Lee H. Beecher, MD

More and more frequently, I’m seeing patients with a type of anxiety not described in psychiatric textbooks. I call this condition "health care cost anxiety." This increasingly common condition has its roots in uncertainty and fear of the unknown, not the least of which is the unknown cost of recommended medical care and medications – what the patient (or the patient’s family) will need to pay out of pocket.

Health care cost anxiety arises when we tell a patient she needs an MRI but she is not sure whether her health insurance plan will pay or whether she’ll have to pay $3,000 out of pocket. It occurs when the pharmacy clerk tells the patient that, instead of the $12 copayment he expected, he’ll need to pay $200 to pick up his medications.

Simply being ill, or being afraid of becoming ill, causes plenty of anxiety. And when the patient is already ill, getting the straight story from an insurer about costs and coverage is all the more difficult. Other factors – financial stressors such as unemployment, worry about losing or loss of employment or health care benefits, escalating insurance premiums, and difficulty in getting appointments with providers who will accept the patient’s insurance plan or medical assistance – are driving anxiety about health care.

Clearly, in our uncertain health care insurance environment, patients need to become much more involved in knowing and managing their own health care spending. This editorial outlines what you can tell your patients about how health insurance coverage is changing, what this means for empowering them, and steps they and their families can take to help manage health care cost anxiety.

Paying More Out of Pocket

The days of first-dollar insurance coverage without copayments or deductibles are over for most of us. In addition, although 58 percent of U.S. workers are still covered by employer-sponsored insurance, that percentage is diminishing. Many small businesses are dropping coverage or not offering it to their new hires.

A June 2011 McKinsey & Co. survey of 1,300 businesses found that 30% of employers plan to drop employee insurance altogether and that 60% will be looking for alternatives to traditional employer-funded insurance by 2014, under the federal health care law employer insurance mandate. Employers are already dramatically increasing the employee share of health costs, often requiring their employees to come up with $1,000 to $6,000 in medical expenses before their health insurance takes effect.

Shift Toward High-Deductible Health Plans

Many larger employers still offer several choices of health care insurance plans, but these choices are narrowing:

• A health maintenance organization plan offers first-dollar coverage.

• A preferred provider organization (PPO) plan offers greater choice of providers, but patients pay more or cannot see physicians out of the PPO network.

• High-deductible health plans (HDHPs) offer much lower monthly insurance premiums than the other two plans.

HDHPs are becoming much more prevalent because of their much lower premiums. They operate on the principle that health care insurance should cover high-cost medical services and unpredictable costs while most low-cost forms of health care are financed outside of an insurance protection contract. There are basically two types of HDHPs: insurance policies in which high deductibles are completely managed by the insurance company (such as Medica Solo); insurance that is paired with a health savings account (HSA) regulated by the federal Internal Revenue Service.

Both kinds of HDHPs require that individuals have money from a source other than health care insurance – such as a health care reimbursement arrangement (employer funded), an HSA, or a direct government subsidy – to cover the costs of care until the insurance plan deductible is satisfied. Independent insurance agents can provide details.

With the rise of HDHPs, patients and doctors will need to deal with the permutations of payment, costs, and restricted options in health care services. The increasing variety and scope of health insurance plans means that patients (and their doctors) will need to know actual costs of their care and assume a collaborative role in cost management. Doing so is often challenging in the current environment. Below are some guidelines for getting the cost and coverage information needed from the clinic and the pharmacy.

Learning From the Insurer

As of this writing, getting specific answers on benefits or allowed dollar coverage from medical care insurance company continues to be a daunting task. The process of calling the insurance company might take an hour or longer. In my office, we offer a "team call" with a clinic staffer (outside of the patient’s appointment time with me) to help patients or family members get this information. The call helps clarify the insurance rules of the road and also improves the doctor-patient alliance.

When phoning the insurance company about enrollee benefits and the schedule of allowable payments, it is important for the patient to have the policy and group numbers from her insurance card in front of her. Callers typically encounter many programmed responses and holds. When an actual person is reached, even the most pleasant and consumer-oriented insurance company representative is often unable to explain the allowable payments for a specific service or specific physician. Typically, the representative will tell the patient whether the doctor or clinic is in or out of the health plan provider network and refer the patient to a website.

