Blog | 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.