Sunday, September 29, 2013

Why Obamacare could slash my medical costs 84% and other lessons from a screwed-up health system

Gannett's sweeping new 2014 employee health plan is based on the much-debated concept of consumer-driven health care. The theory: Workers control an employer's medical costs much better when their own money is at stake.

My employee ID card.
Under Gannett's new Consumer Choice Health Plan, you'll still pay monthly premiums. But you'll also pay for all doctor's visits and prescription drugs up front, with your own money, until you satisfy an annual deductible. Only then will the insurance benefits really start, paying 80% of expenses going forward. You'll pay the remaining 20%.

The deductibles are steep. For employee-only plans: $1,500. For family plans: $3,000.

Feeling sick already? You'll now have a big financial incentive to ask how much a doctor's visit costs before scheduling an appointment, or the price of meds when a prescription needs filling. Then you'll weigh those certain costs against the uncertain severity of your symptoms -- and the potentially awful consequences if you make the wrong choice. You'll ask before spending, instead of spending without asking.

I feel your pain
My recent experience as a patient -- a shoulder injury that's cost $600 so far -- is a story about the pluses and minuses of traditional health insurance plans. In other words, plans like the ones 31,000 Gannett workers and thousands more retirees are about to lose.

The extraordinary price I pay for insurance premiums -- nearly $11,000 a year, just to cover myself -- starkly illustrates the grim life many older Gannett employees face if they get laid off. Yet, that's tempered with a new reality: Under Obamacare, my premiums for exactly the same coverage could plunge to less than $2,000 a year.

Or not. As I post this, both political parties in Washington are holding Obamacare hostage in a searing battle over government spending. Simultaneously at 12:01 a.m. Tuesday, the health reform law kicks in and the federal government shuts down, barring an increasingly unlikely ceasefire.

Against that backdrop, Gannett has just launched one of the biggest medical plan overhauls in its history. And no wonder: With a self-funded plan, the company spent more than $100 million on medical care alone last year. Employees paid only 40% of that. Shareholders paid the rest.

Welcome to one of the world's most dysfunctional health care systems, and certainly the priciest. That's where one frustrated consumer's story begins: mine.

A little health history
I am 56. I don't smoke or drink. I'm 5'6" and weigh about 155 lbs. My health is good to great, except for high cholesterol that I've beaten into submission with a daily statin pill.

My medical plan is Kaiser Permanente, an enormous non-profit based in Oakland, Calif., near my San Francisco home. Kaiser employs 17,000 doctors and 160,000 other employees at 37 hospitals and 611 medical centers across California and nine other states. With nine million members, its $51 billion in annual revenue last year was 10 times more than Gannett's.

Kaiser was my provider when I was a USA Today reporter. I paid $150 in monthly premiums for a comprehensive, employee-only plan that included benefits like acupuncture and classes on nutrition, yoga and how to quit smoking.

When I accepted a USAT buyout in 2008, I continued getting Kaiser care for the same monthly premium until my severance benefits ran out 10 months later. Then, COBRA kicked in for another 18 months of Kaiser benefits -- but at a much higher price: $450 a month. That was because Gannett was no longer subsidizing my costs.

Once COBRA expired, I stayed with Kaiser -- even after it turned down my request for a less expensive high-deductible plan -- because I liked my doctor and other services that much. My monthly premium jumped to $600. Then, nearly every year after, it rose another $100.

I'm now paying nearly $900 a month, with a $1,500 annual deductible. Kaiser covers 80% of my expenses. My 20% is mostly co-pays of $30 per office visit, more if I see a specialist.

Martore and Obama.
Add it all up, and I've spent nearly $42,000 on premiums alone since I left USAT nearly six years ago. As you see, without access to an employer plan, it's insanely expensive to buy insurance on the individual market at non-group rates. That's why many older Gannett employees fear leaving the company without first lining up a new job with health benefits.

These crazy-high prices are a main reason why 48 million Americans -- about 15% of all -- don't have health insurance. That's what Obamacare is supposed to fix. But richly paid Gannett CEO Gracia Martore will have none of that.

