Can someone make sense of this? (Pittsburgh: neighborhood, to buy, subsidized)

[Hopes]

Originally Posted by track2514

In other words, people with Highmark insurance would basically have to pay close to full price in order to go to certain doctors and hospitals.

That's an exaggeration. Most health insurance policies pay 80% for out of network. There are various percentages but I've never seen one under 60%. If those policies exist, they are rare. It's not anywhere near full price to go out of network. This is also another reason UPMC is very likely to agree to this contract eventually. Most Highmark patients will stop using UPMC to save money because they don't understand how out of network works. UPMC won't want to lose their business.

Originally Posted by track2514

On other side of the issue, UPMC has a significant presence in western PA and it is hard as a patient to find good doctors and hospitals who are not affiliated with UPMC. I am not saying all UPMC doctors are better or anything like that, but there are so many specialties it would be hard for most patients to still have good doctors and not use any UPMC physicians.

I disagree with the "most" patients part. I think a small percentage of people will run into this problem. WPAHS has great doctors in many specialties. It's a teaching hospital. There will be very few specialties that WPAHS doesn't have too. As WPAHS grows, it will add doctors too. All of my doctors were former UPMC doctors who left for WPAHS. I followed them even when they were out of network for me. They're fantastic doctors.

Originally Posted by track2514

For instance, I currently have Highmark insurance and my primary care physician is UPMC, but my dermatologist is Highmark. If the contract expires I will have to find a new primary care physician or pay insane prices.

When I see a doctor out of network, the prices aren't insane. I pay my copay. The insurance company pays 80% of the total bill. I usually get a bill for a small difference. I've always been amazed at how low the remaining balance is. Sometimes just a couple of dollars. Say I have a doctor bill for $100. I pay a $10 copay. The insurance pays $80. I have a balance of $20. The entire visit cost me $30. That's not insane. Also, there is an out of pocket maximum for out of network too. Eventually the insurance pays 100% for out of network once you reach the out of pocket maximum. So there is a limit to how much you will pay to go out of network for expensive procedures such as surgery. Sure, it's more expensive than staying in network, but it's not "close to full price" or "insane prices."

[trackstar13]

Originally Posted by Hopes

That's an exaggeration. Most health insurance policies pay 80% for out of network. There are various percentages but I've never seen one under 60%. If those policies exist, they are rare. It's not anywhere near full price to go out of network. This is also another reason UPMC is very likely to agree to this contract eventually. Most Highmark patients will stop using UPMC to save money because they don't understand how out of network works. UPMC won't want to lose their business.

Well Hopes where do I start? You are completely wrong so I will start with this post and then dissect further in later posts. My Highmark healthcare, which is similar to that of many others in western PA has a deductible for out of network providers. So here is how it works:

1) I have to pay a $1,400 deductible first for out of network providers
2) Next Highmark will pay 80% of the allowable costs. Well guess what the allowable costs are less than what UPMC bills.
3) Finally, I have to pay my 20% plus the difference between the allowable costs and what is billed.

Just so you understand I immediately have to pay for the first $1,400 in medical costs for out of network before anything is covered. When everything is finally covered I then have to pay 20% plus the difference between billing and what is paid. To illustrate the example further, lets pretend I have already paid the $1,400 for out of network. Now I go to see a UPMC doctor for a basic visit. They charge me $400 for the office visit. Well next Highmark determines the allowable amount for the visit is $300 so they pay their 80% or $240. Well that means I have to pay $60 for my 20% share and potentially another $100 to UPMC for the difference that Highmark does not pay. So even after paying the massive out of network deductible I still have to pay for a huge portion of each office visit. A few final notes to this post:

1) $1,400 or the deductible I have to pay for out of network providers up front is only slightly less than my share of payments for health insurance premiums for my family for the entire year.
2) According to my plan some services with out of network providers are not covered at all, which means I have to pay 100% all the time regardless. For instance, physical exams out of network are not covered.

Originally Posted by Hopes

That's an exaggeration.
I disagree with the "most" patients part. I think a small percentage of people will run into this problem. WPAHS has great doctors in many specialties. It's a teaching hospital. There will be very few specialties that WPAHS doesn't have too. As WPAHS grows, it will add doctors too. All of my doctors were former UPMC doctors who left for WPAHS. I followed them even when they were out of network for me. They're fantastic doctors.

