为什么你的医疗保险公司不关心你的巨额账单（上篇） [美国媒体]

Why Your Health Insurer Doesn’t Care About YourBig Bills

为什么你的医疗保险公司不关心你的巨额账单



Patients may think their insurers are fighting on theirbehalf for the best prices. But saving patients money is often not their toppriority. Just ask Michael Frank.

病人们可能会认为其保险公司正代表他们争取最好的价格，但为病人省钱通常不是他们的首要事项。问问Michael Frank吧。

This storywas co-published with NPR.

该报道被共同发表于NPR。

Michael Frank ran his finger down his medicalbill, studying the charges and pausing in disbelief. The numbers didn’t makesense.

Michael Frank放下了医药账单，仔细检查着医药费，难以置信地停下来。这些数字没有任何意义。

His recovery from a partial hip replacement hadbeen difficult. He’d iced and elevated his leg for weeks. He’d pushed his49-year-old body, limping and wincing, through more than a dozen physicaltherapy sessions. 

他从部分髋关节置换手术中艰难的恢复过来。几周以来，他的腿敷着冰，一直抬着。一瘸一拐地拖拽着他49岁的身体经历了十几次理疗。
The last thing he needed was a botched bill.

他需要做的最后一件事就是付清账单。

His December 2015 surgery to replace the ball inhis left hip joint at NYU Langone Medical Center in New York City had beenroutine. One night in the hospital and no complications.
 
2015年12月，他在纽约市NYU Langone医疗中心接受了左髋关节置换手术，这也就是日常的手术。只需一晚上，毫不复杂。

He was even supposed to get a deal on the cost.His insurance company, Aetna, had negotiated an in-network “member rate” forhim. That’s the discounted price insured patients get in return for payingtheir premiums every month.

甚至有人建议他达成一份费用方面的协议。他的保险公司Aetna已经为他商定了一个网内会员费率。那是被保病人每月支付保费而获得的折扣价。

But Frank was startled to see that Aetna hadagreed to pay NYU Langone $70,000. That’s more than three times the Medicarerate for the surgery and more than double the estimate of what other insurancecompanies would pay for such a procedure, according to a nonprofit that tracksprices.

但弗兰克惊讶地发现，Aetna公司已同意付给NYU Langone 7万美元。据一家追踪价格的非营利组织报道，这是手术医疗保险费率的三倍多，也是其他保险公司为这种手术支付费用估值的两倍多。

Fuming, Frank reached for the phone. He couldn’tsee how NYU Langone could justify these fees. And what was Aetna doing? As hisinsurer, wasn’t its duty to represent him, its “member”? So why had it agreedto pay a grossly inflated rate, one that stuck him with a $7,088 bill for hisportion?

Frank怒气冲冲地伸手拿起电话。他看不出NYU Langone能证明这些费用是正当的。Aetna公司在干什么？作为他的保险人，代表他这个“会员”不是他的责任吗？那么，为什么它同意支付一个极度夸张的费率，而该费率让他为自己的那部分承受7088美元的账单？

Frank wouldn’t be the first to wonder. TheUnited States spends more per person on health care than any other country. Alot more. As a country, by many measures, we are not getting our money’s worth.Tens of millions remain uninsured. And millions are in financial peril: About 1in 5 is currently being pursued by a collection agency over medical debt.Health care costs repeatedly top the list of consumers’ financial concerns. 

Frank应该不是第一个想知道答案的人。美国人均医疗保险的开支高于其他任何国家。而且，从多方面看来，作为一个国家，我们并没有得到我们的钱代表的价值。数千万人仍未投保。数百万人处于财务困难的境地：每五个人中大约就有一个目前正被医疗债务代收机构追缴债务。医疗保险开支一再占据着消费者财务问题的榜首。

Experts frequently blame this on the high pricescharged by doctors and hospitals. But less scrutinized is the role insurancecompanies — the middlemen between patients and those providers — play inboosting our health care tab. Widely perceived as fierce guardians of healthcare dollars, insurers, in many cases, aren’t. In fact, they often agree to payhigh prices, then, one way or another, pass those high prices on to patients —all while raking in healthy profits.

