On the Third Hand: HSAs

The doctors and hospitals upcode mercilessly, without the health care system providing any effective, straightforward path for consumers to talk to a halfway knowledgeable medical billing person let alone negotiate.

Non-grandfathered health account plans now bundle the cost of preventive care into the cost of the plan. In theory, a high-deductible plan enrollee will pay nothing to get a checkup, but, in reality, the upcoding game seems to turn every checkup into a sick visit.

The patient ends up with an incentive to say phooey on conventional medicine and question whether the group health plan has any value whatsoever.

A patient might have no claims expenses in a quarter, and no use of conventional professional medical care of any kind during the quarter, because she decided that taking Ibuprofen for a 104-degree fever and lower back pain was a lot less daunting than the idea of dealing with the medical bills that would result if she went to a physician and survived to see the medical bills.

On the one hand, doctors have successfully persuaded members of Congress and regulators that insurers are economic goons. Maybe, from the doctors' point of view, there's some justice to that.

On the other hand,  insurers have to figure out how to bite the bullet and remind us of what we used to know back in the 1970s: That, from a financial perspective, the doctors are also a bunch of greedy goons and give the patients tools to deal with medical goondom. Assuming that patients will immediately understand that they've been misbilled and have much luck dealing with the misbilling under current conditions seems overly optimistic.

On the third hand, doctors and hospitals bill the way they do because the health care finance system is working poorly, Care providers are responding to demands to supply what seems to be an unreasonably huge amount of care for an unreasonably low amount of cash at least partly by pushing the pay up a bit, rather than relying entirely on providing less care than the patients want. To some extent, when patients push back, call to be huffy with the doctor's receptionist, then go on to write angry blog entries, that's a sign that health account plans are working and getting patients riled up about what riles insurance companies up.

But I think letting market forces work in that, when the market itself is so messed up, is that it gives patients who are bit tight with money to be complete penny-wise, pound-foolish idiots. 

What I think the country needs if it's going to turn health account plans into a mass-market product:

1. Widespread access to special credit cards designed for people who may need to pay high out-of-pocket costs associated with high-deductible plans. In the old days, when dogs could get credit cards, access to health bill credit was not really an issue for anyone except for hardcore deadbeats who clearly should not have access to any additional credit. These days, in the wake of the credit crunch, people who have paid their bills on time for decades and rarely carried a credit card balance over from one month to the next may find themselves with a $500 credit limit and no easy way to get a new card.

2. Clearly written, clearly posted rules for distinguishing between checkups and sick visits. Hint: Even if you're a little bored with papers about value-based insurance design (VBID), if you want people in high-deductible plans with, say, obesity or high cholesterol and no other noticeable symptoms to get checkups and take anti-cholesterol medications, don't let the total out-of-pocket cost of their annual office visits be $400. Maybe punishing people for having high cholesterol by making their office visits cost $50 more than what healthy people pay makes sense, but letting the out-of-pocket costs go too high may cause the patients most likely to benefit from preventive care to rely on crossing their fingers as their main strategy for maintaining wellness.

3. Some kind of Web-enabled, semi- or completely automated patient advocacy programs. Having a topflight health advocate intervene personally over a checkup that was billed as a $200 sick visit probably does not make much economic sense. But requiring every patient to be a great bargainer to get a fair deal doesn't seem to make that much sense, either. If I were a great bargainer, I'd be a businessperson or a trial lawyer, not a reporter. But, right now, it doesn't seem as if there's anyone out there that I can hire to represent me in routine health care fee negotiations. Maybe there could be some kind of app for that.