No questions asked
Last February, when I called Kaiser about recurring pain in my right shoulder, I wasn't worried about big up-front expenses. Indeed, I wasn't worried about any expenses, because I knew Kaiser would pick up most of the tab.

At the office, I paid my $30 co-pay with a credit card, then headed for the examining room. There, my doctor asked a few question, gave me an exam, and then a diagnosis of adhesive capsulitis. He referred me to a Kaiser physical therapist.

I didn't ask how much the PT would cost. Over the next month, I saw him three times, paying a $55 co-pay for each session.

Soon enough, I received monthly statements showing how much I had paid toward my deductible. As always, I tossed them aside, unread. In 13 years at Kaiser, I've only reached my deductible once -- in 2000, a very bad year for both me and Gannett. Two surgeries cost $35,000, nearly all of it paid by the company itself. (A belated thank you, shareholders.)

The physical therapy didn't help much. I e-mailed my doctor, who replied: "Let's go for a steroid injection this week. It will definitely help." He referred me to one of Kaiser's sports medicine doctors. No co-pay for that, because the "visit" was by e-mail.

The sports med guy also gave me an examination. And then he told me something I didn't want to hear.

It's my choice
He said it was very unlikely a steroid shot would help. What's more, potential complications included an infection. And even in the best cases, steroids only work about a third of the time. And then there was this kicker:

"But I'll give you a shot if you still want one," he said.

Now, it would have been easy to say yes. After all, Kaiser was footing most of the bill. I said no, however, mostly because of the potential complications.

It wasn't until later that I found the encounter crazy. Why didn't he just say: steroids won't work. No shot for you. There would have been immediate savings from the unused medicine, needle, cotton swab, etc. And not least: his time. Plus, further down the road, there were potentially huge savings for not having to treat a costly infection.

Maybe he was taking the path of least resistance. I might have chewed up more precious time arguing. Or worse, complained to my main doctor -- his colleague.

And the real cost?
Researching this post yesterday, I surfed Kaiser's website for copies of those monthly statements I'd thrown away. And here's what I learned.

Kaiser billed $170 for the office visit with my main doctor -- the one where I'd paid only a $30 co-pay.

They billed $431 for the three physical therapy sessions, but zip for the sports medicine guy, although I don't know why.

Total: $601. Of that, my share was only $224. Kaiser paid the rest.

This year has been unusual in terms of using Kaiser. More typically, my annual charges would run closer to $500. That means I've received a total of $3,000 worth of care in the nearly six years since I left Gannett. But I've paid those $42,000 in premiums, so Kaiser's gotten the better end of the deal financially. On the other hand, I've enjoyed really good health. That's what matters in the end.

Dollar-wise next year, things could be very different.

Time to shop
Under Obamacare, Kaiser will sell me a plan with a higher annual deductible: $4,500 vs. $1,500. Co-pays will barely change. Otherwise, my coverage will be identical. My premiums will drop to about $500 from $900. And Kaiser can't turn me down for pre-existing conditions this time, also because of the health reform law.

In fact, that Kaiser plan costs even less when bought through California's government-run healthcare exchange. There, it's only $139 a month for individuals earning less than $50,000 a year. Same coverage, deductible and co-pays.

With Obamacare, my premiums could plunge 84%, to under $1,800 a year from $11,000 -- if I qualify.

But across Gannett, few employees will catch a break like that, especially the lowest-paid ones. The top brass? Not a problem.

Whatever my plan next year, I'll ask questions I've never asked before. So will Gannett employees:
  • How much will this office visit cost? 
  • Is there anything you can tell me over the phone or on the Web for free?
  • What's the charge for that X-ray, and is it really necessary?
  • I can't afford those pills. Will something over the counter work?
  • I can buy groceries. Or I can see the doctor. But not both. What should I do?
My shoulder still hurts
More than $600 later, I'll take my now pre-existing condition to the new medical marketplace on Tuesday.

But I've recently discovered what's causing some of the pain: too much typing. Best of all, the remedy is free.

