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The Effects of Insurance Involvement on Primary Care

An excerpt from Medical Answers Now!: How Direct Primary Care Guarantees Fast Access to Your Doctor.

Americans have a love-hate relationship with health insurance. It is universally accepted that we all need health insurance, but selecting and paying for it is often frustrating and always complicated. Whether major medical insurance is offered to us through an employer or if we are shopping for it as an individual or for our family, there are invariably multiple plan options presented to us that include extensive and overwhelming details. Since we aren’t health insurance industry experts, we are faced with making a decision (on a deadline) without understanding all of the implications of our choice. And, although we feel like there is too much information and too many choices being presented to us, the choices are predefined by our employer, an insurance broker, or a health insurance marketplace “exchange” in accordance with the Patient Protection and Affordable Care Act (ACA) known as Obamacare.

This pick-a-card-any-card approach often finds us living with consequences that never occurred to us when we selected our insurance plan. Surprises may come up at the time you receive care but are most commonly realized long after the fact when the bill or Explanation of Benefits (EOB) arrives. Unexpected costs may be in the area of coverage (such as exclusions of coverage for various services) or in unexpected costs from deductibles or various categories of copayments.

As with most things in life, health insurance can be a mixed bag of good and bad. Major medical insurance is literally a life-saver when catastrophe strikes. It singularly allows Americans to expect high-quality, high-tech, modern care that is the envy of the world. When we require hospitalizations, surgeries, and chronic specialty care for serious medical conditions, we fully realize the value of having comprehensive health insurance.

We can receive care that hardly anyone would be able to afford without insurance. That’s the good. The bad is in the many strings that are attached. Each insurance plan stipulates the conditions under which they will pay for services you receive. Medical services and products are only covered and reimbursed according to plan details, which determine where you receive care, who delivers the care, which doctors and facilities are in-network participating, which services (including types of visits, tests, and treatments) are allowed in network and out of network, what preventive and nonpreventive services are covered, your premiums, your deductibles, your copayments, your out-of-pocket limits, and what your doctors and other healthcare providers are paid and allowed to charge. Whew! It is clear who is in charge of your healthcare. In this book, I briefly consider how and why health insurance began in the United States and how it has evolved. I also explore the six major challenges and disadvantages to health insurance involvement in the relationship between you and your primary care physician.