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About Health Insurance There is probably no topic so fraught with emotion in today's political climate as health insurance. Everyone feels that good health care should be a right of all Americans. The problem is that good health care has become very expensive and the question arises as to who will pay for it. The reasons for this are complex but they include the costs of new technology (the latest MRI, CT and PET scanners are extremely sophisticated computerized equipment), the costs of developing new drugs (which have to go through multiple stages of testing and development), the growing elderly population requiring health care (thanks to advances in medicine and social conditions) and the increasing costs of running a hospital or a medical office (personnel, equipment, insurance, government regulations). It has also been determined that the arrival of crime victims in emergency rooms and the costs of caring for uninsured patients have driven up hospital expenses. Because of all this, the days of the $5 doctor visit and $2 prescription are long gone. In the past, employers would provide health insurance which would cover almost every need. Now, the cost of providing health insurance has risen to the point that employers are finding it difficult to offer the traditional plans and a variety of attempts to limit costs or cut costs have come about. Competing companies have tried to undercut the costs of premiums in order to get the business of large employers, sometimes with disastrous results (such as the now defunct Harvard Health Plan in Rhode Island, which went belly up, stranding large numbers of patients and doctors). This an extremely political area. There is much lobbying going on constantly regarding regulation of insurance companies covering healthcare and Medicare, both at state and federal levels, lobbying by several groups, those representing doctors, those representing consumers and those representing the insurance companies. Plans now being offered almost all have developed restrictions in services. These may take the form of drug formularies, where certain medications are on a preferred list and where there are various "tiers" of coverage. The preferred drugs are covered with a lower "copay" than the others and some are not covered at all. Each insurance has different lists of covered drugs and these list change from year to year. Some plans, such as traditional Medicare, do not pay for drugs at all. In our practice, we try to work with patients and their plans to provide medications that are effective but are also covered. Unfortunately, sometimes the best medication is not a preferred drug or may not be covered at all. For example, the newer antifungal creams for athlete's foot are far more effective than the older ones, but one of the major plans in Rhode Island will not cover these newer (more expensive) creams at all, and the ones it will cover are often ineffective. Another example is bleaching creams containing hydroquinone, which are used for conditions of excess pigmentation, such as melasma. Almost all insurers now view this as a cosmetic treatment and will no longer cover it. One insurer will no longer cover most acne medications for people over the age of 18. Presumably they have determined that people over 18 either don't get acne or that it is not of medical significance in people over 18!! Another way of cutting costs has to do with access. Many plans require a referral to specialists from the primary physician. The thinking is that most medical conditions can be treated by the primary doctor and that limiting access to specialists will save money. There are a number of instances where this has been shown not to be true. For example, several published studies have shown that dermatologists are far more accurate in diagnosing skin cancers, including melanoma, upon examination than non-dermatologists. This not only would save unnecessary surgeries but might lead to more cancerous lesions being removed early, saving lives. However, this system of referral is with us and many of you will need a referral from your doctor to see us. We do not have enough personnel to be phoning (and often sit "on hold" for long periods of time) for referrals so we need to ask you to call and obtain the referral prior to your visit. If the referral is not in our office when you come, we may ask you to sign a paper that you understand you may be responsible for the costs of your visit if a referral is not received in a timely manner. There is another way in which insurers are attempting to cut costs. There are certain services which are not covered because they are viewed as "not medically necessary". For example, the removal of skin tags is not covered by many insurance plans, no matter how irritating, annoying or painful they may be. Other plans do cover this. There is also the question of intent. If a mole is removed because "it's ugly" or a person simply doesn't like it there, then that is viewed as a cosmetic procedure. If there is a question about diagnosis and the mole is removed for diagnostic reasons, then this is usually covered. Some plans will not cover costs if several procedures are performed on the same visit. This also varies from plan to plan. If you are in doubt about coverage, we advise you to call your insurance company and ask them. We will not knowingly perform an uncovered procedure on you without telling you in advance, but coverage varies so much that we cannot always know. For specific questions concerning coverage of services provided by our office, feel free to speak with Lorraine, in our office. She can be reached by calling (401) 943-0761, X102. For general questions and concerns about your coverage, you must contact your insurer. At the time of writing, many of the insurers have cut their payments to doctors. We no longer determine what we get paid. The rates are set by the insurers. At the same time, our costs of doing business have risen sharply - insurance premiums (health premiums - up 50% - , malpractice premiums - up 100% ), supplies, costs of hiring good staff. In some areas there are doctors who have found it impossible to continue in practice. Fortunately, we have every intention of continuing to provide you, our patients, with the best dermatologic care available. We have written this statement about health insurance to try and explain some of the confusing changes that are happening and to suggest ways in which we might work together with you (and you with us) to continue the excellent relationship we have had with our patients for many years. Ellen H Frankel, MD |