What's your healthcare story? Please post your replies in the comments section, below. To e-mail confidentially, write jimhopkins[at]gmail[dot.com]; see Tipsters Anonymous Policy in the green rail, upper right.

47 comments:

  1. No, that's not my home address on the Kaiser billing statement I've used to illustrate this post. It's my business address.

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  2. So taxpayers who actually work for a living will pay most of your medical bills, while you party in your Mediterranean villa? Some might say that's fucked up.

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    1. I agree. But let me repeat two things from my post, with emphasis:

      "Welcome to one of the world's most dysfunctional health care systems."

      And:

      "With Obamacare, my premiums could plunge 84%, to under $1,800 a year from $11,000 -- if I qualify."

      But I won't qualify -- unless something shocking happens with the economy between now and the end of the year.

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    2. Here are TWO things Jim:

      - Your premiums may plunge, but an estimated TWO TRILLION to pay for this health care scheme has to come from somewhere, but what do you care as long as you have yours right.

      - And, your incessant whine about your costs is a bit comical considering where you reside. Will we you complain about your rent next?

      Sorry, but the naiveté and blinders some but on in defending ObamaCare (a phrase you long banned) is astounding.

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  3. Look, conceptually, I understand and support the idea of you asking about medical costs and using the power of the marketplace, but it doesn't work. When I was with Gannett, I took one of those plans where you got $600 to spend for the year. YOU go ahead and ask the doctors what it costs. They either don't know, or won't tell you. They are paid differently by different companies, and they charge cash customers more to make up what insured customers don't pay. All it leads to is adversarial doctors visits. The system is not built for this, and any insurance that requires you to price-check or negotiate with your doctor is going to end up hurting you. This system is not built as a consumer marketplace.

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    1. Corporate says this won't be a problem if you stay within the one network it's offering because office charges, etc. , have been negotiated to fixed prices. Problem, of course, comes when you leave the network.

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    2. You don't ask the doctor. They all think they're Mother Teresa. You find out from the insurance company (and they're making it a lot easier than in the past), and/or from the provider's billing department. Particularly when it comes to tests and procedures, there are wide and largely irrational price variations that should gradually go away as consumers get better informed. Meanwhile, how can it be other than to your advantage to know what's what?

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    3. I don't think anyone's suggesting you ask the doctor him/herself, although Kaiser is so networked, I bet my guy could look it up on his smartphone.

      Also, yes, knowing is a good thing.

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  4. My sister and her kids went to the doc office 28 times last year. Hypochondriacs for sure. Never much wrong. But because it was a small co pay she went. Heck she was incented to go to the doc. Her visits for nothing eventually cost me money.

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  5. Do you think your shoulder pain might be due to the cholesterol medicine, which, like all drugs, causes side effects?

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    Replies
    1. Possibly. But with the statin, my cholesterol fell nearly 100 points to 139. I'll take that over shoulder pain any day.

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    2. This comment has been removed by a blog administrator.

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  6. Remember one thing. Martone and other Corporations that are drastically cutting their medical coverage and blaming it on the Affordable Healthcare Act are lying to their servants. The idea of the Affordable Healthcare Act was to provide people that don't have insurance with an economical alternative. People like Martone are twisting the fabric to avoid doing the morally responsible thing for their employees and slashing benefits to provide only the minimum required by the law. Martone and her greedy executives in the crystal palace could always continue the plans in place and even provide better plans if they want. But that would take away from their precious multimillion dollar bonuses and retirement parachutes.
    Another point to be looked at, She blames implementation of the Act for the cuts. Yet the requirements for big business (Gannett) were delayed for a year.

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    Replies
    1. You have no idea what you're talking about.

      (And who's Martone?)

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    2. @4:23 PM =-One hopes you're not on the journalism side as you really don't get even simple economics. Then again, you probably are as too many like you really still beleive you can keep your doctor and plan, period.

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  7. Good piece, Jim. Thank you.

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  8. Last year we were encouraged to take Healthy Actions (or El$e). This year, we're going to be bled dry and and the high priced deductibles will prevent Gannett employees for taking any kind of healthy action. Where can I buy some leeches?

