Insane Healthcare Costs Complaint

[mpbaker22]

I'm not sure which category this should really go in, as it's sort of a question and sort of a complaint.
I just had my first doctor's visit on my own insurance about a month ago.  I got the bill today, and my out of pocket is only $30. 
I had jammed my thumb but it still hurt over a week later, and was getting worse, so all I really wanted was an X-ray to make sure it wasn't broken.
The initial final bill was -
New Doctor Office Visit - $160
Wrist-hand-finger Brace - $307.55
Splint or Brace Fitting - $95.00
X-ray of Hand - $48.00

I have no problem with the visit cost (it's high, but it's the 'cost of doing business') or the x-ray, which actually seemed low.
The brace I received is identical to this one for $30.
And I put the damn thing on myself, how do they get away charging $95 for the fitting?

It just seems insane they can more than double the cost of the visit by adding on a splint that wasn't necessary to begin with.  If I didn't have insurance, what would I do differently to lower the cost?  Would I just question the expense of everything?  I mean, for $400, I could have made myself a pretty f'in awesome splint.

[Sparafusile]

The doctors office is a business just like any other. You are free to shop around and pick the cheapest one. Next time you go, ask for a quote before any work is done. Hopefully you would have seen the x-ray cost was pretty decent, but the extra labor and price of the splint was way out of whack. Having known that, you could have refused that part of the service and bought/made your own splint.

[Forcus]

My guess is it is a "necessary" gaming of the system based on reimbursement rates, etc.

[bluecollarmusician]

The doctors office is a business just like any other. You are free to shop around and pick the cheapest one. Next time you go, ask for a quote before any work is done. Hopefully you would have seen the x-ray cost was pretty decent, but the extra labor and price of the splint was way out of whack. Having known that, you could have refused that part of the service and bought/made your own splint.

This is unfortunately not true, particularly in emergency care, but also in general practice.  Pricing is not transparent.  When you go in for a visit and ask for an estimate, you are met with blank stares, followed by fumbling responses about "impossible to estimate until seen by dr., prices depend on service rendered, etc, we code in the numbers not easy to see actual cost, etc. ad nauseum." 

You are correct it is a business, but you are not able to shop around because there is no transparency in pricing- it is willfully obfuscated by a system run by the insurance programs.  For people who choose to pay their own way the system is absolutely broken.

Once after receiving treatment with an "estimated cost of service of $300," and receiving an x-ray and 5 minutes with Dr. (who read the x-ray in front of us since the radiologist was off that day) we received a bill for $850.  When I went in and raised hell about it, I was told "it's ok, just fill in this form and government assistance will take care of it."  Needless to say this did NOT diffuse the situation.  We have money and simply wanted to pay a fair (and transparent) price for services rendered.  Not only did we receive completely inadequate and poor service, we were charged almost triple what we were quoted.  This is not an isolated incident in the medical industry.  This is one reason why so many simply do not pay their medical bills.  In the end they offered me a 20% discount to pay in cash that day.  I later learned that an insurance company would have settled it for about $200-$250 dollars. 

Keep in mind this was for a 45 minute wait, 5 minutes with a distracted Dr., and no helpful diagnosis of any kind.

[Marmot]

The doctors office is a business just like any other. You are free to shop around and pick the cheapest one. Next time you go, ask for a quote before any work is done. Hopefully you would have seen the x-ray cost was pretty decent, but the extra labor and price of the splint was way out of whack. Having known that, you could have refused that part of the service and bought/made your own splint.

I think that the notion that a doctors office is a business "just like any other" is misguided. The economics of healthcare are notoriously opaque. Also, "...decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping." (from a Paul Krugman article from 2 yrs ago) It is possible to comparison shop, though can be extremely cumbersome.

The information is simply not freely available and the staff working the front office often do not know the pricing (that even includes some of the medical coders).

