Author Topic: Please help me understand US healthcare system  (Read 4855 times)

gbbi_977

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Please help me understand US healthcare system
« on: November 30, 2015, 10:43:53 AM »
Hi Mustachians,

You may remember me from the 'Trying to conceive the mustachian way' thread - good news, we're 7 weeks pregnant!

But oh gosh, I am at my wit's end trying to choose a healthcare provider.

Background: being from England, I love the idea of using a Certified Nurse Midwife. I am currently with Aetna, but moving to a Blue Cross Blue Shield PPO plan as of 1/1/16 (Highmark, if relevant). According to their online search, the nearest in-network midwife is 10 miles away (this took me awhile to figure out).

So now I'm searching for an ob-gyn. But of course, each ob-gyn practices at different hospitals. So when I choose an ob-gyn, I'm also choosing a hospital, right?

So I think to myself, "There are two great hospitals within 6 miles. Let's just pick based on the price."

HAHAHAHA says the US healthcare system. WE WILL NEVER TELL YOU IN ADVANCE WHAT ANYTHING COSTS EVER.

(OK, sorry, I'm frustrated).

What I mean is: I call Hospital A, and speak to the pricing department, having selected "Press 2 for a cost estimate". I am told the rates for non-insured patient ($17,000 for vaginal, $34,000 for C-section) but patiently explain that I have insurance and I'm trying to find out the contracted rate with my provider. "We can't tell you that without the CPT (?) codes from your doctor".

To which I patiently explain: I don't have a doctor yet. Choosing a doctor requires choosing a hospital, and I need this information in order to choose the hospital.

"We can't help you."

Hospital B: same rigmarole.

Is this a rant or a question? Probably mostly a rant. But am I missing something? Is there really and truly no way to find out in advance what labor will *likely* cost at Hospital A v Hospital B? [I get that there is no way of knowing if things will go to plan, if I'll need a C-section, if there'll be complications. Some degree of uncertainty is obviously guaranteed.]

FWIW, Hospital A is non-profit. Can I guess that things will be cheaper there? Should I compare the non-insured rate at Hospital B, see which is lower, and just go with that hospital, on the assumption that there'll be a comparable saving for insured patients between the two?

Thank you!

pbkmaine

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Re: Please help me understand US healthcare system
« Reply #1 on: November 30, 2015, 10:47:59 AM »
The most important thing in terms of cost is finding out what doctors and hospitals are in your network, and what the insurance copays are for in- network services. In short, you want to talk to the insurer, not the hospital.


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bacchi

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Re: Please help me understand US healthcare system
« Reply #2 on: November 30, 2015, 11:02:28 AM »
FWIW, Hospital A is non-profit. Can I guess that things will be cheaper there?

No, that's probably not a good assumption. A "non-profit" in American means that there are no owners. The executives can (and will) still pay themselves outrageous salaries.

Re: in-network hospitals, you need to make sure that any and all doctors that assist are also in-network. An in-network hospital doesn't mean that everyone on staff is in-network. You might get stuck with a full price bill.

As to your question, this is how American healthcare works. Yes, it sucks.

gillstone

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Re: Please help me understand US healthcare system
« Reply #3 on: November 30, 2015, 11:04:36 AM »
You're in an insurance information doom-loop.

You need the CPT codes from the hospital to ask the insurance company what they will pay for and how much is applied to your deductible.  The hospital is reluctant to release the codes because they can't guarantee that you'll actually be charged on those codes since no one can predict the exact kid of labor you'll experience.  In a given labor the hospital may have charges from the maternity wing for the room & supplies, the OB, a pediatrician, an anesthesiologist, the nursing department, a surgical suite, and the cafeteria.  All items are related to specific charge codes which may or may not be covered by your insurance.

Take the hospital with the lowest C-section rate (unless you want your kid to be able to kill Macbeth) and the lowest maternal/infant re-admittance or mortality rate. 

No matter which one you choose your insurance will be a complete dick knuckle about paying for it.

Congratulations and welcome to the USA

I'm a red panda

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Re: Please help me understand US healthcare system
« Reply #4 on: November 30, 2015, 11:08:48 AM »
My BCBS plan allowed me to use an estimator on the website. I found out that one hospital in our town was going to be a few hundred cheaper than the other for vaginal, but pretty near my out of pocket max, and both would be well beyond my out of pocket max for Cesarean; so the the choice financially seemed moot. I chose based on who had the better NICU, just in case.  (I know other people who choose the other facility because they apparently have better bedside care of the mother.)  That hospital also has CNMs who deliver there, I preferred that over an OB, but then I couldn't get into the clinic :(

So maybe you could see if your plan has a similar estimator available. 

