NEW YORK (MainStreet)The healthcare industry is in a murky transition. What the landscape of the entire sector will look like three years from now could be vastly different from what it is today. As a result, there is confusion among consumers concerning the smartest, most efficient way to spend their healthcare dollars.
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Unfortunately, there is no quick answer to this. There is no umbrella statement that can be made. This is mostly because health insurance greatly varies depending on region, employer and provider.
Right now, many plans offer in-network and out-of-network benefits. If a patient books an appointment with an in-network provider, the provider is contracted with the insurance company. This means the health insurance company agrees to pay a particular set rate for services, and every patient is responsible for a set rate usually this is called a co-pay.
When a provider is out-of network, it is not contracted with the insurance company. The provider sets its own rate. Health insurance companies pay an allowed amount to an out-of-network provider. This allowed amount is based on many contributing factors including demographic location, similar Medicare reimbursement and an internal system of rating services. When a patient uses an out-of-network provider, the patient is often responsible for his deductible and coinsurance.
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Many providers are often forced out-of-network because of lack of contract negotiations with practitioners not tied to larger hospitals and the rising cost of treating a patient. Others drop out simply because they can build a better business being out-of-network depending on their location. Consumers often seek out-of-network providers because they believe they are receiving a better quality of care from them. Professor James Burgess, a health economist who teaches health policy and management at Boston University's School of Public Health, does not believe that spending more healthcare dollars on an out-of-network provider gains a patient a better quality of care.
"Generally, this is not true, but part of the problem is defining what we mean by quality of care," he said. "There is not a clear metric for quality. It is multi-dimensional and encompasses four aspects: patient experience, structure, process, and outcome."
He went on in detail to explain how structure and process are measured in the way in which they are delivered while outcomes measure if a patient got better, died or had a complication. He added that often these measures do not appear together and noted that the people who design them and work in the field do not regularly understand them.
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"Insurance coverage and care you need also are not that well connected to each other," he said. "Sometimes you get a great deal, sometimes you get a terrible deal and sometimes you get no deal. The problem is that people are complex. They have many complex conditions that interact with each other and insurance pays for "things done to patients." This is sometimes related to what they need, but often not."
For example, if someone walks into a doctor complaining of a pain in his leg, the doctor may examine their leg and bill to insurance for their leg in the visit; however, the patient really might have a back problem like sciatica, and the back problem and the leg pain might be one in the same.
While insurance companies are covering conditions one body part at a time, the horror stories about medical debt mount.
"Medical debt happens not at all just from lack of insurance," Burgess said. "The Affordable Care Act is supposed to decrease how often this happens from 'pre-existing conditions.' This is a huge problem in many states. However, sometimes insurance does not cover what is needed, or bought, or enough of what is needed or bought. Patients sometimes end up with very large payments anyway, and patients do not have a good idea of what is expensive."
Measuring what is expensive in an industry responsible for health and well-being can be difficult. Just ask five random people what they think an MRI costs, and then call five facilities that administer MRIs ranging from private companies with free standing machines to hospitals and the numbers will be all over the place.
Many insurance plans also have hard caps on the number of treatments for a given condition. Patients need to be aware if hard caps are part of their plan. These caps can range from cancer to physical therapy. For example, a patient going for cancer treatment might believe they have full coverage, but after a certain number of treatments they will reach the maximum covered by their plan.
Despite hard caps and the measure of what is expensive, a Nielsen Report called "New Wealth, New World: How We Shop Around The Globe" indicates that 43% of people in North America are spending their healthcare dollars based on price. 29% are spending based on quality, and 27% are spending based on function. The Nielsen Global Survey of Consumer Shopping Behavior was conducted between August 10 and September 7, 2012, and polled more than 29,000 online consumers in 58 countries.
As Americans book medical appointments and fill prescriptions, the cost of premiums appear to go up each year and more money will be taken out of each paycheck. Where are premium dollars going? Almost every major health insurance company makes the Forbes 500 every year.
Health Senior Research Analyst Patrick Riley of Frost & Sullivan described where this money is projected to go, "Insurance premiums are a function of an insured population," he said. "The Affordable Care Act requires health insurance companies to maintain medical loss ratios at a minimum of 80%. It is the law. This means that 80% of premiums must be spent on healthcare delivery." He agreed that financial reporting for large insurance companies has been encouraging and that net profits are up and briefly spoke on the fact that premiums are down for the most part.
As a consumer--whether the patient's condition is sciatica, or frozen shoulder, or something more chronic like Crohn's disease--the best course of action to protect healthcare dollars is to research the practitioner and make the determination if this provider is really worth the money.
Ask the question: "Am I getting what I am paying for?" Prior to the first visit, ask the billing office how much the appointment is going to be, and if possible get everything in writing. Insurance companies can change policies every year in January. In January, check your carrier's website to see if there are vast changes to your plan.
--Written by Leigh Held for MainStreet