How should health insurance be used?

[Deleted]

Do you go to the hospital for a mammogram? Or through your regular doctor? Because i would think it would be difficult to constantly be a 'new patient'? ... and wonder if doctors would even allow you to do that?

[whoisjohngalt]

I could be wrong, but I was under impression that insurance pays ABC for an XYZ procedure and it really doesn't matter where you do it and how much that doctor/hospital charges. So, what does shopping around would accomplish?

Lena

[Deleted]

Yeah... if your plan pays 75$ and doctor one charges 100$ and doctor 2 charges 150$, either one would still only get 75$... now i guess if someone charged 50$ instead... but i'd have to wonder why they generally charge UNDER the minimal negotiated payment the insurance provides...

[The Walk of the Penguin Mich]

I could be wrong, but I was under impression that insurance pays ABC for an XYZ procedure and it really doesn't matter where you do it and how much that doctor/hospital charges. So, what does shopping around would accomplish?

This is correct.

[ihearyou2]

In order to understand medical care, you need to step into the doctor's shoe's. Over the past thirty years everything has moved into liability and potential litigious patients. This has caused enormous changes in the medical landscape. If you take a look at something as simple as giving birth a common procedure. The growth in C-sections is astounding due to the fact that it is considered a less complicated procedure. Breech babies doctors want a C section, a long labor c section, always to avoid liability. You had a C section then the next should be a C section.

This is part of what causes the rise in cost, doctors are frightened rabbits and want to give patients all the tests necessary, "just in case" not because they think its necessary but so they can say they did that test if they get sued. Doctors will pressure you for tests so they can cover their ass not because it is necessary or probable. Those tests run their own risks of false positives and so on but that is another subject.

[daennera]

I'm not entirely sure where you get mammograms at actually. I've never had one. I'm only 27 with no familial history. Since I do know that the outpatient clinics in our area do have the ability to run other tests (labs, x rays, cat scans) I would imagine I would go to one of them for a mammogram.

I guess you pick your surgeon for a surgery. But that is so weird that your surgeon is not in your network but the hospital is. All the hospitals in my area require that any doctors (surgeons, anesthesiologists, etc) that work out of that hospital accept the same insurance the hospital does. They implemented that almost a decade ago so people would not be hit with charges from a surgeon or an anesthesiologist who was not in the same network the hospital was. I remember being really really little and needing surgery and my mom trying to coordinate all the personnel for the surgery so that it would all be covered by insurance. Later when my sister needed surgery, they said she didn't have to do all that anymore as any procedures done in the hospital are required to be covered by insurance that the hospital accepts.

Which makes sense and I'm extremely surprised that all hospitals are not this way anymore.

[Angel!]

Jan 19, 2011 12:50:28 GMT -5 whoisjohngalt said:

I could be wrong, but I was under impression that insurance pays ABC for an XYZ procedure and it really doesn't matter where you do it and how much that doctor/hospital charges. So, what does shopping around would accomplish?

I was wondering the same thing. For the most part, for a doctor or hospital to be in-network they have to accept what an insurance company is willing to pay for a procedure. I can't imagine the costs vary too significantly when you are going through insurance. My doctors can bill whatever they want, but insurance only will pay X. So calling to find out what a doctor bills is kind of pointless.

[daennera]

And yes, my insurance does only pay the negotiated rate. But I still have to spend the first $500 in a year to do that. And I know for a fact that the negotiated rates are not the same between all hospitals. Hospital A might have a negotiated rate of $200 for a procedure and Hospital B might have a negotiated rate of only $150. Even after my deductible I still have to pay 20% of the negotiated rates. And I'd much rather pay 20% of 150 than 200.

[ihearyou2]

Jan 19, 2011 12:55:45 GMT -5 Lady Gaga Gaga Snerd said:

If you take a look at something as simple as giving birth

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What is simple about giving birth? There is a real risk of maternal and infant mortality.

Statisitcs in America? For the quantity of births we are actually realtively high in comparison to other countries but that number is very low overall.

