Physician Patient

Consumers need to ask how much their health care costs and where the money is going

How much does my medical care cost? This question usually goes unanswered today in the Minnesota health care system. Unless a doctor is a Direct Pay physician and posts his or her fees, most doctors don’t know. Certainly the insurance company doesn’t know what your care will cost until after care is provided to you or your family and “adjustments” are made to the clinic or hospital bill regarding how much they will actually pay. The pharmacist runs the insurance card to see what of your doctor’s prescription is covered and what your co-pay will be. And, if you pay cash at the pharmacy (or clinic), the price actually goes up! What’s this about?

David Goldhill says that the consumer is the only player in our health care system who can ultimately change these realities (StarTribune, September 25, 2014 But, sadly Minnesota consumers are largely insulated from the prices of their health care.

As consumers evaluate their 2015 Minnesota health plan policy rates and shop for health insurance during Open Season this November (hopefully rates will be available very soon from MNsure), They will compare monthly health care insurance policy costs and what they will pay out of pocket before the “insurance” kicks in.
Here are pertinent questions consumers should consider before choosing a health care insurance policy or doctor or clinic:

Quality: Who are the doctors, clinics, and hospitals under contract in the health plan’s provider network? I want to have ready access to their credentials and the clinical experience of available doctors and other professionals who have treated cases similar to mine, especially if I am sick and/or have known diseases or problems.
Choice: Does my health insurance or clinic provide useful tools to help me find a doctor whose training and clinical care experience is best suited to my case or needs? What tools are there (online or by phone) for me to be personally evaluate and if necessary decide how and when to change doctors or clinics? If I have a health care savings account (HSA), do I need to go exclusively to care providers under contract with the insurance company in order to satisfy the insurance deductible (is the plan compatible with my HSA)?
Access: When I want to get a timely appointment with a well trained, credentialed physician or health care professional, does my policy offer a wide range of accessible care venues — such as store front clinics, Urgent Care, and ongoing specialty care? Can I find a trusting doctor-patient relationship?

Cost: How much will I pay to see the doctor, for lab tests, imaging and procedures? Are these prices available online through the clinic website? Can I find out online exactly what the insurance will pay a doctor or clinic for recommended procedures, lab tests or imaging? Can I shop for these? How much will I pay out-of pocket? Is the insurance policy compatible with using my HSA to pay for retail medical services while also satisfying the insurance deductible — what rules apply?

Provider bonuses and pay-for performance incentives: Do clinics or doctors in the insurance plan’s provider network receive increased pay for prescribing or not prescribing specified drugs or treatments or ordering or not ordering certain lab tests or imaging? If I want to know the financial incentives and arrangements for my “providers” who I am paying directly or indirectly, can I find out?

As David Goldhill advises, “Let’s reduce the role of the big intermediaries who have allowed our system to become so expensive and opaque, and increase [the power] of the one force that can drive good behavior — the consumer.”

When a mighty mouse consumer knows how much her medical care really costs — that is, who is getting paid, how much, and for what — she may well become the mouse that roars!

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