Insurance Changes

Medical insurance, for years, was a drain on our family budget.  We spent way more money buying insurance than we saved on medical bills.  Even the first year I was diagnosed with RA (MCTD initially), we would have been money ahead paying out-of-pocket than paying the extortion payment premium to the mafia insurance company.

My family has had various policies in the past, but have been able to stick with the same terrific insurance for the last dozen years.  Then this summer we learned that our premium would be raised and there were a few rumblings that the company might switch carriers.  I found this an extremely stressful prospect, not believing it possible to get better coverage than we already had.  It was quite a relief when no change was made.

My relief was short-lived.  A few months later, the owners decided that they ought to have switched and actively started looking at different insurance plans.  Once a proposal was in-hand, I was given a copy and allowed to ask questions so that I’d know how I and my family would be affected.  I even posted some of those questions here.  Unfortunately, I was right.  None of the plans offered better coverage.

After all the stress and anxiety surrounding a change in insurance, the owners didn’t accept any of the proposals and stuck with our existing policy.  I was (again) relieved that no change would occur.

Then three weeks ago, I received a letter saying that our carrier would be modifying our prescription coverage effective November 1.  It seems wrong for the existing plan to change the rules!  Expensive medications for things like RA must now be obtained from a mail-order pharmacy.  I immediately wrote to the plan administrator and pointed out that although mail-order pharmacies have a reputation for saving money on medications, those savings are due to the fact that they don’t send patients their medications in a timely manner.  I also asked if there is any recourse when that happens, or if I’ll just be stuck without the prescription that makes it possible for me to walk.

Fortunately, there is a loop-hole.  If my Enbrel doesn’t arrive when it’s supposed to, I can contact the plan administrator and he’ll make arrangements for me to pick up my prescription at a local pharmacy.  Whew!!  It’s not perfect, but I can make this work.  It won’t be without a whole lot of stress, but at least I shouldn’t have to go without my prescription.

Then last week I received a new insurance letter, and I’m starting to feel like I’m on a roller coaster.  Apparently the new prescription requirements aren’t the only change that went into effect the beginning of this month.  Consequently, the company decided to pursue the insurance switch.  It’s official.  Papers have been signed.  We’ll be getting a new carrier on December 1.

From my standpoint, this is bad.

Very, very bad.

  • my premium will be an extra $400 per month
  • the deductible will septuple
  • my out-of-pocket max will more than triple
  • co-pays will be 50% higher

I’ll gulp at the expense, and pay it, though.  Given the cost of my current prescriptions, I’ll still be saving money. 


I’m still thinking about “rules” but between houseguests and insurance, have been pretty busy.


In a comment on my Rules post, swdoc commented:

I wish people in this thread sat in my waiting room!  Our patients do not seem to have the same understanding of the time issues, and I’m not sure would really want to see a rule book.  Everyone is busy, and it takes time away from other tasks to go in to see the doctor; patients often feel their time is not “respected” by the physician, because physicians typically are not  able to stay on schedule.  My patients do not want to make several appointments for several issues – they want them all handled during their 15 minute time slot – though do not think it is appropriate to be delayed because every other patient feels the same way.
Patients are consumers of healthcare, and understandably want to get the most for their money.  I am not a mechanic, and may think the tune-up is more important that the brake job, and would really appreciate the opportunity and understanding from not only the patients, but more importantly, those insurance companies with their rules books!

Do patients want everything handled in fifteen minutes?  No.

Do patients want everything handled in a single appointment?  Yes, whenever possible.

So if it’s not feasible, explain why.

It would be much better to stretch that appointment to 25 or 30 minutes than to have to make a separate trip another day.  Patients assume that a 30 minute appointment will cost more than a 15 minute appointment.  That would be reasonable.  I expect my doctor to be paid for his work.  I honestly thought that he could deal with any number of health problems at a time, then bill my insurance to receive fair compensation for the time and complexity involved.  I was shocked when I learned that’s not the way it works.

I think most people assume that the doctor’s bill will reflect what is owed.  I don’t understand why, if my physician takes time to listen to me and address all my concerns, he isn’t paid for that.  If he has clearly documented four distinct problems, the insurance company should pay for the handling of four problems.  Instead, my doctor gets the same amount of money for a one-problem fifteen minute appointment as he does for a multiple-problem appointment that takes an hour.  That’s wrong!

If I were the one doing four times the work for exactly the same amount of pay, I’d be highly resentful.  It’s no wonder that so many doctors in the blogosphere feel pressured and unappreciated.

Maybe the solution is to be very clear that there are different kinds of appointments so that patient expectations are realistic.

When patients realize that their insurance will only pay for one problem at a time, they might be a lot more understanding of the external forces at play.  I certainly am.