Encourage your patient to ask the insurance company these important questions:

• Does the insurance plan have a restricted provider network of clinics or doctors? If so, when are these network clinics/physicians available to see me? What coverage is available if I decide to use physicians or clinics that are not in the provider network? It is very important for the patient to contact the clinic directly to see if and exactly when one of its physicians can see her.

• What is the insurance plan deductible, and how do I satisfy the documentation of medical services that apply to satisfying the insurance deductible amount? Either the clinic or the patient submits the clinic charges using current procedural terminology (CPT) codes. Following submission to the insurance company, these charges are first "denied for payment" by the insurance company and then are accounted toward satisfying the enrollee’s insurance deductible.

• Does my insurance plan cover this health service? For example, there are often strict limits on mental health and chemical dependency care, despite Minnesota and federal mental health parity legislation. Most Minnesota health plans, for example, require treatment at in-network mental health or substance abuse clinics or programs, even though none may be available.

• Are there providers in the network who are appropriately trained and available to see me? The health plan will refer patients to its website so they can search out names and locations. Patients should insist on getting personalized help from their health plan or insurance company to connect with an available provider suited to their particular medical needs, since availability is part of an insurance contract.

• Do medication copayments qualify toward satisfying the insurance deductible? And how are they to be accounted? The insurance company should know this. Medications are handled by a pharmacy benefit manager (PBM) company, so the patient will need to go to her retail pharmacy (armed with her insurance card) to learn about medication copayments and restrictions, as explained in the section below.

Pharmacy Benefits

When asked about prices, community pharmacists quote their retail prices for medications they have on hand or dispense. They can, however, readily check on the out-of pocket cost of a given medication for a specific patient if they have the insurance information. With a swipe of an insurance card, the pharmacist can instantly find out from the patient’s health plan pharmacy benefit manager (PBM) what the patient must pay at the pharmacy.

Patients should know that, armed with their insurance card, they can check with their pharmacy about which drugs are on your insurance plan formulary that pertain to their care needs. The formulary is a list of prescription drugs, both generic and brand name, that are covered by their health plan. The health plan will pay for a portion of the pharmacy cost, but the amount of coverage varies greatly. Patients need to get the specific details of their copayments directly from the pharmacy. I recommend that they do this before the physician or prescriber writes or renews their prescription.

Knowing the actual cost of a medication is a big deal for our patients. After all, if patients cannot afford medications, their prescriptions are likely to go unfilled or to be insufficiently dosed, which in turn leads to poor treatment outcomes. A recent Consumer Reports survey showed, unsurprisingly, that patients do not follow our recommendations when they believe they cannot afford their medications.

When it comes to shopping for health care insurance, encourage patients and their families to consult a qualified independent insurance agent to discuss their health care insurance options. This proactive approach on the part of patients will help relieve a lot of their health care cost anxiety.

Dr. Lee H. Beecher is president of the Minnesota Physician-Patient Alliance and a psychiatrist in private practice in Minneapolis. He also serves as a member of the editorial advisory board for Clinical Psychiatry News, a publication of Elsevier.

More and more frequently, I’m seeing patients with a type of anxiety not described in psychiatric textbooks. I call this condition "health care cost anxiety." This increasingly common condition has its roots in uncertainty and fear of the unknown, not the least of which is the unknown cost of recommended medical care and medications – what the patient (or the patient’s family) will need to pay out of pocket.

Health care cost anxiety arises when we tell a patient she needs an MRI but she is not sure whether her health insurance plan will pay or whether she’ll have to pay $3,000 out of pocket. It occurs when the pharmacy clerk tells the patient that, instead of the $12 copayment he expected, he’ll need to pay $200 to pick up his medications.

Simply being ill, or being afraid of becoming ill, causes plenty of anxiety. And when the patient is already ill, getting the straight story from an insurer about costs and coverage is all the more difficult. Other factors – financial stressors such as unemployment, worry about losing or loss of employment or health care benefits, escalating insurance premiums, and difficulty in getting appointments with providers who will accept the patient’s insurance plan or medical assistance – are driving anxiety about health care.

Clearly, in our uncertain health care insurance environment, patients need to become much more involved in knowing and managing their own health care spending. This editorial outlines what you can tell your patients about how health insurance coverage is changing, what this means for empowering them, and steps they and their families can take to help manage health care cost anxiety.

Paying More Out of Pocket

The days of first-dollar insurance coverage without copayments or deductibles are over for most of us. In addition, although 58 percent of U.S. workers are still covered by employer-sponsored insurance, that percentage is diminishing. Many small businesses are dropping coverage or not offering it to their new hires.

