The cost of coverage

As health-care costs rise, insurers help you sort out where to go, which treatments are worth it

Idaho's largest health insurers are offering customers more information about the quality, effectiveness and cost of health care in the Treasure Valley. And customers are more likely to zero in on the information as they pay for an ever-larger share of their own health care.

One in eight new policies at Regence BlueShield of Idaho and Blue Cross of Idaho, the state's largest insurers, is some version of high-deductible health insurance, often $2,000 or greater, combined with a health-savings account.

"The concept behind all of these plans basically is to have the consumer more involved, more 'skin in the game,' " said Karen Early, director of corporate communications for Blue Cross. "They are more involved because it has a direct financial impact," she said. "There is a lot of interest based on cost issues and employers wrestling with health costs," Early said.

In 2006, employer health-insurance premiums nationwide rose 7.7 percent, twice the rate of inflation. Employees and the companies they work for split annual premiums of nearly $11,500 for a family of four, according to the National Coalition on Health Care. The coalition is a large, nonprofit alliance of business, academic and other organizations.

Many employers still shy away from such plans, as do their workers. But one company seeing if high-deductible policies work without breaking employees' banks is Healthwise, a Boise-based nonprofit organization that develops patient-friendly health information.

Employees there now have a health plan with a $2,000 deductible. To help employees with some of those deductible costs, Healthwise puts $1,750 into a health-savings account, and employees have the option of adding $250 to that.

If employees don't use all the money in their tax-advantaged accounts by the end of the year, it stays there and builds up for use during a year of more ailments, or a big surgery. Employees who have money in their accounts at age 65 can withdraw it and use it any way they want, although it will be taxed as ordinary income.

The plan has been in place for more than a year now. "The goal of the high-deductible plan at Healthwise is to provide really good coverage that is simple, has the tools our employees need to make better health decisions and the tools they need to manage their account," said Brenda Foster, director of corporate communications for Healthwise. "Employees really understand our high-deductible plan options and benefits a lot better today than they did a year ago," she said.

Whether Healthwise sticks with health-savings account plans or switches to something else depends on what workers there need and what the insurance market has to offer.

The cost of insurance is rising as technology increases the scope of treatments available in the Treasure Valley. Is more care better? That depends.

Blue Cross and Regence BlueShield are among insurers, government agencies and consumer groups trying to find ways to rate the quality and cost of care hospitals and doctors provide.

Here is some of the information available from the insurers:

Regence BlueShield’s Web site provides information on the quality of care at Boise hospitals. Information on the effectiveness of treatments is available, as are estimates of the cost. The Web site is accessible only to Regence BlueShield patients.

A new feature for Regence patients is an open forum called My Community, which allows members to interact in real-time discussions on health and lifestyle topics and find helpful community resources.

"Many Web tools provide health information, but no other site combines cost and quality comparisons on hospitals with planning tools - and the ability to integrate this information to individual health-care benefits," Regence BlueShield spokeswoman Georganne Benjamin said via e-mail. "In doing so, we are providing an unmatched, empowering experience that will increase the value of each employee's health- care dollar," she said.

Regence BlueShield's hospital comparison data comes from the Subimo health-data company, featured in publications ranging from The New York Times to Modern Healthcare. Regence BlueShield partners with Subimo and other health-care data providers to offer health planning and advice tools on MyRegence.com.

Subimo’s Web site lets anyone sign up for My Healthcare Advisor for $24 a year. The Web site lets you compare hospitals based on criteria you set, including its experience with a procedure you need. Hospitals can see what is written about them, submit questions and corrections or add to the data. Subimo does not rate doctors.

Blue Cross provides similar information through a link on its Web site to a company called HealthGrades, which offers provider quality ratings and profiles.

HealthGrades offers detailed information on how well and how appropriately hospitals treat patients for a variety of conditions. It also provides information on doctors, including professional misconduct, if any, specialties, education and training, board certification and comparisons to national and specialty averages.

