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“And the illusion posted to the feds is that there is a range of options available. And it seems to me that BCBS is basically using the Obamacare turmoil as a cloak for forcing everyone into higher cost plans (and blaming it on the federal law). And, well you know all that. But still.” e-mail from Bill

The system I work for charges about $120 for an office visit to those who are uninsured (increasingly the poor in Alabama). I am an “in-network” provider for Blue Cross of Alabama as well as other insurance companies. This means that I have agreed to accept payment of less than $120 from patients (typically $60 for a routine visit)  in exchange for them referring people to me. The payment generally requires the patient to cough up about $25 up front and me submit a bill (costing my practice about $10) to collect the other $35. The difference between $60 and $120 I never see and is referred to in the office as an “adjustment.” Pre-ObamaCare, I could be fairly certain that if I submitted the bill to Blue Cross I would get the $35. In addition, as an in-network physician if I ordered x-rays or blood work it was paid for no matter where the patient went to get it. If I had a lab in my office I would get paid but, since I don’t, we have a LabCorp draw station in our building. The patient walks 50 feet and stick an arm out and I get the lab results in my electronic health record.

In the post-ObamaCare days, things are a little trickier.ObamaCare required  insurance companies tell tell us a little more about what we are paying for. Remember the list of essential services? When you pay your premium there are 10 things you are supposed to get. No fine print, no bull. One of the 10 things is Laboratory Services. My friend Bill, who is self-employed and purchased an individual Bronze Plan policy (low monthly, high deductible), had an illness. His policy was through Blue Cross of Alabama. He went to an in-network physician who took 50% of what the cash payment would have been (and paid $10 to get some of it from Blue Cross). In good faith he was sent down the hall to get labs (a covered service). He just got his lab bill for $200 which is the full freight, cash price. No adjustment, no Blue Cross portion. My friend Bill, we now know, is virtually uninsured for Labs (and a bunch of other stuff as well).

Here are the fun activities you get to learn about if you have a Blue Cross Bronze plan.  Your money no longer pays for someone to negotiate rates for your labs, x-rays, or surgeries. Better sharpen your negotiating skills.  For you Bronze plans holders, they’ve already negotiated an exclusive contract with Quest who will gladly schedule that stat CBC in Foley, 25 miles away, on Wednesday (true story). Want something a little more convenient, pay full freight. You need a little minor surgery or even major surgery?  My friend Bill will get to employ one of two strategies. The first is to do what he can to get the costs as low as possible. The second will be, rather than worry about the $5 aspirin,  to forfeit his $6000 deductible up front and ask for the single room and steak dinner, secure in the knowledge that they can’t hurt him more.

Turns out that Blue Cross Silver is the plan to get in Alabama, by design. For the extra $81 a  month you pay to Blue Cross, here is what you DON’T have to do. If you need an X-ray, CT, MRI or any other imaging, you DON”T have to negotiate the price yourself. You will pay only $300 a test, no matter how expensive the test is. If you need a lab, you DON’T need to drive over 25 miles to have it done. and then ask them to only process your blood in a single lab in the state. If your in-system doctor orders it, Blue Cross will negotiate for you to get the best price possible from LabCorp or whomever.  You need a little minor surgery or even major surgery? You Silver slackers DON’T need to negotiate the anesthesia fee, surgeon’s fee, or operating room costs.

This likely isn’t tomorrow’s problem. Even with the limited price pressures in the Silver plans (by far the most common), the prices in most states are less this year than they were last year. What this illuminates more than anything else is the crazy and perverse incentives that are currently incorporated in our health care system. We in health care set our prices crazy high and let Blue Cross or some other insurer reduce them arbitrarily. The bill for surgery includes $5 aspirin and $3000 MRIs, prices that no one is expected to pay. Look for the pricing structure to change dramatically in the next 5 years with many things getting bundled together and much greater transparency. Meanwhile, Bill, I understand Humana is looking to compete head to head with Blue Cross in Alabama. You may, however, want to find out which lab they use first before changing.