I’m certainly not the first person to complain about the dysfunctional nature of healthcare in the US, but with a recent health issue, I’m that much closer to the source of my near-rage.
I have an HMO plan in Northern California; Kaiser is highly-rated for quality of care, and of course trade-offs are inherent when choosing coverage. I’d love to choose a plan that provides for catastrophic coverage only, max out my HSA and pay out of pocked with a focus on convenience. But I can’t do that because I am in a high-risk pool (ie, not 18-24 years of age), so I get the worst of the worst– approximately $340/month premium with a non-catastrophic high deductible plan. Because I do not have a catastrophic plan, my pre-tax contribution caps are lower than a catastrophic plan. Go figure.
Fast forward to a few weeks ago when I develop severe leg pain, eventually incapacitating me. I’m unable to sit or stand. Pain is beyond unbearable.
I have a $5,000 deductible and out of network coverage doesn’t exist, apart from emergency room visits only, which may count toward this deductible. So I’m confronted with a few bad choices.
In short, I’m screwed purely because of my current geography, 2,400 miles from my HMO. Why am I penalised with zero insurance options when traveling? What if I were based in NYC for three months? I’d likely cancel my plan and get one that is ‘designed’ for NYC and cancel that plan when I return to San Francisco. But this makes no sense. Airlines figured this out years ago and committed to alliances that recognize this simple fact– people don’t always fly on their preferred carrier, but loyalty can be maintained by inter-airline agreements. It’s a reasonable market-based solution to maintain customers. Because US insurance regulations tend to exist at the state level, there are arbitrary restrictions imposed on market behavior. This sucks for the consumer, but allows everybody else to make money.
Back to my example…The essential issues are summarised in the chart below.
What happens if I go to the ER v. going the outpatient route? Here’s what the factors mean:
Counts toward deductible: This is the sole ‘benefit’ of my plan, but it also forces me into very expensive and inconvenient care (see below).
Specialist Consultation: Because I grew up with a physician father, I’m ok at self-diagnosis. I know I needed to see a neurologist or physiatrist. Not likely one will be hanging around the ER, and when I get a consult those fees paid won’t count against my deductible anyway.
Market Pricing: I know I’m paying out of pocket, but how much? Good luck asking an ER doctor with a syringe how much that lumbar spine epidural costs. After waiting 2-10 hours, she’ll probably roll her eyes and see somebody who she can stick a needle into with no questions asked. By seeing a consult I’m at least able to find out the procedure cost and shop around*.
MRI: I saved $1,000 on my MRI by taking a cab seven miles into Queens. Pain does have a price.
Cost Confidence: Do I have any peace of mind about costs in an ER? Doubtful, as costs is the last thing people think about in a high-stress environment.
If you’ve made it this far, you are wondering where am I going…
*To be clear, it isn’t easy (but is entertaining, if you aren’t in pain) to find out how much a procedure actually costs.
Post-employment 