May 15, 2017: Musings About Healthcare Reform…

Don’t get me wrong – I completely understand that healthcare is expensive.

Quality, specialized care in particular, and I say that as the father of three kids who collectively spent 141 days in the NICU because they were born prematurely. Those months represent some of the most nerve-racking times that I’ve ever experienced, and yet thanks to the skilled professionals and incredible technological achievements, all three of my boys are alive and well, and that’s something that I certainly don’t take for granted.

I know that my family wouldn’t be where it is today without health insurance. We racked up hundreds of thousands of dollars in medical bills while each of our babies were cared for in the hospital, and yet we only paid a fraction of that out of our own pockets – the rest was paid for by insurance.

The concept of insurance is sound – everyone pools their money together just in case some of them have expenses that they cannot handle on their own – but it still needs some work.

I say this because today we received a letter explaining that our local children’s hospital here in Tampa – Johns Hopkins All Children’s Hospital – has reached an impasse in contract negotiations with our health insurance provider – United Healthcare – and that as a result, care provided by All Children’s will now be considered out-of-network by United Healthcare…

This hits home for two reasons:

  1. Only last month, my youngest underwent surgery there and ended up having to stay overnight. In total, his stay will cost us roughly $1,900 out of pocket, however as an out-of-network provider it would’ve cost us $7,500 – or 4x the cost – for the exact same care.
  2. Looking back at those 141 days of NICU care, though it was provided at a hospital that is still in-network, the doctors who directed our boys’ care billed for their services through All Children’s, meaning that if we were to go through the same toils tomorrow, the out-of-pocket costs that we incurred would likely have been triple what we paid.

I find it interesting to look at those two scenarios because for the latter when our children were in the NICU, we would still very much benefit from out-of-pocket caps that despite being twice what we have for in-network claims, establish an upper limit for out-of-network charges. The smaller surgery, oddly enough, would end up costing us more proportionately because the charges – while 4x what we paid in-network – wouldn’t exceed the cap.

If anything, it seems like it would be more fair to have a higher out-of-network maximum and better co-insurance to make smaller, but not insignificant care easier to handle.

Regardless, I think the challenge that we face as consumers and patients is in having to navigate this maze of terms and conditions and pricing – some of which isn’t really available until after care is received or isn’t negotiable on account of the urgency required. When each of my sons were born early, we didn’t have time to sit down with the insurance company AND the hospital AND the doctors AND the anesthesiologists AND the lab to discuss prices and verify that everyone was on the same page!

It’s complicated, yet in a way what healthcare in the United States needs is to be simplified by establishing common standards for care – something that I’m sure already exists, as it does in most industries – and right there the biggest hurdle of in-network / out-of-network goes away because everybody across the board charges and accepts the same pricing, so everybody could just work with everybody.

At that point, the insurance companies would truly begin to compete on a level playing field determined only by their own premium structures because they’ve essentially become the big pools of money that they were originally intended to be. Decouple insurance from employment … without sticking it to employees in the process … and then consumers would actually have the freedom of choice once again, as opposed to now where yeah, you can technically buy your own policy, but employers subsidize so much that most people can’t afford to do it!

Obviously there are lots of other angles to address – most of them by going single payer like the rest of the industrialized world – but these just seemed like simple ones to pick at from the top down because in no world does it really make sense for a hernia surgery to cost $1,900 for one patient and $7,500 for an identical patient who just happens to have different insurance coverage.

And yes, even these “simple things” would be a major disruption to our healthcare industry and a lot of big businesses wouldn’t like it. But what’s the point of healthcare, really, when you get down to it???

The intent of healthcare is to help sick people get better, and so many providers – my wife as a nurse included – go into their field expressly for the purpose not to get rich, but to help people.

Healthcare is due for another disruption. The Affordable Care Act made huge strides by doing away with the frankly ridiculous notion of pre-existing conditions, but it’s time to continue moving forward until we get to the point where people can just get the care that they need without the rest of their world collapsing trying to figure out how to pay for it all.

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