Self-insured employers are beginning to take the drastic step of sending patients overseas for expensive, complex medical procedures. While there are likely just a few employers doing this now, there are several companies formed expressly to provide these services to employers. And, at least three large employers have contracted with benefits consulting house Mercer to research medical services offshoring.
The rationale behind these decisions is obvious – greatly reduced expenses. Procedures done in India or Thailand commonly cost one-tenth to one-fifth what they do here. And this is in facilities that have been likened to five-star hotels, with very high staffing ratios and round-the-clock pampering of American patients.
Hospitals, at least American ones, are not happy about this. Private-pay patients (those covered by private insurance) overpay for care, and that overpayment helps cover the cost of indigent care. As hospitals are required by law to provide care to all, they have relied on this cost-shifting to help balance the books.
Some employers are no longer willing or able to pay this hidden tax
What does this mean for you?
Another thread is being pulled from the worn fabric that is the US health care system.

Most employers are not confident that they understand their companies’ High deductible health plans (HDHP). According to a study released by Buck Consultants, only 20% of respondents said they understood their HSHPplans “very well”.
Notably, 81% of respondents said the key challenge to successfully implementing these plans was employee education and understanding of the plans.
It is encouraging that employers recognize that the plans will not be successful without an educated and informed employee base; it is somewhat less encouraging that these same employers don’t think they know their own plans very well.

The premise of health insurance is simple – insureds pay insurance companies a premium with the expectation that when the insured needs medical care, it will be funded by the insurance company (subject to the policy conditions). And if the care required is really expensive, well, that’s why you have insurance.
The relationship is inherently based on trust; the insured trusts the insurance company to pay the bills and the insurance company trusts the insured to pay the premiums. Actually, there’s not a lot of trust on the part of the insurer, as they just cut off benefits when premium payments stop coming in. But the insureds trust the insurer to pay the bills, cover expenses, and treat them fairly.
What happens when that trust breaks down? Does it do lasting damage to the relationship between and among individuals and insurers? Absolutely.
“While deception may be tempting because it can be used to increase short-term profits for the deceiver, we find that the long-term costs of deception are very high,” the researchers conclude. In other words, in long-term relationships, it pays to cooperate.” This quote is from a very interesting experiment conducted by a couple Wharton Business School professors which examined the implications of deception on relationships between individuals.
Research indicates the health insurance industry ranks pretty low in terms of respecting customers, and customer respect, with 3 out of 5 respondents saying their general trust for insurance companies is “not much” or “not at all”.
Moreover, polls indicate that people would be willing to pay more to see certain doctors, under certain conditions. This being the case, it is puzzling as to why HSA plan sponsors (insurance companies) aren’t more forthcoming, and don’t explicitly inform insureds that services rendered by providers must be “covered” under the plan definitions if the negotiated rate is going to apply. If their members are OK with paying more, then insurers should just tell them, clearly and up front, that non-covered services are going to cost whatever the provider charges.
Many health insurance executives appear to have a large blind spot when it comes to their customers’ reactions to policy limits and restrictions. They don’t seem to “get” that customers are not expert in parsing policy language, don’t understand the intricacies of policy limits and restrictions, and get angry when they think they’re being mistreated.
The net is, insurance companies may save a few bucks by not telling HDHP buyers that their negotiated discounts don’t apply to non-covered services, but they will likely lose customers, and may well lose their battle against tighter regulation as a result.
What does this mean for you?
Perception is king, and customers/voters/health care consumers perceptions of insurers’ practices may well result in “unintended consequences” for the insurers.

Here’s the latest on my Colleague’s battle with his/her health plan over accessing their negotiated rate for non-covered care. While the health plan (United Healthcare/Golden Rule) promised to respond, the customer service folks had not resolved the question by the end of last week. So, s/he is still waiting.
The contention of Colleague is that since the marketing materials and policy did not state that UHC’s negotiated rates did not apply to these services, and in fact stated that one of the advantages of the plan was that access, the marketing materials are misleading at best.
Meanwhile, Hank Stern and Bob Vineyard at InsureBlog invested a considerable amount of time investigating this, and have written an excellent synopsis of the situation and the insurer’s perspectives. Hank and Bob also asked insurance companies to explain why they would adopt a policy that is so obviously consumer unfriendly; as of yesterday they are still waiting for a response…
The net from InsureBlog is that the insurance companies reprice the services to reflect their negotiated rates, but it is up to the provider to determine if they will accept that rate . So, the health plan informs the consumer what their cost could be, and the provider then says “nope, you’ve got to pay the full boat”.
Boy is this dumb. The consumer is now “educated”; they know what they could pay, and they also know that they have to pay the higher rate. Result – really angry consumers, who feel they have been bait-and-switched. Yes, the insurance companies are technically within their rights to do this, as are providers, but this will undoubtedly stoke the anger of voters, an anger that may well be directed at both offending parties.

