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Price transparency can be hard to come by in health care. Putnam County Memorial Hospital, a small hospital in Missouri, is banking its future on having its prices out in the public.

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Kate and Scott Savett were trying to be responsible when they needed some medical care. They live about an hour north of Philadelphia with their dog, Frankie. Scott, 43, is a chemist and designs software for labs; Kate, 37, works in life insurance.

They buy their health insurance through Scott’s job, and to keep their premiums affordable, they chose a high-deductible plan. They understood from the beginning that this would mean shopping carefully when they needed care, because costs can vary a lot among doctors and hospitals.

For years the couple didn’t use their insurance much — but that all changed this year.

Kate was diagnosed with multiple sclerosis in January. Doctors did a lot of tests and then follow-up tests. On top of that, Scott needed some imaging tests for a spinal issue.

Under their insurance plan, the two have to pay in full for the first $3,000 of their combined care. After that, they still have to pay 20 percent of the cost, until they reach a total of $8,000 in out-of-pocket expenses.

That experience made them want to find the best care for the best deal. But how?

They investigated, using an online cost estimator offered through their insurance company.

Scott logs in to use the tool, and searches for the typical cost of MRI scans in his region. The online calculator tells him the average cost is $1,270; the lowest is $512 and the “above average” is $1,790.

The tool then produced a list of different providers and an estimate of how much they will specifically charge under the plan the Savetts have.

At first, this kind of information seemed great to the couple. But it quickly proved to be quite the headache.

A few days before Kate was scheduled to have her first MRI, she and Scott got a call from the radiology office, saying that the scan would cost them $2,400. They were shocked — the online calculator had told them it would only be about $500.

What’s the source of the disconnect?

A hospital had bought the imaging center and raised the price.

There were misquotes on other procedures, too. The Savetts received some bills from health providers that were as much as a thousand dollars higher than the price the online calculator had led them to expect. Another time, they couldn’t find any listings at all for a procedure one of them needed.

The two quickly plowed through their $3,000 deductible. Financial planning became increasingly difficult. They delayed buying a new water heater for their house.

“It’s hard for us to pull the trigger on that, knowing that another bill could be coming around the corner,” Kate says.

It’s unclear how common these inaccuracies with online estimators are, but the tools are becoming more popular, as patients shoulder a bigger share of the cost of their medical care. Outside companies are developing the online calculators, and most insurers offer them.

“Each one of them — whether it’s Aetna, United, Cigna — they all have something,” says Francois de Brantes, the director of the Health Care Incentives Improvement Institute, a nonprofit based in Connecticut. De Brantes has been paying close attention to price-transparency tools.

“There’s lots and lots of variability in the information that’s provided to consumers,” he says.

Some of the estimators reflect an aggregate range of possible costs; others are based on historic pricing, or claims data from varying sources. Many, he says, are limited in the type of procedures they include.

As for United Healthare’s cost estimator — the one the Savetts used — Craig Hankins of UHC gives it an 8 out of 10 in terms of accuracy.

“Right now, I would say if we look at our tool, relative to others that are offered, I would say ours is average — if not above average — in terms of breadth of services as well as accuracy,” Hankins says.

UHC’s cost calculator is based on current information, he says, adding that it is in the insurer’s interest to have the online tool work. If members get care at an acceptable cost, that saves everyone money.

But, he says, the tool has limits — it’s hard to predict what a particular doctor will actually do during an exam, treatment, or office visit, and how he or she will bill for it.

That gets at a deeper challenge with these online estimators, says David Newman, director of the nonprofit Health Care Cost Institute, in Washington, D.C. The way billing and reimbursement works in health care is extremely complicated, he says.

“There are 8,000 procedure codes, tens of thousands of diagnostic codes, a million different providers, and hundreds of insurance companies,” says Newman. Calculators are often based on one specific procedure, so they may not reflect all that happens and is billed for during a visit. In that way, he says, “this is probably going to be as good as it gets.”

But de Brantes thinks much more improvement is possible.

“It’s not that difficult. It really — technologically — is not that difficult at all,” he says.

The information people like the Savetts are seeking exists in the health care system, de Brantes says, even if in some cases it is hidden behind contract agreements. The bigger problem, he says, is that there is no internal pressure to make the online calculator work as well as it could. Health care has thrived in an opaque environment where costs are hard to find.

But the needle is starting to move. Employers are demanding these tools for their employees. And several states mandate public reporting of price information.

As for Scott and Kate Savett, the current climate has turned each of them into a new breed of health care consumer: a savvy one.

Scott says he knows they are approaching their $8,000 out-of- pocket cap for the year, which means insurance will soon cover the entire cost of their care. But he doesn’t want to give in. He wants to see improvements.

“I would rather crawl to that $8,000 cap than sprint to it,” he says. “I know we’re going to get there this year, unfortunately, but to blow it all on an MRI that’s excessively priced rubs me the wrong way.”

