And this means higher costs for those getting treatment outside of their core networks, and especially for work comp payers.
While Medicare reimbursement has remained pretty level, hospitals have been busy raising their list prices by more than 10 percent over the last couple of years. This doesn’t really affect most patients as their rates are negotiated by private insurers or set by CMS for Medicare recipients (or Medicaid on a state-specific basis).
Examples of procedures with the highest increases are:
- Back and neck procedures except fusions – 22.5%
- Medical backs – 17.5%
- Most fractures – 17.3%
The impact is felt most directly by privately-insured patients seeking care outside of their network, as deductibles will almost certainly be much higher, as will copays and out-of-pocket limits.
For workers’ comp payers in states without DRG-or similarly-based fee schedules, the price increases are having even more of an impact. For example, employers in states such as Florida that base reimbursement on a percentage of charges are seeing significant jumps in the prices paid for facility-based care.
But that’s only part of the issue. There’s a “multiplicative” effect as well. With more and more physician practices bought out by health systems, and more and more docs working for those health systems, their services are increasingly billed as facility codes which tend to be higher and include costs that don’t show up on physician bills.
Medicare is doing an admirable job holding down costs while increasing its focus on quality.
That said, there are some pretty ugly side effects.
As facilities scramble to increase their quality ratings; staff is evaluated on “patient satisfaction” which is a pretty iffy metric. The understaffing of inner-city emergency rooms is gaining more attention, as well it should. These are just two of the unintended consequences of what are dramatic and often wrenching changes in the American health care system.
What does this mean for you?
Higher facility costs for comp payers means they will need to focus even more tightly on the amount paid, and not the network discount for facility care.