Insurers to Patients: Heal Thyself or Pay

Sticking the critically ill with a hefty tab for expensive medications is enough to turn my stomach. But the practice may become widespread among health-insurance companies.

Insurers are embracing new pricing plans for drugs that typically require patients to pay between 20% and 33% of certain high-price medications, according to a report by The New York Times. The plans often require that patients suffering from serious afflictions such as hepatitis C and cancer shell out thousands of dollars, instead of predetermined co-pay amounts.

One such drug, Copaxone, developed by Teva PharmaceuticalTEVA in Israel, is a treatment option for multiple sclerosis patients.

Why shortchange the seriously ill? Apparently, insurers want to keep premiums down. Requiring patients to fork over significant cash to treat a life-threatening illness, however, defeats the purpose of health insurance.

Health insurance premiums for employers increased by 6.1% in 2007 -- two times the rate of inflation, according to the National Coalition on Healthcare, a Washington, D.C.-based nonprofit health-care advocacy group. The increase parallels the rise in national health expenditures, which were expected to rise 6.9% last year.

It seems that many Americans -- and their employers -- pay more every year to reap less. Sure, there may be coverage for the more predictable medical expenses such as preventive care, childbirth and perhaps an appendectomy. The emerging trend in drug coverage, however, is disturbing evidence of diminishing coverage for Americans who need it most -- and who are, perhaps, the least capable of fighting back.

Medical expenses seem to consume more of my family's bottom line every year. That's scary, because my family enjoys the best situation possible. We're a healthy bunch with good coverage under a free employer-sponsored plan. But our coverage has changed over the years, due to rising, employer-funded premiums.

We once enjoyed the former gold standard -- a fee-for-service service plan under which we could freely choose our medical providers, visit specialists without referrals and reap 80% coverage for allowable expenses. A "point of service" plan ultimately replaced that coverage. We choose from a network of physicians, whom we can see for nominal co-pays, or we can visit out-of-network doctors, which are typically covered at 70%.

I've never allowed the lure of inexpensive co-pays to dictate the selection of my family's medical professionals. That's especially true when it comes to my children. They see an out-of-network pediatric group that doesn't accept insurance. Some people have gasped when I've mentioned this -- and erroneously assumed that the doctors were unreasonable ogres.

But their insistence on steering clear of insurance companies has meant superior care for my children. It's an office where people remember my name, take their time while speaking with me, and make recommendations based on medical protocol -- not whether we've exceeded a limit for strep tests. As for payment, I write a check and submit the bill to my insurance, just like my mother did upon visiting my old-fashioned childhood pediatrician.

It's always a bonus when my favorite physicians are in-network providers. But I'm also resigned to pay the 30% in some circumstances. The latter option, however, requires me to weigh risks and benefits. For example, if my "out of network" physician discovers a problem that may someday be the onset of a major illness, my family could be stuck with less generous "out of network" insurance reimbursements throughout the process.

In a perfect world, none of us would have to contemplate how to get the most for our health care bucks, or contemplate financial devastation due to illness. Choosing medical services requires far more serious considerations than buying bulk cereal at Costco.

But I'm content with at least having choices -- and coverage -- for as long as the present health-care system exists.

Besides, I've already instructed my family on how to beat the system: We're just not allowed to get sick.