President Obama’s health law was expected to cover 32 million uninsured Americans by 2022. But that number will be much smaller if some states don’t buy in.

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

Photo by Sanja Gjenero

By Michelle Andrews 

This KHN story was produced in collaboration with 

When Maria and Vadim Brodsky’s then 7-year-old daughter needed an MRI two years ago to examine a tumor in her head, they took her to a hospital in their health plan’s network and were dismayed to receive a $4,500 bill.

The couple had a $6,000 deductible on their family plan. And even though the bill was reduced to $3,000 — the price the provider and insurer had agreed to by contract — the Brodskys had to cover all of it.

The following year when their daughter needed another MRI, the Huntingdon Valley couple took her to a standalone facility and put the procedure on a credit card. The total bill: $600.

Welcome to the new world of health insurance where high deductible plans are growing more popular and the consumers in those plans often have an incentive to haggle with providers.

Although many plans still protect people from high out-of-pocket costs for care, these days an increasing number of consumers have cheaper, high deductible plans where they must cover the first $1,000, $5,000 or even $10,000 of care before insurance kicks in.

For this group, it pays to shop around, say experts.

“It’s definitely worth it to look at different hospitals or outpatient services, because prices can vary dramatically,” says Carrie McLean, senior manager of customer care at eHealthInsurance.com, an online vendor.

Five years ago, 12 percent of workers faced a deductible of at least $1,000 for single coverage. Today more than a third do, according to the Kaiser Family Foundation’s 2012 survey of employer-sponsored plans.

Increasingly, a high-deductible plan, often linked to a tax-advantaged health savings account, is the only insurance offered on the job, even at big companies that have long offered generous coverage.

Proponents of high-deductible plans say consumers will make more cost-conscious health care choices if they have to spend more of their own money. According to  an analysis by the Robert Wood Johnson Foundation, consumers in such plans cut their medical spending by between 5 and 14 percent. But results were mixed on whether they cut back only on unnecessary care or on treatment that was needed.

As patients increasingly owe a bigger share of the bill, “providers and patients have gotten creative about paying out-of-pocket costs,” says Mark Rukavina, a principal at Community Health Advisors in Boston who consults for nonprofit hospitals. “The price that appears on an invoice may be fluid.”

Insurers in recent years have helped ease some of the burden by only billing consumers for the companies’ lower contracted rates just for the companies’ lower, contracted rates.

And the Affordable Care Act takes some pressure off by requiring many health plans to cover preventive services without applying those charges to the deductible. Still, high bills are a fact of life.

One effective way patients can cut costs is by agreeing to pay cash at the time a service is provided. Many doctors and hospitals offer such “prompt pay discounts.”

“If they’re willing to pay in cash and I don’t have to wait six weeks for reimbursement [from the insurer], I’ll reduce the bill by 10 to 25 percent,” says Dr. Joseph Mambu, a family physician in Lower Gwynedd, Pa.

Patients who pay hospitals within 30 to 60 days of billing — the time frames vary — can often get up to a 30 percent discount, adds Rukavina.

It’s also worth asking a hospital about their financial assistance policies, says Rukavina. They’re not necessarily only for uninsured patients. “Many have policies for the uninsured as well as underinsurance and might provide relief for the amounts due after insurance has paid,” he says.

Paying directly, however, can have downsides because it bypasses the insurance claims process, advocates warn. For one thing, those immediate payments won’t be applied to the deductible, so if the patient has more medical expenses later in the year, he or she won’t get “credit” for the amount spent. And, if there’s an error in the bill, you may not find out about it.

“If you don’t use your insurance, the bill won’t be reviewed [by the insurer] for errors,” says Pat Palmer, the founder of Medical Billing Advocates of America, which helps consumers resolve medical billing problems.

Some patients are willing to take those chances to snag a “cash” discount.

Typically, consumers’ medical bills are adjusted to reflect the contracted rate that the provider has agreed to accept from the insurer. This lower rate is applied even when consumers are paying 100 percent of the bill because they haven’t yet satisfied their deductible.

That’s how the Brodsky family’s first bill was reduced.

Still, it doesn’t hurt to ask. “As consumers, we shop around for just about everything else,” says Martin Rosen, executive vice president at HealthAdvocate, a company in Plymouth Meeting, Pa., that gives consumers clinical and administrative help to navigate the health system.

Among other tips:

You are more likely to negotiate a lower price for care that’s not covered by insurance or that’s done by an out-of-network provider, say experts. “Usually patients are very successful in appealing [higher charges for] any out-of-network providers that took care of them while at an in-network facility,” says Palmer.