专家们经常将此归咎于医生和医院收取的高额费用。但是，保险公司——病人和医院之间的中间人——在增加我们的医保账单方面所扮演的角色却没有那么引人注目。保险公司被广泛地视为医疗保健资金的有力保护者，但在许多情况下他们却不是。事实上，他们常常同意付出高昂费用，然后以某种方式把这些高昂费用转嫁给病人——所有一切都是伴随着牟取巨额医疗费用利润。

ProPublica and NPR are examining thebewildering, sometimes enraging ways the health insurance industry works, bytaking an inside look at the games, deals and incentives that often result inhigher costs, delays in care or denials of treatment. The misunderstoodrelationship between insurers and hospitals is a good place to start.

ProPublica和NPR正在研究医疗保险行业的运作方式，这种方式令人困惑，有时更是惹人恼怒。他们从内部审视这个游戏、交易以及激励措施，而这些经常导致较高的成本、护理延误或拒绝治疗。（来看看）保险公司和医院之间被错误理解的关系是一个好的开始。

Today, about half of Americans get their healthcare benefits through their employers, who rely on insurance companies tomanage the plans, restrain costs and get them fair deals.

如今，大约有一半的美国人通过其雇主获得医疗福利，而其雇主依靠保险公司来管理计划、控制成本并获得公平交易。

But as Frank eventually discovered, once he’dsigned on for surgery, a secretive system of pre-cut deals came into play thathad little to do with charging him a reasonable fee.

但正如Frank最终发现的那样，一旦他签约接受手术，一个秘密的预定好的交易系统就开始运作，这与向他收取合理的费用毫无关系。

After Aetnaapproved the in-network payment of $70,882 (not including the fees of thesurgeon and anesthesiologist), Frank’s coinsurance required him to pay thehospital 10 percent of the total.

Aetna批准网络内部支付70882美元(不包括外科医生和麻醉师的费用)后，弗兰克的共同保险要求他支付医药费总额的10 %。

When Frank called NYU Langone to question thecharges, the hospital punted him to Aetna, which told him it paid the billaccording to its negotiated rates. Neither Aetna nor the hospital would answerhis questions about the charges. 

弗兰克打电话给NYU Langone询问收费情况时，医院把他推给了Aetna，Aetna告诉他，其按照协商的费率支付账单的。无论是Aetna还是医院都不会回答他关于费用的问题。

Frank found himself in a standoff familiar tomany patients. The hospital and insurance company had agreed on a price and hewas required to help pay it. It’s a three-party transaction in which only twoof the parties know how the totals are tallied.

弗兰克发现自己陷入了许多病人熟悉的僵持状态。医院和保险公司已经商定了一个价格，并且要求他共同支付。这是一项三方交易，但只有其中两方知道是如何计算总费用的。

Frank could have paid the bill and gotten onwith his life. But he was outraged by what his insurance company agreed to pay.“As bad as NYU is,” Frank said, “Aetna is equally culpable because Aetna’s jobwas to be the checks and balances and to be my advocate.”

Frank本可以付了账单，继续他的生活。但是他对保险公司同意支付的费用十分愤怒。“Aetna和NYU一样坏，”Frank说道，“Aetna同样应该受到惩罚，因为Aetna的工作是核查、平衡并且维护我。”

And he also knew that Aetna and NYU Langonehadn’t double-teamed an ordinary patient. In fact, if you imagined the perfectperson to take on insurance companies and hospitals, it might be Frank. 

并且Frank也知道Aetna和NYU Langone并没有共同对付普通病人。事实上，如果你能想象出一个完美的人去接手保险公司和医院，那可能是Frank。

For three decades, Frank has worked forinsurance companies like Aetna, helping to assess how much people should pay inmonthly premiums. He is a former president of the Actuarial Society of GreaterNew York and has taught actuarial science at Columbia University. He teachescourses for insurance regulators and has even served as an expert witness forinsurance companies.

