursements below private insurance rates and the myriad billing contracts that hospitals have to set with each insurance provider, patient payment defaults and increasing regulatory administrative work, they're doing what they can, said Berkshire Health Systems' Vice President of Revenue Cycle Laurie Lamarre.

"People sometimes think that BHS is doing that, putting the obligation on the patient, but we're not doing it to them," Lamarre said. "It's the plans they purchased."

Fairview, for example, works with about 200 insurance providers. The hospital always is involved in new contract reimbursement negotiations with at least one of them.

Useless information?

Patients got what was supposed to be a shot in the arm for hospital price transparency in January, when the Trump administration required institutions to post "master charge lists" that show price per service — everything from getting a bandage to having a heart transplant. Massachusetts has been making this type of information available to people for years. On June 24, Trump returned to his work on health care cost transparency and signed an executive order to compel hospitals to provide further price information to people before they undergo a medical procedure. It is not yet clear how his order would be put into action. 

Hospital and medical professionals have said the charge lists aren't helping patients. They're written in abbreviated medical jargon and do not include insurance coverage in the final price.

It also would be difficult for a potential patient to gauge what additional costs could be attached to a procedure — anesthesia and recovery, for example — to arrive at a reliable estimate.

All local hospitals post a disclaimer with their charge lists warning people that the lists are difficult to understand. People are encouraged to get help from the hospital's service estimator or to call their insurance provider to get a more accurate forecast for an individual's cost.

Health Care For All, a national patient advocacy group with an office in Massachusetts, is among the organizations pushing for better medical cost information.

"With the growth of high-deductible health plans, people have a right to know cost information before care," said Alyssa Vangeli, co-director of policy and government relations for the Massachusetts HCFA chapter. "The burden shouldn't only be on consumers. When you need emergency medical care, there's no time for people to shop around and find out in advance how much something will cost."

Vangeli said many hospitals, including Berkshire Health Systems, offer payment plans to patients as well as potentially lower-cost services for out-of-pocket payers. Ultimately, what a person will pay for medical treatment comes down to the health insurance plan involved, she said, which is why price transparency is so important.

Many Western Massachusetts hospitals have comparable service charges with some wild outliers, but Holyoke Medical Center, overall, is charging the least out of any other medical provider in the area.

Holyoke's prices are kept down by its clientele, which includes many low-income individuals. About 80 percent of Holyoke Medical Center's patients use Medicare or Medicaid as their health insurance, meaning the hospital has a cap on how much it can charge for services.

A popular misconception is that paying more for a service means a higher-quality outcome, but Holyoke Medical Center's patient results are on par with the region, according to the national Medicare Hospital Compare tool, which ranks hospitals by patient experience, care effectiveness, complications and deaths, unplanned hospital visits, and payment and value of care, among other factors. At the Medicare Hospital Compare website, Holyoke, Berkshire Medical and Baystate all received similar quality rankings.

Vangeli said Health Care For All's free help line — 800-272-4232 — also can assist people in digging up medical outcome data on local hospitals.

"It's a good service for people who have questions about their health plans or are shopping for health plans," she said.

Future health

In Massachusetts, the future of health care pricing is largely in the hands of lawmakers. The Massachusetts Joint Committee on Health Care Financing, on which Hinds sits, has had 169 bills referred to it this legislative session dealing with topics of patient abuse, retroactive charges, cost transparency, elder care, nursing homes, pharmaceutical pricing and MassHealth rates, to name a few.

The committee has held or scheduled hearings to address health system contracting and prices, care management, health care financing, MassHealth enrollment and eligibility and health agency oversight.

At the federal level, lawmakers are seeking to lower costs by simplifying administrative work and providing mental health care. This year, the U.S. Senate Committee on Health, Education, Labor and Pensions held hearings on lower health care costs, the 21st Century Cures Act, which would make electronic medical records more available to medical professionals and individuals, addressing campus sexual assault. On June 24, U.S. Rep. Richard Neal, D-Springfield, advanced a proposal to improve access to mental health and substance abuse treatment and expand Medicare's beneficiaries.

Meanwhile, the struggle to pay for basic medical care continues to be a problem for many people.

Rose, the patient advocate, said that, with more local primary care doctors, medical bills would be lower. Rose said doctors once had more time to provide preventive care and to connect the dots between the care they provided patients and the care they received from specialists and in emergency situations.

Massachusetts needs an additional 110 primary care physicians, mostly in the rural parts of the state, to fill a gap in services, according to the U.S. Bureau of Health Workforce Health Resources and Services Administration.

"I have people in this area who will drive to Boston every week to see a doctor; the fee is $250 to $300 per trip," she said. "To see a doctor once a week, that's the cost for a lot of people here."

Reach Berkshire Business Insider Editor Kristin Palpini at kpalpini@berkshireeagle.com, @kristinpalpini.


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