A June 2011 McKinsey & Co. survey of 1,300 businesses found that 30% of employers plan to drop employee insurance altogether and that 60% will be looking for alternatives to traditional employer-funded insurance by 2014, under the federal health care law employer insurance mandate. Employers are already dramatically increasing the employee share of health costs, often requiring their employees to come up with $1,000 to $6,000 in medical expenses before their health insurance takes effect.

Shift Toward High-Deductible Health Plans

Many larger employers still offer several choices of health care insurance plans, but these choices are narrowing:

• A health maintenance organization plan offers first-dollar coverage.

• A preferred provider organization (PPO) plan offers greater choice of providers, but patients pay more or cannot see physicians out of the PPO network.

• High-deductible health plans (HDHPs) offer much lower monthly insurance premiums than the other two plans.

HDHPs are becoming much more prevalent because of their much lower premiums. They operate on the principle that health care insurance should cover high-cost medical services and unpredictable costs while most low-cost forms of health care are financed outside of an insurance protection contract. There are basically two types of HDHPs: insurance policies in which high deductibles are completely managed by the insurance company (such as Medica Solo); insurance that is paired with a health savings account (HSA) regulated by the federal Internal Revenue Service.

Both kinds of HDHPs require that individuals have money from a source other than health care insurance – such as a health care reimbursement arrangement (employer funded), an HSA, or a direct government subsidy – to cover the costs of care until the insurance plan deductible is satisfied. Independent insurance agents can provide details.

With the rise of HDHPs, patients and doctors will need to deal with the permutations of payment, costs, and restricted options in health care services. The increasing variety and scope of health insurance plans means that patients (and their doctors) will need to know actual costs of their care and assume a collaborative role in cost management. Doing so is often challenging in the current environment. Below are some guidelines for getting the cost and coverage information needed from the clinic and the pharmacy.

Learning From the Insurer

As of this writing, getting specific answers on benefits or allowed dollar coverage from medical care insurance company continues to be a daunting task. The process of calling the insurance company might take an hour or longer. In my office, we offer a "team call" with a clinic staffer (outside of the patient’s appointment time with me) to help patients or family members get this information. The call helps clarify the insurance rules of the road and also improves the doctor-patient alliance.

When phoning the insurance company about enrollee benefits and the schedule of allowable payments, it is important for the patient to have the policy and group numbers from her insurance card in front of her. Callers typically encounter many programmed responses and holds. When an actual person is reached, even the most pleasant and consumer-oriented insurance company representative is often unable to explain the allowable payments for a specific service or specific physician. Typically, the representative will tell the patient whether the doctor or clinic is in or out of the health plan provider network and refer the patient to a website.

Encourage your patient to ask the insurance company these important questions:

• Does the insurance plan have a restricted provider network of clinics or doctors? If so, when are these network clinics/physicians available to see me? What coverage is available if I decide to use physicians or clinics that are not in the provider network? It is very important for the patient to contact the clinic directly to see if and exactly when one of its physicians can see her.

• What is the insurance plan deductible, and how do I satisfy the documentation of medical services that apply to satisfying the insurance deductible amount? Either the clinic or the patient submits the clinic charges using current procedural terminology (CPT) codes. Following submission to the insurance company, these charges are first "denied for payment" by the insurance company and then are accounted toward satisfying the enrollee’s insurance deductible.

• Does my insurance plan cover this health service? For example, there are often strict limits on mental health and chemical dependency care, despite Minnesota and federal mental health parity legislation. Most Minnesota health plans, for example, require treatment at in-network mental health or substance abuse clinics or programs, even though none may be available.

• Are there providers in the network who are appropriately trained and available to see me? The health plan will refer patients to its website so they can search out names and locations. Patients should insist on getting personalized help from their health plan or insurance company to connect with an available provider suited to their particular medical needs, since availability is part of an insurance contract.

• Do medication copayments qualify toward satisfying the insurance deductible? And how are they to be accounted? The insurance company should know this. Medications are handled by a pharmacy benefit manager (PBM) company, so the patient will need to go to her retail pharmacy (armed with her insurance card) to learn about medication copayments and restrictions, as explained in the section below.