I agree that things like infant mortality rate, readmittance, and low % of C-section is more important than cost; because it likely isn't going to be drastically different if they are both in-network; it all depends on your insurance. Two people in rooms next to each other will pay very different amounts for the same procedure.

Left

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Re: Please help me understand US healthcare system
« Reply #5 on: November 30, 2015, 11:09:59 AM »
you need to talk to insurer...
they need to "approve" procedure if it is something that is possible... or they might "decline" to pay it...

It doesn't really even matter what each hospital "charges"... the insurance may just pay whatever they want depending on their contract with hospital. So the prices really don't matter much if you get a cash quote

CMS has it downloadable but this site while old is easiest to get to excel page. Unless you want to spend time on CMS
http://www.businessinsider.com/hospital-medicare-billing-practices-vary-report-2013-5

Exflyboy

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Re: Please help me understand US healthcare system
« Reply #6 on: November 30, 2015, 11:18:07 AM »
I'm from the UK too and have lived in the US for 19 years.

Honestly my best advice is if you can take a 3 month holiday and go back to Blighty to have your baby..

The US HC system is designed to do one thing well.. that is to drain you of as much money as possible.. And they are damned good at it.

gbbi_977

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Re: Please help me understand US healthcare system
« Reply #7 on: November 30, 2015, 11:23:54 AM »
Thanks everyone.

I'm sorely tempted to have the baby abroad. But there are costs with that too, like flights for us both, time off work for husband, flight back for baby.

I need to stop complaining, be grateful I get good healthcare even if it's an opaque and darn expensive system. Your advice and listening ears help with that!

So moving on, to make this decision, here's what I'm thinking:

Insurance cost estimator said Hospital A is $7315-$13315; Hospital B is $9689-$12090 [assuming vaginal, no complications - I can dream!]

My max out of pocket is $6850-ish. So maybe it's a moot point after all.

They have very similar C-section rates, and very similar ratings on other indices on the websites I've found.

One is about a 6 block walk from here, the other is about 4 miles away. So at the end of the day, I think I'm going to pick based on proximity, because I like the idea of being able to walk to prenatal/postnatal visits (the ob-gyn I'm considering has her office at the hospital).

Do people go and tour labor wards, to see what the rooms are like, etc.? I don't think I care that much. I'm looking for healthcare, not a hotel room. I guess I can also accost random mothers I see in the street and see what they think. After my prenatal visit today, I don't need another visit (assuming no complications) until January/Febraury, so the decision isn't too urgent. I think wanting all this info is part of how my weird, Type A brain adjusts to the idea of having a baby.

SKL-HOU

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Re: Please help me understand US healthcare system
« Reply #8 on: November 30, 2015, 12:17:53 PM »
...
Insurance cost estimator said Hospital A is $7315-$13315; Hospital B is $9689-$12090 [assuming vaginal, no complications - I can dream!]

My max out of pocket is $6850-ish. So maybe it's a moot point after all.

They have very similar C-section rates, and very similar ratings on other indices on the websites I've found.

One is about a 6 block walk from here, the other is about 4 miles away. So at the end of the day, I think I'm going to pick based on proximity, because I like the idea of being able to walk to prenatal/postnatal visits (the ob-gyn I'm considering has her office at the hospital).

Do people go and tour labor wards, to see what the rooms are like, etc.? I don't think I care that much. I'm looking for healthcare, not a hotel room. I guess I can also accost random mothers I see in the street and see what they think. After my prenatal visit today, I don't need another visit (assuming no complications) until January/Febraury, so the decision isn't too urgent. I think wanting all this info is part of how my weird, Type A brain adjusts to the idea of having a baby.

The way it works is, you pay the deductible first, then whatever % you are supposed to pay of the remaining bill. So for example if you have a $1000 deductible and the plan pays 20% after deductible, the two different scenarios look like this (based on highest cost):

Hospital A: $1000 + (13315-1000)x0.2 = $3463
Hospital B: $1000 + (12090-1000)x0.2 = $3218
(assuming you had not met any of the deductible prior to birth)

I would check on reviews, word of mouth, etc and go with the better one. You are right, you are not looking for a hotel room but comfort and the little things are very important. Also, you never know if you will have a preemie or any other issues. I never thought I would but I gave birth at 25 weeks. So I would make this important decision based on which in network hospital/doctors/facilities is better rather than a few hundred or even a couple of thousand dollars.

