I believe that it is better to think about health insurance before becoming a patient. A befuddling market is easier to deal with while relatively well, instead of when ill or injured. Health insurance can be staggeringly confusing, even for the most motivated and knowledgeable consumers. For those who have high deductible insurance (such as being offered by many employers and exchanges), it is essential to be engaged in making good decisions. One should access care in the most efficient way, follow cost-effective treatments, and even make sure to decline services that are unnecessary. Healthcare consumers are being asked, more and more these days, to be involved in choosing their treatment options; they are supposed to be engaged and ask questions.
This can be difficult for anyone, especially those with low health literacy. Health literacy involves a patient’s ability to comprehend medical directives, such as how to take medication correctly (e.g., 3x/day, roughly every 8 hours--not at 9am, noon, and 3pm). While studies show that literacy within the health care context tends to be lower among the less educated and those of lower income, poor health literacy can cut across all levels of education and income. Someone with an advanced degree can have difficulty managing decisions about the risks versus the benefits of medical interventions, especially when anxiety and pain come into play. When patients have a limited framework for understanding and using health information, they tend to generate higher healthcare costs, achieve worse health outcomes, and have lower adherence to treatment.
Literacy regarding healthcare benefits (sometimes called Health Benefits Literacy) is a related phenomenon; it is focused on the degree to which an individual understands the health insurance options available and how to use those options effectively. Some interesting survey results are offered by the nonprofit International Foundation of Employee Benefit Plans (IFEBP), which has over 33 thousand members representing public and private sector employers that insure over 25 million people. Only 19% of respondents believe that their employees' understanding of health benefits is at least somewhat high; 23% believe that their employees have low understanding of their health insurance. Human resource managers and benefits counselors in companies across the country report spending more than half of their time answering employees' questions about healthcare benefits. And yet a lot of motivated, capable people remain confused.
Learning about your healthcare plan involves issues that can be intimidating: premiums, deductibles, in-network versus out-of-network providers, percentage coverage, visit limits, and preventive services, just to name a few. Most employers, health insurance exchanges, and health plan providers (insurance companies) offer large amounts of information. But studies show that most employees and subscribers (that is, the people who buy health insurance for themselves and their families) don't fully understand what they have or how to use it. Informal employer surveys show that less than half of employees even read all the materials they receive about their health plan benefits. (Quality research on this topic is sparse, though, and more is needed). Many people who buy health insurance don't even know that they have certain preventive visits and tests available to them at no cost. Of course, simply deluging people with information does not work very well; being told a lot of confusing facts can be overwhelming and not very helpful.
I once had a high deductible plan that was supposed to save me money if I chose the right providers and asked the right questions. But I had the same feeling as my friend who had some construction work done on her house. She was dissatisfied with the results, and in response the contractor told her that she should have, up front, asked more questions! "If I knew what questions to ask," she said, "I would have asked them!" The same is true in health care, where we want people to be astute consumers of medical care when the information available can be confusing, anxiety-provoking, and sometimes even inconsistent. I have had years of experience in the healthcare field, working with health plans, employer groups, integrated systems, and patients; I don't think I have low health (or benefits) literacy. But last year I was pretty confused by my own health plan. I had moved to a new area, and tried to "front load" decisions and care plans for myself and my family before becoming ill or having a crisis. (I am the one in my family who is responsible for knowing the steps necessary to access care and clarify medical choices; most families have a member who does that, whether they enjoy it or not.) This kind of exercise is something that all health plan subscribers and employees should do in order for them to make the right choices, insofar as those are possible, if and when the time comes to do so. One scenario I 'walked out' in my mind was being ill on a Saturday night. Which urgent care establishment is within a reasonable distance and open on a Saturday after 6pm and in our network? (answer: none) There's always the emergency room, of course, and the closest (much admired) hospital is "in network." (smile). However, many of its doctors are not. In planning this out, I checked the website which was confusing enough to prompt a call to my plan to clarify. The names of in-network doctors and hospitals, according to the website and according to the person on the phone, were different. These experiences are not unusual.
Health plan information is not just difficult to understand and negotiate when one is ill; it can be copious, complicated, and anxiety-provoking at best, and unclear or inaccurate at worst. Yes, there may be a lot of information for people to read, but even if they read it, can they translate it into their own lives? Will they take the right steps when they are ill on a weekend? Do they understand the potential consequences of being unprepared? Do they have an extra few thousand dollars sitting around in case they make a suboptimal decision, or get the wrong information?
Not all of my family's healthcare is frustrating; veterinary care is a dream. I just got another new puppy (photos available upon request), and I considered, again, the issue of whether I should buy him health insurance. Today's options include "wellness plans" which cover only preventive services, and "canine veterinary medical plans" which cover illnesses and accidents, excluding pre-existing conditions. I read the policies offered and the "pre-existing condition exclusion" is quite broad. After calculating monthly premiums and deductibles for various possible unsettling future scenarios, I decided instead to open a 'personal health savings account' for my puppy (i.e., just some money put aside to ease the sting of a big vet bill.). This is the same conclusion I came to for his older brother and many dogs before him. And although the world of veterinary healthcare is not a space in which I have great expertise, I did figure it out because it is not nearly as complicated as human insurance. In my efforts to make a decision, I considered this veterinary scenario: It's Saturday night, and the puppy needs care--now. We pile into the car, drive to the animal emergency hospital a few miles away. After diagnostic tests and discussion with the kind veterinarian about risks, benefits, and costs of various courses of action we make a decision. (I like to make these scenarios end happily.) We eventually head home with medicine, having paid the bill with said puppy's personal health savings account. I did all the thinking ahead of time and made the financial decisions, and now I can just focus on my family and getting our puppy well again. I was able to do this for pet insurance because pet insurance is easy, veterinary care is much cheaper than human medical care, and the number of insurance options is fairly limited. It took some time, but it was manageable. I don't feel that way about medical insurance.
How can these challenges be managed? Maybe we should start by helping people, when they are healthy, to ask the right questions of their doctors, and plan hypothetical courses of action for themselves and their loved ones. Maybe experts on health insurance could offer some more support for this. We ask people to be good consumers, but it's frustrating and difficult unless they get help asking the right questions and dealing with the answers, making plans, and front-loading decisions whenever possible. The motivations to plan ahead are clear (save money, plan out-of-pocket costs ahead of time, get the best care). But that support is rarely available; as consumers we have to figure it out on our own.
Nearly every year, with new health insurance options and costs, I had to plan out potential scenarios in my mind --what to do under various emergency situations or chronic disease diagnoses, what general questions to ask, what pathways to take, how much to spend in premiums for what benefit -- knowing that I could not know what the future would hold. Certainly these thought-exercises can cause existential anxiety for all of us; thinking about future health challenges can be upsetting. But medical plan information should help to reduce that anxiety, not increase it, or consumers will never want to plan ahead. As a psychologist, I considered the possibility that stress about my health insurance might someday make me sick. So, I finally threw in the towel and joined an Accountable Care Organization (ACO), one that prides itself, as many do, on its safety and effectiveness metrics. In a medical crisis, I know exactly whom to call and where to go, and I know exactly what's covered. I don't even have to remember my health history because it is available in a detailed electronic health record. Also, I trust that this ACO's focus on safety and effectiveness makes it unlikely that I will be offered unnecessary, expensive procedures that have questionable benefit. I can concentrate instead on asking about treatment options and considering how they fit with my own values and expectations. And I can spend more time playing with my puppy.
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