A few weeks after we first talked, Savett received a bill for his MRI. Turns out, it’s pretty close to what the estimator predicted it would be — $1,100. He says he will keep using the tool; but he sees it as an imperfect clue rather than a price tag.

This story is part of NPR’s reporting partnership with WHYY’s The Pulse and Kaiser Health News.

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Many primary care practitioners will be a little poorer next year because of the expiration of a health law program that has been paying them a 10 percent bonus for caring for Medicare patients. Some say the loss may trickle down to the patients, who could have a harder time finding a doctor or have to wait longer for appointments. But others say the program has had little impact on their practices, if they were aware of it at all.

The incentive program began in 2011 and was designed to address disparities in Medicare reimbursements between primary care physicians and specialists. It distributed $664 million in bonuses in 2012, the most recent year that figures are available, to roughly 170,000 primary care practitioners, awarding each an average of $3,938, according to a 2014 report by the Medicare Payment Advisory Commission.

Although that may sound like a small adjustment, it can be important to a primary care practice, says Dr. Wanda Filer, president of the American Academy of Family Physicians. “It’s not so much about the salary as it’s about the practice expense,” she explains. “Family medicine runs on very small margins, and sometimes on negative margins if they’re paying for electronic health records, for example. Every few thousand makes a difference.”

Doctors in family medicine, internal medicine and geriatrics are eligible for the bonuses, as are nurse practitioners and physician assistants.

Medicare generally pays lower fees for primary care visits to evaluate and coordinate patients’ care than for procedures that specialists perform. The difference is reflected in physician salaries. Half of primary care physicians made less than $241,000 in 2014, while for specialists the halfway mark was $412,000, according to the Medical Group Management Association’s annual provider compensation survey.

The effect the bonus program is larger on practices with more Medicare patients. Dr. Andy Lazris estimates 90 percent of the patients that his five-practitioner practice in Columbia, Md., treats are on Medicare.

“When the bonus payments started, it was a pretty big deal for us,” Lazris says. The extra $85,000 they received annually allowed them to hire two people to deal with the administrative requirements for being part of an accountable care organization and to help the practice incorporate two new Medicare programs related to managing patients’ chronic diseases or overseeing their moves from a medical facility to home.

Next year, if they can’t make up the lost bonus money by providing more services, it’ll mean a pay cut of $17,000 per practitioner, Lazris says.

The incentive program was an effort to address shortcomings in Medicare’s system of paying providers mostly a la carte for services, which tends to undervalue primary care providers’ ongoing role in coordinating patients’ care.

The expiration of the Medicare incentive program comes on the heels of a similar bonus program for Medicaid primary care services that ended in 2014, says Dr. Wayne J. Riley, president of the American College of Physicians, a professional organization for internists.

“There will be some physicians who say they can’t take any more Medicare patients,” Riley predicts.

An attorney for an advocacy group for Medicare beneficiaries says they support the bonus payments and hope physicians won’t shut them out.

“We don’t have any evidence to show that primary care docs will stop seeing Medicare beneficiaries without the payment bump,” says David Lipschutz, a senior policy attorney at the Center for Medicare Advocacy.

The vast majority of nonpediatrician primary care doctors accept patients who are covered by Medicare, according to a national survey by the Commonwealth Fund and the Kaiser Family Foundation. But while 93 percent take Medicare, a smaller percentage, 72 percent, accept new Medicare patients. [Kaiser Health News is an editorially independent program of the nonprofit Kaiser Family Foundation.]

Not all primary care practitioners will miss the incentive program, according to the Commonwealth/KFF survey.

Only a quarter of those surveyed said they received a bonus payment; half didn’t know the program existed.

Of physicians who were aware of and received Medicare bonus payments, 37 percent said it made a small difference in their ability to serve their Medicare patients, and 5 percent said it made a big difference. However, nearly half—48 percent—said it made no difference at all.

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Two years ago my mom fell at home and ended up being admitted to the ICU with four broken ribs and internal injuries. She was lucky. After two weeks in the hospital and a few more in a rehab unit she was back home, using her new blue walker to get around.

I think of that each Thanksgiving as I make pies just the way she taught me, grateful that she’s still with us and that she’s told us how she wants to die

Before she was discharged, Mom signed a POLST form, short for a Physician Order for Life-Sustaining Treatment. I’d heard of advance directives, which spell out the kind of medical care a person would want if they become too ill to communicate those wishes. But I’d never heard of POLST.

In Oregon, where my mother lives, it’s a one-page piece of pink paper that bluntly asks if you want to have CPR performed if your heart stops and you’re not breathing. Three other check boxes ask how much medical intervention you want: going to the hospital and an intensive care unit; perhaps the hospital but no ICU; or skip the hospital altogether. A third question asks if you want to be fed through a tube. That’s it.

Because it’s signed by a doctor or other provider, a POLST has teeth. It overrides the legal obligation of an EMT or a hospital to provide CPR and other emergency care that for old and sick people can lead to a long, miserable hospital stay.

