Category: Insurance & Costs

The Affordable Care Act — Scrap or Save?

By Mark A. Kelley, MD |5/16/17

You may have noticed that we have been busy “tuning up” HealthWeb Navigator over the past few months. Based on your feedback we are expanding the number of our reviewed websites. We have also improved our review process. The details can be found in the section “Our Process” on our homepage.

Our blog will also be posted more frequently so we can update you on the current advances in medical science and healthcare policy. We encourage you to share your thoughts.

This week’s post will focus on the fate of the Affordable Care Act under the Trump administration.

The Affordable Care – What’s Behind the Politics?

The politics of federal health policy have dominated the headlines for weeks.

The House of Representatives narrowly passed a bill called the American Health Care Act (AHCA) to replace the Affordable Care Act (ACA, also known as Obamacare). The AHCA has now been sent to the Senate.

The ACA has expanded healthcare insurance to 20 million uninsured Americans. It also mandated basic benefits for all insurance plans. Among them is a law that prohibits financial penalties for patients with pre-existing conditions. The result is that many more Americans can protect their health and avoid bankruptcy from medical payments.

Critics claim that the ACA has failed. They describe higher premiums, insurers leaving the program, and excessive costs. These are real problems—but not failures. The AHCA will make them worse by reducing coverage with no significant cost savings.

The U.S. has not caught up with most other developed countries that have government-supported universal health care. These programs are funded by taxes on everyone. That policy distributes the financial risk across the population and gives everyone the same health insurance benefits.

That approach could work in the U.S. At least 50% of Americans are very healthy and have little or no health care costs. If these healthy consumers would buy health insurance (or pay taxes), we could cover the 20% of our population who consume 80% of health care costs.

But the U.S. has never viewed health care that way. There is no tax for health care (except Medicare for the elderly).

The ACA tried to fix that by requiring healthy, uninsured Americans to buy health insurance to support sicker patients. That law, called the “individual mandate,” has not worked because the government has not enforced it.

That worries insurers, who have enrolled many sick people but few healthy ones. Now some insurers are facing losses. By law, the insurers cannot charge sick people more. The ACA gave insurers temporary guarantees against losses but that guarantee period is ending.

The responses are predictable. Insurers are increasing their premiums to cover any losses. Some have left unprofitable marketplaces or exited the ACA altogether. Lacking any enforcement, millions of uninsured healthy Americans still pay nothing into the pool. Meanwhile, millions more Americans have new health insurance that they want to keep.

For universal coverage, all Americans must contribute to the costs of health care. Our taxes pay for defense, education, highways – why not health? In fact the Supreme Court ruled that the ACA is legal because the individual mandate is basically a tax that the government has the right to impose.

We already have experience with such a plan. For decades, taxes have supported Medicare for our elderly population. Medicare took years to evolve but is highly successful and popular with patients. It has survived many challenges. Elected officials have found that “messing with Medicare” can be politically dangerous.

The American public has been strongly in favor of universal health coverage, which exists in every other developed country. The ACA has been a major step in that direction. Many more citizens now have the opportunity for a healthy life and freedom from medical bankruptcy. They will not easily surrender these benefits.

The AHCA is a setback for universal coverage. The proposed law will reduce insurance for millions of Americans, and use those savings to cover a tax cut for the wealthy.

It is time for our elected officials to get down to business and fix the ACA without threatening patients with the loss of their health insurance.

The only political “win” is assuring that all Americans have affordable health care long into the future.

When Your Doctor Doesn’t Accept Your Health Insurance Plan

By Nathan Blake | 1/17/17
Updated | 9/14/18

When I relocated from Massachusetts to Virginia, I was lucky to find a doctor I really liked. She was smart, sympathetic, had a sense of humor, and treated me like a person instead of a checklist.

But a few weeks following one of my routine checkups, I was shocked to find that the clinic had charged me nearly 3 times more than what they usually did for such a visit.

I called my insurer thinking there must have been some kind of billing error. Come to find out, that surprise bill was the result of a recent restructuring of my insurance plan. My doctor no longer worked with my employer-based health insurance and was now considered “out-of-network.” If I wanted to continue being her patient, I would have to pay the full cost for every visit out of my own pocket.

