New Year, New Deductible

The world counts down while the ball drops, symbolizing the new year and reason to celebrate. That is until you return to work and the painful reminder that a new year comes with newly calculated premiums (often higher than last year) and a reset deductible, which means although your premiums are going up, you’ll be paying for your healthcare out-of-pocket for awhile – until you meet your deductible all over again.

The rising cost of healthcare

It’s a catch 22; the sicker you or the members of your organization were last year (measured by the dollar amount of claims submitted), the higher your premium is this year. That essentially means the more you paid last year, the more you’ll pay this year. Perhaps even more frustrating is the fact that if you became ill toward the end of the year and finally paid your deductible on December 31st, you’re back to square one on January first despite needing ongoing care for your acute illness, so you have to pay your full deductible twice before your insurance benefits kick in. (Please note that not all plans operate on a calendar year, so your premiums may change and deductibles may reset at another time during the year.

This isn’t even half of the story. In order for clinics to become participating providers with your insurance company, they need to participate in the credentialing process. This includes submitting dozens of documents, some many pages long, on each provider and the facility itself to get through the system. The time and effort involved in credentialing adds overhead and makes services more expensive for you.

These beginning-of-the-year changes can have a direct impact on your health. Because healthcare premiums and out-of-pocket costs amount to as much as 30% of total household income for a family of three, many patients choose not to see the doctor when they normally would. The result is often increased out-of-pocket costs when complications arise from a condition that should have been otherwise easy to treat, such as hospitalization or surgery.

Additionally, when health insurance premiums rise each year, your employer is forced to take a better look at their options to determine the best plan for the organization and its team members. As a result, many employers change plans or carriers somewhat regularly to keep costs low, which often means you have to choose a new primary care provider to ensure you’re able to receive healthcare services at the in-network rate. Finding a new primary care provider (or specialist if you see one regularly) and establishing a relationship with them can be challenging and time-consuming. Take into consideration the history you lose with your current provider and the need to transfer medical records and the process becomes more and more daunting and burdensome on you, the prescriber.

Additionally, clinics have to charge their payers enough to cover the 40% – 50% of fees they never collect and ensure operations can continue. This means you aren’t only paying for your medical care, but for the care of those who cannot or do not pay.

Breaking the cycle

So what can you do to get out of this vicious cycle of paying premiums in, meeting your deductible out of pocket, rinsing, and repeating? It’s simple: Choose a direct primary care provider. Direct primary care providers are striving to change the healthcare industry by fixing the broken system surrounding health insurance, which directly impacts the services they’re able to provide and the time and effort they’re able to put into those services.

Direct primary care providers across the nation are demonstrating that can healthcare really can be different. By offering a simple structure to give and receive healthcare services that focused on the patient’s experience and a high standard of care rather than credentialing, insurance payouts, and other burdensome healthcare traditions, these providers are able to make ends meet while keeping costs low for patients and providing the best care possible during every single patient encounter.

What does this mean for you? It means that you can have longer appointments, 24/7 access to your provider or his team, and better comprehensive care all at a lower cost. It doesn’t mean you can completely escape the insurance game (not until the Affordable Care Act requirements change, anyway), but it does mean you can spend less on your healthcare coverage and get better service in return.

The winning edge

Let’s take a look at the benefits of direct care over traditional healthcare, both paired with health insurance:

1. The cost is less. With direct primary care, you pay one low annual or monthly fee to receive a wide range of services, perks, and benefits. You’ll still have to maintain insurance to cover specialized services, hospitalizations, and other major medical occurrences per the Affordable Care Act, but your overall healthcare costs should decrease.

2. You play a more pronounced role in your care. When your provider works with insurance companies, he or she has to follow their rules and regulations if you expect the cost of your care to be covered. This means that if he believes a test is necessary but your symptoms don’t meet their criteria for necessity, you may not receive the tests you need to rule out or diagnose a problem. When you work with a direct primary care clinic, you and your doctor get to make the decisions that have the most positive impact on your health and well-being despite insurance requirements.

3. Your rates don’t fluctuate based on your usage. Although few people know it, health insurance premiums are usually calculated based on the group’s usage of the plan in the previous year, so if your group experienced some major medical problems, your premium can increase when it’s time to renew. With direct primary care, you pay the same low annual or monthly rate as everyone else despite your usage and your medical history.

4. You get more face-to-face time with your provider. Because insurance reimbursement rates are often much lower than the cost of providing care, traditional clinics are forced to shorten appointment times to ensure they see enough patients to meet their financial goals each day. Direct primary care providers charge an affordable monthly or yearly fee to ensure they can afford to spend as much time as needed with each patient, answering all of their questions and providing thorough education on their diagnosis and treatment plan.

5. You know exactly what to expect. Budgeting is easy when you choose direct primary care; your primary care visits are covered as long as you pay your predictable annual fee, which means you know exactly what you’ll spend on your primary care visits at the start of every year.

If you’re like most, you’ve been the victim of a broken healthcare system for most of your life, waiting for premium hikes every January and saving up all year so you can meet your deductible again at the beginning of the next. This year, you have an opportunity to choose a different route and contribute to a patient-centered system by choosing a direct primary care provider for the diagnosis, treatment, and maintenance of acute and chronic health conditions.

Wishing you health and wellness,
Dr. Zivich