Here’s the latest on my Colleague’s battle with his/her health plan over accessing their negotiated rate for non-covered care. While the health plan (United Healthcare/Golden Rule) promised to respond, the customer service folks had not resolved the question by the end of last week. So, s/he is still waiting.
The contention of Colleague is that since the marketing materials and policy did not state that UHC’s negotiated rates did not apply to these services, and in fact stated that one of the advantages of the plan was that access, the marketing materials are misleading at best.
Meanwhile, Hank Stern and Bob Vineyard at InsureBlog invested a considerable amount of time investigating this, and have written an excellent synopsis of the situation and the insurer’s perspectives. Hank and Bob also asked insurance companies to explain why they would adopt a policy that is so obviously consumer unfriendly; as of yesterday they are still waiting for a response…
The net from InsureBlog is that the insurance companies reprice the services to reflect their negotiated rates, but it is up to the provider to determine if they will accept that rate . So, the health plan informs the consumer what their cost could be, and the provider then says “nope, you’ve got to pay the full boat”.
Boy is this dumb. The consumer is now “educated”; they know what they could pay, and they also know that they have to pay the higher rate. Result – really angry consumers, who feel they have been bait-and-switched. Yes, the insurance companies are technically within their rights to do this, as are providers, but this will undoubtedly stoke the anger of voters, an anger that may well be directed at both offending parties.

Health Affairs’ article comparing the health status of Americans and Canadians doesn’t break new ground nor shatter any perceptions, at least not any perceptions held by informed folks. Tops among the popular misconceptions about the Canadian health care system is the old saw that people have to wait forever for care, with the unstated resulting negative impact on health.
Well, 11% of Canadians do think they have unmet medical needs, primarily because they have to wait too long for care in some instances. In contrast, 13% of Americans have unmet needs, primarily due to cost.
A few more factoids to ponder –
–Most respondents in both countries are in good very good or excellent health, although a few more Canadians enjoy this status (88% v US’ 85%)
–31% of the poorest Americans considered themselves to be in fair or poor health compared to 23% of Canadians.
–Canadians and Americans exhibited similar results regarding access to physician services.
The statistics come from the Joint Canada/US Survey of Health, a joint effort of the National Center for Helath Statistics in the US and Canada’s Statistics Canada; sample sizes are large and the methodology robust.
When one considers that we Americans are paying 50% more for health care than our northern neighbors, it’s hard to see what we get for our dollars.

A study released by the Mayo Clinic, reports that there is far too much money spent on end-of-life care. The study is paralleled by a newly released Dartmouth study , reports that indicates Medicare spent about $40 billion more than it should have on end of life care, due to the inefficiencies of many hospitals.
By any accounting, that’s a lot of cash. Enough, in fact, to provide coverage to a substantial number of Americans presently without health insurance.
While it can be argued that one does not know when a person’s life is ending within six months, it can’t be argued that some hospitals are much more efficient than others. And this inefficiency is costing taxpayers, employers, and individuals billions of dollars.
The Mayo Clinic study found that a substantial portion of Intensive Care Unit patients were the elderly with terminal conditions. ICUs are notoriously (and appropriately) expensive, require high staffing levels and very sophisticated equipment, and are expressly designed to help really sick people get better. That does not make much sense for many elderly with chronic, life-ending conditions.
The Dartmouth study, which was authored in part by John Wennberg (one of the most insightful people in health care), recommends that terminally ill patients be treated outside of acute care facilities. This seems to be common sense; acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
This is one of those apparently simple solutions that can save billions of dollars while improving quality of care and end of life experience, and is likely to be acceptable to individuals of all political stripes and inclinations.
Sign me up.

HSA plans do not require contracted providers to accept the health plan’s negotiated rates when members receive non-covered care. That’s what I’ve learned about the coverage policies of United/Golden Rule, Coventry, Assurant, CIGNA, Aetna, Humana and a couple of the Anthem Blues.
Quoting Hank Stern of InsureBlog, “In Ohio (and, as far as I know everywhere else), individual (as opposed to group) plans exclude normal childbirth. So someone covered under a HDHP would not get the negotiated rate for any pre-natal care…”(or the actual childbirth, or any associated expenses).
Hmmm, I wonder the rate of “complications” experienced by moms covered under HSA plans is higher than one would expect… But I digress.
The key here is what is covered, and what is not. To find that out, ask for a specific list of covered and excluded items from the broker and/or the health plan. And ask if services that are paid out of the HSA, but appear to be covered, fall under the provider’s contracted rates.
Why would you do this? Because the contracted rates are likely less than half the “retail” rate.
As to why a health plan would do this; not require their providers to accept contracted rates, that’s a mystery to me. As a couple ofcommenters have noted, if the insureds pay the higher rate, they are going to pierce their deductible layer much faster, thereby incurring claims expense and costing the health plan money. To say nothing of the consumer backlash when people find out their coverage through a national plan does not give them better rates.
I’m really surprised that health plans would do this, and do very little to educate their customers about this pervasive policy (nowhere on any website did I see this policy referenced). It makes little sense from a consumer marketing perspective, is likely to alienate customers, looks very short-sighted, and flies in the face of their touted desire to provide consumers with more education and make them better health care buyers.
Did the health plans think consumers wouldn’t figure this out? And be angry when they did?
Thanks much to Hank, my “colleague“, and several other un-named and un-nameable industry sources.