I am a health economist, a professor with a PhD from Harvard. I’m supposed to be an expert on health insurance and its complexities. How did I end up in such a bind?
I tried to recover my dignity and act like an expert: “How much does it cost if you pay out of pocket? $20,000?”
“For the surgeon. . . . But you have to pay for the hospital, too, even if the hospital is in-network. When you use an out-of-network surgeon, the whole thing counts as out-of-network,” she said.
How could I have forgotten that? I hung up with the depressing impression that having Bruce as my surgeon would cost me around $60,000 out of pocket.
Whether it is President Obama praising the Affordable Care Act or critics of “Obamacare” describing their ideal system, such words as “choice” and “competition” figure greatly. The idea is that informed consumers shopping for health care will lower cost and improve quality.
Yet my difficulties show how hard it is — even for someone who has studied health-care and insurance issues — to navigate the health-care marketplace, particularly when you have a serious medical condition.
My problems began in November 2006, during open enrollment for insurance, when one can switch plans. I had switched from a point-of-service (POS) plan, where you can pick your own doctors and just pay more if they are out of the carrier’s network, to a health maintenance organization (HMO), in which only in-network doctors and hospitals are covered. HMOs are often cheaper: Switching saved me about $500 a month. The downside is that if you go outside the network, you must pay 100 percent of the doctor and hospital cost. But my main motivation for the switch was the ease of getting specialists and treatments approved with the HMO as compared with my POS plan.
When I switched plans, I had known that I might have a pituitary tumor, which can cause a condition called Cushing’s disease, and that neurosurgery was the recommended treatment. Opting for a POS and its out-of-network benefits to give me a free choice of surgeon would have been best. But I had overlooked that. Why? Ironically, years of careful research on insurance options, particularly for my husband, were to blame.
Several years earlier, my husband, Howard, who was born with only one kidney, had a lot of health problems, including a heart murmur that had required heart valve surgery. For years he had been on my plan, but when I switched jobs in 2004 we had to redo things, and both his employer and mine offered the exact same options. Two of them had out-of-network benefits, a feature I had always insisted on. Aetna had a great reputation, but its out-of-network coverage was expensive: The employee contribution for one person would cost $3,700 per year. The contribution for the equivalent POS plan offered by another insurer, HIP, was $2,450 per year, but its reputation among some friends and colleagues at my old job was not as good as Aetna’s. After consulting other colleagues who were using HIP, I decided to give it a try anyway. For Howard, we chose the deluxe Aetna plan with out-of-network benefits.