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  9. Let me ask you, if I quit my job, there is a strong possibility I will qualify for better benefits for less? I'm over 60

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    Replies
    1. Maybe. That's the good part of moving away from employer-based insurance and canceling exemptions for pre-existing conditions.

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    2. To find out whether you'd get better medical coverage, go to your state's exchange webpage and shop the different plans. It should show what you'd qualify for, and how much it would cost.

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    3. This comment has been removed by a blog administrator.

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  10. Yipes. $392 a month for employee plus child(ren) is a killer. One kid or many..... same bill. Ridiculous and unfair. How is it that the spouse coverage costs so much more than the employee?Do you believe this crap?

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    Replies
    1. How was/is it ever "fair" to single employees for the employer to offer married workers more compensation in the form of subsidized family coverage? Eh?

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  11. Great piece, Jim.

    I was forced out of Gannett via layoffs even though I had better reviews than anyone in my department. After COBRA, I was denied health insurance from big companies like Humana due to a pre-existing condition. Now with the Affordable Care Act I can be covered again.

    The commenter who wrote "So taxpayers who actually work for a living will pay most of your medical bills ..." is typical of the Tea Party and their shenanigans. No, no, no. We are paying for our premiums ourselves. BUT AT LEAST WE NOW CAN BE INSURED. And you won't have to pay more for me. Your costs will likely go down too, as proven in states like California who've already implemented the exchanges.

    It makes me sick hearing people come up with arguments against Obamacare based on lies. Fortunately I have insurance now and can be treated for that sickness.

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    Replies
    1. If you follow the thread a little more carefully, you'll see that the comment you cite was responding specifically to a scenario that DID involve taxpayer-funded subsidies. If that doesn't apply to your particular situation, fine, but that's has no bearing on the validity of the comment.

      In any event, we're going to add 35-50 million people to the rolls overnight, and somebody's going to have to pay for it.

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    2. Hee hee, you made me smile. Thank you for proving my point. 35 million people entering the system overnight will add 35 billion to the system overnight even if they only pay $1,000 per year for their health insurance through the exchanges. Most workers will pay more than $1,000 per year.

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    3. No. You, your children and your grandchildren are going to be subsidizing them.

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    4. Give it up, 11:17/12:21. You have no idea what you are talking about. None. Zero.

      9:26 might not have it quite right, but that post is far closer to the mark than yours. Take off the blinders, read up, get some facts, then come back.

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    5. Take your own advice, 12:18. Your comments are devoid of clue.

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    6. People like 12:18 think their fairy godmothers are going to sprinkle magic dust to come up with the 1.3 trillion Obamacare is going to cost.

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    7. Lots more money going into the system, 12:55. You and others choose to ignore that part. Maybe you need some intelligence dust.

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    8. Back in the 90s I left Gannett to pursue a medical degree. I am now a nurse practitioner and a Republican in a red state. I voted for McCain but here is the thing: Obamacare is going to work.

      Sure, it'll have some fits and starts, but everyone in my hospital knows it had to be done. Sure, we'll still go to rallies and support sensible fiscal conservatives. But this, thankfully, is a done deal.

      Even our administrators who hate change, secretly talk about how the Affordable Care Act will forward everyone's goals of more healthy Americans. We just grumble that California had to get the ball rolling.

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  12. Companies charge more to insure families/children/spouse because they are only rensible to the employee and include or included that benefit in the benefits pkg. that's true of most companies besides Gannett. However, gannett has chosen to insure the minimum by law. Shame on you Gannett!

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  13. Responsible for

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  14. Unbelievable ... I just received my Blue Cross notice telling me what my insurance will cost starting Jan 1. And BCBS does not hide their opinion. They clearly blame nearly all of the increase on OBAMACARE.... For a family of four our rate climbs 67.7% !!! from $930/month to $1563/month. THANKS mr PRESIDENT !!!

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    Replies
    1. Blue Cross is wrong. They are running scared and blaming Obamacare. Dump them immediately and check out the national averages a family of four should really be paying. You can find a calculator, among other places, at the Kaiser site. If your family makes a hefty $100,000 per year, you should "only" pay about $8,300 a year. It's shameful that Blue Cross would try this tactic.

