Ask A Therapist - Why Are Health Care Professionals Not Taking Insurance

This week’s question is about health insurance.  The question is why are health care professionals not taking insurance? 

To answer this question, we need to talk about how insurance works.   Medical insurance helps you “afford” expensive medical procedures for you and your family.   Just like car insurance, you typically reach a deductible before the insurance company will pay (unless you do not have a deductible, which is rare).  Insurance does not make medical care “free” just as your car insurance does not make owning and operating a car “free.”   To complicate matters, medical insurance in its current form is a business in which its primary purpose is to make a profit.  This means that the care you are afforded is dictated first by profit, then by actual medical importance (and evidence-based practice).

Let's start by discussing co-pays.  Co-pays are the amount you owe for covered health care services after you have reached your deductible. According to the American Physical Therapy Association, co-pays are as high a $60 per visit, although I have seen as high as $70.  Recent legislation in Colorado limits specialty visit co-pays to $40 per visit but is not yet in effect.  What this means is you could pay up to $70 per visit to your physical therapist once you have reached your deductible (or $40 per visit once the legislation kicks in).  Additionally, most insurance plans separate medical (doctor’s visits) and rehabilitative services.  This means you have a specific deductible for rehabilitative services which is typically $2,000.  And remember that your co-pays and deductible are in addition to your monthly premiums.  So let's do the math, you pay the first $2,000 for the year and then $40/visit after that for someone your insurance company wants you to see?  How is that a deal?

Your insurance company has certain providers whom they have negotiated contracts (in network).  Surprisingly, provider selection is not based on how great the outcomes of their patients are.  It is based on how cost effective the provider is and how “fast” they can see you.  Insurance companies do not recognize certain treatments that are effective such as dry needling.  Insurance companies do not pay for injury prevention, education, or performance enhancement.  The insurance company is not concerned with your passion for Cross Fit, running, or other recreational activities.  They are concerned with your “minimum” function at work and home.

So how does this contract work?  Insurance companies negotiate a reimbursement rate with your provider.  If the visit cost $120 dollars, you pay the entire $120 if you have not met the deductible or $40 if you have met the deductible.  The insurance company pays a percentage of the left over portion (usually $20 of the remaining $80).  This is the agreement providers sign when they accept insurance.  For the physical therapy clinic this means that the provider must see more patients to make up for the loss of money.  Quantity of care trumps quality of care. 

Insurance is a “wager” that you will not encounter major medical issues.  The company covers you but the intention is to bring in more money than the company pays out.  This is why insurance companies will refuse to cover prevention or other helpful services.  Prevention requires regular check ups that are accessible to everyone.  This means the insurance company would have to pay out on everyone versus a percentage of the people who end up sick or hurt.  It seems counter intuitive that insurance companies do not pay for prevention or education.  Prevention and education could reduce the risk of medical issues.  Aetna, Anthem, Cigna, Humana, and United Health Care (the top five insurers in the United States) all have outperformed the S&P 500 for the last 5 years according to a CNN report.  Despite rising profits insurance companies have deferred more of the costs for routine visits and prevention onto the consumer.

Because of the current state of health insurance and its for-profit architecture, many providers are cutting out the middle man.  High deductibles mean that patients may save money dealing directly with the provider for the true cost of services.  Providers are also cutting out the expense of negotiating with insurance companies and having to hire coding experts in order to get the money they are entitled too.  Providers are emphasizing more prevention and individualized services that insurance based medicine will not cover.  Finally, the non-insurance provider is not “hedging” any bets on your health.  Your visit is about your health and well-being entirely...it's not a negotiation.