Just about every health care reform proposal includes payment reform as an important part of its platform. Most of the proposals come from organizations representing providers. Not much is heard form the other side of the exchange.
Two stories recently highlight the need for payment reform from the consumer point of view.
Number one. My son recently visited friends in New York City. An unfortunate accident landed him in the New York University hospital for two days. He is 23 years old and has his own very good insurance.
Several weeks after he returned home, he received a bill from one of the doctors that treated him in the hospital. Apparently the insurance only paid him a bit more than $200 of the $800 bill. Because he was an out of network doctor, he could and did bill for the balance.
Number two. A Participant called our plan recently. His daughter was travelling with her mother to visit her grandmother in a southern state. She too wound up in the hospital. The family belongs to an HMO and so the HMO paid the Emergency Room bills and the follow on hospital stay. But they are having difficulty with the follow up care. HMOs routinely do not pay for services provided by out of network providers.
These examples represent the most frequent type of complaints that we hear from members and why payment reform should matter to consumers.
Before I explore these two stories more detail, I wanted to outline why providers, academics and some large purchasers are advocating for payment reform.