[hoodedfalcon]

That really sucks. You may try to contest the bill. I have done that twice and both times the bill was adjusted (one time was for not covering anesthesia during wisdom tooth extraction, which they said was "elective" but I was never given an option) and another time was for an MRI where the doc did some creative billing. All in all, being the squeaky wheel saved me about $900. What do you have to lose?

[mpbaker22]

That really sucks. You may try to contest the bill. I have done that twice and both times the bill was adjusted (one time was for not covering anesthesia during wisdom tooth extraction, which they said was "elective" but I was never given an option) and another time was for an MRI where the doc did some creative billing. All in all, being the squeaky wheel saved me about $900. What do you have to lose?

My out of pocket is $30, but I think it's insane the insurance company is paying for several hundred, I think their discount was $300 and they pay about $250.  The fitting for the splint in particular is insane as it didn't take place.

The doctors office is a business just like any other. You are free to shop around and pick the cheapest one. Next time you go, ask for a quote before any work is done. Hopefully you would have seen the x-ray cost was pretty decent, but the extra labor and price of the splint was way out of whack. Having known that, you could have refused that part of the service and bought/made your own splint.

Except I asked them how much things cost and they didn't know.  I actually called and told one office I didn't have insurance to see what their costs were.  They said "about $x plus $y for the x-ray."
I suppose I should have refused the splint, but they just walk in with it and it's assumed you're taking it.  Since I have insurance, I didn't care too much, but I never thought it would be $300!

In general, my complaint is more that my insurance company is paying for this, not that I'm paying for my $30.

[sol]

Health services are about the least free "market" I can imagine.

When you walk into an ordinary store, you look at clearly marked prices and then decide to buy or walk away.  Imagine how that interaction would work if walking away meant your possible death, or the store was legally obligated to give something to every customer through the door.  The incentives are exactly backwards from what would encourage price efficiency.

[Marmot]

I later learned that an insurance company would have settled it for about $200-$250 dollars. 

This is not an outlier or specific to this set of medical procedures. Those without insurance often have to pay several times more since they lack the negotiating leverage that a large insurance company has. Even if you have a very high deductible plan, you still get to take advantage of the in-network pre-negotiated rates.

I would recommend that anyone that is really interested in this issue at least skim the following article from time magazine ("Bitter Pill: Why Medical Bills Are Killing Us" http://www.time.com/time/magazine/article/0,9171,2136864,00.html

In general the US healthcare industry is extremely inefficient on a cost benefit basis. Silver lining is that things should be getting better over the next 2 decades, which will not only help individuals but the country overall.

[ivyhedge]

The doctors office is a business just like any other. You are free to shop around and pick the cheapest one. Next time you go, ask for a quote before any work is done. Hopefully you would have seen the x-ray cost was pretty decent, but the extra labor and price of the splint was way out of whack. Having known that, you could have refused that part of the service and bought/made your own splint.

Spara is correct. At a friend's company, HR showed costs climbing as folks selected their "most convenient" option for care, rather than preplanning and shopping a bit. They warned employees that premiums would increase if employees acted without regard for the communal good. Costs rose. Folks changed their behavior. Costs fell. Just an anecdote...

[jba302]

I work in insurance, to be honest those costs don't seem too off, except the brace itself (don't get me started on the durable med business... fuckers). Good thing you didn't get an MRI or CT, we get billed anywhere from $400 - $2,000 for those.

Just option me for a no type-2 diabetes induced incidence coverage and I'll be happy, probably see my premiums cut by 70%.

[rubybeth]

I have tried asking the price of a particular test before it was done, but nobody really knows. It depends on your insurance provider and many other mystical factors. I told my doctor that I wanted to know the price of things before they were done, and she actually told me that it's clinic policy not to quote prices on needed tests. :/

[mpbaker22]

I work in insurance, to be honest those costs don't seem too off, except the brace itself (don't get me started on the durable med business... fuckers). Good thing you didn't get an MRI or CT, we get billed anywhere from $400 - $2,000 for those.

Just option me for a no type-2 diabetes induced incidence coverage and I'll be happy, probably see my premiums cut by 70%.

