news Need a clue about medical costs upfront? New tool challenges it | Analysis

Julie Appleby, Kaiser Health News

Need treatment this year and want to finalize your out-of-pocket costs before you go to the clinic? There’s a new tool for that. At least for patients with insurance.

As of January 1, health insurers and employers offering health insurance have online calculators that allow patients to get a detailed estimate of their costs, taking into account deductibles and co-payments, for various services and medicines. Must provide.

This is the latest effort in an ongoing move to enable price and upfront cost comparisons in a business known for its opacity.

Insurers should make available cost information for the 500 non-emergency services that are considered “purchasable”. That means patients usually have time to consider their options. The federal requirement stems from the transparency of the Press Regulations, which were finalized in 2020.

So how does it work?

Patients know they need a particular treatment, medication, or medical service and first log on to a cost estimator on a website provided by their insurance company or employer. You can then search for the care you need by billing code, which many patients may not have. Or by generic descriptions like “knee joint repair” or “her MRI of the abdomen.” You can also enter the name of the hospital or doctor you are asking for pricing information, or the dosage of the drug.

Not all drugs and services will be available in the tool’s first year of rollout, but the list of 500 items needed includes a wide range of medical services, from acne surgery to x-rays.

Once the information is entered, the calculator is supposed to estimate the patient’s out-of-pocket costs in real time.

From 2024 onwards, the requirements for insurance companies will be expanded to cover all medicines and services.

The requirements for these estimation tools, in addition to other price disclosures that have been in effect in the last two years, include prices negotiated by hospitals and insurance companies, along with cash or uninsured patient costs. demanding that it be published. .

Still, some hospitals have not fully complied with this 2021 disclosure directive, and the data released by insurance companies in July is so vast that even researchers have to download and analyze it. I feel that it is troublesome.

A price estimator might help fill that gap.

The new quote is personalized and calculates how much of the patient’s annual deductible is outstanding and the out-of-pocket limits that apply to that coverage. It should also show how much the insurance company will pay if the service is out of network. Patients may request if they prefer to provide information on paper rather than online.

Insurers and employers who do not provide the tools could be fined at least $100 per day per person affected.

Also, there is a caveat. Consumers using the tool must have their own health insurance and there is no guarantee that the final cost will be as shown.

This is because “unforeseen factors in the course of treatment that may involve additional services or providers may increase the actual cost sharing liability.”

The insurance company is not responsible for incorrect quotes.

One of the risks is the “$4,000 charge”, as the cost estimate may differ significantly from the final price because the procedure was more complicated than originally anticipated or was handled by another provider at the last minute. Recipient of the letter, Gerald Anderson, professor of health policy and management and global health at the Johns Hopkins Bloomberg School of Public Health.

Many insurers have previously offered versions of cost estimators, but research shows that only a small percentage of policyholders actually use them.

Federal regulators have defended their requirements for estimators, and many insurers have provided estimators, but the new rules set specific parameters and are more detailed than previous versions. I wrote that it is possible.

In outlining the final rule, the Centers for Medicare and Medicaid Services noted that some previous calculators “only offer broad or average estimates of pricing using historical claims data on the market. not providing,” and patients were accumulating toward their annual deductible or out-of-pocket limit.

Such price disclosures help people compare shopping, and could ultimately help curb rising medical costs.

But that is not the case.

David Brueggeman, director of commercial health at consulting firm Guidehouse, said:

In the short term, the results may be hard to see.

“Most patients don’t move en masse to use these tools,” said Dr. Ateev Mehrotra, a professor of health policy at Harvard Medical School.

He said there are many reasons, including little financial incentive if you face the same dollar out-of-pocket regardless of whether you go to a very expensive facility or a cheaper one. A better way to switch patients to low-cost providers is to create price tiers that reward patients seeking cost-effective providers with lower out-of-pocket costs, he said. rice field.

Mehrotra is skeptical that cost estimators alone will have much of an impact on rising healthcare costs. He argues that the requirement to publish all prices negotiated by hospitals and insurers will further reduce costs by showing which providers will eventually be the most expensive and which insurers will negotiate the best rates. I hope it will lead to

Still, cost estimators could help increase the number of people with high-deductible health insurance plans who directly out-of-pocket much of their medical costs before reaching the deductible. Some people can save a lot by shopping during that period.

These deductibles “put pressure on consumers to shop on price,” said Guidehaus’ Brugesmann. “Whether they’re actually doing it is debatable.”

Julie Appleby is a reporter for Kaiser Health News where this article was originally published. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. KHN is one of her three main operating programs at KFF (Kaiser Family Foundation), along with policy analysis and polls. KFF is a donated non-profit organization that provides information on health issues to the public.

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