Health insurance is about as easy to grasp as quantum physics. Deductibles, out-of-pocket maximums, copayments, in-network coverage, co-insurance, accumulation periods — few people know how their health plan works, especially since plans change over time. But not knowing what your health insurance policy does — and doesn’t — cover can leave you exposed to unexpected medical costs down the road.

What do you do when your doctor doesn’t accept your health insurance? Keep reading for a few tips that might just keep you under your preferred doctor’s care no matter what your health insurance situation is.

What to Do When Your Doctor Doesn’t Accept Your Insurance

So your preferred doctor doesn’t accept your new health insurance, and you don’t want to find another provider. The first step you should take is an easy one: Ask your doctor what insurance carriers they DO accept.

Rather than finding a new doctor, you can switch to a different health insurance policy that you know your doctor will work with.

Unfortunately, Marketplace plans can only be changed during certain times of the year or for specific “special enrollment” scenarios like having a baby, getting married, losing a job, etc.

Check online to see if you qualify for special enrollment before you make any big decisions. If you’re eligible for special enrollment, this is by far the most painless solution.

But there are other options if you can’t afford the cost or hassle involved with switching policies. If you desperately want to keep your doctor, you can:

Ask your insurer to add an out-of-network doctor to their network. If your doctor isn’t in your insurer’s network, call the insurer directly to see if they’ll consider adding your doctor to their network of providers. If they refuse, ask for specific reasons why. You can also try convincing your doctor to join a particular insurer’s network. Sometimes just being determined is enough to do the trick. It may not work, but it can’t hurt to try!

•  Negotiate a discounted “cash price” with your doctor. It’s common for medical providers to limit the number of insurers they work with. The result is that patients insured through incompatible plans are forced to pay the price for medical services up-front. Thankfully some doctors will negotiate prices with patients on an individual basis, especially if there’s already a long-standing relationship. The key to these negotiations is knowing the fair price for a given health expense and working from there. Again, it costs nothing to ask, and the potential payoff is worth it.

•  Visit an urgent care center or walk-in facility. Urgent care centers and walk-in clinics are set up to treat patients with non-life-threatening illnesses and injuries like fevers or the flu, bleeding/cuts, sprains/strains, etc. They’re also good for immunizations and some diagnostic services such as X-rays and routine lab work. What’s great about these centers is that they are relatively inexpensive, don’t require appointments, and are often open seven days a week. If you can save money on “small” issues, then you may be able to afford seeing your doctor for the more serious issues that crop up from time to time.

•  Pay the difference out-of-pocket and seek reimbursement later. This one hurts. But if you have the financial resources to do so — and your doctor is too good to let go of — then you can pay for their services out of pocket and then submit insurance forms for reimbursement. It’s important to note that insurers will often apply reimbursements to your policy deductible (how much you’re expected to pay before the insurer picks up the bill) rather than give you the money outright. There’s also a good chance you will be reimbursed for only a portion of the original cost. Stay in touch with your insurer during the reimbursement process and make sure your voice is heard.

When It’s Time to Move On

Sometimes the cards just don’t play out the way you want them to. If you can’t afford to see your doctor without health insurance, and none of the above options works for you, then it might be easier to simply move on and find another doctor in your new network. Most health plans these days provide a list of physicians in their network. Call your plan directly for more information.

There are a lot of great websites out there to help you find the doctor of your dreams. Check out of collection of websites for finding a doctor in the Doctors & Hospitals category.

Being prepared for change and knowing what options are available is your best bet for making a smooth transition between providers. Comment below and let us know how your situation worked out!

Choosing Your Primary Care Physician

By Nathan Blake |12/19/16
Updated |7/3/17

When my partner and I moved from Virginia to Massachusetts, neither of us had any idea what we would do once we got here. Those days we were scraping by without: an apartment, jobs, state driver’s licenses, a local bank, and health insurance.

Fortunately we were able to cross off everything from that list within a month. But the last item — getting health insurance — was only the first step in health maintenance. I knew eventually I would want a medical professional I could trust to help me make my healthcare decisions, both big and small.

What I was needed was a primary care physician, or PCP.

What’s a Primary Care Physician?

Primary care physicians (also called “primary care doctors”) provide general medical services to specific patient populations.