Pharmacy Benefits

When asked about prices, community pharmacists quote their retail prices for medications they have on hand or dispense. They can, however, readily check on the out-of pocket cost of a given medication for a specific patient if they have the insurance information. With a swipe of an insurance card, the pharmacist can instantly find out from the patient’s health plan pharmacy benefit manager (PBM) what the patient must pay at the pharmacy.

Patients should know that, armed with their insurance card, they can check with their pharmacy about which drugs are on your insurance plan formulary that pertain to their care needs. The formulary is a list of prescription drugs, both generic and brand name, that are covered by their health plan. The health plan will pay for a portion of the pharmacy cost, but the amount of coverage varies greatly. Patients need to get the specific details of their copayments directly from the pharmacy. I recommend that they do this before the physician or prescriber writes or renews their prescription.

Knowing the actual cost of a medication is a big deal for our patients. After all, if patients cannot afford medications, their prescriptions are likely to go unfilled or to be insufficiently dosed, which in turn leads to poor treatment outcomes. A recent Consumer Reports survey showed, unsurprisingly, that patients do not follow our recommendations when they believe they cannot afford their medications.

When it comes to shopping for health care insurance, encourage patients and their families to consult a qualified independent insurance agent to discuss their health care insurance options. This proactive approach on the part of patients will help relieve a lot of their health care cost anxiety.

Dr. Lee H. Beecher is president of the Minnesota Physician-Patient Alliance and a psychiatrist in private practice in Minneapolis. He also serves as a member of the editorial advisory board for Clinical Psychiatry News, a publication of Elsevier.

More and more frequently, I’m seeing patients with a type of anxiety not described in psychiatric textbooks. I call this condition "health care cost anxiety." This increasingly common condition has its roots in uncertainty and fear of the unknown, not the least of which is the unknown cost of recommended medical care and medications – what the patient (or the patient’s family) will need to pay out of pocket.

Health care cost anxiety arises when we tell a patient she needs an MRI but she is not sure whether her health insurance plan will pay or whether she’ll have to pay $3,000 out of pocket. It occurs when the pharmacy clerk tells the patient that, instead of the $12 copayment he expected, he’ll need to pay $200 to pick up his medications.

Simply being ill, or being afraid of becoming ill, causes plenty of anxiety. And when the patient is already ill, getting the straight story from an insurer about costs and coverage is all the more difficult. Other factors – financial stressors such as unemployment, worry about losing or loss of employment or health care benefits, escalating insurance premiums, and difficulty in getting appointments with providers who will accept the patient’s insurance plan or medical assistance – are driving anxiety about health care.

Clearly, in our uncertain health care insurance environment, patients need to become much more involved in knowing and managing their own health care spending. This editorial outlines what you can tell your patients about how health insurance coverage is changing, what this means for empowering them, and steps they and their families can take to help manage health care cost anxiety.

Paying More Out of Pocket

The days of first-dollar insurance coverage without copayments or deductibles are over for most of us. In addition, although 58 percent of U.S. workers are still covered by employer-sponsored insurance, that percentage is diminishing. Many small businesses are dropping coverage or not offering it to their new hires.

A June 2011 McKinsey & Co. survey of 1,300 businesses found that 30% of employers plan to drop employee insurance altogether and that 60% will be looking for alternatives to traditional employer-funded insurance by 2014, under the federal health care law employer insurance mandate. Employers are already dramatically increasing the employee share of health costs, often requiring their employees to come up with $1,000 to $6,000 in medical expenses before their health insurance takes effect.

Shift Toward High-Deductible Health Plans

Many larger employers still offer several choices of health care insurance plans, but these choices are narrowing:

• A health maintenance organization plan offers first-dollar coverage.

• A preferred provider organization (PPO) plan offers greater choice of providers, but patients pay more or cannot see physicians out of the PPO network.

• High-deductible health plans (HDHPs) offer much lower monthly insurance premiums than the other two plans.

HDHPs are becoming much more prevalent because of their much lower premiums. They operate on the principle that health care insurance should cover high-cost medical services and unpredictable costs while most low-cost forms of health care are financed outside of an insurance protection contract. There are basically two types of HDHPs: insurance policies in which high deductibles are completely managed by the insurance company (such as Medica Solo); insurance that is paired with a health savings account (HSA) regulated by the federal Internal Revenue Service.

Both kinds of HDHPs require that individuals have money from a source other than health care insurance – such as a health care reimbursement arrangement (employer funded), an HSA, or a direct government subsidy – to cover the costs of care until the insurance plan deductible is satisfied. Independent insurance agents can provide details.