“It’s not for healthy people,” says Dr. Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health Science University. Instead, it’s for someone who is aware that they may soon die.

“We would encourage doctors to reach out to patients if they would not be surprised if they died in the coming year,” Tolle says, “or if they had advanced frailty. The little old lady hunched over their walker, that’s the definition of frailty.”

That’s also the definition of my 92-year-old mom. She can still beat me handily at hearts, but she’s physically weaker each time I see her. “Do everything” is the default mode for American medicine, but that all-out approach often doesn’t serve the very old well.

CPR works only about 10 percent of the time in the general population, Tolle told me, and it’s even less successful in a frail old lady.

First, if someone at that age collapses, it’s usually because there’s a serious medical problem like a heart attack or stroke. And performing CPR on someone with osteoporosis breaks ribs rather than circulating blood. “That isn’t walking off the film set looking good with your hair nicely combed,” Tolle says. “That’s going to the ICU on a ventilator.”

In studies, Tolle, who helped develop the POLST form, has found that just about 12 percent of permanent nursing home residents would want to go to an ICU. “Most say, ‘I want to go to the hospital to get the easy things fixed, but I don’t want the ICU. I don’t want CPR.’ “

POLST forms work well in nursing homes, where they’re often taped on a resident’s bathroom door. But they can be harder to put in force when people are still living in the community.

Oregon has an electronic POLST registry that EMTs and hospitals can check remotely. But only 18 states have POLST programs in place, though many more have them in the works. Most have no registry, meaning that someone intent on having the directions on their POLST form followed would need to wear a medical alert bracelet.

Some members of the disability community have questioned whether POLST is being too broadly applied. Rather than give people more control over end-of-life medical care, they say, it could mean interpreting “disabled” to mean “on death’s door”.

“Our concern is that it’s being used with non-terminal people,” says John Kelly, a 54-year-old quadriplegic who lives in Boston. He was taken aback when a nurse showed up with Massachusetts’ version of the form, called a MOLST. “I joke that I’ve got my pink MOLST on the fridge, and I’m afraid that the firemen will come in and glance at the refrigerator and say, OK, he’s got [a do-not-resuscitate order]. They interpret it as meaning no treatment at all.”

POLST is almost certainly inappropriate for someone disabled but otherwise healthy, Tolle says. “People are handing out the form a little too early sometimes, and we want to push back on that,” she says. “It’s for people who we can say are in the winter of their lives. They have advanced illness and frailty. They have declining health.”

Since her fall my mom has been quite clear about what treatments she doesn’t want. I realize that her desires may change and that the POLST form should then change, too. And I know we’ll be talking about this more, even though I have a hard time thinking about it without tearing up.

Family gatherings like Thanksgiving can be a good time for adult children to ask aging parents about their wishes for end-of-life care, and whether those wishes would be best expressed through an advance directive or a POLST. A number of groups offer crib sheets with questions that aren’t entirely scary, like “Would you rather die at home or in a hospital?”

It’s also a good time for parents to speak their minds if the kids don’t ask.

“Lean into it, step up to the plate,” Tolle says. “On Thanksgiving after dinner, tell your children what you want. You really will lift a burden.”

An earlier version of this story ran on Nov. 28, 2013.

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The name that UNC Health Care is giving its children’s clinic in North Carolina has been raising a lot of eyebrows. The facility is slated to be renamed the Krispy Kreme Challenge Children’s Specialty Clinic. But criticism from the medical community at the University of North Carolina and elsewhere is making the health care system rethink that choice.

Since the announcement last month, Barry Popkin, a nutrition professor at UNC-Chapel Hill, says he’s heard from a lot of colleagues wondering, “What the heck is going on at UNC?” The clinic in question is actually about 25 miles away, in Raleigh — home to North Carolina State University.

“For them to name it this way — to give advertisement to a very unhealthy food, high in added sugar and unhealthy fats and refined carbs with no nutritional value — was quite surprising to people around the nation,” Popkin says.

The name seems particularly unfortunate, some critics say, because North Carolina ranks poorly in measures of childhood obesity.

For the Krispy Kreme company, the advertisement is both free and unintentional. Leslie Nelson, head of fundraising and communications at UNC Children’s Hospital, says the clinic – and the race — are in no way sponsored by the doughnut maker, which is based in Winston-Salem.

“The corporation is definitely not part of the name,” she says. “It’s named for a race! The name of the doughnut happens to be in the name of the race. But at the heart of it, it’s about the race and about these kids.”

The Krispy Kreme Challenge is an annual, 5-mile charity race that student volunteers at NC State University created about a decade ago, initially just for fun, and then to raise money for the hospital. The event, always held in February, has grown in size over the years, and now includes about 8,000 runners.

Chris Cooper, a junior in chemical engineering and economics at NC State, is the current executive director of logistics for the race, which does involve eating doughnuts.