[The Walk of the Penguin Mich]

I'd rather pay 20% of whereever I'd get the best care.

You're only talking about the difference between $30 and $40. Is that little really a dealbreaker for you? You probably spend that amount of time at work trying to get the answers as to which facility charges the cheapest price.

[Deleted]

I'd think i'd want my primary care persons to be getting information on my mammogram, etc.... I'd think i'd want centralized records and someone who knows my entire picture, as it were... i use the lab at my gen pract... if necessary... for instance... and hospital my obgyn uses... ?...

[daennera]

I was using 150 and 200 as examples. Of course the higher the dollar amount the more return you get by shopping around. And again, does something as routine as let's say an appendectomy really require the greatest surgeon on the planet? Or is that something your average physician can handle just fine? Why pay for the the world renowned nobel prize winning physician when the average physician will do fine?

[Deleted]

Yeah, if my doc says i need an appendectomy, i'm not going to waste a lot of time shopping it around...

[Angel!]

Jan 19, 2011 13:05:35 GMT -5 @daennera said:

I was using 150 and 200 as examples. Of course the higher the dollar amount the more return you get by shopping around. And again, does something as routine as let's say an appendectomy really require the greatest surgeon on the planet? Or is that something your average physician can handle just fine? Why pay for the the world renowned nobel prize winning physician when the average physician will do fine?

You are really oversimplifying this. With something as complex as an appendectomy you won't just have a single bill from the doc you choose. You will have the doctor's bill, a hospital bill, and an anesthesiologists bill at a minimum. Even if you pick a cheap doc, you aren't going to necessarily have a choice to which hospital or which anesthesioligist you get. There are probably different options as to how the surgery is performed as well. There might be a more expensive type of surgery that requires a more experienced doctor, but is less invasive & requires less healing time. So why would you want to cheap out on stuff like that.

Price is not the only factor to consider at all. I would rather find a good doctor I like even if I pay more for my health care.

[The Walk of the Penguin Mich]

Why pay for the the world renowned nobel prize winning physician when the average physician will do fine?

Again, I'll use hip replacements as an example as this is what I know best.

There is one guy who has now had his 8th surgery on his same hip in the last 2 years. He went to a local yokel, who does not have a volume practice. Hip replacements are surgeries where you want your surgeon to do a LOT of them. Practice makes perfect.

He got an infection in his joint. They pulled it out (#2) and put him on antibiotics. They put the hip back in (#3), they had to do #4 almost immediately afterwards since something broke. He now has another infection in the joint so it needs to be pulled out again (#5) with another spacer put in. Later, rinse, repeat with yet another infection.

He has gone to the same surgeon each time, despite being told that he should likely go elsewhere since even though he *should* have had an uneventful primary hip replacement, repeated infections at the same facility screams that there is something really screwy in the OR protocols.

You do not need a Nobel prize winner, but you need to realize that doctors graduate at the bottom of their class too and not all of them are good. Some should never be doctors and you, as the patient, need to be your own advocate since no one else will.

[Gardening Grandma]

And again, does something as routine as let's say an appendectomy really require the greatest surgeon on the planet? Or is that something your average physician can handle just fine? Why pay for the the world renowned nobel prize winning physician when the average physician will do fine?
1) My physician does not do appendectomies - I don't think there are many general practicioners who do. She would refer me to a surgeon.
2) My insurance company pays xxx amount for a procedure. It doesn't matter who does the work (as long as they are on the ins co's list).

You are 27, have never had a mamogram and it appears that you've never had surgery. You have great insurance and world renowned hospitals to choose from.

I'm 66, have been having mamograms for 30 years, have had surgery three times (not counting smaller procedure done in the office). My insurance company pays x amount for a procedure and has a short list of approved providers and you tell me I should "shop around".... Hmmmm...

[ysi]

I hate going to the dr. I sound like a lunatic and I know it. I would rather have a drs appt via a forum like this where I could type out my info, they could ask any questions, I could type my replies, and keep everything organized and on topic. If they then need to see me in person either for physical exam or labs etc I would be scheduled for onsite visit. Also, there is always some form of visual/auditory/olfactory/mental bias during an in person appt, whether you are hot hot hot or disgusting LOL.

