As Americans begin shopping again for health insurance under the Affordable Care Act on Saturday, theyāll be wrangling with premiums, deductibles, out-of-pocket costs and other vague and confusing insurance-speak.
Believe it or not, thatās the easy part compared to figuring out what the overall cost of health care is.
Sal Morales of Miami bought insurance in March during the ACAās first enrollment period on .
āI got my cards and it was like amazing,ā Morales says, ālike if I got an American Express Platinum card. Thatās how I felt.ā
Morales was unemployed at the time. Money was tight. And he knew he needed regular doctor visits to manage his high blood pressure. He diligently researched what he would get for the price before settling on a plan.
Sal MoralesĀ poses with some ER bills in September. In March, he bought health coverage on healthcare.gov (Photo by Al Diaz/Miami Herald)
āInstead of me paying $560 [a month] for COBRA, I found out that I would have insurance for $145. I have a network deductible of $500,ā Morales says. āMy first three visits to a primary care physician, theyāre zero dollars. Then itās $5 out of my pocket.ā
Morales understands his end of the health care equation, but what he sees doesnāt necessarily reflect what gets paid to doctors and hospitals for his care, says , president of the Florida Hospital Association.
Hereās how he breaks it down: āThereās one party, the hospital who provides the service. Thereās a second party, the patient, who receives the service. And thereās a third party, the insurance, who pays for the service.ā
That third part is where health care pricing gets really squirrelly.
Every hospital has its own āmaster listā of charges for different services. Those charges are different from hospital to hospital.
But insurance companies donāt pay those listed charges. The listed charges are almost fiction. Instead, each insurer negotiates for lower prices with each hospital and doctor on every plan. And insurers can have multiple plans with multiple agreements for the same hospitals or doctors.
Even if two patients have the same insurer, if their plans are different, the insurer may pay the doctor differently for the same care for each of the patients.
All of this means there are about as many pricetags for that hypertension checkup as there are insurers and providers.
āFor an individual consumer I am completely sympathetic that itās very confusing,ā says Dr. Ezekiel Emanuel, who was an adviser to the president during the drafting of the health law and is now a health policy expert at the University of Pennsylvania.
āThere are at least six different prices for a hospital day. And then thereās the cost of actually delivering the service, which, for most of these things, even hospitals donāt know what that is. So when you say, āWhatās the price?ā Itās almost a meaningless question, because there [are] all these different prices.ā
Those negotiated ratesāthe prices insurance companies really pay hospitalsāare treated like trade secrets. Insurers and many hospitals donāt want their competitors to know what Ā the payments are
It is only on an individual basis that people can see the prices their insurer paid for their care. And itās after the care has been delivered and only if the person is already insured.
Itās buried in a statement called an explanation of benefits. These are the letters from insurers that look like a bill but say āthis is not a bill.ā
Efrain Monzon helps patients interpret those explanations for , the largest insurance company in the state of Florida.
āWeāre identifying the procedure, weāre identifying the provider, the date of service and then making sure the amount, the member responsibility has to be in there,ā Monzon says.
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. The industry terms are usually āadjusted rateā or ānegotiated rate.ā
In Florida Blueās explanation of benefits to patients, itās called simply āamount paid.ā
To get a clearer sense of what health care costs, someone would have to collect enough of those statements from patients at all different hospitals with all different insurance.
There are companies and trying to do just that around the country.Ā And Massachusetts has a law that says insurers some of these prices in a way that is accessible to patients.
But so far, thatās not happening in South Florida.
This story is part of a partnership that includes , theĀ , and Kaiser Health News.