Ronald Jones of Alto has been dealing with lingering health issues for six years, as a career in construction work took its toll.
He has had back and neck surgery and still needs another procedure.
Jones was going through Gainesville-based Northeast Georgia Health System’s charity fund to cover expenses, but, in the last two months, is now getting help through Medicaid and disability payments, which hospital financial counselors helped him finally achieve.
“This is the first time I’ve been relaxed on the medical part of it in a long time,” Jones said.
The cost of health care is a big issue for all consumers, regardless of income, and involves a broad spectrum of concerns — from doctor’s bills to health insurance premiums.
While patients may have at one time relied on doctors and insurers to guide them through processes involving medical care, industry folks suggest that, with all the changes in recent years, patients take the initiative in directing their care.
“We must always be good consumers,” said Stacey Cummings, NGHS’ director of system patient receivables.
Doing the work on your own — without contacting a real person — can be challenging.
NGHS has an Excel document listing prices on its estimates website, but the file is broken down by “reference numbers” instead of procedures or names of items. Even if a patient is able to identify costs based on the numbers, the website advises “it’s important to note that these charges do not reflect what insurance providers and patients are typically responsible for paying.”
There are price estimators on the web, such as Fair Health Consumer, that people can get possible costs for certain procedures, but NGHS spokeswoman Beth Downs said, “The reality is that everybody’s surgery is so different that there is really no way to give (average cost amounts) that is actually going to be right enough.”
Price transparency has been an issue with Lt. Gov. Geoff Duncan’s Task Force on Healthcare Access and Cost, which held public hearings this fall and could produce legislation in the 2020 General Assembly starting in January.
“Any other industry that operated like this would be shut down,” Duncan told The Times last month.
Basically, “if you go to have a medical procedure done, you have no idea how much that’s going to cost until you get home and wait a few weeks to go to the mailbox.”
Ethan James, executive vice president, external affairs at Georgia Hospital Association, said GHA hosted a price transparency website about a decade ago, “and it was not getting any traffic … and was significantly expensive for us to run.”
Website hits were about 5-6 people per year. Asked whether the site was promoted, GHA said, “Since that site was taken down so long ago, we’re having trouble finding much detail in regards to how it was publicized.”
“Patients with commercial insurance are the ones interested in price transparency,” particularly copays, deductibles and other information that health care providers don’t have, James said.
“So, I would say the focus should almost be more on the commercial insurance plans to participate in a price transparency conversation,” he said.
Consumers can visit insurers’ websites or apps — especially the big five, Anthem Blue Cross and Blue Shield, Aetna, Cigna, Humana and UnitedHealthcare — to get estimates on surgeries, procedures and medications.
But they also should become familiar with the coverages, copays and deductibles of their insurance — and call when there are any questions or concerns.
“That’s why we pay (insurers’) premiums,” Cummings said. “They should be helping us.”
The Georgia Hospital Association said in a statement that hospitals charge the same prices to all patients as a requirement of participation by Medicare, the federal health insurance program for people age 65 or older, younger people with disabilities and people with end stage renal disease.
“However, the hospital will receive different payment amounts depending on the payer source — for example, commercial insurers versus government payers like Medicare and Medicaid.”
The hospital group goes on to say that “hospitals strive to be as transparent as possible regarding the cost of their treatments and procedures, (but) the amount paid by the patient will differ based on insurance status.”
Jamie Cleverley, president of Ohio-based Cleverley & Associates, which does financial consulting for hospitals, has worked with NGHS for a couple of decades.
“The hospital will work with third-party payers (typically insurance companies) to arrive at a payment rate for those services,” he said.
So why the high charge for things that seem ordinary, like aspirin?
“There are a number of patients who pay less than the cost of care, so the hospital will have to be mindful of that when they are setting their payment rates and pricing rates,” Cleverley said.
The hospital offers charity care for insured and uninsured patients — on a sliding scale and up to three times the poverty level. The poverty level for a family of four is $25,750.
According to NGHS policy, family income of 150% or less than the federal poverty guideline qualifies for 100% financial assistance, while a family with income 2.3 to three times the poverty level qualifies for a discount of 5-10%.
The big player in controlling hospital costs is Medicare, which pays on average 7.5% less than the cost of care.
“The average hospital typically has half of its patients on Medicare … so hospitals have this delicate balance to (determine) the money they need to keep the doors open and to back into the rates necessary to make that happen.”
Medicare patients made up about 50% of those admitted in 2018 to Northeast Georgia Medical Center in Gainesville and Braselton, according to data submitted to the Georgia Department of Community Health.
Rates played a role in the ongoing dispute between Anthem and NGHS, according to Steve McNeilly, vice president of managed care with NGHS, who said that NGHS was asking for a single-digit rate increase but the insurer was requesting that NGHS take rate cuts.
Anthem has said it has concerns about rising costs at facilities that NGHS acquires. “What NGHS has proposed up until now is simply not sustainable for our members,” it said in a statement.
The two couldn’t come to terms and went out of contract earlier this year due to disagreements over rates and what kind of services should be covered.
NGHS has employees who can help patients assess costs on the front end, as well as after bills arrive in the mail.
The same is true at Longstreet Clinic, which has offices in Gainesville and Oakwood.
“As a community provider, we’ve always been very engaged in the market with and for patients who need care, so we see a number of patients who qualify as indigent,” CEO Mimi Collins said.
Healthcare.gov, a federal government website managed by the U.S. Centers for Medicare & Medicaid Services, suggests that consumers “estimate the medical services you’ll use for the year ahead” when determining health care insurance — often during open enrollment in the fall.
“Think about how much care you usually use, or are likely to use,” the government says.
For Andrew Beccue, president and CEO of ETHOS Search Group, a Gainesville executive and management search firm, the real cost of health care is health insurance.
“It seems like every third year, our rates tend to go up about 30%,” he said.
In 2018, his family paid $21,000 in premiums and “if we received even $3,000 in payout benefits (from the insurer), that would be surprising,” he said. “So, they’ve got a positive $18,000 net.”
“Even though my business can afford this expense, it’s just bad financially and I cannot continue this trend of ever increasing insurance costs with such a discrepancy of benefits to my family,” Beccue said.
“In my estimation, despite the lofty promises of both political parties, they are equally responsible for failing us in leading reform,” he said. “In the meantime, all you have to do is review the quarterly earnings of the major insurance providers and they are at all-time highs, not to mention the unrestrained mark-up on prescription drugs.
“It’s a runaway train with no end in sight.”
Lives on the line
This special weeklong series explores how cost and bureaucracy stand between local residents and their health care. Times reporters pored through the latest Community Needs Health Assessment, conducted numerous interviews with those in the local health care industry and those affected by it and examined the latest efforts by state government and politicians to remedy problems in our health care system. Read other stories in the series at gainesvilletimes.com/livesontheline.