About Health Insurance
There is probably no topic so fraught with emotion in today's political climate as health insurance. Good health care has become very expensive, and the question is, who will pay for it? The reasons for rising costs are many:
- The expense of new technology (the latest sophisticated computerized equipment such as the MRI, CT and PET scanners)
- The cost of developing new drugs (with the multiple stages of testing and development)
- The growing elderly population, requiring more health care
- The increasing cost of running a hospital or a medical office (personnel, equipment, insurance, and government regulations)
- The increase of crime victims in emergency rooms and the costs of caring for uninsured patients
Because of all this, many things have changed. The days of the $5 doctor visit and $2 prescription are long gone. In the past, employers provided health insurance that covered almost every need. Now, employers find it difficult and expensive to offer the traditional plans and try to limit or reduce their costs. Competing insurers have sometimes tried to undercut the costs of premiums to get the business of large employers, sometimes with disastrous results (such as the fate of the now defunct Harvard Health Plan in Rhode Island, which went belly up, stranding large numbers of patients and doctors). On this politically-charged subject of health care, much lobbying goes on regarding regulation of health insurance companies and Medicare, both at state and federal levels. Lobbying is by those representing doctors, those representing consumers, and those representing the insurance companies.
Almost all currently offered health plans restrict services. Drug formularies classify certain medications as preferred and have various "tiers" of medication coverage. The preferred drugs have a lower "copay,” while some other drugs are not covered at all. Each insurer has different lists of covered drugs, and these list change from year to year. Some plans do not pay for drugs at all.
In our practice, we work with patients and their insurers to provide medications that are effective but are also covered. Unfortunately, sometimes the best medication is not a preferred drug or is not covered. For example, some new medications are far more effective than the older ones, but some plans will not cover these newer (more expensive) medications. Another example involves bleaching creams containing hydroquinone, used for conditions of excess pigmentation, such as melasma. Almost all insurers now view excess pigmentation as a cosmetic problem and will no longer cover treatment. One insurer will no longer cover most acne medications for people over the age of 18!
Many plans also try to cut costs by restricting access. They require a referral to specialists from the primary care physician, maintaining that most medical conditions can be treated by the primary care doctor. Sometimes this is not true. For example, several published studies have shown that dermatologists are far more accurate in diagnosing skin cancers, including melanoma, than non-dermatologists are. More accurate diagnosis, done by specialists, would avoid unnecessary surgeries and 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 phone primary care doctors (and often wait "on hold" for long periods of time) for referrals, so we ask you to obtain the referral prior to your visit. If the referral from your primary care doctor is not in our office when you come, we may ask you to sign a paper agreeing to be responsible for the costs of your visit if a referral is not received in a timely manner.
Insurers cut costs further by not covering services they view 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. There is also the question of intent. If a mole is removed because "it's ugly" or a person simply doesn't like it, that is viewed as a cosmetic procedure. If the mole is removed for diagnostic reasons, the procedure is usually covered. Some plans will not cover costs if several procedures are performed on the same visit. If you are in doubt about coverage, call your insurance company and ask. We will not knowingly perform an uncovered procedure without telling you in advance, but coverage varies so much that we cannot always know. For specific questions concerning coverage of services we provide, call our office at (401) 943-0761. For general questions and concerns about your coverage, contact your insurer.
Many insurers have cut their payments to doctors. We no longer determine what we get paid. The rates are set by the insurers. But our costs of doing business have risen sharply. Insurance premiums are up 50%, malpractice premiums are up 100%, and the costs of supplies and staff have risen. Some doctors have found it impossible to continue in practice. Fortunately, we intend to continue providing you, our patients, with the best dermatologic care available.
We have written this statement about health insurance to 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
Michael A Bharier, PhD, MD
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