We make educated decisions on the products and services we purchase every day by using the information provided to us on cost and value. Yet, we go blindly through the health care system with little to no knowledge of what it costs us.

Consumers and providers have been shielded by the real cost of healthcare for far too long.  Up until now, most healthcare insurance policies cover the majority of the charges, leaving the patient to pay the small portion that remains. As a result, most of us have been lulled into a false sense of security until we are thrust into the system due to an illness, injury or need for high-cost medication. It is then, once medical bills start coming in that we realize how expensive health care is and how unprepared we might be for a medical crisis.

Understanding the basics of how our healthcare insurance policy works is something that most of us don’t worry about until we become sick. I hope this article opens your eyes to the actual cost of health care and the importance of taking steps to prepare for a medical detour.

Health Insurance

Let’s start with your healthcare insurance policy. Nearly 66% of people get their health insurance through their employer. In this scenario, the employer pays an average of 83% of the cost of the plan, leaving the employee to pay the remaining 17%. With the rising cost of health care, many employers are flipping this ratio and requiring the employee to pay higher rates. This means that more and more money is going to come out of your paycheck for health insurance.

If you are among the growing number of people who do not receive healthcare insurance through your employer, you are probably aware that private healthcare policies can be costly. In fact, many people are paying rates that compare to a home mortgage for an individual plan. The Affordable Care Act, which was signed into law in 2010 was meant to help make healthcare insurance more affordable for the average consumer through a mixture of incentives. Today, the ACA is in a state of constant change and its future is unclear.

In an attempt to keep costs down, insurance companies have raised the deductibles and out of pocket costs that people have to meet before their insurance policy pays on a claim. This means that the cost of care is left to the employee until they reach their annual deductible and out of pocket costs. If you are healthy, you might never reach your deductible, which means you will pay the full price of your healthcare costs. This is why many employers offer medical savings accounts (MSA) or health saving accounts (HSAs) so that employees can put money into the account to pay for the out-of-pocket costs they are responsible for before they meet their deductible.

Other tactics employers are using is purchasing high deductible health plans. Premiums are lower than a traditional plan, but the deductible the policyholder has to meet is high. High deductible plans can be as high as $10,000-$20, 0000 before the program pays out the first dollar of coverage.

Even after you have met your deductible, you may still have a percentage to pay based on your policy before the insurance company starts to pay on the claim. The key to the success of these plans is being prepared and setting aside money in an account that you can tap into if there is a medical emergency.

With the rising costs of healthcare, employers are shifting more of the cost to the employee raising your premiums, deductibles and out of pocket costs. As a result, there is a call for transparency around healthcare costs so people (the patient and the provider) understand the value and quality of the services they’re receiving/providing and can make educated decisions on their care.

Importance of Having Information 

When providers and patients understand the cost of health care services they can make more informed decisions. The provider may opt for another type of treatment that is less expensive while still meeting the needs of the patient. Taking the same line of reasoning, when a patient knows the costs of services they are able to ask questions of their doctor, such as: Do I really need this test? If I don’t have the test, what will it mean? If I do have the test, will it change the outcome? The answer to these questions can greatly influence decisions.

The Robert Wood Johnson Foundation explores the importance of transparency in healthcare and the need for data so patients and providers can make informed decisions in this short educational video, which is well worth your time to watch.

Help Your Provider Help You

 So, what can you do? What can your provider do? It all comes down to preparation and communication. Here are a few tips to prepare yourself and get the conversation started with your doctor.

 Know Your Insurance Policy

Many people don’t take the time to read their member handbook, but that is a big mistake. The member handbook gives you essential information about your plan that allows you to be informed about the benefits and limits of the policy.

Talk to HR

If you have any questions about your policy, don’t hesitate to talk to your human resource department. Many times they can help you understand the details of your policy and let you know what your out of pocket cost will be. Ask if they have a medical savings account so you can have money set aside that will help you pay your out of pocket costs. This is especially important if you or a member of your family has a chronic medical condition. Your HR team can help you estimate what your contribution should be, as well as provide you with the rules for any unused funds in your account at the end of the year.

Ask Questions

What is the cost of the service/procedure/medication? To find this answer, start with your insurance company. Today, most insurance companies have provider networks and set prices with the organization who will provide services. Providers who join the network agree to the price structure established by the insurance company. Once you find out the cost of the procedure, you can ask what your share of the cost will be based on the policy you have.

Talk to Your Doctor

Talk to your doctor about what you find out. Sharing the cost of care with your doctor will help them weigh the value of the test against the price. If the benefit does not outweigh the cost or you cannot afford the service, your doctor can look at other options with you.

Be Open with Your Doctor

Sharing your goals with your doctor is essential. When you have a serious medical condition or need a procedure to address a problem, be sure to ask your doctor how the procedure will impact your quality of life. Will it make you more functional? Are there other things you can do to address your problem?

If you are not committed or ready to make a commitment to change your behavior or do what needs to be done to have a successful outcome, having a procedure or taking a high-cost medication might not be right for you. Having this discussion with your doctor is important so they know what your goals are and can design your care plan to meet them.

If you do decide on a high-cost procedure or medication, find out what your share of the cost will be. Can you afford it? If not, what arrangements can be made to help you pay your portion?

Many times there are ways to offset costs or allow you to pay off a bill in payments that meet your budget. Your provider may have a case manager or patient advocate who can help you find resources. There is a lot of help out there, but it takes research to find it.

Thank you for reading this post. Please feel free to check out other posts from my Blog Nurse Advocate as I cover topics that will inform, educate and empower, you – the patient, the caregiver and members of the heatlhcare team. Together we can do better!

If you have a comment or a question, post in the comment section or email me at [email protected]

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