Insurance should pay (for example) $100 for a single-problem visit, $170 for a two-problem visit, and $240 for a three-problem visit.  Don’t get hung up on round numbers, because that’s beside the point.  The point is that it’s less work for the doctor and his staff to handle everything in one appointment instead of in three, so a discount for extra problems handled at the same time is reasonable.  It takes less of everyone’s time to handle multiple things at once.  In a system that permitted this, patients would be explicitly asked how many problems they wished to discuss, and a corresponding amount of time would be scheduled.

Instead, insurance pays for one problem, so doctors only schedule for a single problem.  Patients who don’t understand how this works (because the rule book is a secret) get frustrated.  Insurance companies won’t tell what the rules are because it makes them look like money-grubbing cheapskates.

Insurers try to weasel out of paying fairly.  They greatly discount the doctor’s fee, they play games trying to discourage doctors from ordering needed tests, and make it nearly impossible for patients to get needed treatments.  Well, I can play games, too.  Since my insurance company doesn’t value my doctor’s skill or time, nor do they value my time, I can make it cost the insurer extra.

By planning my appointments carefully, I make it cost the insurer as much as possible and get my doctors more money.  Instead of trying to squeeze three problems into a single appointment, I intentionally schedule separate appointments so that the insurer is on the hook for three times the amount of money.  Some people might point out that I owe an extra copay when I schedule extra appointments.  While this is true, 1) the cost is small compared to the full fee for an office visit, and 2) if I schedule appointments with multiple doctors on the same day, I only owe a copay to one doctor; insurance picks up the full cost of the other appointments.  In the long run, it’s a wash.

Patients expect that their insurers will pay doctors fairly.  It seems as though the first rule patients need to know is that this simple expectation is not met.


For years I’ve viewed the insurance industry as a form of legalized mafia.  Patients feel that they must carry insurance for fear of what will happen in a catastrophe if they don’t have coverage.  Doctors have felt that they must accept insurance for fear that they won’t be able to stay in business otherwise.  Insurers threaten both patients and doctors, intimidating helpless patients into thinking that they’ll die or go bankrupt if they don’t have insurance; doctors face a very real threat of loss of business if they don’t play the insurer’s game.  Exactly how is this different from the protection money extorted by those in organized crime?

I wasn’t around when dinosaurs roamed the earth, but I remember when doctors started posting a little sign saying that the receptionist could help patients file an insurance claim.  Help, because doctors were paid by patients, not insurers.  I was in high school, and didn’t understand what was so hard about shoving a piece of paper into an envelope and affixing a stamp.  Nonetheless, some people found the paperwork confusing and thought it was really nice to have the doctor’s office hand them a nice neat bundle of papers that could be sent to their insurer, knowing that they were providing all the information needed.

That changed over time.  Instead of the receptionist’s help being a wonderful bonus, doctors agreed to bill insurance directly and hired extra staff to do it.

I’m not convinced it’s been a change for the better.  Sure, more things are covered, but at what price?

Why do people pay $1000 per month ($12K per year) to have a “free” annual physical?  Throw in one or two illnesses severe enough to need a doctor, and paying cash to the doctor would cost less than $500 a year for most healthy people.  That extra $11,500 could do quite well in a savings account, accruing interest until the money is needed.

Last year I added up all my medical expenses for the previous couple years.  A zillion doctor’s appointments, physical therapy, medication, x-rays, ultrasounds, blood work, EKG, and a brief stint wearing a king-of-hearts monitor averaged out to significantly less than $1000 per month – and that’s after I was diagnosed with RA.  That’s right.  Even with all those things going on, the insurance company still made a profit off my family.  Now that I’m on Enbrel, I’m costing them money, but for two decades, they made a tidy sum off of my premia.

Doctors are starting to re-evaluate things.  From some blogs I’ve read, it sounds as if the threat of losing patients is no longer as great a deterrent as it once was.  The insurance industry is pushing too hard, and some physicians are deciding that they can’t go on.  They’re either going to retire early or find a different way to practice.  If they stop jumping through the hoops held out by insurance companies, they can spend more time treating patients with significantly less time doing paperwork, document for treatment instead of external audits, pay fewer support staff, and still make a decent living.

Without insurance hassles, cash-only practices sound like a great business model – from the doctor’s perspective.  As a patient, though, I’m not seeing any advantage to my pocketbook.  Right now, I pay $20 every day I visit a doctor’s office (when we change to the new insurance plan, it will be $30).  My insurance picks up the remainder of the cost.  It would not be to my advantage to increase that payment to $100 (FP) or $215 (rheumy), even if there’s a chance I’ll get part of it back.  I have a strong financial incentive to see doctors who accept my insurance.  The mafia might be losing its grip on doctors, but that’s not true for patients.