Spend less, get more

As a family physician for 14 years, four of them outside this country, and CEO of the largest local primary care group during the last four years, I see daily the problems the United States faces in getting healthcare to the people. I’ve witnessed high cost, confusing services, no clear quality guides and poor access to care in a nation with 50 million uninsured citizens despite 17 percent of the world’s biggest economy being spent on health.

As costs rise, employer and government payers are pushing more costs onto the patient, which raises barriers to care. We are spending more and getting less–why?

The dirty secret in healthcare is that only insurers and drug companies are making profits while the “providers” (doctors and hospitals) are being squeezed by costs rising 7 percent or more a year as private insurers and Medicare pay little or no increase year after year (Medicare has just cut doctors’ pay by 4.4 percent). Meanwhile, unfunded federal and state mandates add to the ever-rising price tag.

Each year insurance premiums rise 10 percent to 30 percent and you pay more, but providers get less from these big monopolies that won’t negotiate fairly and so you get less service while the insurer profits. Patients find it hard to understand, when their insurance is $400 to $600 per person per month, why so little is covered and why there are large deductibles and co-pays.

There is a lack of serious competition among insurers who do not care if patients cannot get a service because that would reduce the carriers’ “medical loss ratio,” which is what they call any money paid by the insurer to provide healthcare. The result is a growing shortage of providers distorting the free market in a society that cannot decide whether healthcare is a business or a social right. Our medical group has found that only the threat of withdrawing services gets any attention from the insurers who play doctors’ concern for their patient’s wellbeing for all it is worth to them–their profits.

So, what can you do to make sure you get good healthcare at a price you can afford?

1. Have some form of insurance. Even if it has a high deductible, being insured gets you the much better “insurance contract” price for any service and medicines rather than the “self-pay rate.” If you qualify for a Health Savings Account (HSA), use one; the dollars are tax-deductible and roll over year to year. See if your employer will contribute to your HSA. However, don’t assume insurance will pay for any service you think you might need—it won’t. Know your coverage; read your insurance “binder.” If you cannot afford insurance, apply for Medi-Cal. Although private doctors generally don’t take it (due to very low payment rates that don’t cover our costs and also the administrative hassle), even if you have a “share of cost” it will protect you if hospitalized and can let you access subsidized clinics locally.

2. Get care at an appropriate level. A family physician or a prompt care facility will provide services much cheaper than specialists or the costliest place, the emergency room. Save the ER for serious injuries or a life-threatening condition.

Have a primary care physician (PCP) to coordinate your care and advise on the most cost-effective options. A good PCP can save a lot in unnecessary costs by knowing your medical history, and avoids duplicating services as he or she acts as your guide in the healthcare jungle.

3. Plan ahead for doctor visits. Make a short list of problems in order of importance. I see patients arrive with lists of 10-plus problems for a 15-minute office visit (the time allotment insurers cover). If you go over 15 minutes or three major problem areas, you are likely to be charged more, because just like any other service, more costs more. If you have a deductible, this could mean it costs you more directly. Be realistic. If you really have 10 problems, then two or three visits would be needed to do them justice. Often, doctors would like to spend more time with their patients, but insurers won’t pay for it, and patients don’t want to either. Physicians are like any professional service: You get what you or the insurer pays for; more is extra.

4. Do show up for visits or telephone to alter or cancel an appointment ahead of time. If you do not, you are likely to be charged. Given the tough financial climate for medical practices today, patients who repeatedly fail to show for appointments are likely to be asked to go elsewhere. It is not well known that a doctor can terminate you as a patient with 30 days’ notice without giving a reason.

Some doctors offer “non-visit care” for known patients with simple conditions, by phone, e-mail, etc, but expect to pay for this–insurance doesn’t. But you can save an office visit. Some practices may also offer after-hours clinics staffed by nurse practitioners for simple conditions—again cheaper than an urgent care or ER visit.

5. Get a physical or preventative care annually. Even with high-deductible policies these services are often covered without having to meet the deductible. Finding a problem early saves money, keeps you healthy and might just save your life.

6. Check out a doctor/clinic you are considering. Use the state Medical Board Web site, an insurance company Web site, ask friends and neighbors, check the physician group’s website (if any), physician’s interests, opening hours, convenience, location and consider whether they use new systems like electronic records and if they see patients on time. Find out: Do the doctors also care for you in the hospital?

In the confusing maze that is healthcare today these are the simple tactics you can use to make yourself an informed consumer and make better choices.