A pediatrician manages the health of infants and children. Internists provide care to adults, diagnosing the nonsurgical treatment of diseases. A gynecologist specializes in pregnancy, childbirth, and the postpartum period. Each is a primary care physician, just with different specialties.

Why Are Primary Care Doctors Important?

PCPs, unlike many other health specialists, get to know their patients intimately and over a longer period of time. The ongoing nature of the PCP-patient relationship means the doctor can better assess what’s considered “normal” (and what isn’t) for each patient.

But those aren’t the only benefits of having a primary care physician.

The PCP often serves as a patient’s go-to medical resource. No more Dr. Google — with a primary care physician, you can talk about all of your health concerns with an expert you trust. It’s the primary care physician’s job to provide the patient with the very best care available, whether that care is in-house or through a referral to another specialist.

Primary care physicians and patients engage in what is called “continuity of care,” which means building a personal relationship that develops year after year. Keeping a close watch over a patient’s health allows PCPs to better intervene with disease prevention, patient education, health maintenance, and the diagnosis and treatment of both acute and chronic illnesses.

Lastly, the ease of access and communication involved with visiting a primary care physician is unrivaled. Longstanding doctor-patient relationships afford patients the opportunity to truly understand and participate in decisions that affect their health.

Once I settled down in Massachusetts, I knew I would need a primary care physician in my corner if I wanted to stay on top of my health. Turns out I had no idea how to actually go about choosing a primary care physician.

How Do I Choose a PCP?

Choosing a primary care physician is sort of like dating: there’s a large pool to choose from, and finding the right fit may take some trial and error.

Here are some tips I picked up that may help you find the doctor who best fits your personal needs. Let us know in the comments if they help!

Understand your insurance plan: Contact your health insurer or check your policy’s benefits to find out which doctors are considered “in-network.” Doctors in your insurers network will offer you discounted rates negotiated in advance by your health plan. Doctors considered “out-of-network,” on the other hand, often require patients to pay for their services up-front and in full.

It’s almost always a good idea to choose a PCP who is willing to work with your health insurance. We have an entire post focused on how to work with a doctor who doesn’t accept your health insurance.

Ask people you trustConsider asking for recommendations from friends, family, and coworkers. Most people feel more comfortable visiting doctors who have been recommended by someone they trust. Another benefit is that other people (or websites if you’re looking online) can help you pinpoint exactly what you want in a healthcare provider.

Are they male or female? Old or young? Laid-back or over-serious? The more you know about a doctor increases the chances that you’ll find one you like.

Keep an eye out for compatibilityMany patients schedule preliminary interviews with potential doctors to determine “fit.” Imagine the first visit as a trial run, and don’t rule out your gut-feeling.

Does the doctor explain things clearly? Do they listen without interrupting? Is the doctor relatable or more formal than your liking? Can you tell if the doctor prefers aggressive treatment or a more prolonged “wait-and-see” approach? All of these questions will help you in your search for a primary care physician.

Plan logisticallyIf you have a specific health condition like diabetes, you should choose a PCP who has specialized training or experience in endocrinology to receive the best care for your needs.

Other logistical considerations include the distance required to travel to the doctor’s office, schedule flexibility, and whether or not the doctor can understand you preferred language.

Make a list of your “wants” and “needs,” which you can then use to narrow down the list.

Know their availabilityNot all primary care physicians accept new patients. Even doctors with availability may have hours that conflict with your schedule. Some PCPs have dozens of patients, and those with more responsibilities require longer wait times to schedule an appointment.

Reach out to the doctor to get a better idea of their availability before you commit. You may be able to find someone who is a better fit for your schedule.

Check for qualifications:  A doctor is tasked with matters of literal life and death. Of course you’re not going to take advice from someone who isn’t qualified to give that advice. You want your health advisor to be an authority in their field, with an education and professional background that reflects expertise.

Check online or through the doctor’s office to see if the doctor is board-certified in the field(s) that you are visiting them for.

Are you ready to choose a primary care physician? Check out our “Doctors & Hospitals” category to browse resources we recommend for locating doctors online. Happy hunting!

Is Obamacare Affordable?

By Mark A. Kelley, MD |10/13/16

The upcoming election has dominated the media lately. Health care is not far behind with reports about Obamacare, health insurance and drug costs.

What’s behind the headlines?