“You run 2.5 miles, starting at the NC State Belltower,” Cooper explains, “and then the challengers eat a dozen doughnuts,” which they pick up mid-way, at stations set up in front of the local Krispy Kreme shop.

But most of the runners raise money without scarfing down fried sweets.

“The casual runners normally just pick their doughnuts up and keep running,” Cooper says. “And then you run 2.5 miles back to the Belltower.” The students got permission from the pastry company to use the Krispy Kreme name — but they pay for the doughnuts.

If all that pastry pounding and distance running sounds kind of sickening, well, Cooper says it can be.

“After Krispy Kreme, when people are running back, there is normally a fair amount of throw-up that happens,” he says. “We have a group of students whose job is to go around and clean up the streets.”

Gross, sure. But the race has raised nearly $1 million for UNC Children’s Hospital and clinics so far, and the student leaders have committed to raising another $1 million.

“Behind all of this is a group that’s committed to making a difference for our patients and families,” says Leslie Nelson.

UNC Health Care is now having conversations about whether to go through with the name change, Nelson says. An online petition to scrap it has gathered about 13,000 signatures so far.

Marion Nestle, a public health professor at New York University, and former adviser in nutrition policy for the federal government, says public fallout from awkward pairings of corporate brands with health causes has been increasing.

She points to Coca-Cola’s corporate partnership with the American Academy of Family Physicians as another high-profile example.

“There was a big demonstration in front of a California hospital a few years ago,” Nestle says, “in which physicians burned their membership cards to the academy in protest.”

Last summer, the physician’s group and the soft drink company announced they’re ending their deal.

Nestle says that’s certainly not apples to apples with what’s happening at the UNC clinic. But she does think putting Krispy Kreme in the clinic’s name — for whatever reason — sets a bad example for kids.

Race coordinator Chris Cooper says if UNC decides to back off the name change, he’s OK with that.

“I don’t think anyone in the organization was really excited about us having a name on the clinic,” he says. “I think a lot more of it was, ‘How are we going to use this name to help the children’s hospital even more?”

But, if it isn’t helpful in drawing more people to the race and in raising more money for the good cause, Cooper says, then he has no attachment to the name.

This story is part of NPR’s reporting partnership with WFAE and Kaiser Health News.

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Thousands of Americans are again searching for health insurance after losing it for 2016. That’s partly because some large, low-cost insurers — health cooperatives, set up under the Affordable Care Act — are folding in a dozen states.

The startups were supposed to shake up the traditional marketplace by being member-owned and nonprofit. But it was tough to figure out how much to charge. Plans available through the co-ops tended to be priced low, and customers poured in. Yet many of these new customers, it turned out, had costly medical conditions, so when co-ops had to start paying their bills, the math didn’t add up.

On top of that, co-ops were counting on a variety of funding streams from the federal government, and some of that money never materialized. Of the 23 health co-ops that opened in 22 states with the advent of Obamacare, just 11 are still in business.

The failure of one of these insurers, Colorado HealthOp, has hit Rick and Letha Heitman hard. The couple says that Colorado HealthOp, which is due to close at the end of the year, saved Rick’s life when he was diagnosed with an aggressive prostate cancer last spring.

“I owe them for taking care of me,” says Rick, who owns a construction business with his wife. “They helped me at a time when I needed it a lot.”

Now, about 80,000 people, including the Heitmans, are suddenly on the hunt for new insurance plans on Colorado’s exchange.

Co-ops Left Holding the Bag

Julia Hutchins, HealthOP’s CEO, says the co-op got walloped by the equivalent of a fast-moving tornado after the federal government said it wouldn’t be paying co-ops millions in subsidies that she and others expected.

“We were really blindsided by that,” Hutchins says. “We felt like we’d done our part in helping serve individuals who really need insurance, and now we’re the one left holding the bag.” HealthOp was on track to becoming profitable, she insists.

Linda Gorman, director of the Independence Institute, an advocacy group and think tank in Colorado, says the new co-ops were in over their heads.

“You shouldn’t go into business counting on federal subsidies,” Gorman says. “The notion that you should beat up on for-profit entities and then form these nonprofits and everything will be magically OK is unfortunate to begin with, and we’ve wasted a lot of taxpayer money on that. We’ve wasted two to three billion dollars on subsidies for these co-ops.”

But the HealthOP’s senior IT manager Helen Hadji, a Republican, says she blames conservatives in Congress for not authorizing the money needed to keep the cooperatives afloat.

“This is a federal failure,” Hadji says. “This is all a political battle to dismantle Obamacare.”

Colorado’s co-op captured 40 percent of the individual market on the state’s exchange. Now, as customers like Rick and Letha Heitman hunt for new insurance for 2016, they are facing higher prices.

The Heitmans paid about $500 a month last year for their co-op plan. For 2016 they’ll likely have to pay double or triple that to get health insurance that includes the doctors who are treating Rick’s cancer.