三十年来，弗兰克一直在像Aetna这样的保险公司工作，帮助评估人们每月应该支付多少保费。他是大纽约精算学会前会长，曾在哥伦比亚大学教授精算科学。他为保险监管机构教授课程，甚至在保险公司担任专家证人的职务。

The hospital and insurance company may haveexpected him to shut up and pay. But Frank wasn’t going away. 

医院和保险公司可能希望他沉默并付钱。但Frank并没有就此停息。

Patients fund the entire health care industrythrough taxes, insurance premiums and cash payments. Even the portion paid by employerscomes out of an employee’s compensation. Yet when the health care industryrefers to “payers,” it means insurance companies or government programs likeMedicare. 

病人通过税收、保险费和现金支付为整个医疗保健行业提供资金。甚至雇主支付的部分也是由雇员的报酬而来。然而，当医疗保健行业提到“支付者”时，它指的是保险公司或政府计划，如医疗保险。

Patients who want to know what they’ll be paying— let alone shop around for the best deal — usually don’t have a chance. BeforeFrank’s hip operation he asked NYU Langone for an estimate. It told him to callAetna, which referred him back to the hospital. He never did get a price.

想知道自己将付了多少钱的病人——更不用说货比三家寻求最好的待遇了——通常没有机会。在Frank做髋关节手术之前，他向NYU Langone索要评估的估价。其告诉他他打电话给Aetna，而Aetna又把他推给了医院。他从来没有确切的得到价格。

Imagine if other industries treated customersthis way. The price of a flight from New York to Los Angeles would be a mysteryuntil after the trip. Or, while digesting a burger, you’d learn it cost 50bucks.

想象一下，如果其他行业这么对待客户。从纽约到洛杉矶的机票价格在飞行结束之前都是个迷，在你消化汉堡时，你才知道你要花50美元。

A decade ago, the opacity of prices was perhapsless pressing because medical expenses were more manageable. But now patientspay more and more for monthly premiums, and then, when they use services, theypay higher co-pays, deductibles and coinsurance rates.

十年之前，价格不透明也许并不这么紧迫，因为医疗费用更加可控。但现在患者每月支付的保费越来越多，然后，当他们使用服务时，他们支付更高的共同支付额、免赔额和共保率。

Employers are equally captive to the risingprices. They fund benefits for more than 150 million Americans and see healthcare expenses eating up more and more of their budgets. 

雇主同样受制于上涨的价格。他们为超过1.5亿的美国人的福利提供资金，却眼睁睁看着医保开销蚕食着其越来越多的预算。

Richard Master, the founder and CEO of MCSIndustries Inc. in Easton, Pennsylvania, offered to share his numbers. By mostmeasures MCS is doing well. Its picture frames and decorative mirrors are soldat Walmart, Target and other stores and, Master said, the company brings inmore than $200 million a year. 

宾夕法尼亚州伊斯顿市MCS工业公司创始人兼首席执行官理查德·马斯特提出分享他的数据。从大多数方面来看，MCS都经营得很好。其画框和装饰镜在沃尔玛、塔吉特和其他商店出售，Master说，公司每年的收入超过2亿美元

But the cost of health care is a growing burdenfor MCS and its 170 employees. A decade ago, Master said, an MCS family policycost $1,000 a month with no deductible. Now it’s more than $2,000 a month witha $6,000 deductible. MCS covers 75 percent of the premium and the entiredeductible. Those rising costs eat into every employee’s take-home pay.

但是对MCS及其170名员工来说，医保成本是一个越来越大的负担。Master说，十年前，在没有免赔额的情况下，每份 MCS保单每月花费1000美元。现在每月两千多美元，还有免赔额六千美元。MCS支付75 %的保费和全部免赔额。这些不断上涨的成本侵蚀了每个员工的实得工资。

Economist Priyanka Anand of George MasonUniversity said employers nationwide are passing rising health care costs on totheir workers by asking them to absorb a larger share of higher premiums. Anandstudied Bureau of Labor Statistics data and found that every time health carecosts rose by a dollar, an employee’s overall compensation got cut by 52 cents. 

