Montana grandmother changes healthcare costs

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Montana was no different. And so Bartlett pitched a bold strategy. Take it or leave it. Step two: Demand a full accounting from the company managing drug costs. ProPublica and NPR are investigating these little-seen aspects of the health insurance industry and the way Americans pay for medical care. Previous stories have examined how health insurers profit from big medical bills and how the industry is teaming up with data brokers to rate how much patients cost based on their lifestyles.

They needed something radical. To her knowledge, no one had ever tried anything like this. If it did, it could create a blueprint for employers everywhere. Bartlett knew employers have negotiating power that few of them use. The health care system depends on the revenue produced by the surgeries, mammograms, lab tests and other services it provides, and it can ill afford to lose it. Bartlett got the job. Employer-sponsored health benefits are almost as old as America itself.

In , John Adams, the second U. After the Civil War, lumber, mining and railroad companies in the American West withheld money from employee paychecks to pay for doctors and hospitals.

After World War II, such plans became mainstream. Today, about million Americans get their health benefits through their employers. Half a dozen health insurers currently sit near the top of the Fortune , with combined annual revenue of about half a trillion dollars.

Despite the money at stake, many employers have, wittingly or not, deferred to the industry. Decisions about health benefit plans are usually made by midlevel human resources managers, who may not understand the forces in the medical industry operating against them. The conventional wisdom is that insurance companies want to reduce health care spending.

Employers often feel caught between rising costs and concern that changes they make will be bad for their employees, says Michael Thompson, president of the National Alliance of Healthcare Purchaser Coalitions, which represents groups of employers who provide benefits to more than 45 million Americans.

And, he says, they rely on the advice of industry experts instead of digging into the details. This is not a small issue. Bartlett arrived in Helena, the state capital, in the fall of as an outsider navigating a minefield of established relationships.

Montana, like many large employers, self-funds its plan. That means it pays the bills and hires an insurance company or other firm to process the claims. More than half of American workers are covered by self-funded plans.

But when she asked Cigna for its pricing terms with the hospitals, Cigna refused to provide them. Its contracts with hospitals were secret, Cigna representatives told her.

A cumbersome querying process set up by Cigna allowed her to get individual claims and other limited information. But the company would only give her aggregate data, with things lumped together, to show what she paid each hospital.

It was like telling a family trying to reduce its grocery spending that it could only see what it spent in a year, not a breakdown of what bread and fruit and other items cost at each market. When Bartlett continued to demand information, Cigna balked; it needed to balance what she wanted with keeping the hospitals happy. Bartlett ultimately settled on a radical solution: The plan would set its own prices for the hospitals.

In the illusory world of hospital billing, the hospitals typically charge a high price for a procedure, then give insurers in-network discounts. These charges and discounts might be different for each procedure at each hospital, depending on who has more leverage during negotiations.

Bartlett recalled wondering why anyone would think this was okay. Her battle to upend the status quo riled some employees of her own office, who complained that she was demanding too many changes. Some quit. Allegiance had been studying variation in hospital prices for years and had twice sent reports to Montana hospitals showing how their prices for the same procedures differed significantly.

Allegiance got the state contract and began by comparing what the plan paid the 11 biggest hospitals in the state to the Medicare rates. The cheaper ones averaged about twice the Medicare rates, the most expensive one about five times the Medicare rates. No one wanted to stiff the hospitals, but this was ridiculous, Bartlett recalls thinking. She determined the new rate for all hospitals would be a little more than twice the Medicare rate — still a lucrative deal, but a good starting point to get prices under control.

It would mean a boost for some lower-cost hospitals. Now, she had to persuade the more expensive hospitals to take less. Kirk Bodlovic, the chief financial officer of Providence St.

Patrick Hospital in Missoula, remembers the day an entourage from the state health plan, including Bartlett and Hogan, arrived at his hospital. Its competitor, one of the lower-priced facilities, had already agreed to the deal. Bodlovic says that thought gives him heartburn to think about now, envisioning the wrath of doctors if some 3, state plan members had ended up at a rival hospital. In their final analysis, he says, St.

When they arrived for the meetings, they found that Bartlett had also been invited. Telehealth by text messaging and fax alone is also still illegal. The boom in virtual health care is being met with concern by local providers who worry that large out-of-state providers might poach patients and by regulators who see the potential for telehealth scams and fraud.

Lawmakers fettered local public health officials with legislation after local health departments implemented and enforced state and federal recommendations to stop the spread of the coronavirus, such as mask mandates, limits on gathering and bans on indoor dining. Many public health officials have faced threats and harassment over their work to enforce those covid restrictions, leading to high rates of turnover in health departments across the nation.

One measure passed by Republican-majority lawmakers ensures that any Montana public health order can be changed or repealed by elected officials, such as a county commission, and it bans officials from placing any restrictions on attending church services. Another measure bars public health officials from issuing orders that restrict the ability of a private business to operate. There are some exceptions, such as restaurant health inspections.

A third allows citizens to amend or reject public health orders by referendum, while a fourth overturned a law that penalized law enforcement officials who refused to enforce public health orders. Gianforte lifted those statewide restrictions after taking office, and the provision takes aim at local governments, like Gallatin County, that decided to keep their own restrictions. Frank Garner R-Kalispell , who backed the provision.

Continuous eligibility is meant to reduce the churning of Medicaid expansion rolls as people are added and removed if their income fluctuates, such as with seasonal work. Instead, those enrollees will be required to certify their eligibility more than once a year. Nearly 98, Montana adults were enrolled in the Medicaid expansion program in March, according to the most recent data. Riding a wave of opposition toward the covid vaccines, the Montana Legislature passed a bill that makes it more difficult to require workers to be vaccinated as a condition of employment.

Another consequential vaccination bill that received less attention will make it easier for parents to obtain medical exemptions for their children for vaccines required by schools. State law requires kids to be vaccinated against illnesses such as measles and pertussis to go to school, but students can be exempted for religious or medical reasons.

Previously, a physician needed to sign off on a medical exemption. The new law allows a wide range of health professionals to do so, including nurses, pharmacists, massage therapists, chiropractors and nutritionists. It also makes it more difficult for schools to share exemption data with health officials.

Some parents who testified in support of the bill during legislative hearings said they wanted a medical exemption option because their children might need that medical documentation in the future to attend college or get a job that might not accept a religious exemption. The state health department and the American Academy of Pediatrics opposed the legislation.

Lauren Wilson, a pediatrician and vice president of the Montana chapter of the American Academy of Pediatrics. Lawmakers passed a bipartisan measure that will require private insurers and the state employee health plan to cover hearing amplification devices and services for children 18 and under.