Insurers often have different discount deals with different types of facilities, says Palmer. At a standard radiology practice, the discount for an MRI may be only 20 percent, she says, but it can be 40 percent at a standalone imaging facility. Charges at teaching hospitals are often higher than at other facilities, she says.

“Look to have the service done outside the hospital or hospital-owned facility,” says Palmer. “It’s often going to be less expensive.”

Drug prices vary widely, even for generic drugs. A recent Consumer Reports analysis compared prices at 200 pharmacies for five common generic drugs. The variation between the highest and lowest priced stores was a hefty $749 for the five drugs. The takeaway: shop around.

Dawn Herbert, 41, of Philadelphia saves a $14 copayment each month by filling her prescription for generic birth control at Walmart instead of CVS. “Whatever the insurance is paying for that drug, Walmart is considering it payment in full,” she says.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Solo time at the gym, during yoga or while walking may be a great way to clear your mind, release stress and get the most from your workout.

Think about your workout sociability this week.

Are you cut out to go solo or do you prefer a fitness friend?

Plan an activity that suits your style.

About the Monday Campaigns:

The Healthy Monday Tips is produced by a national health promotion initiative called the Monday Campaigns.

The thinking behind the initiative derives from two studies done at the Center for a Liveable Future at Johns Hopkins Bloomberg School of Public Health by Jullian Fry and Roni Neff.

In one study, they reviewed the scientific studies that looked at ways to get people to adopt healthy habits.

In that review, they found that one of the most effective ways to keep people on track is simply to remind them from time to time to stick to it.

But when would be the best time send those reminders?

Fry and Neff decided to look at Monday, which many of us consider the start of our week.

To better understand how we thought and felt about Monday, they reviewed the scientific literature as well as cultural references to Monday in movies, songs, books and other forms of art and literature, even video games.

They noted that a number of scientific studies have found that we may suffer more health problems on Monday. For example, a number of studies find that Americans have more heart attacks and strokes on Monday.

There is also evidence that we have more on-the-job injuries on Monday, perhaps because we are not quite back into the swing of things, or are still recovering from our weekend.

Fry and Neff also found that while many of us, facing the return to work, may dread Mondays, Monday is also seen as a day for making a fresh start.

Fry and Neff concluded that Monday might be a good day for promoting healthy habits. Calling attention to the health problems linked to the first day of the work week, such as heart attacks and on-the-job injuries, makes Monday a natural day to highlight the importance of prevention.

And the Monday’s reputation as a day to make a fresh start offers the opportunity to help people to renew their efforts to adopt healthier habits.

Fry and Neff’s findings are put into practice by the Monday Campaigns, which helps individuals and organizations use Monday as a focus for their health promotion efforts, providing free research, literature and artwork, and other support.

To learn more about Healthy Mondays:

• Visit the Monday Campaigns website: www.mondaycampaigns.org

Giving prescribers access to education and advice or imposing restrictions on use can curb overuse or inappropriate use of antibiotics in hospitals, according to a new Cochrane systematic review.

This is important because unnecessary use of these life-saving drugs is a key source of antibiotic resistance in bacteria.

Some infections are no longer treatable due to bacterial resistance. Compared to infections caused by treatable bacteria, those caused by multidrug-resistant bacteria lead to more deaths, longer hospital stays and increased healthcare costs. Reducing inappropriate use of antibiotics should help to slow the spread of resistant bacteria.

Achieving this is proving difficult as by most estimates, antibiotic use in hospitals is rising, with some evidence suggesting more than a third of prescriptions are inappropriate.

The review, published in The Cochrane Library, included 89 studies from 19 countries, with most studies aiming to decrease excessive antibiotic use.

The researchers analysed data from two types of studies. In persuasive studies, doctors were given advice and feedback about prescribing antibiotics. In restrictive studies, restrictions were placed on prescribing, for example, doctors might be required to seek approval from a specialist.

Overall, prescribing in hospitals improved and data from 21 studies showed that hospital infections decreased.

“Our review shows that a wide variety of different interventions have been successful in changing antibiotic prescription in hospitals,” said lead researcher Peter Davey, who is based at the Population Health Sciences Division at the University of Dundee in Dundee, UK. “However, we need more studies that explore how these changes benefit patients and how they impact on healthcare costs.”

Restrictive methods yielded greater improvements in prescription, although no studies undertook direct comparisons between restrictive and persuasive methods.

“The fact that restrictive methods work well is important because it supports restriction of antibiotic use when the need is urgent, such as in an outbreak situation,” said Davey. “However, the evidence base would be enormously enhanced by direct comparisons with persuasive methods.”

Full citation: Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD003543. DOI: 10.1002/14651858.CD003543.pub3.

URL Upon publication: http://doi.wiley.com/10.1002/14651858.CD003543.pub3

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.