Fall is the time of year when people with employer-sponsored health insurance must choose their insurance plan for the next year. Not surprisingly, there is a lot of advertising going on and a lot of potentially confusing information being released that you must try to digest and understand.
Many state governments provide ratings of local health insurance providers to help consumers make informed choices. One component of these ratings is customer satisfaction, a section that naturally attracts a lot of viewers.
Another large part of these state evaluations has to do with the percentage of a plan's subscribers who get routine health screenings and how many subscribers with certain chronic diseases are cared for according to expert-panel guidelines.
But are customer satisfaction and lists of who is eligible for what really among the most important criteria by which you should be judging your insurance plan?
Perhaps I'm living in the past, but it seems to me that the doctor and the patient are the ones who must assure that good health care practices are being followed. I have no objection to (and actually welcome) a health insurance provider helping to facilitate good health, but I believe an insurance plan should be judged by more important criteria.
It's important to remember that these days health insurance is a business, and a portion of your premium dollars is used to pay for multimillion-dollar executive salaries, marketing, advertising, and administrative costs. In some cases, company stockholders are also expecting to see the insurer turn a profit each year. If an insurance provider is to be successful, it must of course make consumer health and customer satisfaction among its chief goals, but profit and loss is the ultimate bottom line for most of these companies.
As a physician, my biggest concern with a health insurance plan is whether a patient is able to access all aspects of care. The unfortunate reality is that medical care is increasingly expensive, and only limited resources are available to pay for it. This means that even without the expenses of running a business and keeping their stockholders happy, insurance plans — in order to balance this conflict — must either raise their policy fees or restrict patients' access to some forms of treatment.
The easiest place to start when comparing plans is with costs and fees. Premiums, co-pays, deductibles, and maximum out-of-pocket costs are usually stated pretty clearly. Sometimes, however, lower premiums are balanced by higher co-pays and deductibles. Keep in mind that a lower total cost might (but doesn't necessarily) mean less customer service or more restricted access to care.
Prescription medication coverage is another area that can be quite variable. There are frequently at least two and sometimes three different co-pay costs for various medications, and some medications are completely excluded from reimburesement. Generic drugs are almost always the least expensive choice, are usually as good as their brand-name equivalents, and should be your first choice whenever possible.
But brand-name medications are sometimes necessary, and they can be quite expensive. Insurance plans vary widely in the access they will allow and the fees they charge for these more expensive medications.
