Wednesday, March 24, 2010
Consider a Doctor Who's Not a "Preferred Provider"
This post by Alan Dappen, MD appeared at Better Health. Dr. Dappen founded Doctalker Family Medicine, which is discussed in this article.
Many companies and consumers are turning to higher-deductible health care plans in order to keep their insurance policies more affordable. The rational basis of these plans is that since you're using your money and you are in control, you will pay more attention to what is really being offered to you as well as to the cost relative to value. You will be more likely to challenge your doctor to provide the rationale for an expensive test or drug, and to encourage your doctor to innovate to provide lower-cost alternatives.
A trap of these new health plans, as currently structured, is that you're herded into in-network preferred providers. The rationale of the insurance company is that they can control doctors' prices, thus brokering a better rate for you. They also want to use your loyalty to the network to control physicians' practices. "Preferred," in reality, does not refer to quality; rather, it just means the doctor has signed an agreement with the insurance company, binding them to the insurance company rules, which favor the insurance company, not the patient.
In most cases, there are good reasons to go out of network for your day-to-day health care. First of all, insurance companies place strict rules on their in-network providers. For example, in-network providers can't be paid without an office visit, so you're forced to come to their office for everything, even though evidence shows that office visits are required for less than half of primary care problems. Second, all medical information the in-network provider receives on you is sent to the insurance company. Insurance companies often will use your health information to justify denials of future care. If you want to protect your confidentiality, don't go through your deductible. Finally, if you find a doctor who works outside the network, these providers may be able to work more efficiently, with greater access and convenience for the patient, while charging the same or lower prices than the discounted rate provided by the insurance company.
However, most people are reluctant to go outside the network, because they fear it will result in higher cost. Insurance companies warn that if you go to a physician 'outside the network' the value of your deductible will double, for example, instead of a $2,000 deductible, it could be $4,000. This makes it look like going out of network could increase your costs by $2,000.
But, in fact, for primary care physicians, this logic does not apply. Why is that?
1) There are an increasing number of doctors who are providing primary care at a much lower cost rate than the standard model, either by avoiding the administrative burden of the insurance system, or by finding more efficient ways to provide care.
2) Most out of pocket costs are not actually to see your family doctor or other primary care providers. Most of the expenses go for laboratory tests, medications, emergency room visits and specialist consultants. For these, you may indeed want to stay within your preferred provider network to capture the discounts on these major costs. But your out-of-network physician can order these for you, and you can still get the discounts.
3) Primary care visits with a physician average $400-500 per year; lower-cost innovators like Doctalker Family Medicine, who charge based on time, rather than diagnosis, and avoid insurance-related expenses, and use modern information technology, can provide that service for $300 per year. This is thus a small percentage of the deductible.
4) Out-of-network physicians can provide other qualities worth any small difference in price, like convenience, accessibility, patient education, high knowledge base, tailoring care to your needs, patient control.
5) Many out-of-network providers can use their flexible situation to hunt out low-cost options for other elements of your care, such as X-rays, labs, etc., that may be significantly cheaper than the negotiated rate of your insurance company.
6) In many years, you won't go through your deductible, so you won't move into insurance coverage anyway. When you do go over the deductible, it is usually because you have had some major health problem, an accident, a surgery, etc., and then the difference in deductible qualification won't make any difference. You will go far over the deductible. For example, an ER visit could easily cost $2,000; a typical one-day hospital stay costs $10,000.
7) In many insurance plants, numerous types of care are not eligible to be counted towards your deductible anyway, such as vaccines, travel medicine or weight control.
The bottom line: don't be distracted by the deductible. Your health is too important. The most important criteria for choosing your primary care doctor should be competence, access and trust. Primary care accounts for such a small percentage of your total health care costs, that you shouldn't worry about whether he or she is a preferred provider; this might impact the quality of doctor you choose. Plus, you may even save money by going out of network.
Until next week, I remain yours in primary care,
Alan Dappen, MD
This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- QD: News Every Day--The 'single-pen' theory
- QD: News Every Day--Who will cover 32 million more...
- Six Reactions to the Health Care Reform Plan
- House passes health reform, now Senate will mull f...
- Does Pay for Performance Improve Health Care Quali...
- QD: News Every Day--Sunday House vote may set up S...
- QD: News Every Day--Spend more to save more
- Insurance Companies Should Pay Primary Care Physic...
- QD: News Every Day--Health care reform amid rising...
- QD: News Every Day--When did voting become passe?
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.