I was just at the dr Mon. 6mos fu at 10mos. I described alarming (to me) reactions to a "new" drug. The dr wanted to increase the dosage OMG. By the time I had described severe flu, food poisoning (twice), engorged ears, exploding head syndrome, chest pain, hand numbness, edema, skipped monthly, meter readings, wt gain and loss-well, neither the nurse nor the dr could keep it all straight having it all delivered verbally all at once. I saved the skin rashes with vascular locations for next time :-)

[dancinmama]

I too usually take a "wait and see approach" when it comes to going to the doctor especially when it comes to common ailments - cold, flu, tummy problems, etc.

First, there are SICK PEOPLE there. I don't want to unnecessarily expose myself to them or them to me.

Second, just because I have insurance does not mean that I should go to the doctor just because I am sick. I can't remember how many times people I knew would run to the doctor any time they were sick because "it was free" (okay, that was back in the day). But still, they abused the benefit.

Third, most common ailments just need to run their course. Case in point: DH has had a head/chest cold for three weeks. He has green sludge, but is not running a fever. I told him that if he wasn't running a fever it was a virus and that the dr. would not be able to help him. We did call the doc cuz our provider will let you talk to a dr over the phone in lieu of coming in AND at NO CHARGE. I LOVE this about them. Dr. told DH that it was a virus and that it would just need to run its course.

If you know your body and listen to it, you can USUALLY tell the difference between something that really needs attention and something that doesn't; when in doubt - call the doc.

[cytoglycerine]

Jan 19, 2011 12:58:47 GMT -5 ihearyou2 said:

Jan 19, 2011 12:55:45 GMT -5 Lady Gaga Gaga Snerd said:

If you take a look at something as simple as giving birth

Read more: notmsnmoney.proboards.com/index.cgi?board=finance&action=display&thread=1883&page=2#ixzz1BVNEjE17
What is simple about giving birth? There is a real risk of maternal and infant mortality.

Statisitcs in America? For the quantity of births we are actually realtively high in comparison to other countries but that number is very low overall.

According to my copy of the Canadian Oxford World Atlas 6th Edition that I have sitting next to my desk, the 2007 infant mortality rate for the United States was 7 deaths per 1000 live births (0.7%).

From Wikipedia under topic "Maternal Death" --- "In the United States, the maternal death rate was 11 maternal deaths per 100,000 live births in 2005.[11] This rose to 13.3 per 100,000 in 2006.[12] "Lifetime risk of maternal death" accounts for number of pregnancies and risk. In sub-Saharan Africa the lifetime risk of maternal death is 1 in 16, for developed nations only 1 in 2,800."

So while the risk of maternal and infant mortality does indeed exist in the US, I'd hardly think of it as something that's worth laying awake at night worrying about.

[michelyn8]

You had a C section then the next should be a C section.



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Not always. Subsequent C-Sections are dependant on "how" the surgeon cuts the uterus. Horizontal, its safe to try labor and vaginal birth. Vertical cut requires a repeat C-Section due to the possibility of the uterus rupturing. However, this is information I researched in mid-80's because the birth of my first child was a C-Section and may no longer be relevant. For the record though, I had my 2nd and 3rd via vaginal birth with no complications.

That said, I can see how more Dr's might be doing the vertical cuts since a low horizontal cut like mine means extra work to get the bladder out of the way. Not sure if they have to do that with a vertical but then I can see Dr's may also be leary of even trying the normal labor/birth cycle with someone who's had a prior C-Section because if things go wrong someone will shout malpractice.

[Anne_in_VA]

All the hospitals in my area require that any doctors (surgeons, anesthesiologists, etc) that work out of that hospital accept the same insurance the hospital does.