Health Affairs’ article comparing the health status of Americans and Canadians doesn’t break new ground nor shatter any perceptions, at least not any perceptions held by informed folks. Tops among the popular misconceptions about the Canadian health care system is the old saw that people have to wait forever for care, with the unstated resulting negative impact on health.
Well, 11% of Canadians do think they have unmet medical needs, primarily because they have to wait too long for care in some instances. In contrast, 13% of Americans have unmet needs, primarily due to cost.
A few more factoids to ponder –
–Most respondents in both countries are in good very good or excellent health, although a few more Canadians enjoy this status (88% v US’ 85%)
–31% of the poorest Americans considered themselves to be in fair or poor health compared to 23% of Canadians.
–Canadians and Americans exhibited similar results regarding access to physician services.
The statistics come from the Joint Canada/US Survey of Health, a joint effort of the National Center for Helath Statistics in the US and Canada’s Statistics Canada; sample sizes are large and the methodology robust.
When one considers that we Americans are paying 50% more for health care than our northern neighbors, it’s hard to see what we get for our dollars.

A study released by the Mayo Clinic, reports that there is far too much money spent on end-of-life care. The study is paralleled by a newly released Dartmouth study , reports that indicates Medicare spent about $40 billion more than it should have on end of life care, due to the inefficiencies of many hospitals.
By any accounting, that’s a lot of cash. Enough, in fact, to provide coverage to a substantial number of Americans presently without health insurance.
While it can be argued that one does not know when a person’s life is ending within six months, it can’t be argued that some hospitals are much more efficient than others. And this inefficiency is costing taxpayers, employers, and individuals billions of dollars.
The Mayo Clinic study found that a substantial portion of Intensive Care Unit patients were the elderly with terminal conditions. ICUs are notoriously (and appropriately) expensive, require high staffing levels and very sophisticated equipment, and are expressly designed to help really sick people get better. That does not make much sense for many elderly with chronic, life-ending conditions.
The Dartmouth study, which was authored in part by John Wennberg (one of the most insightful people in health care), recommends that terminally ill patients be treated outside of acute care facilities. This seems to be common sense; acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
This is one of those apparently simple solutions that can save billions of dollars while improving quality of care and end of life experience, and is likely to be acceptable to individuals of all political stripes and inclinations.
Sign me up.

HSA plans do not require contracted providers to accept the health plan’s negotiated rates when members receive non-covered care. That’s what I’ve learned about the coverage policies of United/Golden Rule, Coventry, Assurant, CIGNA, Aetna, Humana and a couple of the Anthem Blues.
Quoting Hank Stern of InsureBlog, “In Ohio (and, as far as I know everywhere else), individual (as opposed to group) plans exclude normal childbirth. So someone covered under a HDHP would not get the negotiated rate for any pre-natal care…”(or the actual childbirth, or any associated expenses).
Hmmm, I wonder the rate of “complications” experienced by moms covered under HSA plans is higher than one would expect… But I digress.
The key here is what is covered, and what is not. To find that out, ask for a specific list of covered and excluded items from the broker and/or the health plan. And ask if services that are paid out of the HSA, but appear to be covered, fall under the provider’s contracted rates.
Why would you do this? Because the contracted rates are likely less than half the “retail” rate.
As to why a health plan would do this; not require their providers to accept contracted rates, that’s a mystery to me. As a couple ofcommenters have noted, if the insureds pay the higher rate, they are going to pierce their deductible layer much faster, thereby incurring claims expense and costing the health plan money. To say nothing of the consumer backlash when people find out their coverage through a national plan does not give them better rates.
I’m really surprised that health plans would do this, and do very little to educate their customers about this pervasive policy (nowhere on any website did I see this policy referenced). It makes little sense from a consumer marketing perspective, is likely to alienate customers, looks very short-sighted, and flies in the face of their touted desire to provide consumers with more education and make them better health care buyers.
Did the health plans think consumers wouldn’t figure this out? And be angry when they did?
Thanks much to Hank, my “colleague“, and several other un-named and un-nameable industry sources.