Slower Growth Was Key To A Connecticut Co-Op’s Success

In Connecticut, a different story is playing out. If Colorado saw an early surge in membership because of low prices, Connecticut’s co-op nearly priced itself out of the market in its first year, charging rates that were much higher than its competitors. For 2015, HealthyCT only got 3 percent of the state’s business under the Affordable Care Act.

“In that first year, the reason we had such low market share was that consumers — new to the industry, new to insurance — most of those individuals bought on price,” says Ken Lalime, who runs the co-op.

And starting the business was hard, Lalime says.

“Nobody’s built a new insurance company in the state of Connecticut in 30 years,” he says. “There’s no book that you pull off the shelf and say, ‘Let’s go do this.’ “

Lalime faced the same problem other co-ops faced nationally. He didn’t know who his customers would be, didn’t know whether they’d be sick or healthy and didn’t know how much to charge. In the end, his co-op charged too much.

However, even though that meant relatively few signups in year one, the slow ramp-up actually helped. He didn’t have a huge number of claims to pay immediately, and those he did pay didn’t break the bank.

“Hindsight, yes, that didn’t hurt us — to be able to take it slowly,” Lalime says.

In year two, HealthyCT’s average premiums were more competitive — and the co-op went from a 3 percent share of the market to 18 percent. For 2016, its initial premium request came in high; it subsequently revised that number to be much lower, and the state overseers eventually announced that HealthyCT’s premiums will go up 7 percent.

Paul Lombardo, an actuary for the state of Connecticut, says the back-and-forth is an indicator that setting the price of premiums is still a bit of a gamble under the Affordable Care Act. These are still early days, he says. So few people signed up with HealthyCT in the beginning that the health co-op didn’t have enough information to guide its decisions about 2016 premiums.

“There wasn’t a lot of data to say, OK, we can use 2014 experience to project forward,” Lombardo explains.

For now, HealthyCT is holding its own.

“They’re in good standing,” Lombardo says. “The premium we think that we’re setting for 2016 — albeit a little bit higher than they wanted it to be on the revision — is appropriate. And we look to have them go through the full year — as any of our other health plans do in 2016.”

Enrollment for 2016 health insurance on the Affordable Care Act’s exchanges will continue until Jan. 31.

This story is part of NPR’s reporting partnership with Colorado Public Radio, WNPR and Kaiser Health News.

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Flip through a popular children’s furniture catalog and you’ll find baby cribs with bumpers — a padded piece of fabric that ties around the wooden slats, making the crib look cozy and cute. The problem, researchers say, is these bumpers can be deadly, because babies can get caught in the fabric and suffocate.

“They are dangerous; don’t use them,” says Dr. Bradley Thach, a professor emeritus of pediatrics at the Washington University School of Medicine. Thach was the author of a landmark study in 2007 that first documented crib bumper deaths. He says things have gotten worse since then.

Thach is one of the authors of a study, published Wednesday in The Journal of Pediatrics, that shows the number of deaths attributed to crib bumpers has increased significantly in recent years.

Using data reported to the Consumer Product Safety Commission, an independent federal regulatory agency that oversees consumer products, the study found that 23 babies died over a seven-year span between 2006 and 2012 from suffocation attributed to a crib bumper. That’s three times higher than the average number of deaths in the three previous seven-year time spans. In total 48 babies’ deaths were attributed to crib bumpers between 1985 and 2012. An additional 146 infants sustained injuries from the bumpers, including choking on the bumper ties or nearly suffocating.

“These deaths are entirely preventable,” says N.J. Scheers, the study’s lead author and former manager of the CPSC’s infant suffocation project. Babies either got their face caught in the bumper and couldn’t breathe or they got wedged between the bumper and something else in the crib. In all of these instances, Scheers says, “If there were no bumper, the baby would not have died.”

Bumpers were originally intended to stop babies from falling out of the crib; regulations now require the wooden slats to be narrower. Bumpers were also designed to prevent babies from bumping their heads or getting their arms and legs caught in the rails. But Scheers says a sleeping sack is a safer way to keep arms and legs safe, and a little bump on the head is not worth the risk of suffocation.

The American Academy of Pediatrics and the American SIDS Institute have both issued warnings about crib bumpers; they advise parents not to use them. But Scheers says when parents go to buy a crib, they see them decorated with bumpers and say, “if they are dangerous, why would the stores be selling them?”

In 2012, a voluntary industry standard was revised to decrease the thickness of the bumpers to 2 inches or less, with the hope that thinner bumpers would be less likely to cause suffocation. But this most recent study found that three deaths occurred with the thinner bumpers.

In 2011, Chicago became the first city in the country to ban the sale of crib bumpers. And in 2013, Maryland also banned the sale of crib bumpers with two exceptions: mesh or breathable bumpers made of thin fabric that allow air to pass through, and vertical bumpers that wrap around each individual crib rail. Scheers wants a similar ban nationwide, with the caution that mesh and vertical bumpers still need to be studied because there’s no data available to prove they are safe.