Daennera - This does not happen in many areas. A friend recently had outpatient surgery at a local hospital and was discharged the same day. She subsequently received a bill from the anethesiologist (sp?) who is not in our insurance's network. Come to find out, none of the anesthesiologists in our area are in our network and because that practice covers just about all the hospitals in our area, they don't negotiate rates.

[ronbuck]

Jan 19, 2011 12:21:21 GMT -5 @daennera said:

You can still shop your health care. My insurance covers all of the hospitals and outpatient clinics in the area. I still go to the one that I know is most cost effective and charges the insurance the least.
quote]

Serious health care shopper here, but I carry only a catastrophic policy.....the first $5000/year is out of pocket. I am very careful about checking any medical advice I am given, starting with asking the doc a lot of questions about options, outcomes, and probibilities. In an emergency, I will pay whatever I need to. But so little in life is an emergency.

I paid $5,000 for a procedure about six years ago which has since saved me close to the same in savings on prescription costs in addition to making life more enjoyable. It was a good buy and provided great value.

I have a friend who recently went through $6000 in testing because he was a bit anemic. Each successive test was negative, so another was recommended. Finally he said no more, and his original doc put him on an iron supplement after he (the doc) realized that my friend doesn't eat much meat. The anemia is improving. A little more communication might have prevented all the testing. The doc could have asked more questions. And my friend certainly should have.

A generation ago, the doc would have put him on the iron and told him to come back in 2 months to retest. But docs do a lot more defensive medicine now, and cost is not a factor in the decision because someone else is paying for it, whether the insurance company or the government.

It is awfully hard to make good consumer choices when we don't know what something costs. And there is no reason to keep cost reasonable if it is not a factor in consumer purchases.

[Deleted]

Jan 20, 2011 18:58:42 GMT -5 ronbuck said:

Serious health care shopper here, but I carry only a catastrophic policy.....the first $5000/year is out of pocket. I am very careful about checking any medical advice I am given, starting with asking the doc a lot of questions about options, outcomes, and probibilities. In an emergency, I will pay whatever I need to. But so little in life is an emergency.
<snip>
It is awfully hard to make good consumer choices when we don't know what something costs. And there is no reason to keep cost reasonable if it is not a factor in consumer purchases.

I really think this is the way insurance should work, although the annual deductible could vary depending on income. In fact, a previous employer (sub of the Prudential in 1985-1995) had a plan with a deductible that varied depending on your salary.

[ronbuck]

Jan 20, 2011 19:22:06 GMT -5 @toughtimes said:

Anemia can also be a sign of internal bleeding.

Actually he is an older (67) man. Because of a history of heart trouble he is very careful about diet and eats very little red meat.

Of course the doc was concerned about internal bleeding and that was the reason for the 1st test (colonoscopy). But the GI doc kept recommending additional tests after that was negative. Interestingly, my friend would hear from the GI's office with the additional test recommendation, but never from the doc himself. I think a face to face (or even phone consult) with the GI could have been another chance to exchange information. My friend would have been more likely to ask "what are we looking for with this test that didn't show up with the other tests?"

Often patients are hesitant to ask their MDs for the information they need to make informed decisions. No particular harm to my friend. Just a lot of time and discomfort which may not have been necessary.

I am pretty ambivalent about a lot of testing which has been deemed necessary for everyone, including colonoscopies for people over 50 with no risk factors. I don't know if this is a really good allocation of resources compared to other uses.

And we heard this past year that mammogram screening for young women without risk factors is probably not necessarily a best practice. Smilier concerns with some prostate treatments, and with the prostate treatments there is a real possibility for harm and decreased quality of life.

I am old enough to remember when darned near every kid needed their tonsils removed. And many postmenopausal women needed hysterectomies. And a kid that got two ear infections in a year needed tubes.

My point is that we, as a society, do a lot of things medically which turn out after 20 years of data is sorted not to be all that useful....and at some cumulative cost (in resources mis-allocated, increased medical and insurance costs). These things are eventually somewhat corrected by market forces and improved information in the medical community. And of course by better treatments being developed.

