Start with the care you need, not 'Is my doctor in-network?'

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When most people feel sick, they make an appointment with a health care provider. Feeling sick? Call the doctor. The two concepts go hand-in-hand.

“Traditionally, people have thought the path to managing sickness has been to go to the doctor,” says Marcus Thygeson, MD, MPH, chief health officer at Surest. “That was your resource.”

When health insurance is involved, there’s likely another step—to see if that doctor is in-network.

This way of thinking has become ingrained.

Most people hardly question it. You get your list of in-network providers. You see your doctor and go with their recommendation. There is little or no comparing treatment options. There is no comparing prices. Afterwards, you pay whatever the insurance company negotiates on your behalf. (The bill will show up in your mailbox a few weeks after you have your appointment, and odds are you won’t know the exact cost until after you open it.)

Until recently, doctors have been many people’s main source of health and wellness information. Some would say this has fostered an environment of patient dependence. But the Internet and the information revolution is changing things.

The birth of managed care (and gatekeepers)

Worrying about who is in or out-of-network is a direct result of managed care, a concept born in the U.S. nearly 100 years ago.

Managed care consists of health services delivered by a network of providers, a very different type of model than indemnity plans, when people would choose any doctor they wanted, pay the providers directly, then submit a form to their health insurance for reimbursement. The thought was that, through negotiating reduced costs with doctors, hospitals and clinics, employers or groups could save on their overall spend and providers would receive a steady stream of patients.

The concept picked up speed when the Health Maintenance Organization (HMO) Act passed in 1973, a government intervention designed to hold down rising health care costs. There are now several categories of managed care, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), point of service plans (POS) and the Surest personalized health plan (PHP).

Differences between plans

Before managed care was introduced, “it was irrelevant if your doctor was in-network,” says Thygeson, who has been on both sides of health care—as a treating medical doctor and now through plan delivery.

Some people have described providers in HMOs as “gatekeepers,” coordinating and managing all of their patients care, without giving participants the freedom to self-refer. Some have expressed frustration that telling a person who they can and cannot see is too restrictive.

Over time, people became more concerned with whether or not their doctor was in-network than they were about other important factors. The network became the be-all, end-all. This mindset, he says, does nothing to change our broken system.

A big black hole of health care spending

And it is broken. For one, there is a big black hole of health care spending, with costs continuing to rise. According to the Institute of Medicine, the U.S. spends $750 billion per year on health care waste. Let that sink in. $750 billion on high prices, administrative expenses, fraud and unnecessary health care. According to the U.S. Public Education Spending Statistics, that amount is more than the nation’s entire budget for K-12 education ($612 billion).

Why and how we use health care is a big piece of the equation.

One solution is for providers to stop ordering high-cost diagnostic tests or recommending surgeries that have little to no benefit or value, like an MRI for an uncomplicated headache or knee arthroscopy for age-related joint damage.

Overdiagnosing and overtreating are also common issues. It makes sense that some of the biggest savings can come from avoiding tests and procedures that shouldn’t be done in the first place—tests and procedures that don’t actually improve health outcomes or help people feel better for longer.

Another factor in the equation is the current payment system. Today’s doctors are more commonly rewarded for quantity vs. quality. (There are financial rewards for overtreatment, and no relationship between costs and quality.)

One way this can be addressed is through showing members transparent prices and high-quality, low-cost options, spurring competition in the marketplace.

Empowering the people

People have become so reliant on their doctors to “fix” them, that “they haven’t thought about how they can become effective, active agents in their own health care,” Thygeson says.

In order to improve outcomes while lowering costs, it comes down to a patient-centered approach to health care, a patient-centered approach that includes patient empowerment.

Patient empowerment is when people have the knowledge and the skills to safely manage their illnesses to the extent that they can. It’s knowing when and how to effectively use the system to achieve the best health care outcomes. - Dr. Marcus Thygeson, Chief Health Officer at Surest

One example of how empowerment can influence behavior and outcomes is type 2 diabetes management care.

In the past, type 2 diabetes was much more difficult to manage than it is now. Thanks to breakthroughs in lifestyle management and self-monitoring, people can manage—and even reverse—their type 2 diabetes from home.

First though, they need to understand what diabetes is, why it can be dangerous, how to track glucose levels and the role insulin plays. People benefit from education and support. It’s all part of empowering them to become actively involved in their own health care stories.

Empowering communities

Patient empowerment goes beyond the exam room into schools, work environments and in homes. The process of working together for the betterment of communities and populations is called health promotion. Health promotion programs are a discipline within public health.

To move the process along, people need the right information at the right time. This is the health disease and prevention approach. The goal of the health disease and prevention approach, as reported in the National Center for Biotechnology Information (NCBI), is to “to identify the health problems for which preventive efforts can result in more appropriate utilization of health services and improvements in health status.”

This approach doesn’t replace medical care for acute disease or chronic illness, but instead focuses on promoting preventive health to improve health and wellness—education, regular checkups and follow-up and support.

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