Jacana

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Re: Please help me understand US healthcare system
« Reply #9 on: November 30, 2015, 12:42:19 PM »
We had BCBS PPO (but the federal employee version) when I gave birth to our daughter and despite complications and an emergency forcep delivery we paid practically nothing out of pocket. Almost all maternity costs were covered by insurance. It was great.

Except..... Once we were discharged that was apparently the end of 'maternity' coverage. So a necessary follow-up surgery 12 weeks later was not covered by maternity rules, and we paid deductible and then co-ins for that even though the surgery was entirely related to delivery complications. That was a big surprise.

Your insurance company is your best source of that info, and they should be able to at least tell you what is covered 100%, and what would incur deductibles and copays. Also ask about anesthesia because our anesthesiologist was out of network (they all were??) But for maternity no cost for the epidural. For the postpartum surgery, out of network, out of pocket. Healthcare here is ridiculous.

As for tours, yeah we went on a tour and it was all very nice but I don't think it helped us choose. They can decorate nicely and spout all sorts of impressive things about being baby oriented and all that, but your experience will differ greatly based on what is happening and which nurse you get and everything. But I will say the classes were very helpful and you should look into those.

Left

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Re: Please help me understand US healthcare system
« Reply #10 on: November 30, 2015, 01:41:36 PM »
wait... your prenatal is in an office? doctors are in network or out, not the actual hospital.

ie, your doctor might be in network at both places, or out at both. even if the hospital itself takes it, it will only be the in patient portion that is counted. but the doctors treating you may or may not be in network.

confusing if you arent used to it? not sure, i just go to where i work, they cover everything for me since im a hospital employee, well, old job did... i miss free healthcare lol

galliver

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Re: Please help me understand US healthcare system
« Reply #11 on: November 30, 2015, 02:15:09 PM »
Don't have personal experience with making this choice but:
-the fact that one hospital is non-profit makes me wonder if it's religiously affiliated, e.g. Catholic. I realize you have a much wanted baby, but God forbid there are serious complications and the hospital won't do their job because the needed procedure to save your life or health is too much like abortion. I've read a few too many stories to this effect; I'm sure it's just a few bad apples, but it was enough to make me wary. If I had a choice, I would avoid a religiously-affiliated hospital.

Congratulations and good luck! :)

Bracken_Joy

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Re: Please help me understand US healthcare system
« Reply #12 on: November 30, 2015, 02:59:42 PM »
Following. Even though I am a- an american and b- a nurse, I still have essentially zero idea how insurance works.

I'm a red panda

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Re: Please help me understand US healthcare system
« Reply #13 on: November 30, 2015, 04:06:44 PM »
Yes, one is Catholic. This thought has crossed my mind. I'm also not sure if I want congenital testing (Downs etc) done, because I don't think we would terminate unless it was life threatening, but I wonder if Catholic hospitals offer those tests?

Funny how you have all these beliefs and ideas and values, or think you do, and then you get pregnant and realize you have no idea what you'd actually do if push came to shove...

I imagine they would still do those tests, if you asked for them- as for many, knowing ahead of time gives them ways to prepare.

TRIGGER warning (loss) for the content below... it could be difficult for someone pregnant to read.

Spoiler: show
I recently had a stillborn baby, at 29 weeks. He did not have downs syndrome, so my initial screenings were clear- and we didn't choose to have any further genetic testing early on, like you, we would never terminate for something like T21, so we didn't see it as needed, even though I'm getting close to advanced maternal age.  The labs that read my 20-week ultrasound (which came back 100% normal) are now under review by the medical board because my 25 week follow up (due to small size of the baby- just to check for growth) came back with a few abnormalities, and then when I went to a specialist there were multiple severe abnormalities at 26 weeks. Apparently it is not unheard of for a provider to lie and say there are no problems and suggest a followup on a minor issue so that it puts a baby past the point of viability.  By the time I got the absolutely devastating news about my baby's diagnosis (I had an amnio done after that ultrasound- he had an extremely large chromosomal deletion), termination was no longer an option- I was 25 weeks.  I've never seen a doctor so angry as when she was asking me questions about my previous care after doing the specialized ultrasound. I really hope the Dr. who read my first ultrasounds was just an idiot who missed about 15 things and not ill intended. My baby had almost no prospect for life, but there was a chance he would make it, and then it was a matter of 10-15 surgeries in the first two years alone while counting down the time until a very painful death from infection or organ failure. If he got past that he could live until he was 20 or 30 with a host of horrific challenges that would never get better. To not have termination as an option was really horrific for me, because it only meant praying that he would die in utero or shortly after being born. Bringing this child into the world would have been cruel. I could never let a living thing suffer the way he was going to. This was NOT a Catholic hospital; but apparently cases of omission happen enough they reported my case immediately for investigation.