Obamacare—too expensive?

The Affordable Care Act (ACA, Obamacare) was designed to expand health care coverage for those without insurance. Under the ACA, the federal government subsidizes the insurance for those who cannot afford it.

There have been a few surprises since the ACA was implemented. The newly insured folks have had more health problems than anticipated. This has driven up total heath care costs. Insurance companies had subsidies to cover these losses, but they will soon expire and the losses will increase. As a result, some major insurance companies, such as Aetna and United Health, have pulled out of the ACA.

Some policy experts think that the costs of ACA will go down. The theory is that as newly insured sick people receive medical care, their health will improve and they will need fewer services. No one knows if this will happen. Even President Obama admits that the ACA “has some problems”.

Rising Costs  

Aside from the ACA, other health care costs have been rising. A major driver has been the price of prescribed drugs. A second factor is the cost of expensive technologies especially electronic health records, mandated by federal law. These systems can improve communication but do not reduce costs.

These and other factors have created health care “sticker shock”. Employers are seeing their insurance costs accelerate. To reduce premiums, most employees have an annual insurance deductible, averaging over $1000. Prescribed medications often fall into the deductible. For example, someone who once paid a $20 co-pay for a drug must now, with a deductible plan, pay the insurer’s cost. The price can be ten times the cost of the co-pay. That can be an economic disaster for a patient on many medications.

Corporate Scandal

The recent uproar over the “Epipen” may be the last straw for the American public. The Epipen provides a life-saving injection for patients who suffer severe allergic reactions. The price of this product skyrocketed without any new enhancements. In effect, the company used its monopoly to extract extraordinary profits from families who need this “rescue drug”. This maneuver enraged the public and created distrust of the pharmaceutical industry.

The Flaws in the System  

These reports reflect significant flaws in our health system. Unlike most developed countries, we have few price controls for prescribed medications. We are also more liberal in approving new technologies and devices. Finally, in our private insurance system, insurers pass increased costs to employers and patients so there is no brake on inflation. This makes health care prices difficult to understand and to justify.

Employers are losing patience with rising costs of health care. One alternative is to providing employees with a “defined contribution” i.e. a fixed dollar amount for health insurance. This is how 401K-retirement plans work. Most employers can no longer afford pensions. Instead they provide a fixed amount for the employee to set aside for retirement. How the employee uses the money is up to them.

“Public Option” on the Horizon?

Many policy experts believe that we are headed for a “single payer” system. This means that health insurance would be provided and regulated by the federal government. We already have such a plan—it’s called Medicare.

Medicare controls prices, eligibility and coverage rules. It has kept medical inflation low for the past five years and its payment is accepted everywhere. Medicare is not free. It is supported by taxes and premiums and is very popular with its beneficiaries.

Will “Medicare for all” ever happen? The American public is becoming restless for such a change and politicians have noticed. For years, there have been political discussions about a “public option” similar to Medicare. Now, the federal government pays for almost 50% of our nation’s health care costs. That figure is rising as more “baby-boomers” enroll in Medicare. Some policy makers think that a national health insurance plan is inevitable.

They may be right. Studies and polls show that the majority of physicians and voters favor such a system.

That may be the most significant news of all.

Does Your Physician Know What You Pay for Healthcare?

By Mark A. Kelley, MD |07/05/16

All of us should understand our own health care costs. However, as we have discussed here before, the issues can be complicated: e.g. insurance premiums, deductibles, co-pays, etc.

Physicians have a different perspective. Like any professional, they focus on how they are paid. Insurance companies require doctors to submit many details with their bills. Physicians rely on sophisticated billing systems to furnish that information, because without it, they are not paid. In a nutshell, patients worry about paying the bills and doctors worry about sending out the bills.

This raises a key question. How much do doctors know about your insurance and what you must pay?

Of course, the doctor can explain his/her own bills to you. Your doctor’s office has checked your insurance and knows how they should bill your insurance company.   Surprisingly, the doctor may not know much your hospital insurance coverage, or your deductible. Most physicians and their staffs have not been trained to gather this information because it does not affect physician payment.

But things have changed. With high deductible insurance plans, patients have more risk for out-of-pocket costs. A blood test, x-ray, or medication can come with a large bill if it drops into your deductible.