That's my biggest problem.  The brace was $400 total, and I could have bought it elsewhere for $20.  I actually asked them how much it would be and they refused to give me a standard price since it wouldn't be the price I would end up being charged.

[Rollin]

My out of pocket is $30, but I think it's insane the insurance company is paying for several hundred, I think their discount was $300 and they pay about $250.  The fitting for the splint in particular is insane as it didn't take place.

I'd consider pursuing having the $95 dollars removed if they didn't actually earn it.  I would first cite that as the "principle" of the matter.  Second, you do ultimately pay for some of that - above your $30 co pay.  In many cases you might get higher pay if your employer didn't have to cover so much of the cost of health care as a benefit to you.

[mpbaker22]

My out of pocket is $30, but I think it's insane the insurance company is paying for several hundred, I think their discount was $300 and they pay about $250.  The fitting for the splint in particular is insane as it didn't take place.

I'd consider pursuing having the $95 dollars removed if they didn't actually earn it.  I would first cite that as the "principle" of the matter.  Second, you do ultimately pay for some of that - above your $30 co pay.  In many cases you might get higher pay if your employer didn't have to cover so much of the cost of health care as a benefit to you.

While true at the extremes, I would only see more money if everyone at my company started spending less (or at least significantly less on average).  Since that isn't the case, I ultimately have incentive to spend as much as possible, especially if I go over my out of pocket maximum.  It's one of those game theory cases where everyone's incentive is to act in their personal best interest, which ultimately returns less than if everyone acted in union.

[Marmot]

My out of pocket is $30, but I think it's insane the insurance company is paying for several hundred, I think their discount was $300 and they pay about $250.  The fitting for the splint in particular is insane as it didn't take place.

From what I have been told, the amount that the patient sees on the bill to an insurance company is not the amount that the insurer actually has to pay the providers.

[bluecollarmusician]

I later learned that an insurance company would have settled it for about $200-$250 dollars. 

This is not an outlier or specific to this set of medical procedures. Those without insurance often have to pay several times more since they lack the negotiating leverage that a large insurance company has. Even if you have a very high deductible plan, you still get to take advantage of the in-network pre-negotiated rates.

I would recommend that anyone that is really interested in this issue at least skim the following article from time magazine ("Bitter Pill: Why Medical Bills Are Killing Us"
http://www.time.com/time/magazine/article/0,9171,2136864,00.html

In general the US healthcare industry is extremely inefficient on a cost benefit basis. Silver lining is that things should be getting better over the next 2 decades, which will not only help individuals but the country overall.

I agree, and know this is true of any free market.  The individual has little leverage.  I have no problem with this in in principle.  My main gripe is the opacity of the system.  They don't have to give a discount but there is no where else where you can charge whatever you want, provide no guidance on cost, and allow the consumer no recourse for bad service, false fees, etc.

[jba302]

My out of pocket is $30, but I think it's insane the insurance company is paying for several hundred, I think their discount was $300 and they pay about $250.  The fitting for the splint in particular is insane as it didn't take place.

From what I have been told, the amount that the patient sees on the bill to an insurance company is not the amount that the insurer actually has to pay the providers.

This is true, and it's surprisingly complex. It's based on negotiated rates per insurance company (say BC/BS) per insured (your employer). Plus, you can have different policy options per employer, plus medicare/medicaid, state-specific, etc. On top of that, you can have a variety of CPT codes per visit (different "levels" of office visit, as an example). So it's not like they see an insured vs. non-insured price. And then you have alternate coverages, e.g. auto accidents, work comp, etc. that may or may not have alternate rates based on the state guidelines.

On top of that, I've heard a lot of hospitals do a shit job of maintaining the costs correctly (from a friend that is in IT with hospital experience), many just apply a formula percentage boost annually because the databases are so god damn deep that it would never be actually correct without a substantial amount of IT costs.

