Through my job with the city of Portland, I have better health insurance than many Americans. Still, I would gladly trade my adequate insurance and pay more taxes to support all Americans having access to health care.
I will use the rest of this post to demonstrate why my recent eye problems have reminded me there is no such thing as good, fair for-profit health insurance.
Billing for Nothing
When my eye started acting up, I had to go to the emergency room. I went to the emergency room at a Providence hospital. During the intake process, I was honest about my prosthetic eye, the problems I Was having with my eye, the history of issues with my eye, and what I thought was happening.
Yesterday, I mailed Providence a bill for $738. My health insurer and I paid providence roughly $3,000. Let’s see what we got for our money.
- Providence ran several tests, including a Cat Scan.
- Two unduly people checked my eye.
- The person who read the Cat Scan believed I had an abscess in my head that most likely required prompt surgery.
- I was then told Providence didn’t have anyone who could help me. I needed to see a specialist at Oregon Health Sciences University.
To recap: Providence was paid roughly $3,000 to misread a Cat Scan, misdiagnose my problem, and tell me they didn’t have anyone who could help me.
This highlights one of the big problems with America’s for-profit health care industry: they are paid for services provided. It doesn’t matter if the services are competent. It doesn’t matter if the services are needed. What matters is that services are provided and bills for those services are sent.
When I arrived at the emergency room, Providence knew they didn’t have anyone there familiar with prosthetic eyes, or even anyone who specialized in optometry. Yet, they made sure they ran their tests and had people see me so they could send their bills.
Checking the Network
When it was determined I needed a new prosthetic eye, my surgeon referred me to an ocularist (someone who makes prosthetic eyes). When I called the ocularist, I was told they needed to check with my insurer before scheduling me for a new eye. They wouldn’t schedule me until my insurer said I was in the network, determined how much they would be paid, and that I could cover the $603 that wound up being my coinsurance.
My doctor recommended a service I absolutely needed. Yet, my insurer–not my surgeon–decided whether or not I could see the recommended specialist. And don’t forget I wouldn’t have seen the specialist if I wasn’t lucky enough to be able to afford the $603 my insurer refused to pay.
Payments and Timing
The arrangement between my employer and insurer says our plans work off of a fiscal year that starts on July first. The July first date is most likely based on July first being the start of Portland’s fiscal year. But Mota, my insurer, likes the arrangement because premiums, coinsurance, and out-of-pocket limits reset and/or increase every July first.
To make this simple: I’m going to wind up paying double for the procedures on my eye than I would have paid had I first gone to the emergency room in December. This is because had the months-long process ended before the end of June, my out-of-pocket costs would have been capped at $1,800. Since everything resets on July first, I paid $1,800 for the bills incurred before the end of June. By the time I pay for the surgery I’m having in October, I will pay another $1,800.
I have no control over billing schedules. Obviously, I can’t control when my eye will need treatment. But my out-of-pocket costs aren’t related to the services I need, or how much those services cost; instead, they are based entirely on a payment schedule agreed to between my employer and my insurer.
The next time you believe your medical decisions and/or the costs for your medical services are determined by you and your doctor, I hope you will remember this post. In reality, our employers and the insurers they contract with control what treatments we get and how much we pay for those treatments. When you throw in a system that rewards services provided instead of caring about generated outcomes, you have a system that makes huge profits for health insurance corporations at our expense.