Take charge of your healthcare quality and costs

Fed up with our health care delivery system? Maybe even angry? What should a person do? What can a person do?

I recently wrote a post on drivers of change in health care delivery such as the aging population, adverse lifestyle behaviors, shortages of physicians and developing consumer expectations. I planned to follow up today with what those drivers will produce as change in the delivery system. But a commentator responded to the post that patients are being shafted by their doctor, insurance company, the pharmaceutical and medical device industries and others. Maybe you feel the same way. You can wait for the government to fix things – but that could be a long wait. Or, you can take some personal action and fix for yourself or your company what actually can be fixed now. So I decided instead to respond today with just a few suggestions that can make a big improvement in care while actually reducing costs. There are others in “The Future of Health Care Delivery – Why It Must Change and How It Will Affect You.”

If you are a CEO or other senior leader of a company consider these options. Offer your employees a high deductible policy, give the employees the premium savings and create medical savings accounts or health savings accounts so staff can purchase care with tax advantaged dollars. Second, offer wellness programs. Let your staff sign up for nutrition, fitness, stress management or smoking cessation programs. But insist on accountability and in return give them a further break on their share of the health insurance premium. These programs work, can be completely cost neutral to offer and the result can be a healthier more productive workforce with enhanced job satisfaction plus a stable or possibly even lower premium level next year. And you don’t have to invent the wheel yourself; just engage a company such as Orriant that organizes these programs to do the work for you, again usually at no incremental cost to your company.

As an individual, here are some steps to personally take. First, sign up for a high deductible policy. Most health insurance today is not insurance in the usual sense of paying a relatively low premium to cover a major event the way auto collision insurance does. Instead, most insurance today is basically “prepaid” health care, i.e., everything including routine care and all prescriptions are covered, perhaps with a co-pay from you. Better to have real insurance, i.e., it covers major expenses such as a hospitalization, surgery, or very expensive medications for cancer treatment, etc while you pay directly for the routine stuff up to a limit that you pick, say $1000-2000 per year. Best if you can use tax advantaged funds in an MSA or HSA for those expenses. (Medicare does not have high deductible policies but both your Medigap insurer and your Medicare Part D prescription plan probably do have them.) The premiums for a high deductible policy are much less and it does one other important thing.  It encourages you as a patient to challenge your doctor’s recommendations. Maybe that prescription could be changed to a less expense option. Or the MRI could be saved until an observation period elapses, etc.

Second be sure you have a primary care physician (PCP). Tell him or her that you have a high deductible policy so you will be paying directly for most care. Then tell the PCP that you want to negotiate a typical professional-client relationship that works for each of you. You will pay for a visit but you want the visit to be long enough and in enough depth that your issues can be carefully reviewed and considered. Maybe ten minutes is plenty for a check to see if a blood pressure medication is doing the job but you need much more time for certain other encounters. Discuss price up front. Expect (insist) to get the time and attention you need given that you are paying at the door for the service.

Ask that the PCP spend some real time each year addressing preventive medicine. How can you stay well and avoid disease today and tomorrow? Perhaps the PCP will need to refer you to a nutritionist or a personal fitness trainer. If so, ask him to call that person and discuss what your needs are; it will make a real difference in what services you get. And the PCP should monitor your progress, perhaps just by telephone or email but with a definite timetable that the two of you agree to up front.

If you have a chronic illness, say type 2 diabetes, then you need to tell your PCP that you expect him or her to carefully coordinate your care. The same principle as with prevention holds here as well. The PCP should directly call any specialist or other provider to explain what the consult is aimed at determining and should request a return call after the consult.  Your PCP should discuss any test, procedure or imaging study with you in detail: Why does he suggest it? What will he do with the results? Is it important or “just to be complete?” The same concept prevails with prescriptions; ask lots of questions.

Understand that most PCPs don’t do extensive prevention or good care coordination today because insurance pays so little that they simply can’t spend the time required. It is different when you are paying the bill yourself. Ask for, expect and if necessary demand the service that you need – it’s your money and your health!

High deductible policies have been shown to be effective in getting us to monitor our own care better, to challenge our providers to explain recommendations and to substantially reduce overall costs. Prevention, when done thoroughly and correctly, offers a major reward down the road, often with a quick payback in better health. And coordination of the care of patients with chronic illnesses is absolutely critical to better quality, to an improved patient experience and to markedly lower costs of care.

Third, check to see of your company has wellness programs. If so, sign up. It will save you money, lead to better health and you will feel better as a result. There is absolutely no downside.

A reasonable question would be why doesn’t the system work this way now? I will save an explanation for a future post on KevinMD.com.  For now, don’t be angry, do something. You really can have better health at lower cost.

Take charge of your healthcare quality and costs   Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery, published by Potomac Books. 

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  • doc99

    If PPACA stands, the HDP will be unable to live up to the MLR provisions. Also, HSA’s will be capped, making them less attractive.

  • southerndoc1

    This doesn’t make sense.
    Even before a patient has met their deductible, they and their doctor are limited to covered services in the contracted fee schedule. This sort of private contracting is not allowed.

    • jstockberger

      Doctors and patients are not limited to services in the contract.  If the insurance company doesn’t cover a particular procedure and you still want to get it, and your doctor can provide it, you pay standard, out of network rates, which are negotiable with some physician groups.  Additionally, the point was made that the patient who is paying out of pocket for a consult, procedure, etc. should make sure that the doctor doesn’t leave the room until their questions are answered.  This takes some prep for the patient before the appointment, by writing down all questions.  I do not believe  that ANY physician would walk away from you before you were finished with your questions.  If they did need to leave, there is probably a PA or NP who would  be happy to work with you.

