Image of health insurance concept. (Designer 491 via Shutterstock)
(Designer 491 via Shutterstock)
Dr. GREGORY SHANGOLD
Dr. GREGORY SHANGOLD

The past decade has seen drastic changes to how patients access healthcare – some good, like increased and easier access to telemedicine, and some harmful such as the onset of “high deductible” healthcare plans. The steep, out-of-pocket deductibles associated with these plans have created massive financial burdens that are discouraging patients from seeking the safe, quality care that they need – disrupting the trusting relationship between physicians and our patients and leading to larger, more expensive and complicated health problems down the road.

There is a “triangle of care” formed by the relationships between patients, physicians and insurers. When it’s working right, everyone has a role to play. The patient enters into a relationship with the physician based on trust and the physician’s expertise – with quality and safe care being the driving influence. Physicians often have contractual relationships with insurance companies. In most cases, someone else selects the “payment source” (often an insurer) who is responsible for providing the finances to cover the medical services provided to patients. 

The problem: Many patients either do not understand or are unaware of their plan’s details. Often, employers choose the plans to make available to employees. Many employees choose plans with the lowest premiums hoping they will not get sick and require access to healthcare, or just because the other plans are too expensive. The people who do seek healthcare must pay thousands of dollars in deductibles, co-pays, and co-insurance before their plan covers healthcare costs. Many people cannot cover these costs and ultimately, the financial debt interferes with the patient / doctor relationship.

The result: Patients are delaying and foregoing as much essential care as the insurance company’s definition of non-essential care in order to avoid these out-of-pocket costs. Inevitably, these delays will negatively impact the patient’s healthcare. Avoiding the right care at the right time is wrong, life threatening at worse, and dangerous at best.

Some care is provided in a pre-deductible scenario or without additional financial responsibility. Patients are much more compliant in these scenarios. There is no better evidence than with the COVID-19 pandemic. By making testing and vaccines pre-deductible, people sought and received services at a much better rate than if they needed to pay for a COVID-19 test every time one was warranted.

As if the high, out-of-pocket costs were not enough, these plans also require physicians to collect the deductibles from their patients, who in turn are receiving multiple, confusing bills – especially in cases of hospitalization. So what happens? The triangle of care erodes and ultimately fails because physicians are not only providing care, they’re acting as bill collectors for the insurance industry, too.

Fortunately, there have been efforts by the Connecticut General Assembly to restore the integrity of the triangle of care and unravel the complications ensnaring the delivery of quality and timely patient care. Last year, I served on the legislature’s High Deductible Task Force, which issued recommendations which can help everyone. The task force proposed simplifying the confusing insurance paperwork and billing by having insurance companies pay the contracted rate directly to the physicians and if the patient’s specific plan requires a patient responsibility, the insurer bills the patient directly in one bill for an episode of care. This will remove a patient receiving multiple bills from all of the different providers.

We salute the legislature’s overwhelming bipartisan passage this week of a bill that provides relief for patients who participate in prescription drug copayment assistance programs. Senate Bill 1003 guarantees that the assistance patients receive – often provided by a drug manufacturer or another third party – is credited toward the patient’s deductible obligation. This is an important first step to addressing the problems posed by high deductible plans, and we look forward to working with legislators to make more progress in the next legislative session.

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Click above to vote on SB 1003: AN ACT PROHIBITING CERTAIN HEALTH CARRIERS AND PHARMACY BENEFITS MANAGERS FROM EMPLOYING COPAY ACCUMULATOR PROGRAMS

This way, physicians can go back to doing what we do best—treating our patients—and patients will undergo the necessary medical procedures and tests in a timely manner without worrying about eroding the relationship with the physician over finances. Insurance companies will gain a more streamlined way of processing claims and ensuring payments can be made seamlessly. 

That’s the triangle of care we all need in order to keep Connecticut healthy.

Dr. Gregory Shangold, an emergency physician, is President of the Connecticut State Medical Society, which is included among the advertising sponsors of this website.

The views, opinions, positions, or strategies expressed by the author are theirs alone, and do not necessarily reflect the views, opinions, or positions of CTNewsJunkie.com.