The prices may astound you. A friend recently enrolled in a high deductible insurance plan. She refilled prescription, which previously cost her $40 co-pay. With her new insurance, she had to pay $250 for the same refill because it was part of her deductible. The price was so high because the insurance company passed all the drug cost on to her.

Why is this important?   It is wise to know what you are paying for — and health care is no exception. Health care bills can mount quickly and squeeze the family budget. Sometimes, families face the tough choice of either paying the rent or seeing the doctor.

Physicians are seeing more of their patients struggling with health care bills. This pressure may discourage them from seeking medical care. Tight finances are becoming a health care risk, even for families with decent incomes.

How can patients and doctors work together to control the “costs of care”?

Here are a few suggestions:

1. Know the details of your own insurance policy, especially “out-of-pocket costs”such as co-pays, coinsurance and deductibles. If you have any questions or concerns, contact your insurance company.

2. When your doctor recommends a test, procedure, or treatment, make sure you know what it involves, why you need it, how effective it will be and how soon it must happen. These are questions that any good doctor would be glad to answer.  The timing of the test or procedure may be important if you have already paid out your deductible before the end of the year. In that case, you may not have to pay anything for the service.

3. Cost may (or may not) influence your decision to get a test or procedure. For example, for an urgent life-saving procedure, cost may not even enter your mind. However, some tests or procedures may not be so convincing. In those cases, cost might influence your decision. If so, discuss the cost issue with your doctor who may suggest less expensive alternatives. The timing, location and type of service may all influence the cost: most often for planned (elective) procedures, x-rays, or some medications.

4. If health costs worry you, talk to your doctor. Don’t be afraid to bring up the issue. You are not alone. Many more patients are asking about costs these days. Physicians welcome solving these challenges with you. They can be very helpful if they understand your concerns.

Learn how physicians are addressing this problem on the website Costs of Care.

What You Should Know About Health Insurance — The Details

By Mark A. Kelley, MD |06/15/16

Understanding Private Health Insurance – Part II

It is important to understand the coverage of your health insurance plan.
Previously, we covered deductibles, and premiums. There are other details that are important:

“Co-Pays”: These are fees that you pay whenever you receive certain services or purchase drugs or devices. The dollar value of co-pays varies by insurance plan and by the type of service provided.

The fee must be paid to the provider at the time of the service. In most plans, the co-pays are counted toward the deductible.

“Co-Insurance”:

Some insurance plans require you to pay a certain percentage of the cost of a medical service. For example, a 20% coinsurance for a procedure or hospitalization means that the insurance company pays 80% of the cost. You pay the rest. Plans with “co-insurance” usually have a lower monthly premium.

Some plans may include both co-insurance and deductibles. It is wise to contact your insurance company to learn these details.

“In Network”:

Insurance companies may offer a lower premium if you only use doctors and hospitals within a defined network. Typically, the insurance company has negotiated a discount with the network and passes some savings on to you.

To get this discount, you must stay in the network. If you go to providers outside the network, you may have to pay more for the service.

This arrangement should be very clear in your policy. If you are unsure, check with your insurer. If you already have a favorite doctor or hospital, check beforehand to see if they are in the network you are considering.

How to Manage “the Deductible”:

If you have a $1000 deductible, you are responsible for paying for medical services out-of pocket until the sum total of all such payments for the year reaches $1000. After that, the insurance company covers all costs.

Deductibles usually apply to visits to physicians or other health professionals; hospitalizations, procedures, diagnostic tests and prescription medications. It pays to know the exact details of your policy.

The insurance company will ask you to pay their usual cost, and no more. For example, if the company usually pays $50 for the doctor visit, you would pay that cost.

But there may be surprises. Some prescribed drugs and technologies have become very expensive, even for insurance companies. You may get sticker shock when you are handed some of these bills. If so, ask your doctor if there are less expensive alternatives.

The deductible “resets” to zero at the end of every year. If you are planning an elective procedure, like joint surgery, check the calendar. If you have paid many medical bills in the calendar year already, you may have reached your deductible. In that case, the insurance company would pay for all the cost of the surgery…provided it happens before the end of the year.


Good News/Bad News – there are limits to your out-of-pocket costs –but not your premiums
.

