They Paid How Much? How Negotiated Deals Hide Health Care's Cost : Shots - Health News A patient's portion of a health care bill is the result of a complicated equation. But it's simple compared with the variety of deals insurers negotiate with hospitals and doctors.
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They Paid How Much? How Negotiated Deals Hide Health Care's Cost

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They Paid How Much? How Negotiated Deals Hide Health Care's Cost

They Paid How Much? How Negotiated Deals Hide Health Care's Cost

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As Americans begin to shop again for health insurance under the Affordable Care Act, they'll wrangle with premiums, deductibles, out-of-pocket costs and other insurance buzz words, but as Sammy Mack, of member station WLRN, explains, that's the easy part, figuring out what health care actually costs is harder.

SAMMY MACK, BYLINE: This March, Sal Morales bought insurance on the website.

SAL MORALES: I got my cards and it was, like, amazing, like, if I got an American Express Platinum card. That's how I felt.

MACK: Morales was unemployed at the time. Money was tight and he knew he needed regular doctor visits to manage his hypertension. He diligently researched what he would get for the price before settling on a plan.

MORALES: Instead of me paying $560 for COBRA, I found out that I would have insurance for $145. I have a network deductible of $500. The first three visits to a primary care physician - they're zero dollars, and then it's $5 out of my pocket.

MACK: But what Morales pays is part of a very complicated equation and it doesn't necessarily reflect what gets paid out for his care, says Bruce Rueben, president of the Florida Hospital Association.

BRUCE RUEBEN: That gentleman knows what it costs him, but he may not know the actual cost of his health care.

MACK: Here's how Rueben breaks it down.

RUEBEN: There's one party - the hospital that provides the service. There's a second party - the patient who receives the service. And then there's a third party - the insurance company that pays for the service.

MACK: And this is where health care pricing gets really squirrelly. Every hospital has its own master list of charges for different services, but insurance companies don't pay those listed charges. Those listed charges are almost fiction. Instead, each insurer negotiates for lower rates with each hospital and doctor on every plan. All of this means there are about as many costs for that hypertension checkup as there are insurers and providers. Dr. Ezekiel Emanuel is a health policy expert at the University of Pennsylvania.

DR. EZEKIEL EMANUEL: For an individual consumer, I am completely sympathetic that it's very confusing. There are at least six different prices for a hospital day and then there's actually the cost of delivering the service, which, you know, for most of these things, even a hospital doesn't know what that actually is. So when you say what's the price? That's almost a meaningless question because there are all these different prices.

MACK: Those negotiated rates - the prices insurance companies really pay hospitals - they're treated like trade secrets. There is a small window to see that price after it's been paid and only if you're already insured. It's buried in a statement called an explanation of benefits. If you've ever gotten a letter from your insurer that looks like a bill that says this is not a bill you've seen one. Efrain Monzon helps patients interpret those explanations for Florida Blue, the largest insurance company in the state of Florida.

EFRAIN MONZON: We're identifying the procedure. We're identifying the provider, the date of service, which is important, and then making sure that the amount - that the member has responsibility - has to be in there.

MACK: Wedged into that statement, somewhere between the billing code and the member deductible, is a column for the amount paid. This is the secret number the insurance company and the provider have worked into their contract, says Monzon.

MONZON: We pay the contracted amount based on whatever the provider has, so that would be the amount paid.

MACK: Collect enough of those statements from patients at all different hospitals with all different insurance and you could get a clearer sense of what health care costs. There are companies and crowdsourcing projects trying to do just that around the country. And Massachusetts has a law that says insurers have to disclose some of those prices, but that's not happening in Florida, which is all part of why someone like Sal Morales can know what his care will cost him every month.

MORALES: For $145 I was able to get health care.

MACK: But he won't necessarily know the true price of that health care. For NPR News, I'm Sammy Mack.

SIMON: And this story's part of a reported partnership between NPR, WLRN and Kaiser Health News.

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