Is it Always Better to Have Health Insurance?

by Dr. Jane Orient

Uninsurance is portrayed as being like a disease; it has even been called an epidemic. At a minimum, it puts you one medical bill away from bankruptcy, and you might even die from it, they say.

eye-exam-2_slide_show1

Yet some people I know, even doctors, do not want to buy health insurance.

And I know of at least one person who was very lucky to have had hers cancelled.

Here’s her story. She told an acquaintance, who happened to be a physician, about her eye symptoms. “Wouldn’t you know! I lost my insurance a couple months ago, and now this!”

The physician happened to have an ophthalmoscope in her truck, and took a look in the patient’s eye. Then she called a retinal surgery practice and told the receptionist the patient’s history, and the results of the limited examination she could do. She thought the patient might have a detached retina.

The receptionist asked what type of insurance the patient had and was told she had none.

“Oh, self pay,” the receptionist said.

The technician said to send her over. “And by the way, ask her not to eat or drink anything in case she needs an operation.”

The outcome? The patient was seen within a couple hours, diagnosed, and treated immediately. Fortunately, she just had a retinal tear and a lot of blood in her eye. A simple in-office procedure probably prevented a detachment. The bill: $900. She’ll pay it off over time.

“What’s an eye worth?” she asked.

Now, what would have happened if the Medicaid program hadn’t cut her off—because she earns $100/month too much? In that case, she wouldn’t have had to worry about the bill.

But—the receptionist would have had to say: “You’ll need to fax over a referral.”

A Medicaid patient can’t be billed, except for a nominal copayment. Without a referral, Medicaid can’t be billed. So if the specialist, or in this case subspecialist, sees the patient, he cannot be paid. Moreover, he is probably violating a rule and conceivably might be prosecuted for soliciting business (that’s called “fraud”). Discounts and freebies are marketing strategies, after all, and the poor and vulnerable have to be protected.

Not just any doctor can give the patient a referral. This doctor couldn’t. It has to be the patient’s primary care provider, who is contracted with the patient’s plan. And the specialist has to be in the plan too.

Say that a seizure patient needs to see a neurologist promptly to have his medications adjusted. Sorry, the emergency room doctor can’t write the referral. Neither can the hospitalist who is discharging the patient from the hospital. It has to be the “primary.” If the primary happens to know the patient, he might just send the referral. But most of the time, the patient will have to come in. The primary won’t want to risk getting an unnecessary referral or an incident of “inadequate documentation” on his report card.

For a retinal problem, there are probably three hurdles: the primary gatekeeper (who might not even think of the diagnosis), then the general ophthalmologist (who will make the diagnosis but can’t treat it), and finally the subspecialist. All probably have waiting times for appointments, especially for Medicaid patients. Most doctors can’t afford to see very many of those.

Not just Medicaid, but all managed-care plans have a structure like that. It’s part of the cost-containment strategy. I know of three insured patients who had retinal detachments. They all had premonitory symptoms, and they all—eventually—had elaborate and costly operations, as many as six procedures. They were “covered,” and they didn’t get a bill for $900, but they had a poor visual outcome that might have been prevented by prompt treatment.

With “health care reform,” most Americans, aside from politicians, would be stuck in such a system. The new idea is “to change the [fee-for-service] payment model to a system in which doctors and hospitals earn more by keeping patients healthy and out of doctors’ offices and hospitals” [emphasis added].

And we need more primary care providers and fewer specialists, the “experts” say. More people to “coordinate care” and determine eligibility and conduct smoking cessation counseling. Fewer doctors to actually give care or examine eyes.

The system will not prevent retinal detachments, or epilepsy, or leaking aneurysms, or appendicitis, or other conditions that need a doctor with specialized skills. It will just create barriers to direct, timely access to such physicians.

Insurance is supposed to help you pay bills in the rare event of a catastrophe. If it morphs into a scheme for emptying your wallet in advance, and then prevents bills by preventing treatment, we  just might be better off without it.


Email this to a friend | Print | Share on Facebook | | Bookmark and Share

Tags: , , , , , , , , , , , , ,
Posted Dec 14th 2009 at 4:00 pm in Healthcare, News, Politics | 139 Comments