Disagree all you want, but you are missing the point that people like myself search out the best doctor for a certain specialty in that given area and want to go to that doctor. If the best neurologist in my area is a UPMC doctor and I can't affordably see said doctor with Highmark insurance that is problematic. It seems that you are not understanding the true magnitude of this issue and Pittsburgh unlike some other similar cities does not have much competition when it comes to physician and hospital services.

Originally Posted by Hopes

When I see a doctor out of network, the prices aren't insane. I pay my copay. The insurance company pays 80% of the total bill. I usually get a bill for a small difference. I've always been amazed at how low the remaining balance is. Sometimes just a couple of dollars. Say I have a doctor bill for $100. I pay a $10 copay. The insurance pays $80. I have a balance of $20. The entire visit cost me $30. That's not insane. Also, there is an out of pocket maximum for out of network too. Eventually the insurance pays 100% for out of network once you reach the out of pocket maximum. So there is a limit to how much you will pay to go out of network for expensive procedures such as surgery. Sure, it's more expensive than staying in network, but it's not "close to full price" or "insane prices."

You are lucky to have better healthcare than most it sounds like and your own personal experiences might be clouding your understanding of this issue. In a previous post, I gave an example of my healthcare and my out of pocket maximum for out of network providers is $2,000, which is more than my entire healthcare premium for the year. In other words, yeah I can see out of network providers and have Highmark pay 100% if I literally more than double my healthcare premium costs for the year. The issue I think you are having trouble grasping is that many people who work for small or medium size companies will be significantly impacted by this issue. A few years ago I worked for an organization out of state with over 30,000 employees and my healthcare was very cheap and I had no co-pay, no deductible for out of network or in network, small out of pocket costs for out of network, and my premiums actually went down almost every year because we were expanding and adding more employees. That is not the reality for most people though and my current healthcare in PA is much different with a huge deductible for out of network and pretty high out of pocket costs. I talk to many people with Highmark insurance in both Pittsburgh and Erie who are following this issue very closely and most of them are in the same boat as me. This issue literally affects millions of people and many of them are working for smaller to mid-size companies who have a deductible for out of network providers and significant out of network out of pocket costs.

[greg42]

If I remember right most of my out of network coverage is at 50%, with a number of things not covered at all out of network. It's not that unusual. We certainly don't have enough employees to have an "unusual" plan.

Of course, UPMC will remain in network for me since this is an Aetna plan.

Hopes, your experiences are on the ideal side of things I am sorry to say. Not everyone gets to have it that good. Quite a lot of people don't get to have it anywhere near that good.

[Hopes]

Originally Posted by track2514

It seems that you are not understanding the true magnitude of this issue and Pittsburgh unlike some other similar cities does not have much competition when it comes to physician and hospital services.

I do understand the magnitude of the problem. The difference is I believe the cause of the problem is the monopoly. It won't be get better until UPMC has healthy competition.

As for the specifics of your policy, that's something to take into consider when choosing between employer provided plans. The cheapest premium payment doesn't buy the best insurance coverage. I've never selected a plan that had such terrible coverage for out of network. I've shopped around and we've had many different health insurance policies from many different insurance companies.

[trackstar13]

Originally Posted by greg42

If I remember right most of my out of network coverage is at 50%, with a number of things not covered at all out of network. It's not that unusual. We certainly don't have enough employees to have an "unusual" plan.

Of course, UPMC will remain in network for me since this is an Aetna plan.

Hopes, your experiences are on the ideal side of things I am sorry to say. Not everyone gets to have it that good. Not even most people get to have it that good.

Greg thanks for providing another example of out of network coverage, I think it really helps to have multiple examples when talking about an issue like this where there are so many different plans.

[Hopes]

Originally Posted by greg42

If I remember right most of my out of network coverage is at 50%, with a number of things not covered at all out of network. It's not that unusual. We certainly don't have enough employees to have an "unusual" plan.

Of course, UPMC will remain in network for me since this is an Aetna plan.

It's unusual based on policies that have been available to myself and my family members. I reviewed every single private policy available in Pennsylvania last Fall when I was looking for insurance for different members of the family. All of our employer provided insurances have had reasonable out of network coverage too. On occasion, I have seen the cheapest group policy option have terrible coverage, but I never chose that option. Sometimes smaller companies have policies that cover less in order to provide insurance that's affordable to the employees. My husband and I haven't worked for exceptionally small companies in quite a long time. It's sad to hear that private policies have better coverage than group insurance provided by some employers. What's wonderful about healthcare reform is employees will no longer need to rely on employers for insurance. Everyone can shop around for the best policy for their specific situation.