My issue partly is that we have skewered the market portion with tax exempt prepaid medical plans (rather than traditional ideas of insurance) which distort pricing and incentives in the use of medical services.

The other issue is personal. I like my doc. He is a really good guy and a customer of mine. I truly and completely believe he has my best interest at heart. But I don't think my health is quite as important to him as it is to me, so I am aggressively involved in decisions about my medical choices. And he appreciates my attitude. When I pay (cash) for an expert opinion I pay attention to what I am told. But I still make my own choices from whatever options are available.

[ronbuck]

quote]
I really think this is the way insurance should work, although the annual deductible could vary depending on income. In fact, a previous employer (sub of the Prudential in 1985-1995) had a plan with a deductible that varied depending on your salary. [/quote]


Athena,

I have always thought that high deductible policies along wtih tax privileged Health Savings Accounts were the best solution for keeping medical cost reasonable. People simply make more conscious and informed choices (in general), when they are paying for a service than when a 3rd party is paying.

Unfortunately the HSAs were very restricted and not available with a lot of the high deductible policies.

I believe that HSAs are going to be less available due to the reform bill passed last year.

I wonder if I will be able to keep my high deductible plan when the new legislation is fully implemented. It has been a good choice for me financially and medically and I would hate to be forced into what is becoming the standard prepaid (and expensive) insurance model.

Lasik eye surgery is a good example of what happens to price when undistorted market forces are at work. Insurance typically doesn't cover this, and the price is a fraction of what it was when it was first introduced.

[Deleted]

Lasik is also a one time thing. And it is elective, not necessary... How does other cosmetic surgery rate? I mean, is the price of a boob job also competitive? although there i guess you also have to still deal with multiple entities, the hospital, anesthesiologist, etc... which you do not have to do with lasik...

[ronbuck]

Jan 21, 2011 0:21:21 GMT -5 oped said:

Lasik is also a one time thing. And it is elective, not necessary... How does other cosmetic surgery rate? I mean, is the price of a boob job also competitive? although there i guess you also have to still deal with multiple entities, the hospital, anesthesiologist, etc... which you do not have to do with lasik...

LOL Oped. As a guy I have never checked into a boob job. I would suspect that a lot of insurance companies don't cover non-medically necessary cosmetic procedures, and that it may be somewhat competitive. Medical necessity would include things like reconstruction from traumas or surgeries.

But that is just a guess.

[Deleted]

So controlling for that type of comparison could be problematic, because most non-necessary procedures will not be covered by insurance, so if they do prove more competative, it will be difficult to isolate whether or not the causal factor is that insurance does not pay, or that they are elective procedures... etc...

[Deleted]

Jan 20, 2011 23:58:51 GMT -5 ronbuck said:

[I am pretty ambivalent about a lot of testing which has been deemed necessary for everyone, including colonoscopies for people over 50 with no risk factors. I don't know if this is a really good allocation of resources compared to other uses.

<snip>I am old enough to remember when darned near every kid needed their tonsils removed. And many postmenopausal women needed hysterectomies. And a kid that got two ear infections in a year needed tubes.

Yeah, my mother remembers one gynecologist in our hometown in Ohio-she said every woman who went to him ended up getting a hysterectomy. And all 5 of us had tonsillectomies.

One of the smartest things my gynecologist did was to suggest a simple, at-home screening test to see if there was an indication that I needed a colonoscopy, since I was avoiding that because I thought it was the usual over-testing. The at-home test came back positive. I understood that it wasn't 100% reliable but it motivated me to get the scope. It turned out I did need that and a potential problem 10-15 years down the road was found and eliminated. (Sorry if that's TMI for some of you.) I thanked the gynecologist profusely. I really appreciated her recommending a simpler, less invasive test to see if there was any reason for concern first.

[The Walk of the Penguin Mich]

The difference between cosmetic procedures and others is that if you do not have the money, you do not get them. Simple as that. So everyone pays $5000 (or whatever the cost) for a boob job rather than the price being negotiated down to $2000 by the insurance company, or them having to go after the person in collections because the doctor has treated them before getting all the money up front.