Health insurance is one of the hot topics every election year. Our new President has committed to reforming health care. At this time, 1/8 (47 Million) of Americans are uninsured. The reasons for this are complex. Our system is based on a privatized model that operates on a for profit system.
This article is the first of a series of articles designed to educate and empower readers and patients to fight back against the mess that the insurance industry is causing for health care in America.
Most patients are not informed of what their plans cover or what the implications of switching their plan to an HMO or Managed Care program are. Most doctors are too busy to educate and spend the quality time needed to get to know, and build relationships with their patients. The whole thing translates to a viscous spiral that can only lead to catastrophe.
I feel that informing the public is the first step to fixing the problem. The public can change the insurance market by driving the demand for products in the direction that serves them and their doctors in an ethical manner; the polar opposite of what is happening today.
Out-of-Network vs. In-Network Doctors
The big insurance providers of this country are running a business that has controlled medicine for the last 25 years. Cornering the market was easy for these massive corporations. When contracting to become an “In-Network” doctor first came into vogue, most insurance companies paid doctors on a fair market, or relative value scale. But when contracts started to bind doctors into a fixed pricing schedule the demise of quality coverage began. Insurance providers played both sides of the fence. Now, a typical insurance provider like Blue Cross Anthem will force patients to see In-Network doctors by penalizing them if they see non-contracted, Out-of-Network doctors. They also punish doctors by not listing them in the “Preferred Provider Book” if they choose to be Out-of-Network; but what you don’t know is that these “Preferred Providers” are doctors who have signed a contract with Blue Cross agreeing to work for significantly less payment for the services they provide.
This happens because most doctors graduate with debt and they need to start practice with some kind of revenue stream. The typical graduate from medical school owes around $180,000 for their education. Combined with the costs of starting a practice, signing a contract with one of the big insurance companies to work for a 75% cut in payment is an attractive offer when your loan note is due in a month.
So big insurers have captive audience on both sides of the fence, the patient is punished if they go out of network, and the doctor is punished by being paid 25% percent of what they are worth, if they are in-network.
I often talk to patients about this on going problem. I ask patients: “what has happened to your insurance premiums in the past few years? They’ve gone up right?” But if you take a close look at your EOBs (Explanations of Benefits) you will see that the reimbursements to doctors has gone down every year. When I first started practice I remember going through some old EOBs from my senior associate and I was shocked. A standard bunion procedure is now paid at 50% less than it was in 1981! Think about this for a second; what has happened to the cost of living and every other cost in the last 20 years? But the reimbursement for procedures is consistently being cut.
Combined with consistently increasing premiums, you and I need to be asking “Where is the money in the middle going?” Insurance companies answer with “the cost of health care is going up as more Americans are getting sicker.” But that’s not true. Except for modern “lifestyle” illnesses like diabetes, obesity, heart disease and cancer, we are the healthiest we have been in the history of our country. Illnesses like malaria, tuberculosis, small pox and other life threatening conditions are almost unheard of in today’s world.
Last year, I decided to take my practice Out-of-Network with every insurance provider. Not because we wanted to make our patients pay, but because I consider it unethical to be tied to a contract that financially controls what, how, when and why I am paid for my services. I pride myself of providing the best that Podiatry has to offer. Surgical techniques that are cutting edge, and facilities that are second to none. But when Blue Cross Anthem or other providers started to give us a hard time getting paid for services that we had already provided, I decided the buck had to stop here… regardless of the economic impact on the practice. Most doctors increase their volume to make up for the reduction in payments. For my practice however, that has never been, and will never be an option. Quality must, and will always come before volume. So we canceled our contracts with all major providers.
What does that means to you as a patient? Not much. We still see patients with insurance, except now that we are not bound to a contract we can provide for services on our terms rather than then insurance company’s profit driven terms. Our patients now enjoy longer visits with more comprehensive care. The take home message is that just because your doctor is Out-of-Network, it doesn’t mean that you can’t be seen or treated. Rather, you will probably receive a higher quality of care and have a better experience.
