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Even With Insurance, Hospital Stay May Cost You $1,000 or More

Key findings from a study of out-of-pocket costs for hospitalization. Image courtesy of the University of Michigan.

Even if you have what you might think of as good health insurance, your next hospital stay could cost you more than $1,000 out of your own pocket.

That amount has gone up sharply in recent years-a rise of more than 37 percent for straightforward hospital stays resulting from common conditions.

Those statistics come from the first published analysis of actual out-of-pocket spending by people with private health insurance, most of it provided by employers. The study is published in JAMA Internal Medicine.

Data from more than 50 million Americans over a four-year period was examined for this study.

The biggest change in out-of-pocket spending came from two types of insurance plan charges. Deductibles-the amount that patients pay for their care before their insurance kicks in-rose by 86 percent. Co-insurance-a percentage of the cost of the hospital stay that insurance plans often expect patients to pay-rose 33 percent.

“These results open up the ‘black box’ of healthcare, and show all the costs of hospitalization that are billed to people with private insurance. For many, these may appear to be ‘hidden costs’ that they didn’t realize they would owe,” said first author of the study, Emily Adrion, PhD, MSc.

She and her colleagues note that the growth in out-of-pocket costs was 6.5 percent a year, compared to a 5.1 percent growth in health insurance premiums and a 2.9 percent growth in overall healthcare spending.

High Costs, High Variation

The study looked at costs billed to people between the ages of 18 and 64, from 2009 to 2013. In addition to a broad-based analysis, the researchers took a closer look at those who had heart attacks, pneumonia, appendicitis, heart bypasses, total knee replacement or spinal fusion procedures, and women who gave birth.

It’s different from other studies that have estimated out-of-pocket spending based on the design of insurance plans.

The percentage of patients who were charged deductibles and co-insurance rose by more than 5 percentage points during the study period.

Co-payments, which are different from co-insurance and are a kind of ‘entry fee’ to a hospitalization, actually fell during this time. But this was due to the fact that fewer insurance plans charged a co-pay for a hospital stay in 2013 than had charged one in 2009-not to an actual drop in the dollar amount of the co-pays charged to patients who owed one.

The study also reveals sharp differences in out-of-pocket costs for people who chose “consumer-directed” health plans offered by their employers-which often take the smallest bite out of each paycheck-and for people who bought individual private plans during the study period.

For those with consumer-directed plans, the total they’d owe after a straightforward hospital stay topped $1,200 on average. Their employer may have also offered them a way to save pre-tax dollars in a special account to help pay for that, but the study data didn’t show that.

For those with individual private plans, the bite was even harsher: $1,800 on average. Adrion notes that in order to qualify for an individual private plan during the study period, patients would have to have met standards for good health. A provision mandating that plans cover all adults regardless of pre-existing conditions didn’t take effect until 2014.

Study authors emphasized that the results showed the importance of reading and understanding the fine print in health insurance plans to avoid unexpected costs. Patients can also make sure they understand which hospitals and doctors are “in network” for their plan, which might mean lower co-insurance costs. And, for people who can’t pay their entire bill at once, or at all, it means talking to the hospital about a payment plan or even a write-off of some costs under their charity care policy.

Coming Next: Looking at Post-ACA Trends

The study period didn’t include private individual and family plans bought on the exchanges set up under the Affordable Care Act (ACA). Those plans began covering people in January 2014 and are open to anyone regardless of health status. The study period did include the first years when the ACA mandated that adults up to age 26 could remain on their parents’ private health plans.

Recent estimates by the Kaiser Family Foundation suggest that the trend seen in the data has continued. According to a recent KFF report, 81 percent of people who get insurance through an employer have an annual deductible of about $1,300, and more than two-thirds of them also have co-insurance as part of their coverage. An even greater percentage of people who bought “silver” plans on an ACA exchange also have co-insurance provisions in their plans.

But plans bought on the ACA exchanges (including come with a federal cap on out-of-pocket spending of $6,800. Plans provided by employers, or bought individually outside the exchanges, don’t have such a cap. Adrion and her colleagues plan to study future data to look at spending trends.

This article was adapted from information provided by the U-Michigan Health System.