Do patients pay less for less expensive care? Why the CVS/Aetna deal matters.

On a recent trip to urgent care for my child, I began to clearly see how the changes in medicine are affecting our patients and who is benefiting from the bottom line of what is occurring in the U.S. health care system.

A minor injury to my two-year-old son had me waiting patiently to be seen at a local urgent care center. Eventually, a nurse practitioner evaluated, correctly diagnosed and successfully treated my son. (I make it a habit not to treat my own children as I feel it more appropriate to be “mom” instead of “Dr. Jones” to my children in these types of situations). I appreciate nurse practitioners and feel they provide a great service and are filling in gaps in areas of need, especially in this time of physician shortage.

My concern arose as I considered how this medical care visit was truly playing out financially. I paid a copay with my insurance; no big deal; it was $30. My insurance would be covering the majority of the visit. However, ultimately the company running the urgent care facility would be charging the same rate to my insurance and the same copay to me for my care regardless of whether I saw a physician or a nurse practitioner. I went as far as calling a billing specialist in membership services at my insurance company to ask if this was the case. She confirmed that there is indeed not a separate charge for urgent care visits depending on the level of provider seen.

My question to anyone who has seen a nurse practitioner or other qualified individual, “Is your co-pay lower for the service? Do you receive a discount for not seeing the higher paid/more trained physician?” In my situation, there was no reduction of copay. So, if they are collecting the same amount for the service provided despite a disparity in income level of the provider, who benefits from this profit?

The company running the urgent care center reaps the benefits of employing a health care provider with a lower salary than that of a physician. Their smaller salary likely means more profit for the company.

Again, I am in no way against using mid-level providers, nurse practitioners, midwives, etc. They are here to stay and provide an important role in health care moving forward. However, my argument is that if a company is benefitting financially from hiring “cheaper” people to provide care to their patients, they should at least be passing the savings on to the patients who are receiving the care. Often, these companies are looking for the financial bottom line and what they can get away with to reap the most profit. It is a primary responsibility of top administrators to make money for the company, and we can hardly blame them for completing the role they were hired to fulfill.

Transparency is required in these situations. The patient must know they are not seeing a physician- when they could be — for the same cost to themselves and their insurance company. They should have the ability to demand physician care if desired.

A prime example how this business scenario is becoming the future of medicine can be seen in the recently proposed merger of CVS and Aetna. The companies involved are in a massive media campaign to make patients think this is to their benefit. Please remember, these are businesses at the end of the day, and their ultimate goal is to increase financial return to investors. The basic facts are still at play: a drug store is buying an insurance company.

On Wall Street, the widely held belief behind this merger is that by teaming up, CVS and Aetna can have a fighting chance against the behemoth that is “Amazon,” as this online giant attempts to get into prescription drug sales.

Often, the patient is the one to suffer in situations such as this merger, as they will actually pay more and receive less choice. It’s a monopoly, and if your insurance is owned by a drug store company, guess which prescription you will likely receive? The one on formulary at CVS of course! So, if the prescription chosen to treat your condition is on formulary at CVS, there most certainly is less overall cost in the health care transaction. Does the patient pay less since their prescription costs less or a lower copay for seeing a mid-level provider in a “clinic” in CVS stores?

You guessed it, the company will profit each time a prescription is written for a drug under their formulary instead of one that isn’t. The company will also profit each time a mid-level provider sees a patient instead of a physician. Again, is this in the best interest of the patient?

One last piece of information to consider, the Aetna CEO will walk away with $500 million in cash and stock.

This executive, who is not a physician, has much to gain from this merger. I don’t begrudge anyone’s good fortune, but I also don’t believe the media should portray that the patients are the primary ones to benefit in a deal such as this.

Patients and physicians are no longer accepting the status quo and what everyone outside of health care is telling us is “in our best interest.” We see and understand what is going on. We are speaking up and demanding better.

Valerie A. Jones is a obstetrician-gynecologist who blogs at OB Doctor Mom.

Image credit: Shutterstock.com

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