[smalllife]

Occasionally some doctor's offices will work with you.  I went to an orthopedic doctor for my knee and needed a specific brace - they had one there but I mentioned that I wanted to see if I could find it cheaper elsewhere so she happily measured my knee to make sure that I would buy the right size, gave the item code number, and a website to go to.  It would have cost my insurance company $200, the doctor's office's time and paperwork plus restocking, and I found it from a medical supplier for $100.  The ortho was happy to have a customer engaged in reducing overall health costs. 

Granted I went to Patient First before that and walked out with a huge unnecessary splint for the same injury, distracted doctor, etc. ... .so it really is luck of the draw.   

[KimPossible]

Occasionally some doctor's offices will work with you.  I went to an orthopedic doctor for my knee and needed a specific brace - they had one there but I mentioned that I wanted to see if I could find it cheaper elsewhere so she happily measured my knee to make sure that I would buy the right size, gave the item code number, and a website to go to.  It would have cost my insurance company $200, the doctor's office's time and paperwork plus restocking, and I found it from a medical supplier for $100.  The ortho was happy to have a customer engaged in reducing overall health costs. 

I do this all the time with my patients.  When you need a custom fitted orthosis, it's worth it to pay for the expertise of the Orthotist.  But if all you need is a knee brace, walking boot, simple splint, etc., the prices I've seen charged by local DME providers are highway robbery. 

I had a friend need a brace a few weeks ago.  I called the brace place in town and asked how much it would cost.  They quoted me $500+/-, and said it would take 3-4 days to get the brace in.  I went online and ordered it for $200--including overnight shipping.

When it's not an emergent situation (and most aren't), it's worth it to take the time to do a little research.

[Marmot]

@Meoates1 Fully agree with your gripe regarding opacity.

On top of that, I've heard a lot of hospitals do a shit job of maintaining the costs correctly (from a friend that is in IT with hospital experience), many just apply a formula percentage boost annually because the databases are so god damn deep that it would never be actually correct without a substantial amount of IT costs.

It is called a "chargemaster" and everything your IT friend told you is correct. That "Bitter Pill" time magazine article that I recommended in an earlier post is about this. Here are the first couple lines about the chargemaster from wikipedia:

"In the United States, the chargemaster, also known as charge master, or charge description master (CDM), is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider. In practice, it usually contains highly inflated prices at several times that of actual costs to the hospital.[1] The chargemaster typically serves as the starting point for negotiations with patients and health insurance providers of what amount of money will actually be paid to the hospital. It is described as "the central mechanism of the revenue cycle" of a hospital."

[EMP]

You should try having a baby. I haven't added it up yet because I'm kind of scared, but so far my insurance company is over $15k and that's before the c-section charge from my doc.

[renbutler]

Silver lining is that things should be getting better over the next 2 decades, which will not only help individuals but the country overall.

Based on ... what exactly?

[mpbaker22]

You should try having a baby. I haven't added it up yet because I'm kind of scared, but so far my insurance company is over $15k and that's before the c-section charge from my doc.

At least if you have a c-section, you won't be charged for your screams.
http://www.usatoday.com/story/news/world/2013/07/12/newser-charged-labor-screams/2512015/

[mpbaker22]

Silver lining is that things should be getting better over the next 2 decades, which will not only help individuals but the country overall.

Based on ... what exactly?

Clearly based on the Obamacare provisions taking affect January 1, 2014 er um 2015, er um never.

[Marmot]

Silver lining is that things should be getting better over the next 2 decades, which will not only help individuals but the country overall.

Based on ... what exactly?

Clearly based on the Obamacare provisions taking affect January 1, 2014 er um 2015, er um never.

Based on the system-wide roll out of electronic health records, quality metrics (which correspond with penalties for poor performance), implementation/testing of new payment models (ie accountable care organizations, risk-adjusted capitation, etc.), bundled payments for episodes of care (meaning paying a flat rate for a certain episode of treatment), moving away from fee-for-service payment etc. Also, the non-partisan Congressional Budget Office (CBO) has been lowering their projections for total healthcare expense growth.

