Last week’s post, Is My Hospital In-Network? relieved some anxiety and misunderstandings about local hospital network status with health insurers. Now, you can take some comfort knowing:
- In a true emergency, health care rights and services rules, not insurance companies (IN or OUT-of-network) will assure that you are most quickly and most appropriately cared for.
- You will further benefit from Continuity-of-Care-Protections, wherever you undergo medical care
- For hospital-based medical services that can and should be pre-planned, your treating physician will have the important considerations for you about where and when that care should occur.
So now, perhaps your anxiety has moved to “Is My Doctor is In-Network?”
Context: There are around One million physicians in the US, or about 1 for every 325 man, woman and child. Seems like plenty to meet the personal needs of working Americans.
Looking Closer: Fully half of them do not provide primary medical care at all (they are specialists of one kind or another). Further, physician concentrations and availability vary widely by geography and population dynamics. Finally, its nearly impossible to determine IN ADVANCE the complicated physician affiliations between and among hospitals, insurance plans and each other. These changing and complex affiliations often make access to care challenging. Emergency Room, Anesthesiology, Lab & Pathology services are especially unpredictable.
But these concerns are not critical for everyone:
- 22% – 46% of men and 13% – 32% of women (depending upon race/ethnicity) do not even have “a regular doctor”
- 37% of young adults did not visit a doctor even once during the year
- 22% of women / 33% of men did not visit a doctor even once during the year
- The “now real” Virtual Care movement allows an increasing number of Americans to get care over their cell phone, laptop or kiosk, eliminating some physician network issues entirely.
And, its great if you are older or poorer:
- Nearly half of physicians participate in Medicare Programs for older folks
- Nearly 3/4 of physicians participate in Medicaid Programs for the poor
But, if you not old and not poor: Things don’t look as great for the rest of us, and there are important trends and dynamics related to In-Network and Out-of-Network status, especially for today’s PPO systems.
- You can be surprised with an Out-of-Network doctor even in a Network Hospital if you are in a PPO plan
- Provider directory issues and resulting coverage problems were reported by over half of (mostly PPO) patients in a recent AMA study, so who knows if your doc is IN or OUT of your insurance plan’s network at any point in time?
- Integrated Systems, where all care is coordinated, now represent over half of commercially available hospitals and affiliated physicians in the US. Often the best way to get to these doctors is by joining these HMO or Integrated health plans themselves.
- Cash only basis is increasingly occurring with well known or highly “branded” physicians with big reputations, who just don’t feel a need to be part of ANYONE’s networks.
Then, is this In-Network issue for “My Doctor” an emotional or even philosophical question rather than economic or practical? It’s an interesting question in today’s marketplace. Consider:
- Recent studies show that 25% of the time the cash price of prescriptions are lower than the current health plan co-pays (you’re better off putting your insurance card away, and just paying the lower cash amount)
- The AMA “Blue Book” shows a 10 office visit minutes with a doctor costs an average of only $68 (Likewise, you might be better forgetting about whether you satisfied your deducible, putting the card away and asking your doctor for the lower cash price for a simple visit, and be done with it).
- Separately, Hixme, who has helped managed reimbursements for thousands of physician office visits, has discovered that average physician visits among our clients are similarly low even before negotiating for a cash price;
- An average cost of $57 per primary care visit
- An average cost of $77 per specialist care visit
- Lower Out-of-Network prices often the result with a prudent patient/doctor discussions and agreement
- For new programs like the one Hixme offers, additional cash available to workers and their families may have far more “buying power” than a traditional benefit plan ID Card.
So why are we so focused on paying a ton more in premiums every single month for the right to “have access to my doctor”, which we likely can’t control much these days any way ?
Perhaps we have been “behavior modified” over the years to expect the answer to “is my doctor In-Network” to be “Yes”…. even if “no” or “maybe not” is far less expensive and perhaps even more workable for those relationships