By Dr. Oren Gersten
Insurance is a card in your pocket, health care is a relationship with a doctor you know and trust. This is a recurrent mantra for doctors across the country who have broken away from fee-for-service, insurance-based health care. This simple phrase illustrates the idea that health insurance in and of itself is not a path to better health. It is important to acknowledge that lack of health insurance is strongly correlated with poorer health outcomes and under-utilization of health care. If the goal is to improve the health of our nation, it would be nice if the solution were as simple as extending health insurance to all people. Unfortunately, as in much of health care, the answer is not that simple.
In order to illustrate the shortcomings of an insurance-based system, I will use three real examples from my primary care practice. I have omitted some details and changed names to maintain patient confidentiality.
Patient A – $600 Shingles Vaccine
Patient A has an employer sponsored health plan through Cigna insurance. After talking with his doctor about preventive care he decides he would like to receive the shingles vaccine. National guidelines recommend Shingrix, an updated version of the older vaccine called Zostavax. Shingrix is about twice as effective at preventing shingles as Zostavax.
When Patient A attempts to use insurance to pay for Shingrix, he finds that it is not covered. As such, he would need to pay $600 out of pocket to receive the vaccine series. He then enlists the help of his primary care doctor to appeal this decision by his insurance company. After one to two hours on the phone with different people representing the insurance company, his primary care doctor cannot get a clear answer on how to get this medication paid for by insurance. What is even more frustrating is that they actually recommend using the older version of this vaccine called Zostavax. This vaccine is not only less effective but was discontinued as of July 1st, 2020.
This patient eventually elected to work around insurance and use a medication coupon through GoodRx to pay for this vaccination.
Patient B – CT Scan Not Covered
Patient B has health insurance through Anthem. His doctor recommends a non-emergent, prognostic CT scan. The insurance company decides that the patient’s insurance plan does not cover the type of CT scan ordered. It doesn’t matter that the patient’s primary care doctor feels it is an appropriate study.
The patient elects to pay for the study in cash instead. However, the study cannot be scheduled until there is an official denial letter from Anthem. The primary care doctor then must take time away from caring for patients to do a “peer-to-peer” telephone call. This is where a physician representative from Anthem discusses the case with the primary care doctor.
After several hours of unnecessary phone calls and paperwork the patient is then free to spend his own money on the CT scan.
Patient C – Referral Denied
Patient C schedules an appointment with her Ophthalmologist. After a discussion she decides to schedule cataract surgery. Her employer is part of a “self-funded” HMO plan managed by Anthem. This plan requires every single referral to pass through her primary care doctor. Anthem considers her chosen primary care doctor to be “out of network,” despite a state law barring this kind of designation. The insurance will not accept a referral authorization from the patient’s primary care doctor.
The patient’s insurance is in effect mandating who she can choose for a doctor.
Unfortunately, these three examples are far from unique. Insurance puts unnecessary burdens on primary care doctors and interferes with a patient’s ability to make independent decisions about their healthcare. So before we decide as a country to extend health insurance to all people, let’s make sure we understand what we are signing up for.
For many people a high-deductible insurance plan paired with a Health Savings Account allows the flexibility to spend tax-free dollars on low cost, high probability services – like primary care – and still have catastrophic coverage in case of emergencies. If an option like this were available to more people at an affordable price, it may be the quickest way to make insurance a useful piece of our healthcare system.
Oren Gersten is a board-certified family doctor who brings his passion for connecting and caring for people to his private practice, Portland Direct Primary Care, at 27 Ocean Street, #3, South Portland.
Reach him at (207) 618-9792 or visit PortlandDirectCare.com.