More and more frequently, I’m seeing patients with a type of anxiety not described in psychiatric textbooks. I call this condition "health care cost anxiety." This increasingly common condition has its roots in uncertainty and fear of the unknown, not the least of which is the unknown cost of recommended medical care and medications – what the patient (or the patient’s family) will need to pay out of pocket.
Health care cost anxiety arises when we tell a patient she needs an MRI but she is not sure whether her health insurance plan will pay or whether she’ll have to pay $3,000 out of pocket. It occurs when the pharmacy clerk tells the patient that, instead of the $12 copayment he expected, he’ll need to pay $200 to pick up his medications.
Dr. Lee H. Beecher
Simply being ill, or being afraid of becoming ill, causes plenty of anxiety. And when the patient is already ill, getting the straight story from an insurer about costs and coverage is all the more difficult. Other factors – financial stressors such as unemployment, worry about losing or loss of employment or health care benefits, escalating insurance premiums, and difficulty in getting appointments with providers who will accept the patient’s insurance plan or medical assistance – are driving anxiety about health care.
Clearly, in our uncertain health care insurance environment, patients need to become much more involved in knowing and managing their own health care spending. This editorial outlines what you can tell your patients about how health insurance coverage is changing, what this means for empowering them, and steps they and their families can take to help manage health care cost anxiety.
Paying More Out of Pocket
The days of first-dollar insurance coverage without copayments or deductibles are over for most of us. In addition, although 58 percent of U.S. workers are still covered by employer-sponsored insurance, that percentage is diminishing. Many small businesses are dropping coverage or not offering it to their new hires.
A June 2011 McKinsey & Co. survey of 1,300 businesses found that 30% of employers plan to drop employee insurance altogether and that 60% will be looking for alternatives to traditional employer-funded insurance by 2014, under the federal health care law employer insurance mandate. Employers are already dramatically increasing the employee share of health costs, often requiring their employees to come up with $1,000 to $6,000 in medical expenses before their health insurance takes effect.
Shift Toward High-Deductible Health Plans
Many larger employers still offer several choices of health care insurance plans, but these choices are narrowing:
• A health maintenance organization plan offers first-dollar coverage.
• A preferred provider organization (PPO) plan offers greater choice of providers, but patients pay more or cannot see physicians out of the PPO network.
• High-deductible health plans (HDHPs) offer much lower monthly insurance premiums than the other two plans.
HDHPs are becoming much more prevalent because of their much lower premiums. They operate on the principle that health care insurance should cover high-cost medical services and unpredictable costs while most low-cost forms of health care are financed outside of an insurance protection contract. There are basically two types of HDHPs: insurance policies in which high deductibles are completely managed by the insurance company (such as Medica Solo); insurance that is paired with a health savings account (HSA) regulated by the federal Internal Revenue Service.
Both kinds of HDHPs require that individuals have money from a source other than health care insurance – such as a health care reimbursement arrangement (employer funded), an HSA, or a direct government subsidy – to cover the costs of care until the insurance plan deductible is satisfied. Independent insurance agents can provide details.
With the rise of HDHPs, patients and doctors will need to deal with the permutations of payment, costs, and restricted options in health care services. The increasing variety and scope of health insurance plans means that patients (and their doctors) will need to know actual costs of their care and assume a collaborative role in cost management. Doing so is often challenging in the current environment. Below are some guidelines for getting the cost and coverage information needed from the clinic and the pharmacy.
Learning From the Insurer
As of this writing, getting specific answers on benefits or allowed dollar coverage from medical care insurance company continues to be a daunting task. The process of calling the insurance company might take an hour or longer. In my office, we offer a "team call" with a clinic staffer (outside of the patient’s appointment time with me) to help patients or family members get this information. The call helps clarify the insurance rules of the road and also improves the doctor-patient alliance.