meandmyfamily

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Re: Please help me understand US healthcare system
« Reply #14 on: November 30, 2015, 04:46:18 PM »
Do you know anyone who recently had a baby and who you trust their opinion?  If so I would talk with them and if they really liked their doctor or midwife they can call and check prices for you or tell you what it roughly cost them based on their insurance.  My sister just had a baby with a nurse midwife in the hospital and loved it.  I come from a family of home-birthers but it was way cheaper for her to have the baby in the hospital with a nurse midwife.  I am guessing you have many options.  Ask around.  You will be able to find someone who can give you more info.  You have time!

meandmyfamily

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Re: Please help me understand US healthcare system
« Reply #15 on: November 30, 2015, 04:53:31 PM »
Can't you tell friends you are trying or hoping to try soon and that you are curious how much it costs, especially since you aren't familiar with the healthcare system?

Other questions:
Are you free to walk around during labor?  Can you eat/drink?  Do you have to be hooked to an IV or can you have a hep lock (I think that is the term)?


I think the doctor matters WAY more than the hospital.

melime

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Re: Please help me understand US healthcare system
« Reply #16 on: November 30, 2015, 06:48:30 PM »
I don't know how the US system works, but other things I considered when choosing a hospital were:

 - whether I'd get my own room or have to share
 - whether my husband could stay with me and the baby in the hospital
 - whether the baby would stay with me in my room or be taken to a hospital nursery
 - whether the hospital allowed water births (I was mostly interested in labouring in the water, rather than birth), and if so how many rooms had that available (here only x of y rooms had a labour pool)
 - how many nights you get to stay in the hospital (and when those nights count from - here if you give birth after midday, the first night doesn't count)
 - how easy the hospital was to get to while in labour (nearby certainly sounds nice)
 - whether they had a NICU on site for any problems

teen persuasion

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Re: Please help me understand US healthcare system
« Reply #17 on: December 01, 2015, 12:55:01 PM »
I chose my doctors first, hospital second.

In retrospect I learned to ask about my OB/GYN's policy on avoiding unnecessary C-sections.  My oldest daughter was breech, and when I said I preferred to avoid a C-section if possible, my OB/GYN agreed to do an external version (manually turning the baby).  Worked great.  Fast forward to child 3 and a new county and different doctor.  When I asked this doctor about a version, she stated that no one in the county did versions, don't worry, won't need it, baby has turned.  Guess what, she was also breech, as discovered when the doctor ordered an ultrasound before planning to induce me since I was several weeks overdue.  I got passed off to another doctor for an emergency C-section.  I was lucky that I was able to do VBACs when delivering my next 2 kids.

I'd try to find a doctor that does things the way you want (within reason): natural birth vs drugs, try things like external version vs scheduled C-section, lots of testing vs minimal, encourages breastfeeding vs formula...  All of these are not black and white decisions but rather continuums, and you need to figure out where you land on the continuum, and if your doctor supports your preferences.  It is harder if you are at opposite ends.  I found out just how different philosophies can be with my second child - we had a clinic style health care plan that time, no way to predict who would deliver the baby when I went into labor, so I opted to see a different doc each time.  One was displeased with everything ( gained too much weight, not growing big enough, baby dropped early, etc.) and was convinced I was going to go into premature labor (got my husband worried).  The next one was much more laid back and unconcerned.

TomTX

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Re: Please help me understand US healthcare system
« Reply #18 on: December 13, 2015, 06:07:40 AM »
Here's something useful you can do:


Ask each hospital "My wife is going to deliver in a few months. How does your hospital coordinate care to make sure all providers are in-network?"


...and yes, the US medical system is totally fucked up with regard to costs and payments.