      Lastly, HDHP’s force us to be consumers, which is a good thing. We have a ways to go in price transparency, and just ask an office manager what the cost for a (fill in procedure here)…they will look at you like you have 2 heads because it costs something different depending upon what color insurance card you have!  Cash pay?  Now you have really stumped them!  You have to be persistent but it is not impossible to comparison shop in medicine, because as the demand for information goes up, supply is sure to follow.

      It is the HMO fest of the 80′s that made us think our insurance should pay for every little thing and we would never see a bill, which has clearly proven to be unsustainable.  We Americans need to go back to basics and remember that the concept of insurance is designed to cover catastrophies, not maintenance! 

      • southerndoc1

        Not exactly. 

        If I’ve contracted with a patient’s insurer, I have to file a claim using standard ICD/CPT coding, even if they haven’t met their deductible. If the patient wants a five hour consulation regarding their diabetes, I still have to submit it using E&M codes with various modifiers, and the insurer will tell me how much I have to write off and how much I can charge the patient, based on my negociated fee schedule. If I use a CPT code for preventative services or care coordination, the allowed fee will probably be zero dollars and zero cents. I can’t charge the patient anything. Similarly, if a patient wants a cardiologist to perform a catherterization as a screening procedure, the allowed fee for that procedure for that reason will be zippo, and the doc won’t be able to collect anything.The ability of patient and physician to negociate fees is almost non-existent if they have contracts with the same insurer.  

        • jstockberger

          I believe you misunderstood me, or maybe I misunderstood you.  If I want a uterine ablation and my insurance doesn’t cover it, but you are able to provide it, don’t you have the ability to bill me on a cash basis and send me a bill directly?  Then I take my bill and pay it (you) out of pocket and file for reimbursement from my HSA.  Most independant physician groups set their own procedure rates, which can be negotiable.  The difficult part can be finding an independant physician group, as most are owned by larger health systems!

          I have personally done this as a patient. I am in MN, maybe we do things differently here.   

  • MissMauer7

    Yes!  I wish more companies would realize the value of wellness programs, etc.  Where I work, we have a HDHP available to us (which I use), as well as an advocacy service and wellness program (both run by Health Advocate).  The advocacy service has expedited doctor appointments for me as well as save me money (finding billing errors for me, etc).  The wellness program is convenient because it gives me online access to webinars, food trackers, and even a wellness coach to answer my questions.  These types of programs go a long way to making sure employees put their health first and focus on preventive care.

  • sFord48

    I have a high deductible plan.  If I want medical service to apply toward that deductible, my medical provider has to bill the insurance.  I can pay the cash price with the cash price discount but that is quite a bit more than the insurance negotiated price.  And I still have a doctor who has to see 40 patients and doesn’t do any urgent care.

    I am more careful on what I care I receive with my high deductible plan.  I do extensive research on symptoms and am willing to diagnose and treat myself based on what I found.  I am not going to pay for that visit for something I can find on the internet.  I am also willing to skip primary care and see a specialist if warranted.  Many times a trip to a PCP is just another expense.  I am comfortable coordinating my own care.  A few years ago during a difficult financial period, I couldn’t afford treatment for a potentially life threatening condition.  I dealt with it on my own.

    To save money, for acute problems that seem straight forward, I go to the urgent care clinic staffed by nurse practitioners.

  • futuredoc

    Thanks for the comments. Here are some personal examples of how a high deductible policy led me to challenge and ask questions – and save money. 

    An ENT give me a prescription for Nasonex along with a free sample. When I went to the pharmacy to pick up the prescription I was told it would be $97. So I asked what else was similar at a lower price. How about Flonase for $7 was the response. I called the ENT who said that would be just as fine. “I only gave you Nasonex becasue I had the free sample.”
    When I needed some speech pathologist assistance, I first had a stroboscopy examination done. When my treatments were over, she said they wanted to repeat the test. I asked why. “We always repeat it to see how things look.” “But I am fine now and besides that test costs $702. I am on Medicare which will pay for part of it but my Medigap is high deductible.” She agreed I didn’t need the test.
    In both cases, I avoided a highly expensive  drug or test because it was in my own self interest to do so. Otherwise I would have just ignored the costs.

    Stephen Schimpff, MD

    • southerndoc1

      But my point is that, even with a high deductible, you and the physician are prohibited from negociating for services, either covered or non-covered, which seemed to be the whole point of your original post. Fees are in the contract and set in stone, whether applied to the deductible or not.

  • Brian

    southerndoc1 and sFord48 both point out barriers to the type of care that Dr. Schimpff writes about.  As I’ve said before on this forum, HDHP/HSAs have gotten a bad rap because those paying directly for their care are still generally confined to getting care in the high-cost, insurance-centered system.  Insurance contracts (as southerndoc1 has pointed out) are also a barrier, as well as the question of care delivered outside of the confines of the contract not being applied to the deductible.  The number of direct-pay physicians is growing, and I have heard anecdotal evidence that insurers are taking notice and that we may see some offering “wrap-around” high-deductible policies that would address these problems.

  • katerinahurd

    Do you endorse an economic informed consent?  Are you describing in your blog that the role of a health coach is to assist the patient- employee to take charge of his health care quality and costs?

  • futuredoc

    There are definite barriers as a few of you have noted to getting the type of extended attention even with  high deductible policies. I appreciate the comments. As Brian noted, more and more PCPs are simply no longer accepting any insurance – they expect either pay at the door or have gone retainer-based.

    A health coach through a wellness program can add to the value of the program. It is sort of like having a personal trainer at the gym – making suggestions, giving encouragement and measuring results can make the program more effective. And it is even more effective yet if the program requires some level of accountability in order to obtain the benefit of a reduction in premium payments
    Stephen Schimpff