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.
“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.”
Although I feel confident in recieving a higher quality of care and a better experience, won’t I also experience significantly higher out-of-pocket costs? That to me, seems to be the dilema for me, the patient. I need your quality of care but can I afford you?
Please respond.
Nate – Can you afford it? That’s a bit loaded. What can you afford? Television? Eating out? What’s your income? It’s a conversation you need to have with a physician after a consultation. What are your medical issues? What are the best methods of treatment?
As for myself, I have hated the insurance industry for a long time now. Insurance is intrinsically fraudulent in my opinion. You can not spend more than you take in. Insurance policies, viewed simplistically at face value, are built to spend more than they take in. How is this possible? They are loaded with loopholes and conditions for the specific purpose of relieving the insurance company of obligation. Every facet of the industry is warped around getting the maximum payment from the insured while paying out as little as possible. How is it in any way ethical for anyone to sell the idea of providing a service/financial support for a specific purpose and then endeavoring in every way not to fulfill providing that service/financial support? It doesn’t matter how nice your insurance agent is – the industry itself is driven by a motive not to fulfill the very service/financial support it pretends to sell.
As for “government provided” healthcare – How in the world have so many people been sold on the idea that “government” is the answer to getting the best healthcare to the maximum number of people? It can not possibly be an honest aim for anyone involved. A doctor can not live on helping patients needing medical care. It doesn’t feed him/her. So one way or another, payment must come from the government or the patient (via private insurance or out-of-pocket). There is no altruism in providing medical care, just as altruism in any profession can not exist. There has to be a trade. The farmer trades in crops, the mechanic trades in machine skills, and the doctor trades in medical care. To siphon private wealth from tax paying individuals to employ a bloated bureaucracy that provides nothing itself directly to any trade or industry in order to provide a better healthcare “system” by a method of “redistribution” is tantamount to lunacy.
What is a healthcare “system” anyway? Doctors can’t collectively treat patients! Inclusion of the word “system” with healthcare is in and of itself is dishonest. An individual doctor may have a system that helps him do things around his office, and organize his practice. A hospital may have a system for processing patient information and for organizing cases to be seen/prioritized. However, individual patients needs must be addressed individually. Those needs take greater or lesser time and effort depending on their individual healthcare needs. Where is the need for government in the process of a doctor – patient relationship? The very lack of government or any other distraction – such as a reliance on an intrinsically fraudulent industry (insurance) – contributes much toward allowing for the most ideal circumstances between doctors and their patients. Healthcare is the service provided by individuals with skills in that industry provided to those patients in need of those skills. It is not a “system”.
To think of providing healthcare in national terms is a concept of defeat before it is even begun. Doctors need to be willing to take responsibility for their own practices, taking the same risks in their industry that everyone else takes in their own. Patients need to work to provide an adequate amount of exchange to give to a healthcare provider. Government needs to ensure that doctors have the right to practice – the right to accept or reject patients based on their judgement – and that patients have the right to chose their physicians and sue for poorly provided service. The only honest/noble role government has is to preserve the rights of its citizens. Not to dominate their lives and livelihood through the healthcare industry or any other industry. As there is no true utopia without liberty, so it is impossible to forcefully create it.
I have always been ashamed of my longer second toe and just recently learned of your “miracle procedure.” I have a Master of Science in Education, am a dual-certified teacher in General and Special Ed, but I’m working as a Teaching Assistant as I continue to look for a full-time teaching position. I currently have EMPIRE/United Healthcare and although I understand that you are “out-of-network,” could you please tell me what type of cost this procedure would cost. I am a single mother with two teenage daughters. Many thanks and God bless you.