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Vanishing Health Care Choices

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Trudy LiebermanAsk someone what he or she remembers Obama promising during the great health reform debates, and the response might be:'  'We can keep the insurance we have.''  The president did offer assurances that there would be no socialized medicine with the government dictating where you could go for care.' '  He did not mention, though, that many insured people already have little say in what kind of coverage they get and who can treat them.'  The private sector'employers and insurance companies'makes the choices for them.

Employers usually offer coverage from one insurer, or maybe two.'  Within those selections, there may be the choice of a cheap, high-deductible plan with a health savings account, or an HMO that usually limits where you can go for care.' '  Sometimes employers do try to influence the choice by making workers' premiums lower for the plan that has the biggest payoff for them'cheaper insurance costs overall.

Keep your eye on Massachusetts, where the practice of telling patients where they must get their care has reached a new level of restricting consumer choice.'  The objective is to put the brakes on health care inflation by making patients pay more if they want to use high-cost hospitals.'  In the last month, hundreds of small businesses flocked to the Blue Cross Hospital Choice plan, a new policy offered by Blue Cross Blue Shield, the state's biggest insurer.'  Policyholders will have to pay an extra $1,000 if they have an inpatient stay or outpatient surgery at what the insurer considers an expensive hospital.'  They will have to pay $450 more if they get an MRI from one of them.'  The hospitals that are now off-limits include some of the prestigious big ones like Massachusetts General and Brigham and Women's.

What's in it for employees whose bosses choose the new health plan?' ' '  Premium reductions of 4.5 percent instead of premium increases of 10 percent.' '  The hope is that the savings will be large enough to compel employees to forget about Mass General and choose a cheaper community hospital for procedures that can be done less expensively there.' '  In the early days of managed care, HMOs strictly restricted their networks to make patients go to providers with lower costs.'  But, patients and doctors protested, and the backlash ushered in wide-open networks of doctors and hospitals that gave patients the choices they demanded and loosened costs controls all around.

Will there again be a backlash?' '  It's too early to tell, but some advocates of limited networks say consumers care more about costs these days than they did 15 or 16 years ago and might not raise a fuss.' '  Others worry that healthy people will choose cheaper hospitals, and sicker ones will still go to the expensive teaching hospitals where they can get the advanced treatments they need.'  That could raise the costs even more for the sick since there will be fewer healthy employees among them to spread the risk.

Health care is becoming more like electricity.'  The more you use, the more you pay.'  You can control the amount of electricity you use. With health care you cannot always do that.'  If you suffer a brain injury in a car accident, the hospital with top expertise may be what you need, but you may have to pay more to be a patient there.'  Sounds so rational and American, doesn't it?

It's likely the Massachusetts model will spread across the country bringing a cluster of new issues for consumers to consider.'  Do you take a risk and choose a restricted network because you think you won't need high-priced treatment at a big teaching hospital meanwhile saving hundreds of dollars in premiums?'  Or do you play it safe and opt for the expensive plan with access to the pricier services'just in case.'  That's what choice is coming to mean.

More Blog Posts by Trudy Lieberman

author bio

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.


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