Originally Posted by Trekchick
Ambulance rides are not always covered by insurance, no matter how good the insurance is and usually the ambulance is expensive.
When I was the risk management officer for a motorcycle track I was involved in a lot of the reports about people who refused an ambulance ride. There is a bit of paperwork to fill out if you refuse a ride after being treated by the EMT's.
That being said, I'd rather go on my own and go to the hospital/doctor I prefer if its possible. If the injury is bad enough that I NEED to go in an ambulance then I guess I'll be happy its available to me.
Coverage for ambulance rides, like most items covered by a health plan, is determined by medical necessity.
I'm in the biz, and will try to address a few of the questions/comments raised in this thread:
Originally Posted by binba
Have you ever, or know anyone who had a skiing/snowboard injury where you used your general health insurance (especially since Obamacare greatly standardized the coverages)? What was the process and outcome? Do you know anything else about this?
As binba was told, general health insurance covers all health needs regardless of how the illness/injury occurred. No exclusions for accidents, self-inflicted injuries, etc. I have a large employer client that incurred a $2 million claim from an employee who botched a suicide attempt jumping off a 6 story building. The plan covered virtually all services.
A related part of the question/follow up relates to coverage for claims incurred "out of area" -- away from where the individual lives and works. In general, plans pay for urgent and emergent care for claims incurred out of area (at the higher, in-network levels of coverage). The emphasis will be on getting the illness or injury stabilized; once stable, the health plan will want the individual to continue care with their health care providers back home. If there is doubt about coverage determination after the initial out-of-area treatment, call your health plan to clarify.
Originally Posted by crgildart
One interesting thing that caught my attention is that antivenom for copperhead bites isn't covered by most insurance policies here and we have those snakes in this area. Some guy on the news said they almost had to pay $20,000 to get anti venom treatment. The anti venom wasn't some experimental non FDA approved thing.
Yes, some crazy exclusions exist, and they vary Health Plan by Health Plan (i.e., Aetna's exclusions differ from United Healthcare's, and both differ from Anthem BCBS). If you are buying coverage on an Obamacare public exchange in your state, exclusions are pretty consistent across coverage options (i.e., Aetna will have the same exclusions for their Gold, Silver, and Copper plans, etc.). If you get coverage through your employer, there are more differences, as employers have the ability to pick and choose the exclusions under their programs.
Originally Posted by anachronism
1. The choice of what care is provided is made by the doctor and patient. The doctor is motivated to make maximize their own income. Their own income maximization in most cases does no harm to the patient and also serves to minimize their own risks of getting sued- there is no downside to suggesting more care. The patient has information asymmetry (economic term). They didn't go to school for a decade to be a doctor, and thus probably aren't good judges of what care is most efficient. They also don't know when the doctor is recommending care simply because a drug company/equipment company paid him a truckload of money to do so, or because the drug rep is really, really hot and buys lunch for the office every week.
I largely agree, although this is beginning to change, as providers are setting up systems to assume the financial risk of treatment and health plans are modifying the way they are structuring payments. Google Accountable Care Organizations if you want additional background on this market shift.
Originally Posted by anachronism
2. The patient also has little motivation to choose cost-effective options, because another party (the insurance company) is paying most of the bill. Furthermore, in many cases the information on cost simply is not available- the doctor has no idea what procedures and medications actually cost, because people don't typically ask that question, and the more urgent the care, the less people slow down to research efficient options.
This is becoming less true, as account-based health plans require significant up-front deductibles and high annual out-of-pocket maximums. And emerging transparency tools make pricing and quality information available to consumers.
Originally Posted by anachronism
3. Meanwhile, the insurance company nominally cares about managing cost, but in a profit maximizing sense- the money they save by forcing less expensive methods of care largely line the pockets of the insurance company. Barriers to entry in the medical insurance world are simply enormous, so they don't have to worry about some upstart firm undercutting them- they just have to set their prices in line with the rest of the players in their market, and follow suite when the rest of the players raise prices. It is the same deal as ski area window prices- Ski areas along I-70 don't really compete with each other on window prices because it is more profitable for all the firms involved to just let the prices rise- Vail goes to $160 Copper goes to $130, all the other firms fall in line according to pecking order and everybody is better off- and nobody has to worry about some 3000 acre ski area popping up overnight and tipping over the apple cart. All medical insurance companies have to do is raise prices like all the rest of the firms, and pass the bill along to the employer. The provision in the ACA that caps profit margins for health insurance providers helps address this- one of the few cost containment provisions in the bill.
In the end, the employer pays most of the cost of healthcare, but had no input in the decisions that led to the cost- and at several levels all the other players in the market get to make decisions that blow up the cost. All the employer can do is shop for cheaper prices or cut plan benefits , but the list of health insurance providers in an area are limit, and they all make money by letting prices slide upwards.
Some misperceptions here, at least from my perspective. Outside of standard Medicare, coverage available through employers and through the Obamacare exchanges all feature health plan options that have physician and hospital networks with reimbursement schedules pre-contracted. Until the ACA, these networks were very broad -- typically 95% of health care providers in a given market. In some markets, plan choices with narrow networks have emerged on the public exchanges. On the public exchanges, individual consumers are proving to be extremely price-sensitive -- health plans need to be within very tight pricing bands for given levels of coverage in order to attract desired enrollment.
Competition to traditional Health Plans/Insurers is beginning to emerge -- initially, it will be from large health systems (like Sutter in the Bay Area and Banner Health in Phoenix) offering commercial health plans featuring their own providers, but is also likely from start-ups. It will likely take 3-5 years to gain traction, but in my view this will be an extremely positive development. I would also rephrase Anachronism's last highlighted point -- it isn't that insurers make more money by letting prices slide upwards, it's that there are very few negative consequences for them doing so.
Where I completely agree with Anachronism is that traditional Health Plans/Insurers essentially operate in a cost-plus environment and pass cost increases (from paying health care providers) along to their customers. With Obamacare turning these companies into de facto public utilities, this will get worse before it gets better. Consumers are insulated from information related to real pricing and quality of care, distorting buying decisions (I mean, how many of us would eat at McDonald's if it cost us $5 to eat dinner anywhere?). And as Anach notes, there is very little in the ACA that reduces costs -- it essentially is a law designed to improve access to coverage.