乔治梅森大学的经济学家普里Priyanka Anand说，全国各地的雇主要求工人承担更高比例的保费，从而将不断上涨的医保成本转嫁给工人。Anan研究了劳工统计局的数据，发现医保成本每增加一美元，员工得到的整体薪酬就会减少52美分。

Master said his company hops between insuranceproviders every few years to find the best benefits at the lowest cost. But hestill can’t get a breakdown to understand what he’s actually paying for.

Master说，他的公司每隔几年就会换保险公司，以最低的成本获得最好的收益。但他仍然无法理解自己为什么要付出这些费用。

“You pay for everything, but you can’t see whatyou pay for,” he said.  

“你为一切买单，但你并看不到你为了什么付钱，”他说道。

Master is a CEO. If he can’t get answers fromthe insurance industry, what chance did Frank have?  

Master是CEO。如果它都无法从保险行业得到答案，Frank又如何可能得到呢？

Frank’s hospital bill and Aetna’s “explanationof benefits” arrived at his home in Port Chester, New York, about a month afterhis operation. Loaded with an off-putting array of jargon and numbers, thedocuments were a natural playing field for an actuary like Frank.

Frank的医院账单和Aetna的“福利解释”手术后大约一个月到达他在纽约切斯特港的家中的。文件中充斥着令人反感的行话和数字，对于弗兰克这样的精算师来说，这些文件就是天然的游戏场所。

Under the words, “DETAIL BILL,” Frank saw thatNYU Langone’s total charges were more than $117,000, but that was the stickerprice, and those are notoriously inflated. Insurance companies negotiate anin-network rate for their members. But in Frank’s case at least, the “deal”still cost $70,882.

Frank在“账单细节”下看到，NYU Langone的收费总额超过了11.7万美元，但那是标价，众所周知这被抬价了。保险公司为其成员协商网内费率。但至少在弗兰克例子中，这笔“交易”仍需70，882美元。

With apracticed eye, Frank scanned the billing codes hospitals use to get paid andimmediately saw red flags: There were charges for physical therapy sessionsthat never took place, and drugs he never received. One line stood out — thecost of the implant and related supplies. Aetna said NYU Langone paid a “memberrate” of $26,068 for “supply/implants.” But Frank didn’t see how that could beaccurate. He called and emailed Smith & Nephew, the maker of his implant,until a representative told him the hospital would have paid about $1,500. HisNYU Langone surgeon confirmed the amount, Frank said. The device company andsurgeon did not respond to ProPublica’s requests for comment. 

Frank熟练地扫描了医院用来获得报酬的帐单代码，并立刻发现了不同寻常的东西：有物理治疗和药物的费用，而这些都从未发生过。有一项很明显——植入和相关用品的费用。Aetna说，NYU Langone为“供应/植入”支付了26068美元的“会员费”。“但Frank不知道这如何会是准确的。他打电话给他的植入体制造商Smith & Nephew，并给他发了电子邮件，直到一名代表告诉他医院本应支付大约1500美元。弗兰克说，他的NYU Langone外科医生证实了这一数字。设备公司和外科医生没有回应ProPublica的置评请求。

Frank then called and wrote Aetna multipletimes, sure it would want to know about the problems. “I believe that I am avictim of excessive billing,” he wrote. He asked Aetna for copies of what NYULangone submitted so he could review it for accuracy, stressing he wanted “tounderstand all costs.”

Frank多次打电话和写信给Aetna，一定要知道问题所在。他写道：“我相信我是超额帐单的受害者。”他向Aetna索要NYU Langone提交的资料复印件，以便他能够核对其准确性，并强调他希望“了解所有花销”。

Aetna reviewed the charges and payments twice —both times standing by its decision to pay the bills. The payment wasappropriate based on the details of the insurance plan, Aetna wrote.

Aetna两次核实了医药费和付款——两次均坚持其支付账单的决定。Aetna写到，根据保险计划的细节，该付款是恰当的。

Frank also repeatedly called and wrote NYULangone to contest the bill. In its written reply, the hospital didn’t explainthe charges. It simply noted that they “are consistent with the hospital’spricing methodology.”

Frank反复地打电话和写信给NYU Langone质疑其账单。在回信中，医院并没有解释医药费。医院仅注明“医药费与医院的定价方法是一致的”。