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    2. This comment has been removed by a blog administrator.

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    3. Biased spike Jim…so, here it is again in what one hopes is a more palatable, pc version for your leanings.

      @9:40 – If you and others were honest, you’d admit and/or know that Democrats in Congress prevented insurance companies from sharing their concerns prior to its enactment, something many are finally sharing with those they cover, like Blue Cross is doing now.

      Fact is, Obama Care is costly, and by CBO projections more than double in its costs of $900 billion, likely doing little for years to cover all those Obama claimed.

      Gannett, like all employers, annually review and revise their plans….Obama Care’s uncertainties, demands and costs dictate all pay more attention to what’s coming.

      It's not pretty for most. Get ready.

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  15. Is Gannett taking advantage of ACA to further bleed their employees and cut costs further? Well, they are the ones who brought you TPP afterall. Heard some buzz head won Accountant of the Year for that one!

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  17. Warning: No truth-telling about Obamacare shall be countenanced on this site.

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  18. First of all, the health care reform failed tragically by not doing anything about the REAL problem with our health care system, the costs for medical care. Also, because most of Washington are lawyers, they are not going to take another step to control costs by limiting lawsuits. So basically, folks, this is all just a matter of cost shifting. And yes, those of us working are going to have less coverage and pay more. And businesses are paying in a lot of ways you don't see, such as reporting all the information to the IRS that is needed for them to oversee the program. I agree with some of the changes brought about by the reform, but I am also angry that the President did nothing to address the real problems of our system. But in order to provide coverage to those who aren't working or who have pre-existing conditions SOMEONE is going to have to pay. That's basically the middle class working people.

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  19. Pfffft. Limiting lawsuits is a red herring given way too much attention in the debate over controlling costs.

    No doubt, costs are spiraling higher: Gannett's medical spending now tops $100 million a year, and employees paid only 40% of that last year. (It'll rise to 50% this year, according to one of my readers.)

    The U.S. spends more per capita on medical care than any other industrialized nation, and we don't even consistently get the best results.

    Ask Gannett why its costs are higher and you'll get a variety of reasons. But one fact remains: a major culprit driving costs across the health industry is Medicare, the government program that pays for most of the care given to those 65 and older.

    Indeed, a sliver of the sickest patients account for the majority of U.S. healthcare spending. In 2009, the top 10% of Medicare beneficiaries who received hospital care accounted for 64% of the program's hospital spending.

    What's more, medicare patients rack up disproportionate costs in the final year of life. In 2009, 6.6% of the people who received hospital care died. Those 1.6 million people accounted for 22.3% of total hospital expenditures.

    That's according to a report in The Wall Street Journal, hardly a leftist rag.

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  20. I will have to continue my research when I have time, but I have seen that costs could be affected by as much as 35% with limitations on law suits. While I can't remember at this time what the source was, I am an avid reader of the Wall Street Journal, so I tend to believe I have seen it there. I have seen the prices physicians pay for mal-practice alone. It's unbelievable, and again, those costs are passed to the consumers. It's also time for Americans to get off their butts and take some control over their own health. Lose weight, eat healthy foods and exercise. You will see an automatic reduction in health care expenses and medications, people.

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    Replies
    1. In your research, please include this article about the questionable benefits of malpractice tort reform already enacted in Texas.

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    2. 9:14 AM: Left wing BS funded by the usual suspects.

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  21. 8:28, eating healthy and exercising are great suggestions. But those alone won't fix the health-care mess. Jim mentioned high cholesterol. I don't know his health history, but even people who exercise a lot and eat healthy can have high cholesterol. There are many, many other ailments of that type.

    In summary, your solution is largely a non-solution.

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Jim says: "Proceed with caution; this is a free-for-all comment zone. I try to correct or clarify incorrect information. But I can't catch everything. Please keep your posts focused on Gannett and media-related subjects. Note that I occasionally review comments in advance, to reject inappropriate ones. And I ignore hostile posters, and recommend you do, too."

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