Are You Among the Millions in the USA at Risk of Losing Your Insurance due to COVID?

According to a report released by the Robert Wood Johnson Foundation, about 10.1 million people could lose employer-based insurance coverage this year as a result of the pandemic. What will that do to people who need surgery and the full service hospitals where they live have suspended elective surgery cases or their doctor gave up and closed up shop (or the hospital that employed them, furloughed them indefinitely)? And even if they live in a place where the hospital is still carrying out elective surgery, many people are "terrified" to have to enter a hospital these days. With 1/7th of the US population employed in some aspect of healthcare, do they know something you don't know? Why are they terrified to go there?

The report, which was prepared by researchers at the Urban Institute, estimated that 48 million non-elderly people will be part of a household where someone loses their job due to Covid-19. Of these, only about 21% will lose their insurance as a result.

A portion of them would have already had insurance coverage through another family member’s job (34%), through Medicaid (27%), or might have already been uninsured (10%), leaving roughly 21% that would lose their coverage as a result of the pandemic.

More and more people are willing to consider and consent to surgery in an Ambulatory Surgery Center (ASC) than ever before. Most ASCs are still in operation doing elective surgery cases even if their local hospitals are not.

But they are also likely to find that not only can they probably avoid COVID contamination in an ASC, they could also save between $20-50,000 on their surgery procedures at the ASC - even if it means traveling down the road or to a different state for an airfare of about $350 per person, round trip...or just getting in the car or a rental car and driving themselves over and back.

Just prior to all the hullaballo of COVID, price transparency was in the in White House news cycle. Now, not so much. At least not inside the beltway. But at the regional and national level, there are many new network organizers who are ready, willing, and able to save independent consumers paying cash or employers who are self-insured for their health benefits under ERISA (technically not "insured" but self-"funded"), an Act under Section 29 of the US Code that is administered through the US Department of Labor and the Internal Revenue Service.

Employees covered under employer-sponsored ERISA plans carry identification cards that have BLUE CROSS, UNITED, CIGNA, AETNA, HUMANA ("BUCAH") logos on them and other logos such as PHCS, and others.

Most ASCs are not ready for the pivot to outpatient surgery so quickly

ASCs are in a tough situation. If a complication arises that requires the surgery be stopped for some reason and the patient be transported to the local hospital, and the hospital is "on divert" for COVID, in a small rural remote area, what happens?

If the complication requires transfer and hospital prices, who pays?

If the ASC doesn't have to price to include cost to collect, account carrying costs, billing costs, or wait to be paid, has the ASC developed transparent, bundled, cash pay case pricing to be paid by employers or consumers in full, on the day of or before surgery? Many have not. I know this because I have been working in the space for decades as an administrator, contract negotiator, network developer, a surgical nurse, and currently as one ASC's Director of Business Development. I know our competition. They don't have transparently priced, bundled case rates ready to sell - not to consumers, not to TPAs, nor to employers.

For one thing, they don't know how to set these prices. It takes hours upon hours to refine the modeling and data gathering to know and maintain data to translate costs and time and overheads by the case into a cash pay price. Most don't have the data. How do I know this? Because I helped to develop some of the world's first software to help them. But if they don't have their cost data, by surgical case, by surgeon, they cannot employ the software to help them.

Then all the hoopla about international or cross border "medical tourism". In the USA, that's not happening much these days. I have a hand in that arena as well.

No matter what the associations that hang out in the medical tourism circles hope you'll believe, cross border medical tourism may not happen from the USA to other countries as it was starting to trend for years to come. That's because right now, we can't travel there because other countries won't let us in. You can thank politics + COVID for that.

So, we need to rethink medical travel and consider domestic options and shoppable prices at ASCs that are still operating during COVID suspensions of elective surgeries at hospitals. This is not only the case if you've lost your insurance from your employer, but also if you've had a car accident and are filing under your auto insurance, or if you've had a workers' compensation injury that requires surgery.

What to Ask and How

If you have to shop whether your insurer, your employer or you have to pay the bill, here's what to ask for:

• A cash pay price that is "bundled"
• Includes the surgeon's fee and the assistant surgeon's fee (if required)
• Includes the anesthesiologist's fee
• Includes any hardware and/or implants, prosthetics, stents, etc.
• Includes all medications used during your surgery from the time you arrive to the time you are discharged. Also includes any high cost drugs, and biologicals for conditions such as hemophilia, that can be very costly.
• Includes an overnight stay, if medically necessary
• Include's the surgeon's initial consultation by telehealth or in person. Also ask for the price if you end up not proceeding with surgery. It should be in the vicinity of about $250-$300.