Hospital reports on the Web site recently were going for $17.95 for one hospital, with an additional $2.95 for each additional report. Reports on doctors, including professional background, board certification and disciplinary actions, were going for $17.95 for one doctor, $9.95 for each additional doctor. Pay an extra $3.95 to learn how much you might have to pay for up to three procedures your doctor performs. Limited information is available for free. Much of the information from HealthGrades and Subimo is available free from other sources, but takes some digging to find.

Information also is available on how well treatments work. Blue Cross and Blue Shield Association's Technology Evaluation Center, assesses the effectiveness of treatments. The idea is to help you understand the scientific evidence, so you can make informed decisions. Evaluating the quality of treatment that doctors and hospitals provide remains a work in progress. "It's a very difficult thing, rating quality in providers," said Early of Blue Cross.

Both of Boise's major nonprofit hospitals provide information on hospital costs for procedures. The amounts do not include charges for medical imaging or physicians, including anesthesiologists.

Here are some free Web sites that can help you

See snapshots of how Idaho stacks up to the rest of the nation in the quality of care it provides for people with heart disease or other common conditions. Go to the National Agency for Healthcare Research to read the comparisons.

See how individual Treasure Valley hospitals compare with national standards and with each other on Hospital Compare, a service of the U.S. Department of Health and Human Services. This tool gives you information on how well Valley hospitals care for adults with pneumonia and other ailments. The information was created through the Centers for Medicare and Medicaid Services, or CMS, and organizations that represent hospitals, doctors, employers, accrediting organizations and the public.

Find the benefits and drawbacks of many new medicines and treatments, as well as step-by-step guidelines for treatment of scores of conditions in the clinical information section of the federal Agency for Healthcare Research. Click on items in the index. All practice guidelines are clearly dated so you know how old they are. You may need to look up unfamiliar terms. Many health Web sites offer that tool.

Illustration by Brad Talbutt / Idaho Statesman

Insurance terms to know

Here are common health insurance terms and their translation into English:

Deductible. A set dollar amount you pay each benefit period for covered services before your health insurance policy pays any benefits. Deductibles are reset each year.

Coinsurance. A percentage (for example, 20 percent) of the allowed amount you pay for a service covered by your insurance. Coinsurance applies after you meet the deductible.

Copayment. A fixed dollar amount (for example, $20 or $30) you pay for specified covered services such as a doctor office visit. A copay applies each time the service is provided.

Amount charged vs. amount allowed. A provider can charge you any amount for a service, but a health insurer may establish the maximum it will pay for a given covered service.

This amount is often less than the charged amount. Contracting or "in-network" providers agree to accept the allowed amount (called the maximum allowance in your policy) as payment in-full for a covered service, and, as part of their contract, they agree not to bill you the difference between the allowed amount and charged amount.

In-network vs. out-of-network. Depending on your policy, there may be a different benefit level for in- and out-of-network providers. When you use providers out of the network, you may have to pay significantly more for your health-care service.

Out-of-pocket maximum. A fixed dollar amount that is the most you will pay for deductibles and coinsurance for most covered services in the course of a benefit period. Once the out-of-pocket maximum is met, most covered services are paid at 100 percent of the allowed amount.

Generic drug. Drugs with identical active ingredients as corresponding brand name drugs. Generic drugs on average cost less than one-third of brand-name drugs but have the same therapeutic benefit.

Formulary drug. A drug that is covered under a health insurer's prescription drug plan. Nonformulary drugs may be covered, but at a much higher cost to you.

EOB. An explanation-of-benefits form (EOB) lists the services for which your providers have sent claims. These forms are not bills, but explain the result for each service submitted.

Noncovered service. A service or type of service that is specifically excluded from coverage in your policy. Read your policy for a full list, but noncovered services often include those considered investigational or convenience items.

Source: Blue Cross of Idaho