With the rise of HDHPs, patients and doctors will need to deal with the permutations of payment, costs, and restricted options in health care services. The increasing variety and scope of health insurance plans means that patients (and their doctors) will need to know actual costs of their care and assume a collaborative role in cost management. Doing so is often challenging in the current environment. Below are some guidelines for getting the cost and coverage information needed from the clinic and the pharmacy.

Learning From the Insurer

As of this writing, getting specific answers on benefits or allowed dollar coverage from medical care insurance company continues to be a daunting task. The process of calling the insurance company might take an hour or longer. In my office, we offer a "team call" with a clinic staffer (outside of the patient’s appointment time with me) to help patients or family members get this information. The call helps clarify the insurance rules of the road and also improves the doctor-patient alliance.

When phoning the insurance company about enrollee benefits and the schedule of allowable payments, it is important for the patient to have the policy and group numbers from her insurance card in front of her. Callers typically encounter many programmed responses and holds. When an actual person is reached, even the most pleasant and consumer-oriented insurance company representative is often unable to explain the allowable payments for a specific service or specific physician. Typically, the representative will tell the patient whether the doctor or clinic is in or out of the health plan provider network and refer the patient to a website.

Encourage your patient to ask the insurance company these important questions:

• Does the insurance plan have a restricted provider network of clinics or doctors? If so, when are these network clinics/physicians available to see me? What coverage is available if I decide to use physicians or clinics that are not in the provider network? It is very important for the patient to contact the clinic directly to see if and exactly when one of its physicians can see her.

• What is the insurance plan deductible, and how do I satisfy the documentation of medical services that apply to satisfying the insurance deductible amount? Either the clinic or the patient submits the clinic charges using current procedural terminology (CPT) codes. Following submission to the insurance company, these charges are first "denied for payment" by the insurance company and then are accounted toward satisfying the enrollee’s insurance deductible.

• Does my insurance plan cover this health service? For example, there are often strict limits on mental health and chemical dependency care, despite Minnesota and federal mental health parity legislation. Most Minnesota health plans, for example, require treatment at in-network mental health or substance abuse clinics or programs, even though none may be available.

• Are there providers in the network who are appropriately trained and available to see me? The health plan will refer patients to its website so they can search out names and locations. Patients should insist on getting personalized help from their health plan or insurance company to connect with an available provider suited to their particular medical needs, since availability is part of an insurance contract.

• Do medication copayments qualify toward satisfying the insurance deductible? And how are they to be accounted? The insurance company should know this. Medications are handled by a pharmacy benefit manager (PBM) company, so the patient will need to go to her retail pharmacy (armed with her insurance card) to learn about medication copayments and restrictions, as explained in the section below.

Pharmacy Benefits

When asked about prices, community pharmacists quote their retail prices for medications they have on hand or dispense. They can, however, readily check on the out-of pocket cost of a given medication for a specific patient if they have the insurance information. With a swipe of an insurance card, the pharmacist can instantly find out from the patient’s health plan pharmacy benefit manager (PBM) what the patient must pay at the pharmacy.

Patients should know that, armed with their insurance card, they can check with their pharmacy about which drugs are on your insurance plan formulary that pertain to their care needs. The formulary is a list of prescription drugs, both generic and brand name, that are covered by their health plan. The health plan will pay for a portion of the pharmacy cost, but the amount of coverage varies greatly. Patients need to get the specific details of their copayments directly from the pharmacy. I recommend that they do this before the physician or prescriber writes or renews their prescription.

Knowing the actual cost of a medication is a big deal for our patients. After all, if patients cannot afford medications, their prescriptions are likely to go unfilled or to be insufficiently dosed, which in turn leads to poor treatment outcomes. A recent Consumer Reports survey showed, unsurprisingly, that patients do not follow our recommendations when they believe they cannot afford their medications.

When it comes to shopping for health care insurance, encourage patients and their families to consult a qualified independent insurance agent to discuss their health care insurance options. This proactive approach on the part of patients will help relieve a lot of their health care cost anxiety.

Dr. Lee H. Beecher is president of the Minnesota Physician-Patient Alliance and a psychiatrist in private practice in Minneapolis. He also serves as a member of the editorial advisory board for Clinical Psychiatry News, a publication of Elsevier.