In regard to the Affordable Care Act (ACA; aka obamacare), as an individual, I am looking forward to insurers no longer being able to deny health coverage due to pre-exisitng conditions which is taking effect on Jan. 1, 2014.

We'll see how the other implementation plays out soon enough. So far, only the requirement for companies of 50 or more employees to provide insurance for their employees has been officially delayed, for a year; state health insurance exchanges will likely be delayed in certain states for a year also. Most employers that have 50 or more employees already provide health insurance, so the impact of the delay is not that big.  On the other hand, if the penalty for individuals w/o health insurance gets delayed, that would have a big impact to the rube goldberg device which is the ACA.

[jba302]

[Based on the system-wide roll out of electronic health records, quality metrics (which correspond with penalties for poor performance), implementation/testing of new payment models (ie accountable care organizations, risk-adjusted capitation, etc.), bundled payments for episodes of care (meaning paying a flat rate for a certain episode of treatment), moving away from fee-for-service payment etc.

This is both a good/great idea and one that is bound to cause some major major problems. In as much as the current system gets needlessly complex due to billing code arrangements, fee for service / performance will host just as many issues.

Here's an example -
John is a desk jockey, clocking in at 350# with a blood glucose level indicating that if he cut his finger, his blood would attract bees. He throws his knee out, and needs surgery. Compared to, let's say Brett Favre, whom you would have to let him know that he just got shot in the knee because his pain tolerance is that high. How do you even begin to decide what the ideal timeline is for recovery, even with ODG criteria? Do you pay more for the land whale because you know upfront he will need 10x the visits? Do you pay nothing because he will need a knee replacement anyway so everything before that is bound to fail? Do you get bonus money for Brett because you treated him twice and he decided that he's fine all on his own? Do you now have to classify guidelines for every variant of age, gender, race, bmi, co-morbidities, job, and desire to recover?

Truly, I love the idea (especially working in insurance) in giving the surgeon, MD, nurses, physical therapist, etc. a little something for getting a perfect resolution on someone who's not ideal. I just don't think it will work, there's too many complications.

[kudy]

The brace was $400 total, and I could have bought it elsewhere for $20.

I am going to have my wrists looked at sometime in the near future - thank you for this tale, because it will prompt me to refuse any equipment they try to "give" me at the appointment. I will instead be asking for advice on what to buy on my own.

[GoodbyeLawSchoolDebt]

Here's my insane healthcare costs story:

I had mono (as a 29 year old...) about 2 months ago. I finally decided that I HAD to go to the doctor on a saturday morning (this had been creeping up on me for a couple weeks, but I thought it was just a flu or something). Insurance not open on saturday morning, nor doctor (what do I pay them for?) so I had to go to the urgent care clinic.

They took my vitals and temp, and shined a light in my throat. The nurse said that it didn't look red and to gargle some salt water. The entire "treatment" took about 15 minutes, including wait room time.

Because I didn't have a prior referral, I was billed for the full cost of the urgent care visit. Over $450! 450 bucks to have my temp taken and my grandma's advice to gargle salt water. Eventually I got insurance to cover all but 30 of it, but 450 is just insane for what was done. No wonder premiums are what they are.

((Also, first post! Hi everyone!))

[Kaytee]

This reminds me of the time I had my annual lady examination and they charged me $25 for a pregnancy test. The same kind that you can pay $1 at the Dollar store or $0.50 on the internet. Or the time I went to the ER with a rupturing fallopian tube - $11,000 to remove the tube - billed to insurance. The cost for all my prenatal care, birth, and 6 weeks of postnatal care for me and baby with my independent midwife was $4250. It was slightly higher because I rented a birth tub and purchased a birth kit from her.

[Spork]

Silver lining is that things should be getting better over the next 2 decades, which will not only help individuals but the country overall.

Based on ... what exactly?

Clearly based on the Obamacare provisions taking affect January 1, 2014 er um 2015, er um never.