The CPSC is currently in the process of putting forward a recommendation on how crib bumpers should be regulated. In the meantime, it recommends that “Bare is Best” — the safest way for a baby to sleep is in a crib with nothing but a tightly fitted sheet.

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Consumers seeking health policies with the most freedom in choosing doctors and hospitals are finding far fewer of those plans on the insurance marketplaces. And the premiums are rising faster than for other types of coverage.

The plans, usually known as preferred provider organizations or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians. They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts.

In Kelly Filson’s Indiana hometown of Plymouth, all but two of the 75 insurance policies available on the health marketplace for 2016 are the restrictive type. Only one of those would provide substantial coverage to the two hospitals her family wants access to next year, a local community facility and a children’s hospital where her 12-year-old will need special surgery. But at $1,109 a month, the policy is twice as costly as the cheapest plans in the area.

“I’m just trying to figure out what we can feasibly afford. That’s the bottom line,” said Filson, a music teacher.

A Kaiser Health News analysis of costs in the three-dozen states selling policies through the federal HealthCare.gov website found a sharp difference in premium prices between plans that offer out-of-network care and those that don’t.

The analysis compared the monthly premiums for the least expensive silver-level plans — the category that are the most popular purchases — for a 40-year-old in each county.

While the average premium for the least expensive closed-network silver plan — principally HMOs — rose from $274 to $299, a 9 percent increase, while the average premium for the least expensive PPO or other silver-level open access plan grew from $291 to $339, a 17 percent jump, KHN found. The cost variations hold true for any age.

Katherine Hempstead, who studies health insurance for the Robert Wood Johnson Foundation, said there are fewer PPOs because insurers found them more expensive to offer: Out-of-network doctors generally charge more than the contracted rates paid to in-network providers by insurers. And, even though insurers pay only a portion of an out-of-network bill, the costs add up.

“Out-of-network providers were causing carriers to lose a lot of money, and they really needed to put their thumbs down on that,” Hempstead said.

Hempstead found that there will be fewer or no silver-level PPOs in 22 states next year. Federal records show there will be none in Miami and most Florida counties, much of Texas, New Mexico, New York and many counties in Mississippi and South Carolina.

The price gap between PPOs and HMOs is growing in many places where both are offered. In Chicago, the least expensive silver PPO next year will cost $270 a month, $75 more than the least expensive silver HMO, and 27 percent more than the cheapest silver plan costs now. Meanwhile, the price of the least expensive silver HMO in Chicago is dropping by 12 percent.

In Salt Lake City, the premium for the only silver PPO is rising by 30 percent, nearly four times the increase for the least expensive HMO.

In Philadelphia, the cheapest silver PPO will be $389, $113 more than the cheapest HMO. This year, Philadelphians wanting a silver open-access plan had to pay just $66 more. As in many places, insurers also are selling different bronze, gold and platinum PPOs (the metals indicate how the insurer and patient divide the cost of care), but the cheapest plan in each tier in Philadelphia is an HMO.

In Houston, the only plans available through the federal exchange have closed networks. Blue Cross Blue Shield of Texas, which offered a PPO plan in Houston for 2015, cited rising costs as a reason it will not offer any open-access plans next year. There is at least one PPO that consumers can purchase directly or through a broker, offered by the Memorial Hermann Health System. But it isn’t listed in the federal marketplace offerings, so premium subsidies aren’t available.

“Everyone is up in arms,” said Jo Middleton, a Houston insurance broker. “I do not have a single client who is happy. They want PPOs and can’t get them. They want the flexibility.”

The biggest complaint, she said, is not that the HMOs don’t allow out-of-network coverage, but that their networks are too small.

“If you are someone who needs several doctors and several specialists, it’s difficult to find a network they are all in,” Middleton said. “In many cases, the doctors may be in a network but only have admitting privileges at a non-network hospital. In the 11 years I’ve been in the business, this is unprecedented.”

None of the plans available through the federal exchange in Houston include the city’s well-known MD Anderson Cancer Center in their networks. “It’s a huge problem,” said insurance broker J. Casey Lowery. “If you’re a cancer patient, think about it. All of a sudden you have to switch doctors. Or, if you want to stay with a doctor because he saved your life, and now you’re in an HMO, you have no coverage.”

Dan Fontaine, an administrator at MD Anderson, said some insurers didn’t invite the cancer center into their networks. Others offered payment rates that, he said, “we don’t consider serious” because they were too low “and oftentimes less than what Medicare or Medicaid pay us.” He said the center was trying to make arrangements with insurers for patients who are in treatment now.

Plans with out-of-network benefits are not disappearing everywhere. Alaska, Arkansas and Wyoming are bucking the trend by only offering PPOs. Out-of-network costs even with PPOs can be prohibitively expensive because many PPOs will cover only a minority of costs, diminishing the difference from HMOs. Also, people who qualify for government premium subsidies can be insulated from the full cost of a PPO.

