JEFFERSON CITY — Whether tens of thousands of lower-income Missourians gain access to health insurance could depend on whether their neighbors are given the chance to shop for doctors like they would a new wide-screen television.
A key lawmaker has laid down an ultimatum: there will be no expansion of government-subsidized health care unless patients get more information about how much their medical care will cost.
The nonnegotiable demand has been attached by Rep. Rob Schaaf to legislation intended as a substitute for Gov. Matt Blunt’s languishing “Insure Missouri” plan. The bill cleared a committee led by Schaaf on Thursday, a necessary step toward reaching the House floor.
Blunt shelved his Insure Missouri program in February after Schaaf’s committee raised concerns about the governor’s legal authority to start the program, its cost and its scope.
Blunt’s plan initially would have expanded health coverage to 54,500 low-income parents, beginning last month, and potentially grown over five years to cover about 190,000 people at an annual cost of $952 million by using state and federal money to subsidize private health insurance.
The revised plan crafted largely by Schaaf, R-St. Joseph, and Rep. Doug Ervin, R-Kearney, would cover fewer people initially while requiring them to put up more of their own money to get the government-subsidized health insurance.
The House legislation, for example, initially would cover a single mother with two children who earns up to $14,960 a year, compared with a three-person family earning up to $17,600 under Blunt’s initial proposal. The House plan could eventually expand coverage to people earning up to 225 percent of the poverty level, or $33,660 annually for a family of three.
But Schaaf says none of that will occur unless the legislation also includes what he describes as cost transparency for health care.
Here’s how it would work: When a patient visits his or her doctor and is diagnosed with an ailment that needs further treatment, the patient can ask the doctor for detailed information.
The doctor must provide the “diagnosis code” and the proposed “procedure code” that would be used to bill the insurer, as well as the name of the health care facility where the procedure would be performed, the amount the doctor plans to charge for the service and — if known — an estimate of the charge allowed by the patient’s insurance company.
The patient, before undergoing the procedure, then can take that information to his or her insurance company. Within five days, the insurer must provide the patient an estimate of how much it would pay for the procedure to the doctor, the health care facility and the professionals providing necessary services such as anesthesia or radiology. The insurer also must tell the patient his or her likely out-of-pocket expense.
The patient — armed with such facts — then could shop around for other doctors or hospitals willing to perform the service for less or negotiate a lower cost with those to whom he or she was referred.
It’s sort of like going to Best Buy, jotting down the price for a particular TV model, then searching the Internet and driving around town to Wal-Mart, Circuit City and elsewhere to compare prices and negotiate a good deal.
Schaaf contends that if only a small percentage of patients shop for the most affordable health care providers, it will force doctors, hospitals and other medical groups to slightly lower their costs, resulting in widespread savings.
A family physician who helped craft last year’s Medicaid overhaul, Schaaf describes his proposal for health care shopping as “the highest and best thing” he ever would have accomplished as a lawmaker.
But the state’s leading association of medical doctors doesn’t like it.
“It’s cumbersome,” said Tom Holloway, a lobbyist for the Missouri State Medical Association. “There are scores and scores and scores of these procedure codes and diagnosis codes. It’s just going to be an administrative headache.”
Many doctors leave it to their staffs to handle particular diagnosis or procedure codes, he said. So before leaving a doctor’s office, a patient wanting the necessary information for price shopping likely would have to first chat with the doctor’s billing staff.
Holloway doubts many sick or pain-stricken patients would go through that hassle, much less the further hassle of dealing with their insurance companies and then digging through the phone book to get price estimates from various medical providers.
“I go wherever my doctor recommends. I trust his judgment,” Holloway said. “You send me to the best place, and I’ll worry about the rest of it later.”
The Missouri Insurance Coalition has no qualms with health care shopping, said executive director Calvin Call. If consumers can find lower prices, that saves insurers money, too, he said. But the bill still makes insurers somewhat uncomfortable, he said, because “what we don’t want to be is continually regulated to death.”
Schaaf believes his cost-transparency provision is pretty simple. Insurers already send patients statements after a medical procedure detailing how much the doctor charged and how much the insurer will pay, he said.
If a patient is having surgery Wednesday, “I want providers and the insurance companies to tell you on Monday what they tell you now on Friday,” Schaaf said.