Based on the system-wide roll out of electronic health records, quality metrics (which correspond with penalties for poor performance), implementation/testing of new payment models (ie accountable care organizations, risk-adjusted capitation, etc.), bundled payments for episodes of care (meaning paying a flat rate for a certain episode of treatment), moving away from fee-for-service payment etc. Also, the non-partisan Congressional Budget Office (CBO) has been lowering their projections for total healthcare expense growth.

The CBO has done exactly that.   The problem is that the CBO works with the assumptions they are given.  The current assumption is that medicare payments to health care providers will be cut by 24.7%.  If you read the Medicare Trustee's report (appendix C), they say that's not likely to occur.  Medicare already pays significantly less than other insurance companies.  If they cut it further, docs are likely to revolt -- or alternatively the price of other services will have to rise to make up the difference.

[kkbmustang]

Here's my latest price of medical-related stuff issue (aside from the cost of COBRA and out of pocket maximums that we hit every year because of some serious healthcare conditions and yes, I've checked health insurance prices online, but I digress):

My 8 year old had to have surgery 2 weeks ago to remove a, thank God, benign growth on her cheek. It took the surgeon 12 stitches to sew her back up after he removed all of the bad cells. (So grateful for the happy pathology report.)

Anyway, she has to wear Mepiform on her incision for six months. The surgeon sent us home with one strip of it which should last several months, depending on how fast it loses its adhesive power each time we put it on her. If we need to buy more (which we likely will), we can either: (1) go through the doctor/hospital which will charge us $500 for more, billed to insurance (for $0 out of pocket to me, other than what I've already paid in premiums/deductibles/coinsurance -- we have maxed out for the year); or (2) buy a box on ebay for $100, questionable as to whether that will be reimbursed through insurance - I have to check.

In what universe does that make sense?

[EMP]

You should try having a baby. I haven't added it up yet because I'm kind of scared, but so far my insurance company is over $15k and that's before the c-section charge from my doc.

At least if you have a c-section, you won't be charged for your screams.
http://www.usatoday.com/story/news/world/2013/07/12/newser-charged-labor-screams/2512015/

Whoa!

[Insanity]

Due to a chronic illness, I need to do self-injectable pens.  Do one a week.  There's been confusion over how much deductible is remaining due to assistance from the manufacturer.  I already had one shipment under my new plan without any.  Now they are saying I owe $2800. 

When I asked how much I would owe, the billing department for the meds literally replied:  We don't know.

[NumberJohnny5]

I remember getting some dental work done. Had to have multiple visits, like one a week for a short period of time. After a few visits, lady at the front desk asked us, a bit rudely, if we were planning on paying any toward our bill. We said "sure, been waiting to get a bill, how much do we owe?" Well, darned it all if they had absolutely no idea, and the one person who knew how to figure it up wasn't in that day.

I mean, come on; if you're gonna hassle someone over paying their bill, the least you could do is actually have a bill for them to pay.

[ep114]

Ive been treated in several hospitals before and after they switched to the electronic records. Huge huge difference. Much more efficient. I expect this to reduce costs from mistakes as well.

[teen persuasion]

I was just paying our share of some lab work DH had done, just basic annual checkup blood work. 

One bill: $761.10 - (721.34 insurance discount) = $39.76 our bill (HDHP).  Second bill: $643.90 - (609.47 insurance discount) - (19.88 insurance paid) = $14.55 our bill. 

So we were billed over $1400 for a few standard blood tests, insurance paid less than $20, and we paid $55!  Really?

[Marmot]

The CBO has done exactly that.   The problem is that the CBO works with the assumptions they are given.  The current assumption is that medicare payments to health care providers will be cut by 24.7%.  If you read the Medicare Trustee's report (appendix C), they say that's not likely to occur.  Medicare already pays significantly less than other insurance companies.  If they cut it further, docs are likely to revolt -- or alternatively the price of other services will have to rise to make up the difference.