Allen Gjersvig, an executive at the Arizona Alliance for Community Health Centers, says one PPO in the state requires approval before seeing a specialist — a restriction often associated with HMOs — while there are HMOs that don’t mandate pre-approval of specialist visits. “The meaningfulness of HMO and PPO is starting to really blur,” he said.

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente.

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Every year before influenza itself arrives to circulate, misinformation and misconceptions about the flu vaccine begin circulating. Some of these contain a grain of truth but end up distorted, like a whispered secret in the Telephone game.

But if you’re looking for an excuse not to get the flu vaccine, last year’s numbers of its effectiveness would seem a convincing argument on their own. By all measures, last season’s flu vaccine flopped, clocking in at about 23 percent effectiveness in preventing lab-confirmed influenza infections.

But that’s not the whole story, said Lisa Grohskopf, a medical officer in the influenza division of the Centers for Disease Control and Prevention.

“Twenty-three is better than zero, but the 23 percent was overall. If you were one of the people who got an influenza B strain, it was closer to 60 percent,” she said. “Even if it’s not going to work against one virus very well, there are other viruses circulating.”

Each year’s flu vaccine contains three (trivalent) or four (quadrivalent) strains of the flu, selected in February by the World Health Organization and then endorsed by the Food and Drug Administration, as the ones experts expect will circulate in the coming flu season. They choose one H1N1 strain, one H3N2 strain and one B virus strain, either from the Yamagata lineage or the Victoria lineage. Quadrivalent vaccines contain a B strain from each lineage.

“Viruses in the Yamagata lineage or in the Victoria lineage are different enough that there’s not a lot of cross-protection,” Grohskopf said. “So if, say, we have a vaccine that contains a Yamagata family virus one season and it ends up being a predominantly Victoria season, we might not get very good protection against B strains.”

But sometimes the experts’ predictions are off the mark, and sometimes a strain they select mutates before the season arrives. Last year, the H3N2 strain they chose was a poor match, and that strain dominated the season, though B viruses became more common toward the end, Grohskopf said. Adjustments were made in the vaccine for the H3N2 virus this year.

“There’s definitely reason to be hopeful that it’s going to be better this year, but it’s a little too early to tell,” Grohskopf said. “Flu seasons can be very variable in terms of how fast they take off, but right now activity is still fairly light.”

The flu vaccine options this year haven’t changed much from last year, with two exceptions. The recombinant flu vaccine, made without the virus and without eggs, is now approved for all adults age 18 and older (instead of just those ages 18 to 49). And the intradermal vaccine, a low-dose vaccine that uses a shorter needle and injects only into the skin, is now available as a quadrivalent vaccine instead of just trivalent.

The CDC does not recommend any one vaccine over another. “We really just think it’s important that people get vaccinated, and depending on where you are, you may not be able to get a particular product,” Grohskopf said. “We don’t want to hunt for one thing and then not get vaccinated until it’s too late and flu is already peaking for the season.”

Getting vaccinated against flu is particularly important for several at-risk groups and people in frequent, close contact with those at-risk groups, Grohskopf said. The populations at the highest risk of serious complications from the flu include pregnant women, people age 50 and older and children under age 5, particularly under age 2, she said.

Anyone with a chronic medical condition, such as lung disease, heart disease, kidney disease, liver disease or a neurological condition also has a higher risk of serious complications with an influenza infection. Those at risk of infecting more vulnerable people include parents of young children, day care workers, teachers, caretakers of elderly individuals and anyone working in health care.

But the problem with limiting flu immunization to these groups, she said, is that the flu is a tricky bug — and unpredictable.

“While some people are definitely at higher risk for severe disease if they get the flu, sometimes even generally healthy, young people — older children, younger adults who are the most hardy folks if they don’t have any other chronic illnesses — can get really sick, hospitalized and even die, and we can’t really predict who those folks are going to be,” Grohskopf said. “The majority of people who get the flu are going to feel really crummy for a time and then recover without any problems.” But even those folks lose work time and risk spreading the disease to family members and others, she said.

Another monkey wrench this year is additional evidence, reported at Stat, that getting a flu shot every year might reduce its effectiveness in warding off the flu. This evidence isn’t entirely new, and scientists still don’t entirely understand it, but it also doesn’t mean that skipping the flu shot this year is wise if you got it last year.

In the meantime, for those who still haven’t gotten the vaccine this year, make sure it’s not because of one of the concerns below. As described in the links, each of these misconceptions is based on inaccurate information, a misunderstanding or an exaggeration.

Concern No. 1: Can getting the flu vaccine give you the flu or make you sick?

Fact: The flu shot can’t give you the flu

Concern No. 2: Do I really need to get the flu vaccine this year if I got it last year?