[Hopes]

Originally Posted by track2514

Greg thanks for providing another example of out of network coverage, I think it really helps to have multiple examples when talking about an issue like this where there are so many different plans.

I agree. There are many different plans. I think we're both making the mistake of assuming that our individual experiences apply to the majority. That's what I took issue with----your stating "most people." I don't believe it is true for most people. Just like you don't believe my experience is true for most people.

[greg42]

You have to keep in mind, many groups don't have multiple choices. That alone is a luxury. Also what is offered through employers can differ from what is offered individually. It can differ in small ways or large ways. Generally what is offered in the individual market is a small subset of the entire variety of plans offered by a given insurer. A large enough employer can structure a plan just about however they want. A small employer is limited to whatever the insurer offers within whatever price structure works for the small company. Some employers do not spend a lot of time scrutinizing the options or negotiating the rates. (Around here we heavily question any renewal increases and never accept the insurance company's first offer.) There are so many ways this can differ it is mind boggling. And ridiculous. You simply can't make reliable generalizations about "most people's" health plans.

I actually do have two options at work right now. Originally I chose the higher option, but last year I think it was I switched to the lower option because realistically I don't go to the doctor very much so I might as well save the $$ upfront on the premiums. We renew in April so it's been over a year that way. Saves me a few hundred bucks a year I think it is. And I still haven't been to the doctor.

[trackstar13]

Originally Posted by Hopes

I do understand the magnitude of the problem. The difference is I believe the cause of the problem is the monopoly. It won't be get better until UPMC has healthy competition.

As for the specifics of your policy, that's something to take into consider when choosing between employer provided plans. The cheapest premium payment doesn't buy the best insurance coverage. I've never selected a plan that had such terrible coverage for out of network. I've shopped around and we've had many different health insurance policies from many different insurance companies so I have a good idea that what you are experiencing doesn't apply to the majority of health insurance policies out there.

Hopes you are just making your previous responses even worse by trying to retroactively say that you now understand this issue when you admitted previously that you do not. My currently employer has roughly 1,000 employees and about 750+ are full-time with health coverage. There is only one policy offered and it is a specific PPO policy through Highmark. For my family I pay a little less than $1,500 per year for my health insurance premium. There are some additional costs that are subsidized by my employer and this is not one of the "cheap" policies that you think I am talking about here. I have already gotten quotes for individual insurance plans that are not subsidized by my employer and they are much more expensive to even get the same level of coverage that I have now. What I am experiencing does apply to the vast majority of people in western PA and to further demonstrate what I am talking about here is an example:

Link to healthcare costs for the 9th largest employer in Pittsburgh (Carnegie Mellon University): http://www.cmu.edu/hr/benefits/OE/ftbook13.pdf

Information:

• CMU offers several healthcare options, which is not unusual because they have almost 5,000 employees.
• The healthcare plan with the best out of network coverage costs $3,792 for a family per year and that is only the employee portion. The employer is also subsidizing that rate to make it more affordable.
• All of the other CMU healthcare plans have pretty high deductibles for out of network coverage
• As a final point, this is still a major employer with benefits that are better than what most people are dealing with in Pittsburgh. The top ten major employers in Pittsburgh only account for about 100,000 jobs in the area. The Pittsburgh total labor force is well over 1,000,000 total workers and this means that those who work for the largest employers and have of the best health coverage are less than 10% of the workforce in Pittsburgh. Now there are small and medium size companies that offer better than normal healthcare coverage, but most of these companies cannot spread the risk as much as the larger companies and offer the same level of healthcare coverage at an affordable cost. The 90%+ of Pittsburghers who are working for smaller or medium size companies and do not have the options offered by the major employers would also probably disagree with your comments about "cheap" healthcare policies and out of network coverage.

[Hopes]

Originally Posted by greg42

You simply can't make reliable generalizations about "most people's" health plans.

That's what track2514 did. He assumed his situation applied to most people. That's why I responded. I really don't believe that's true. Unless someone can provide data and statistics from reliable sources, we'll never have an accurate answer. I acknowledged that we're both making the mistake of applying our individual experiences to the masses.