What you are referring to is called the Medicare Sustainable Growth Rate (SGR). It is the result of a law passed ~15 yrs ago to keep Medicare expenses growth per beneficiary at a lower rate than gdp growth. Congress has been passing one year patches to delay enforcing this law at the last minute every year for the past decade or so (kicking the can down the road), causing the size of the perennially looming cut to get very large. The CBO estimate to get rid of the SGR was cut in half:

"Thanks to lower-than-expected growth in Medicare physician spending, the cost to repeal the SGR formula is now $138 billion—down from $244 billion just last year." http://www.ama-assn.org/ams/pub/amawire/2013-february-06/2013-february-06-general_news2.shtml

This is primarily what I was referring to regarding the CBO.

[Spork]

The CBO has done exactly that.   The problem is that the CBO works with the assumptions they are given.  The current assumption is that medicare payments to health care providers will be cut by 24.7%.  If you read the Medicare Trustee's report (appendix C), they say that's not likely to occur.  Medicare already pays significantly less than other insurance companies.  If they cut it further, docs are likely to revolt -- or alternatively the price of other services will have to rise to make up the difference.

What you are referring to is called the Medicare Sustainable Growth Rate (SGR). It is the result of a law passed ~15 yrs ago to keep Medicare expenses growth per beneficiary at a lower rate than gdp growth. Congress has been passing one year patches to delay enforcing this law at the last minute every year for the past decade or so (kicking the can down the road), causing the size of the perennially looming cut to get very large. The CBO estimate to get rid of the SGR was cut in half:

"Thanks to lower-than-expected growth in Medicare physician spending, the cost to repeal the SGR formula is now $138 billion—down from $244 billion just last year." http://www.ama-assn.org/ams/pub/amawire/2013-february-06/2013-february-06-general_news2.shtml

This is primarily what I was referring to regarding the CBO.

What I am referring to is that their assumptions are that the reductions WILL occur and that if they don't the the predicted savings goes away.  In their words:

"CBO’s baseline projections incorporate the assumption that the automatic spending reductions established by the Budget Control Act of 2011 (Public Law 112-25) will take effect at the beginning of March, that sharp reductions in Medicare’s payment rates for physicians’ services will occur at the beginning of January 2014, and that certain tax provisions that have regularly been extended but are set to expire at the end of the calendar year (or, in some cases, in later years) will expire as scheduled. If those provisions of current law were removed, and if other changes in policies with offsetting effects on budget deficits were not enacted, budget deficits during the coming decade would be substantially larger than those shown in CBO’s baseline projections. Specifically, under an alternative fiscal scenario, if those provisions of law were undone, debt held by the public would reach 87 percent of GDP at the end of 2023."  http://cbo.gov/sites/default/files/cbofiles/attachments/43907-BudgetOutlook.pdf

[Marmot]

What I am referring to is that their assumptions are that the reductions WILL occur and that if they don't the the predicted savings goes away.  In their words:

"CBO’s baseline projections incorporate the assumption that the automatic spending reductions established by the Budget Control Act of 2011 (Public Law 112-25) will take effect at the beginning of March, that sharp reductions in Medicare’s payment rates for physicians’ services will occur at the beginning of January 2014, and that certain tax provisions that have regularly been extended but are set to expire at the end of the calendar year (or, in some cases, in later years) will expire as scheduled. If those provisions of current law were removed, and if other changes in policies with offsetting effects on budget deficits were not enacted, budget deficits during the coming decade would be substantially larger than those shown in CBO’s baseline projections. Specifically, under an alternative fiscal scenario, if those provisions of law were undone, debt held by the public would reach 87 percent of GDP at the end of 2023."  http://cbo.gov/sites/default/files/cbofiles/attachments/43907-BudgetOutlook.pdf

That is interesting. The 2011 BCA did go into effect for Medicare FYI (was a 2% reduction). From same document, what I was referring to was specific to Medicare:

"The estimated cost of holding payment rates constant is much lower relative to this baseline than was the case under previous CBO baselines, primarily because of lower spending for physicians’ services in recent years."

I was referring to comparing current CBO estimates to past CBO estimates, which all also used the same reduction in Medicare payment assumption as the current budget.