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Why your "free" flu that probably cost your insurer as much as $ 85 for vaccination



In the Byzantine world of health care prices, most people would not expect the ubiquitous flu shot to be an excellent example of how a lack of transparency of the system can lead to different costs.

The Affordable Care Act requires health insurers to cover all federally recommended vaccines free of charge for patients, including flu immunizations. Although people with insurance pay nothing when they get hit, many are unaware that their insurers are paying the bill – and that these companies will eventually recover their costs.

In only a small sample of one insurer, Kaiser Health News found drastic differences between the costs of its own employees. At an institution in Sacramento, California, the insurer paid $ 85, but only slightly more than half of that at a Long Beach clinic. A pharmacy in Washington, DC was paid $ 32.

The wide disparity in what insurers pay for the same flu illustration illustrates what's wrong with America's health care system, said Glenn Melnick, a health economist at the University of Southern California. ] "There will always be some price difference, but $ 85 as a bargain sounds like a bummer," he said.

Flu shots are relatively inexpensive compared to most health services, but given the tens of millions of Americans who receive

health plans pass those costs on to consumers at higher premiums, economists say.

"The patient is immune from the costs, but they are the losers because they end up paying a higher premium," said Gai Bai, a professor of accounting and health policy at Johns Hopkins University in Washington

. that change in payments for flu shots has nothing to do with the price of the drug, but is the result of negotiations between health plans and providers.Usually, the salaries of private health care insurers are kept secret.

But there is one place where these figures in flares appear for anyone who can see: "compensation explanation" forms that insurers send to members after paying a claim.

KHN reviewed forms that one of its insurers, Cigna, paid to some colleagues to get flu shots this fall in Washington, DC and California.

Cigna paid $ 32 for a CVS for flu shot in downtown Washington and $ 40 for a CVS less than 10 miles away in Rockville, Md.

In Southern California, Cigna paid $ 47.53 for a flu shot by a primary care physician with MemorialCare in Long Beach. But he paid $ 85 for a shot given at a Sacramento doctor's office linked to Sutter Health, one of the largest hospitals in the state.

Health experts were not surprised that insurers paid Sutter more, though they were astonished just how much more

"Sutter has a huge impact in California and insurers have no option but to pay Sutter the price," Bai says.

For years, Sutter has been faced with criticism that has used its dominance of the market to charge higher tariffs. In October, he settled a lawsuit filed by the Attorney General, employers and unions that accused the hospital giant of illegally raising prices.

The $ 85 was not only much more than what Cigna paid elsewhere, but also more than the triple price Sutter advertised on its website for people without insurance: $ 25.

How Sutter justifies the higher their prices as well as different prices for the same photo in the same place?

Sutter's employees had no simple explanation. "Pricing can vary depending on a number of factors, including the care environment, patient insurance coverage and agreements with insurance providers," Suter said in a statement.

Cigna also said that many problems are taken into account in determining its various payments. [19659011] hidden ad unit

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"What plan reimburses pharmacy / clinic / medical center for flu vaccine depends from the plan's agreed rate with that organization, which can be influenced by a number of factors, including location, number of pharmacies / facilities available in the area (also known as competition), and even the size of the plan (also known as leads), " Tsigna said in a statement. "It's important to keep in mind that hospitals and pharmacies have different economies, including administration costs."

It's also notable that Medicaid, the state's federal low-income health insurance program, pays providers far less for the flu. In Washington, D.C., Medicaid pays $ 15. In Connecticut, $ 19.

Nationally, self-insured employers and insurers pay between $ 28 and $ 80 for the same type of influenza treated in doctors' offices in 2017, according to an analysis of more than 19 million claims by people under age 65 by the Kaiser Family Foundation in partnership with the Peterson Health Center. (Kaiser Health News is the foundation's editorially independent program.)

"Your health plan can end up paying more than twice the price for the same flu care, depending on where you get it," said Cynthia Cox, vice president

"We see the same model for more expensive services like NMR or knee replacement," she said. "This price change is part of what makes insurance premiums higher in some parts of the country."

The wide disparity in costs for the same service highlights a major problem in the US health care system.

"We don't 'I don't have a functioning healthcare market because of all this lack of transparency and opportunities for price discrimination,'" Melnik said.

"Prices are inconsistent and confusing for consumers," he said. "The system does not work to provide effective care and the flu shot is an example of how these problems continue."

An unintended consequence of a health law that makes flu shots free for insured patients is that health plans have little ability to

Across the country, retailers like Target and CVS offer a variety of incentives, such as gift cards and coupons, to encourage consumers to enter their free flu shots in the hope that they also buy other goods. Some hospital systems, such as Baptist Health in South Florida, have also begun to provide free flu shots for people without insurance.

Bye said that while hospitals like a Baptist should be praised for helping there are other factors to improve the health of their communities.

"There is a hidden motivation to use free flu shots as marketing. a tool to improve the hospital's reputation, "she said. "If people come to the flu hospital, they may like the facility and come again."

Phil Halewitz is a senior correspondent for Kaiser Health News national health policy news services. This is the editorial independent program of the Henry J. Family Foundation. Kaiser not affiliated with Kaiser Permanente. Contact Galewitz by email at pgalewitz@kff.org or on Twitter @philgalewitz .




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