Insurance Plans at This Employer Get a Little More Difficult to Decipher – More Confusing Algorithms That Lead to More Cost Out of Pocket for Big Expenditures

The focus here is for more money spent on preventive care, but when the big ones come, such as a knee or hip, or even cardiac care, it will be more out of pocket for the employees here. It is lowering the cost on the preventive side, where we can usually afford, but passing along the bigger expense of surgery to the patient. The prescription drugs for the preventive are not a huge plus as so many of those are generic in the deal, but we have discounted visits or free to the doctors.

I might go on to guess that with negotiated contracts with the doctors and the visits sometimes being free, there goes less in the pockets of the doctors too. It took some fancy formulas (algorithms) to come up with this one. Actually it’s not the small routine expenses for preventive care that hurts everybody, it’s the large expenses and this is an option for employees, and yes, just one more way of crunching numbers with some new algorithms. The plans are being underwritten by Blue Cross/Blue Shield. It’s just one more way to shake out some numbers, and add to the confusion of getting good care. As far as I have seen and heard from individuals I talk with, not much of this is really getting though as most patients don’t understand the entire analytics of the process.

Workers at a Portland, Ore., steel mill soon will be able to pick a new type of insurance that offers free care for some illnesses, such as diabetes or depression, but requires hefty extra fees for treatments deemed overused, including knee replacements, hysterectomies and heart bypass surgery.

The insurance, which will be offered by five different insurers in Oregon, is the most far-reaching and potentially controversial step in an effort by employers nationally to rein in medical spending by redesigning health benefits.

"We're trying to make people better consumers," says John Worcester, head of benefits at Evraz Oregon Steel, the sole employer to sign up since the plans began coming on the market earlier this year.

Workers who choose the option over a more traditional plan next year could see their costs drop sharply if they have one of six chronic conditions but might pay hundreds more in deductibles and co-payments if they need a hip replacement or a heart stent.

At Evraz, Worcester expects only about 30 of the 450 workers at the plant will choose the new option over more conventional insurance — even though the company won't charge workers monthly premiums for the new type of policy. The policies, administered by Regence Blue Cross Blue Shield, will work like this:

Just as in more traditional insurance plans, workers would pay an annual deductible of about $250 before coverage kicks in. Doctor office visits would cost workers $10 to $20. Employees would pay 20% of the cost of hospital care, up to an annual maximum of $1,500 for individuals and $3,000 a year for family coverage.

But employees with certain conditions — asthma, congestive heart failure, diabetes, depression, heart disease, chronic bronchitis or emphysema — would get prescription drugs and visits with physicians free or at greatly reduced rates. High blood pressure, another common condition, would qualify for low-cost care if it was part of an overall diagnosis of heart disease.

Conversely, they'd pay much more if they have a treatment or test from a list of about 20 broad categories, including knee or hip replacement, cardiac bypass surgery, artery-opening stents, hysterectomies, high-tech-imaging exams or emergency room visits. In those cases, they'd pay double the annual deductible, double the amount they'd normally pay for an office visit and up to half the cost of hospital or ER visit, up to the $1,500/$3,000 maximums.