Fact: For now, a new flu shot each year is still recommended

Concern No. 3: Could getting the flu vaccine make it easier for me to catch viruses, pneumonia or other infectious diseases?

Fact: Flu vaccines reduce the risk of pneumonia and other illnesses

Concern No. 4: Isn’t the flu shot just a “one size fits all” approach that doesn’t make sense for everyone?

Fact: You have many flu vaccine options, including egg-free, virus-free, preservative-free, low-dose, high-dose and no-needle choices

Concern No. 5: Can the flu shot cause death?

Fact: There have been no confirmed deaths from the flu shot

Concern No. 6: Aren’t deaths from the flu exaggerated?

Fact: Deaths from influenza range from the lower thousands to tens of thousands each U.S. flu season

Concern No. 7: Aren’t the side effects of the flu shot worse than the flu?

Fact: Influenza is nearly always far worse than flu vaccine side effects

Concern No. 8: Don’t flu vaccines contain dangerous ingredients such as mercury, formaldehyde and antifreeze?

Fact: Flu shot ingredients do not pose a risk to most people

Concern No. 9: Shouldn’t pregnant women avoid the flu shot or only get the preservative-free shot? Could the flu vaccine cause miscarriages?

Fact: Pregnant women are a high-risk group particularly recommended to get the flu shot. Fact: The flu shot reduces miscarriage risk. Fact: Pregnant women can get any inactivated flu vaccine

Concern No. 10: Can flu vaccines cause Alzheimer’s disease?

Fact: There is no link between Alzheimer’s disease and the flu vaccine; flu vaccines protect older adults

Concern No. 11: Don’t pharmaceutical companies make a massive profit on flu vaccines?

Fact: Vaccines make up a tiny proportion of pharma profits. That makes it possible for them to continue making them in the event of a pandemic

Concern No. 12: Flu vaccines don’t really work, do they?

Fact: Flu vaccines reduce the risk of flu

Concern No. 13: But flu shots don’t work in children, do they?

Fact: Flu vaccines reduce children’s risk of flu

Concern No. 14: Can flu vaccines cause vascular or cardiovascular disorders?

Fact: Flu shots reduce the risk of heart attacks and stroke

Concern No. 15: Can vaccines can break through the blood-brain barrier of young children and hinder their development?

Fact: Flu vaccines have been found safe for children 6 months and older

Concern No. 16: Will the flu vaccine cause narcolepsy?

Fact: The U.S. seasonal flu vaccine does not cause narcolepsy.

Concern No. 17: Can the flu vaccine weaken your body’s immune response?

Fact: The flu vaccine prepares your immune system to fight influenza.

Concern No. 18: Can’t the flu vaccine cause nerve disorders such as Guillain-Barré syndrome?

Fact: Influenza is more likely than the flu shot to cause Guillain-Barré syndrome.

Concern No. 19: Can the flu vaccine make you walk backward or cause other neurological disorders like Bell’s palsy?

Fact: Neurological side effects linked to flu vaccination are extremely rare (see Concern No. 18), but influenza can cause neurological complications. Fact: The flu shot has not been shown to cause Bell’s palsy.

Concern No. 20: Don’t people recover quickly from flu since it’s not really that bad?

Fact: Influenza knocks most people down *hard*

Concern No. 21: Can people die from the flu even if they don’t have another underlying condition?

Fact: Otherwise healthy people DO die from the flu

Concern No. 22: Can people with egg allergies get the flu shot?

Fact: People with egg allergies can get a flu shot

Concern No. 23: Can’t I just take antibiotics if I get the flu?

Fact: Antibiotics can’t treat a viral infection

Concern No. 24: Since I got the flu last time I got a flu shot, that means it doesn’t really work for me personally, right?

Fact: The flu shot cannot guarantee you won’t get the flu, but it reduces the risk of catching it

Concern No. 25: But I don’t need the shot since I never get the flu, right?

Fact: You can’t predict whether you’ll get the flu

Concern No. 26: Can’t I protect myself from the flu by simply eating right and washing my hands regularly?

Fact: A good diet and good hygiene alone cannot prevent the flu

Concern No. 27: Won’t getting the flu simply make my immune system stronger?

Fact: The flu weakens your immune system while your body is fighting it and puts others at risk

Concern No. 28: If I get the flu, why won’t just staying home prevent me from infecting others?

Fact: You can transmit the flu without showing symptoms

Concern No. 29: Can having a new vaccine each year make influenza strains stronger?

Fact: There’s no evidence flu vaccines have a major effect on virus mutations

Concern No. 30: Isn’t the “stomach flu” the same thing as the flu?
Fact: The “stomach flu” is a generic term for gastrointestinal illnesses unrelated to influenza

Concern No. 31: Is there any point in getting a flu shot if I haven’t gotten one by now?

Fact: Getting the flu shot at any time during flu season will reduce your risk of getting the flu

Tara Haelle is a freelance health and science writer based in Peoria, Ill. She’s on Twitter: @tarahaelle

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