Your Insurance Sucks (probably more than you realize!)

Don’t feel bad, my insurance sucks, too.

In the United States, it’s no secret that the cost of healthcare and how it’s paid for is a mess. But even if you know this, you may not realize how much worse it is behind the scenes.

The current average premium for commercial health insurance is $560 per month. This of course varies widely between platinum, gold, silver, and bronze plans, but this is the overall average.

Then you add in the deductible, which for plans on the healthcare marketplace vary from $45 to $7481 per year. For employer-sponsored plans, the average premium paid by the subscriber is around $111/month with a deductible between $3,000 and $10,000 per year, and may also have coinsurances or copays.

The increase in healthcare cost over the last several years has outpaced wage increases by about 5%.

What do these things mean?

The premium is what the insurance plan costs to carry, by month most of the time.

The deductible is the additional amount the subscriber (you) must pay out of pocket before insurance kicks in.

A copay is a set amount that is paid out of pocket for specific services (by you), such as a visit to a primary care doctor or specialist. As a physical therapist, I’ve seen these range from $5 to up to $80 per visit over the last 15 years.

A coinsurance a percentage that is paid out of pocket for specific services, often after the deductible is met. So if you have a 10% coinsurance for an office visit, and the contracted rate between the provider and the insurance company is $100 (for easy math), then the subscriber (you) pays $10 for that service (after the deductible is met for the year), and the insurance carrier pays $90 to the provider.

It gets even more convoluted when you look at contracted rates. Since I know physical therapy, we’ll stick to that for explanations. When a therapy practice is in-network, that means that they have negotiated a rate with an insurance company for services. So whatever the practice would normally bill for services, they agree to accept a discounted amount by the insurance company for that service in order to be in their network. Unfortunately, this contract also allows the insurance company to decide things like how many visits you are allowed per year or condition, and if the service is even covered. Even if you have physical therapy benefits as part of your plan that you are paying for, the insurance company can arbitrarily decide not to cover certain conditions or certain treatments, with no real rhyme or reason. The most frustrating example is Blue Cross Blue Shield of Arizona, who has decided that they will only cover pelvic floor physical therapy for stress urinary incontinence, even if your plan that you are paying for has physical therapy benefits. If you need pelvic floor physical therapy for pain or bowel dysfunction for example, then you are on the hook for the full cost at the contracted rate.

Then there is the fun game of “guess my contracted rate”, where you and your provider have no idea what your care is going to cost up front, so after some number of visits, you get a surprise bill that may be close to the full billed rate.

So you may be thinking, well that doesn’t matter to me, because I have Medicaid, Medicare, Tricare, or another government-paid plan. Well I hate to say it, but your insurance sucks even more. I know, it’s shocking to think that the government provide a subpar product, but bear with me. You may not have the out of pocket/deductible portion to worry about, but these plans severely dictate what happens with your care. They typically don’t allow you to seek services that legally are direct access, without a referral. Many states, including Montana, allow direct access to physical therapy. This means if you need therapy, you just go get evaluated by a physical therapist. But if you have Medicare or Medicaid, they won’t cover it without a physician referral/prescription or “script”. They also usually have some arbitrary limit to services, either a number of visits or dollar amount. They are a huge pain for your provider to deal with, costing time and money that they would much rather allocate to providing you with excellent care. Medicare even added a ridiculous element to their reimbursement that allows them to reimburse less, meaning that your provider gets paid the most for the first 22 minutes of treatment, then less for minutes 23 to 37, and less again for minutes 38 to 52, and so on. What this means for your care is that most practices can’t sustainably afford to treat you for more than 37 minutes. And in the case of Medicaid, after factoring in the cost of treatment, from salaries of talented therapists and support staff, to lights and liability insurance, the practice loses money on those visits. So what happens is practices can’t afford to be in-network with certain plans, or they end up shortening your visits or overbooking staff so there are multiple patients being seen at the same time, or you work with an unskilled staff person called a tech or aide, who has a high school diploma and on-the-job training, instead of a graduate-trained doctor of physical therapy with 3+ years of specialized education.

Another issue across the board with insurance is that they only cover what’s deemed medically necessary, and is reactive in nature, treating you for symptoms and dysfunction. They will not cover performance-based, preventative, or wellness treatments. So say you’d like to start training to run a marathon, or ski season is coming up, and you’d like to be evaluated and start a preventative exercise program so you are strong, conditioned, and less likely to sustain an injury, your insurance most likely will not cover that service.

So overall, your insurance sucks because it’s expensive, it doesn’t cover enough, you have a high deductible so you’re still paying for almost everything, it dictates your care, it forces your provider to decrease time and attention to you when you go in, see you less frequently or for shorter visits, and it maybe doesn’t cover your subpar care anyway. It is a huge culprit in provider burnout because of the frustrations of trying to balance giving good care and abiding by the contracts and requirements, and it requires a lot of documentation to defend what they’re doing so they can get reimbursed or get authorization to treat you as your highly-trained provider feels you should be treated. It ends up making it more difficult for you to get high-quality care in a timely fashion.

So what can you do?

You can communicate with your HR departments, your state representatives, and your insurance company to demand better.

If you’re not on a government-sponsored plan like Medicare or Medicaid, you can also opt for catastrophic coverage to reduce your monthly cost, and then utilize a health savings account (HSA) to pay for out-of-pocket expenses. Since you’re paying for most of your care out-of-pocket anyway, you can choose practices that make the most sense for what you need and want, and for most of us that’s more time with our providers. No doubt you’ve seen concierge practices, performance-based cash practices, and other types of out-of-network practices popping up in your area. They are already common for services like chiropractic, naturopathic, and acupuncture, but are growing in areas like functional medicine, primary care, and physical therapy. Your insurance may still cover at least a portion of these services, but you pay for them up front and request reimbursement from your insurance company. Many practices will also offer payment plans and package discounts or memberships to help manage the cost. The goal of these practices is to improve quality of care and how healthcare is delivered, and until we see more of these shifts in what consumers are willing to accept, then the status quo will remain just that.