The Affordable Care Act limits out-of-pocket health costs. For an individual, the annual cost cannot exceed $6850 for an individual; or $13,700 for a family. These costs include, co-insurance, copays, and deductibles. For some plans the limits may be lower.

The limits are helpful but for those with modest incomes, these are still impressive sums. The other flaw is that these limits do not include the costs of premiums to purchase health insurance.
The federal government provides an excellent overview of these issues.

The Health Insurance Checklist:

In evaluating a plan, here are some things to consider:

1. Does the plan include your favorite doctors and hospitals? This is very important for those who are already receiving medical care. Some hospitals and doctors are more expensive and that cost may be passed on to you.

2. How much insurance can you afford? You must decide how much premium you are willing to pay to offset the risk of the deductible. Remember, by law, there are absolute limits on your out of pocket costs.

3. What is included in the coverage? Most common medical and surgical conditions and procedures are covered by insurance plans. However, check into the detials since the coverage can vary for:
Nursing home care, rehabilitation, medical equipment and devices,
Mental health services
Travel in other states or countries
Special drugs like chemotherapy, transplant.

4. Customer Service – health insurance is complex and you may need help to understand your coverage and your bills. Do not hesitate to contact your insurer for advice or questions. These companies must have good customer service to compete for your business. You can check consumer ratings of the companies in your region.

What You Should Know About Health Insurance — The Basics

By Mark A. Kelley, MD |06/10/16

Understanding Private Health Insurance – Part I

By law, everyone must have health insurance. If you qualify, you can use the government plans: Medicare, Medicaid, or Veterans Affairs insurance. If not, you must be covered by a private insurance plan. Read more about health insurance plans at Consumer Reports.

In these next two blogs, I will explain the key points and offer some tips about private health insurance.

Private health insurance is not free and has many different features:

The Monthly Premium:
Health insurance is a contract between you and the insurance company. The cost is billed monthly and you must pay it or lose your coverage. Like all insurance, the more coverage you buy, the higher the monthly bill (premium).

If your employer offers health insurance, you may pay only some of the premium cost. If you do not have employer insurance, you must buy it yourself and pay the full monthly premium. If you go through state or federal health exchanges, you may qualify for a discount if you have a low income. You can find the exchange in your state by going to Healthcare.gov.

Health Insurance Resembles Auto Insurance (Sort of)

The health insurance industry has redesigned its plans to include “deductibles”
This arrangement is familiar to all car owners. The deductible is what you pay out of pocket before the insurance kicks in. For example, if your car is damaged, a deductible of $500 means that you pay the first $500 of the repair bill before insurance pays anything.

To lower your premium, you can buy a higher deductible plan. That means you will have to pay more of any repair bill.

For example, if you choose a $1000 “high deductible” plan, you will pay less for insurance premiums compared to a “low deductible plan” of $500. However, in the event of an accident, you would pay the first $1000 of any collision repairs.

Many health insurance plans have a deductible, which is like a big bucket that fills up with medical bills. You pay every bill yourself until that bucket is filled to the deductible limit. If your deductible is $1000, you must spend that amount on medical care before the insurance begins to pay bills. The deductible applies to most health services and medications that you use during the year.

High or Low Deductible – Your Choice

A very healthy person may figure that the risk of any illness is low. Therefore, that individual might choose a plan with a low monthly premium and a high deductible (like $3000). Of course, an unexpected illness or accident could run up a bill of $3000 but the insurance would cover anything else for the rest for that year.

Those with existing medical conditions may already use medical services frequently. In that case, they might choose to pay a higher premium with a low deductible (like $1000) so that out of pocket costs are limited to $1000.

Obviously, the choice is up to you. The important factors to consider are:

–What is the annual cost of your insurance premiums?
–What is the likely cost of your medical bills next year? (Think carefully—are you planning elective surgery? do have an ongoing serious medical condition or recovering from one?)
–How much of that estimated cost will fall into your deductible? (If you don’t know, assume most of it will)

The major decision is whether you want a lower monthly premium and are willing to accept more risk for medical bills (a high deductible). If you anticipate many medical bills, the insurance company will cover more of the cost, provided you pay a higher premium.

The bottom line is to match your health insurance to your needs.

Only you can make that call.

Next Week – Part II: Understanding (and Using) Private Health Insurance – Details Matter