By Becky Weise
Not since the days when patients bartered livestock or homegrown produce for medical care have they needed to be so cognizant of the costs related to a doctor’s expertise. These days, patients again must learn to be smart consumers, especially due to recent changes in the realm of healthcare, and specifically due to changes in medical insurance.
For example, many employers have recently moved to offering healthcare plans that have higher deductibles and lower premiums. The deductible is a fixed amount the insured employee pays out-of-pocket until a specified maximum amount is reached every year; once the deductible has been met, the insurance pays for subsequent medical expenses. Even after the deductible is reached, certain plans may stipulate which procedures are (and are not) covered and may continue to include co-payments or other out-of-pocket costs.
High deductible health plans (HDHPs) are often coupled with pre-tax savings plans called health savings accounts (HSA) that employees can use to cover medical expenses until they have met the threshold of their deductible. Regardless of the specifics of the plan, these types of changes have forced employee-patients to be more aware of the benefits offered by their healthcare plan as well as the cost of medical services and medications.
Another prevalent phenomenon related to getting the most benefit from a health insurance plan is that many patients are electing to undergo surgery or therapy at a specific time — usually delaying it if possible — until the high deductible of the plan has been met. For example, if your plan has a $5000 deductible and you’ve reached that amount of out-of-pocket expense before the end of the year, you may decide it’s a good time to have your sore shoulder or aching knee looked at.
While that is a good strategy for getting the full annual benefit of your health plan, what patients may forget to consider is the actual timing as far as being able to get evaluated, treated and, if necessary, fully recuperated before the end of the calendar year.
“Many people are aware that doctors and surgeons get very busy towards the end of the year,” says Don Stumpp, Chief Executive Officer of McLean County Orthopedics (MCO) in Bloomington. “What they may fail to consider is that the opportunities for evaluation and treatment are limited due to personnel schedules, operating room availability at the hospitals or surgicenters, and the completion of any follow-up therapy that is usually necessary after orthopedic surgery.” In other words, don’t wait too long to start the process.
Scheduling knee replacement surgery for December 30th might work perfectly in your schedule as far as time off work and help around home, but that timing may not get costs for physical therapy covered — which is an important part of the rehabilitation process that can’t wait until you’ve met your deductible for the next year. And that’s assuming the surgeon, support personal, and facilities are all available in the first place.
Stumpp’s advice? Plan ahead. The earlier you can get scheduled for a surgery you need, the more likely you’ll have options as far as timing and available personnel.
“Toward the end of the year, not only do we have to work around the holidays and any potential out-of-office times for physicians, but we are also limited by the availability of the operating rooms because other types of surgeries are also scheduled during this timeframe. It can become very difficult, if not impossible, to schedule a patient for surgery if a patient waits until too late in the year to start the process.”
The biggest downside to this? Dealing with pain and discomfort for up to another year, especially if the patient decides to wait until their deductible has been met again.
Of course, planning ahead is only a part of what a well-prepared patient consumer needs to do. Stumpp adds this advice:
- Learn the details of your insurance plan — deductibles, coverage, benefits, accepted facilities and physicians, approval process, and other pertinent details. Go into your appointment knowing, at the very least, the basics of your plan — and if you have questions, check the online patient portal for your insurance policy or the benefit booklet. If you still have questions or concerns, contact the customer service department for the insurance company.
- Find out the time-frame of the procedure you need from surgery to complete recovery. If it’s a 12 week process instead of four weeks, it may make a huge difference in your insurance coverage and out-of-pocket costs.
- Consider other potential medical expenses that may occur — physical therapy, a stay in a rehab facility, pain medication, aides such as crutches, canes, stretch bands — and plan accordingly as much as possible.
- Be sure to check the timing of your insurance plan’s “year” of coverage — it may not be the same as a calendar year. And, while you’re checking, find out what your out-of-pocket costs may be even after you’ve met the deductible.
As employees continue to become more cognizant of the details regarding the healthcare plan in which they are enrolled, they will become more savvy healthcare consumers — if for no other reason than the fact that they feel the effects of the costs of medical care now more than ever before.
For more information, you may contact McLean County Orthopedics at 309-663-6461 or www.mcleancountyorthopedics.com. The practice treats all types of orthopedic conditions and offers a comprehensive range of services. Their office is located at 2502 E. Empire in Bloomington.
Photo credit: bowdenimages/iStock