Having dealt with various insurance companies from all three perspectives, that is a tough question to answer. There is evidence that points to each one being more or less beneficial when it comes to health choices. The one variable that research has a hard time dealing with is that each of us is different and we have varying needs. Creating a health care package for millions of individuals is basically impossible. This is one of the reasons why the Affordable Care Act is so huge and daunting. This is why I strongly believe that YOU need to be in charge of your health.
There is some emerging evidence that consumer-directed health care is actually having a positive effect on cost and cost increase. Basically, when you make informed choices and go to the providers you know and feel will give you the best care, cost can be improved. This is no different than shopping for a car or home. I also think that the old saying, “you get what you pay for” can easily help us understand this concept.
Making good choices on your health care along with education and information from your providers can eliminate unneeded visits, tests, medications and treatments. It also decreases the burden on the providers so they can actually spend more time with you when you need it most.
Let me illustrate with a physical therapy example. Jane likes to run. She runs a lot. Jane starts to get pain in her foot but keeps running for a few more weeks. Finally the pain is too much and she goes to see her in network general doctor. The doctor does an exam, gives her medication for inflammation and tells her to stop running for a week and to come back if it is not better. After a week it feels OK and Jane goes running again. The pain comes back. She keeps using the medication, and keeps trying to run. The pain gets worse. She goes back to the doctor who does another exam and an xray. The doctor says the xray seems ok, but to keep taking the medication and no running for two weeks. If the pain does not go away, then to return. Jane stops for two weeks, takes medication and is getting depressed that she will never run again. She waits three weeks and then tries running again. She decides to go for a short run this time. It went OK. She felt weak, but assumed it was because she had not run for 3 weeks. She tries to go running 3 more times that week, by the end of the week her pain has returned and she is getting some swelling. Jane makes another appointment with her primary doctor. The doctor looks at the foot again and basically says, “we need to refer you to a specialist”. Jane says “alright” and the nurse gives her a list of specialists for Jane to call. Jane gets an appointment with a foot specialist two weeks later. The specialist orders xrays. They are inconclusive, but due to her length of pain, he also has her get an MRI. Jane goes to the MRI the next week. Then goes back to the doctor the next day to get the results. The MRI shows small stress fractures in a few of the bones of her foot. To end this story, Jane is given a walking boot and is told she cannot run for 4 weeks. She is to return to the specialist at that time. She gets the boot off and then is instructed to get physical therapy for progressive stretching and return to running over the next 4 weeks. The specialist estimates that she will be back to her previous mileage in about 3 months.
OK lets see, 3 visits with her primary, 4 visits with her specialist, 2 xrays, 1 MRI, about 8 weeks to MRI, 12 weeks to getting the boot off, and then 3-4 more months back to normal including several visits to physical therapy. That could be up to 6 months of little to NO running. So 3 copays ($60) + co-insurance (~$90), 4 specialist copays ($140) + coinsurance ($120), MRI copay ($30), and medication costs ($30), PT copay x 6 ($240) plus any coinsurance = about $710 out of pocket expense give or take on coinsurance.
There are many places that Jane could have taken a little more control, but did she have the information she needed either. It is very hard to say. Did she do any internet searches to get some background information on foot pain with running? Did she contact her insurance to see what types of providers she could go to directly instead of seeing the primary doctor first? What questions did she ask the doctor and how much time did the doctor spend with her to explain the parts of the foot and his thought processes on her injury? There are many directions her story could have taken with just one or two changes:
1. She goes directly to a specialist that works only with knee/ankle/feet injuries: The doctor takes xrays and doesn’t see much, but explains that she could be going down the road of stress fractures. He recommends a boot for 3 weeks at first and also that she see a physical therapist to check running form and help her slowly progress back after the 3 weeks. If the pain increases then the PT can contact the specialist. She does 5 visits of PT with an in-network provider for now. (specialist co-pay $45, PT copay $40 x 5 visits = $245 plus co-insurance ($80-200 depending); 3 weeks in boot, 2-3 week in PT)
2. She looks online and finds information that physical therapy may help: she goes into a local physical therapist whose website lists they are experienced with runners. Only problem is they don’t bill insurance, but they have a great reputation. They do a thorough exam and look at her on the treadmill. The therapist suggests she may be developing stress fractures. He gives her cross training exercises to do during the meantime, but advises no running for 2 two weeks and to come to PT in 2 weeks to follow up and progress. She goes back and the pain has decreased and she has done well with the cross training. The PT gives her a walking routine to start with, but still no running and to return in 8-10 days. She follows the walking routine and returns to the PT again. The PT looks at her on the treadmill and OKs progression to running and gives her a specific plan to follow that will take 8 weeks. (3 visits cash pay at $120 each = $360, no coinsurance and the PT gives her an invoice to submit the bill for reimbursement from her insurance; back to walking after 2 weeks, some running in 4. She gets a reimbursement check for 50% of her out of pocket expense = total cost pf $180)
Now again, this story could go hundreds of ways. Janes insurance benefits may not have coinsurance, or lower copays, or no out of network coverage. However, it goes to show that our involvement in our care directly effects the quality and care that we get as well as the cost. I have seen stories like each scenario above many times. I am asking that each of us, please, take charge of our health and the care that we seek. There are so many great providers out there!!! Take the time to find the ones that work for you and match your needs. Also, don’t assume that just because a provider is “in-network” they are any better or end up costing you any less. Often times, the insurance companies contract to pay less than a providers time is worth forcing providers to see more and more patients per day which affects their productivity.
Below are only a few links to some helpful information including one research article on consumer-directed health care. Please, take the time to think, develop questions and ask them. Make your provider and your insurance work for you!