As we head into the second Obamacare open enrollment season, the media have a chance to redeem themselves from last fall, when skepticism was sometimes left at the door and coverage was dominated by website screw-ups, cancelled policies, presidential false promises, and anecdotes that blew up under scrutiny. All of this noise drowned out the crucial point: what do people really need to know about how to choose—and use—an insurance policy.
When the exchanges re-open on November 15 and in the weeks that follow, reporters should not lose sight of these key questions: How are consumers faring as they sign up on the federal and state exchanges? How are they faring as policy-holders and patients? Is the Affordable Care Act making healthcare affordable (“for many, yes, but not for all,” concluded The New York Times this week) or adding new cost barriers? Among privately insured adults, 19 percent said they did not go to the doctor when they were sick or injured because of costs and 29 percent of those with high deductibles didn’t seek treatment, according to a recent AP-NORC Center for Public Affairs Research poll funded by the Robert Wood Johnson Foundation. There’s a lot going on here. What follows are six areas to probe as open enrollment Round Two begins.
Scrutinize rates and premiums As I’ve reported, basing a story on average rate increases doesn’t cut it as good consumer information. What people need to know is what they actually pay, and whether it’s more or less than last year for exactly the same coverage. That means they have to know the deductible, out-of-pocket limits, copays and coinsurance amounts and what they apply to. An insurer may appear to offer the same silver plan but may have tweaked the coinsurance. An outpatient procedure with some pricey diagnostic tests and coinsurance of 20 or 30 percent could leave someone with a much higher out-of-pocket expense than the policy with a higher premium. Last year, I interviewed a Pennsylvania woman who kept her old Aetna policy because it had no general deductible, but it also had $600 copays for hospital stays and a $1,500 deductible for brand drugs. To really help your readers out, you need to show the interplay between all the elements of an insurance policy and discuss how much risk shoppers are willing to assume.
Rates have been super politicized. Beware of slipping into a political piece about averages with the vested interests touting high or low rates to suit their point of view. Keep an eye on states where rates seem very low and insurance officials are eager to tout the news.
Examine narrow networks These networks have become the cost containment method of choice, since the government doesn’t want to negotiate prices of medical services with providers the way most other countries do. Reporters need to probe the consequences, because the resulting choices for consumers aren’t clear, consistent, or easy to navigate. Insurers allow policyholders to see only providers who’ve agreed to prices the insurers want to pay. Going out-of-network means patients pay most or all the bill themselves. Finding out if your doctor is in the network—the standard advice in those “shop around” stories—doesn’t guarantee patients will be spared large medical expenses. Lots of patients have followed that advice only to find an in-network doctor is not taking new patients, or they’re stuck with big bills from out-of-network docs working at in-network hospitals.
One great way to help keep tabs on the shifting provider lists is to construct a database of doctors, as Los Angeles Times reporter Chad Terhune and his colleagues did in California. If reporters can’t do that, Terhune suggests calling local providers and insurers to see if they both agree they’re in a particular plan and then reporting any mismatches.
Check out other cost-shifting tricks On Sunday, New York Times reporter Elisabeth Rosenthal detailed how, “as insurers and providers fight over revenue in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.” Hospitals have been tacking on “facility fees” to patients’ bills for a while now, but Rosenthal found another one, the “noncritical activation fee” for calling a trauma team into action. On the doctor side, she found ophthalmologists charging special refraction fees. If patients don’t write a check for these fees, docs withhold prescriptions for glasses.
You've covered most of the significant issues around the ACA in this post. I hope reporters use it as a guide.
The skin-in-the-game metaphor is one I wish would be retired. First, essential healthcare is decidedly not a game. Second, skin is a vital organ, and the loss of enough of it is lethal.
A side story re: Medicare Part D drug coverage. The least expensive premium in the Eastern MA area is 15.60 monthly. The annual deductible is 360. Policy holders using tier 1 and 2 medications do much better out of pocket to use GoodRX coupons and the $4 drug lists at Target, Walmart and the like and not use their Part D policies. They will never trigger any actual benefits. So in essence, the premiums become just another expense to patients (please do not refer to patients as consumers 0 two different animals).
#1 Posted by Annie, CJR on Thu 30 Oct 2014 at 02:09 PM