Your lab tests, MRIs, CT scans, x-rays, etc. are all extra and are usually not part of the bundle. Shop those as well. My most recent MRI was $184 for technical and professional fees vs $1800 at the local hospital after my plan's discount. My plain old x-ray was $28 instead of $289. It was cheaper to pay cash than use my insurance.

After your surgery, follow up visits won't be part of the bundle. You'll pay for those separately. They may cost between $80 and $250 per visit and if you need follow up lab tests and images, those too will be extra.

You'll be expected to arrive about three business days prior to surgery and stay about three business days after surgery before you are ready to go home. You should anticipate about $60-$250 per night for hotel stays, much cheaper than a hospital room where you watch TV or read for the duration. You should estimate that you can get airfare to most locations for treatment for about $350 round trip on average. If you drive, check TravelMath.com to estimate driving distance, time, and gas and tolls.

If you are having knee, hip or shoulder surgery, choose a surgical destination that is below 4000 feet in altitude to reduce additional complications risk of deep venous thrombosis (deadly blood clots that could break up and travel to your heart, lungs, or brain) and pulmonary embolism.

Ask where their transfer agreement is set up in case of complications or an emergency, and determine the COVID risk of that hospital. Ask about the hospitals and the ASCs infection rate. The average hospital infection rate is 10X (2.7%) what our infection rate is at our ASC (0.037%).

Ask if the ASC is accredited by the Joint Commission, AAAHC or AAAASF or DNV. Any of those 4 will be adequate. There are other accreditors that are "wallpaper sellers". Write a check; get a plaque on the wall. The four listed above are the ones I respect and I have 40 years in the industry from the admin and the clinical side.

While you may not have the time or interest to learn about what accreditation is and isn't, at least learn which of the variety of accreditors are the ones most reliable. But remember: Accreditation inspections are a snapshot of what was going on the day the surveyors arrived. I can spit shine a hospital or ASC for accreditation in a matter of hours if I am forced to. It's just a snapshot. Accreditations can get pulled and cancelled all the time, for just cause.

What if you chance employers or find a new job and regain your insurance?

New rules may apply if the ACA is cancelled. The biggest risk is to those with pre-existing conditions. One day you are in perfect health, the next day, you have a kidney stone or a heart attack. We never can plan these things. That's why it is called "risk".

Right now, we are learning that COVID can change the makeup of your heart, your lungs, and so much more. If you were stricken with COVID it will show in testing, current or in the past. You may require care for life - or not. Pre-existing coverage is a big deal. Without the current ACA rules, you may be on your own to pay for most of your medical conditions without the benefit of insurance - for all costs until you qualify for Medicare or Medicaid or something else. And if Medicare is changed that could change too. Stay informed.

If your new employer doesn't offer insurance that too, is a problem. Higher percentages of people losing their employer insurance will become uninsured in states that did not expand eligibility. Politics. Gotta love it.

Coverage is also not a "given". You may have some ACA mandated benefits, but you may have claims for things you need that your insurance doesn't pay for. That doesn't mean it isn't medical necessary - for you. It means that your employer chose to do without based on the recommendations of employee councils and task forces, brokers, agents, and other influencers. Covering the needs of the many was the goal, even if you are an outlier.

Then, there are also experimental and investigational procedures, treatments and drugs that may not be covered for years, if ever. You may need them, but your insurance decided not to include these therapies and services. Take out your wallet. But before you cave in, ask the state insurance commissioner if there is any appeal mechanism for your plan. If your employer paid insurance premiums so that the BUCAHs and their contemporaries accepted the insurance risk, you may have state appeal rights. If they are self insured/self-funded, you may have nothing and you'll have the IRS as your appeal route. Yes, the IRS! The state won't be able to help you because ERISA is federal and not subject to many state laws.

What if you have a workers compensation injury and the company folds and declares bankruptcy? That too, could become a problem. If the company was self insured/self funded for workers compensation, you could find yourself in the middle of treatment or rehab and on your own in some cases. In other cases, the state may have a contingency plan. Stay informed.

If you find yourself stuck, reach out. I'll do my best to answer your questions, point you towards options, and explain things to you. I am helping several ASCs to prepare for this transition to bundled case pricing, transparency, and thriving amidst the chaos. I know people, surgeons, prices, locations and more. But if you don't reach out, I can't help you.

Good luck, stay positive, and keep your chin up. We'll get through this.

Maria Todd PhD MHA is the part time Director of Business Development at St George Surgical Center in Southern Utah, and the author of 23 internationally published books on a variety of healthcare business administration topics including direct with employer contracting, managed care, physician integration, concierge medicine, medical travel program development, medical travel case management, and many other innovative topics in healthcare delivery and healthcare reimbursement. She consults with hospitals, ASCs, surgeons and consumers in 117 countries. Reach out at (800) 727 4160.