Hospitals are suing patients. It’s a scary time in healthcare now that hospitals have resorted to filing suit against delinquent patients. The New York Times reported on this last month, which was only five months after NPR reported the same thing. It’s no wonder that most major 2020 Democratic presidential hopefuls have robust plans for changing the healthcare industry. According to both NPR, and the Times, the suits are generally filed, not against uninsured patients but against underinsured patients. These are individuals who thought they were covered for medical expenses, but it turns out that they are absolutely not. At least they aren’t covered to the extent they should be.
For these patients, the real killer to the wallet is the two-headed monster of deductibles and copays. These two are the scourge of patients all over the country. Think about it for a second. If you get your insurance through your employer, you probably pay a monthly premium. On top of that, every time you visit a provider you shell out an additional fee that probably ranges from $5-$40. On top of that, if you are unfortunate enough require a procedure of some sort, you need to pay for some of that out of pocket. My daughter required a relatively routine procedure earlier this year that cost me $200 out of pocket. The total expenditures of procedures and expenses not covered by insurance amounts to a deductible, or the total out-of-pocket fees you have to pay annually before insurance begins to cover 100% of costs. This number varies widely depending on your level of coverage and your insurance provider. And of course, copays don’t count toward this total. One obvious contributor to this issue has been the Affordable Care Act (ACA) or ObamaCare. Plans under the ACA offer low premiums with high copays and deductibles. And it isn’t just those who buy their plans through the ACA who experience this problem. Since the launch of the ACA, many employer-based plans have kept their premiums down while raising the deductibles and copays.
If you listen to the stories of underinsured patients, it’s not the one-time fees that hurt the most; it’s the various follow-ups and medication copays that really put a strain on families. People understand that a medical expense can occur unexpectedly, and a lot of people try to plan for that. But what people tend to not plan for are all the expenses that come after the initial event. Doctors have to make sure everything is fine with the patient, and because of that, post-op patients have to come in for more appointments. This equates to more copays for visits and medications.
According to a 2016 survey conducted by the Commonwealth Fund, 41 million Americans (28% of the population) are underinsured, which was up from 31 million (23%) from just two years prior in 2014. To give you an idea of how large that number is, according the Census Bureau, in 2017 there were only 27.3 million uninsured Americans. The underinsured are becoming the forgotten class, and it is widely this population that’s being squeezed by copays and deductibles. It therefore follows that politicians, especially Progressives, are moving toward Medicare for All, wherein copays and deductibles are eliminated. This would certainly bring much-needed relief to families having to pay off large financial burdens from their ailments.
But this leaves quite an obvious question: If a larger segment of the population is being affected by underinsurance, why are we jumping to Medicare for All? Just go after the copays and deductibles. Now, before we get into this, I hear all those of you who back Medicare for All yelling, “Because Medicare for All would solve this issue and the uninsured issue.” We’ll get to that answer. I promise. For now, let’s look at the reasoning behind these two menaces to our healthcare finances. Both copays and deductibles are put into place for insurance for the insurers. Insurance companies don’t want to pay for unnecessary expenditures. Copays and deductibles are there to deter patients from seeing a medical provider for frivolous reasons. If you have to pay just a little extra, you are more likely to see the doctor only for real reasons. And if you don’t think this currently happens with Medicaid patients, you are absolutely wrong. Medicaid patients enjoy little or no copays, especially if they get care in certain health centers where they are legally not allowed to charge copays to Medicaid beneficiaries. Because of this, there are so-called “daily patients” who come in to waiting rooms and wait to be seen since they have nothing else to do. This is a problem that would be exacerbated with Medicare for All. If every patient in America would no longer be inhibited by the copay and deductible, we will see an even larger strain on our system than we currently have. (See, I told you we’d get there.)
The more practical and more doable answer is to look for a way (or, better yet, a fiscal reason) to reduce or eliminate these extraneous expenses. So because I have a weekly column read by tens of tens of people, I figures that qualifies me to give my opinion. So here goes. Deductibles and copays are obviously necessary for the reasons I have already mentioned. But follow-up appointments for the same issue are certainly not at risk for unnecessary medical visits. If a doctor believes you need to come in for a follow-up, that is already a reason to believe that this isn’t a frivolous visit. The need for a copay is nonexistent. Picture this: A man goes into remission from cancer. For the rest of his life he will need to monitor the potential for it to return. Right now, those visits would require a copay. Why? What are we worried about? The physician asked him to return! There’s even a code doctors can use in their notes to explain that this was a follow-up exam (Z09, if you are wondering). I do believe there is a reason for a copay the first time you see a doctor for an issue, but not for every subsequent visit afterward. Patients dealing with life-long issues would be saving hundreds, if not thousands, over the course of their lives!
You know who understands this? Insurance companies. In fact, most insurers are in the process of changing the ways they reimburse providers. As of now, doctors get paid for providing a service. You see the doctor for a sick visit, a physical, a procedure, and insurance companies write the check to pay for that work. This is called fee for service. Insurers are now looking to change reimbursement to pay for performance. It’s not enough to provide a service to your patient, but we want you to do it well. So, if you perform an appendectomy, the insurance companies won’t pay extra if there is a complication from the surgery you performed. If that patient has to come back to you and get another procedure, they either won’t pay for it, or pay less for it. It’s all about how well you perform. All subsequent follow-up visits and other necessary treatments will be part of the same payment. I call this the Brian Regan method of payment. If you aren’t familiar, please listen to comedian Brian Regan’s analysis of how lawyers are paid.
Why can’t we apply the same idea on the patient’s side? The patient who received the appendectomy already paid his initial copay, and probably the required fee for the surgery that came out of his deductible. At this point the patient doesn’t come back to the doctor unless the doctor asks him to or if there is a problem. It will all be a part of the same performance, so why not eliminate the copays from future visits the same way that the insurance companies are trying to do? The answer is that insurance companies already force you to pay that copay, so why would they want to change? The same way that individuals don’t like when they have things taken away from them, corporations don’t like when things are taken away either. But in this free-market economy, all it takes is for one company to make that change and see people flock to them for coverage to begin to see this become industry standard. So, if by any chance there is some executive from an insurance company out there reading the January 13, 2019, edition of the Queens Jewish Link, please take this suggestion to heart. I am available for a follow-up article.
Izzo Zwiren is the host of The Jewish Living Podcast, where he and his guests delve into any and all areas of Orthodox Judaism.