Imagine one day you determine you need a new sweater. You have to go to Saks Fifth Avenue, because it’s the only store in your city, but you have to go between 1:00 and 4:00 p.m. on a Thursday, four weeks from now. Because that’s when they’re open. You find a sweater, strangely located in the shoe department. You really need the sweater, so even though the price tag is blank, you take it to the dressing room. The salesperson, in a hurry and very busy, races past you — she does not know the price and has no idea how to determine the price–that’s your job, she says. That’s okay, because you happen to know from your internet research that the same sweater costs $20 at Target. (You can’t buy it at Target, though–Target is in another city, and doesn’t take cash, checks or any of your credit cards).
You take the sweater to the register, and after completing 10 forms and waiting two hours in line, a staffer rings up your purchase. Turns out the sweater costs $350.00.
Wait a minute, you say. That seems like a lot. I saw this sweater at Target the other day for $20. Why so much? No one knows. No one cares. You pay the $350.00 after waiting another two hours in line, only to receive a bill for an additional $75.oo in the mail six months later. The sweater? Mailed to your house–in the summer, about a month after you buy it.
Sound insane? This is what shopping at Saks Fifth Avenue would be like if it were part of the American third-party payer healthcare system.
The other day, I spoke with the mother of a patient who was referred to my clinic. When I called her to set up an appointment, it became clear that she did not know her options (such as my out-of-network clinic, a traditional private practice model, or a clinician covered by her insurance policy), so we discussed those at some length.
She could pay at the time of service for my examination: they’d be seen immediately, with same-day report. The hours needed and costs would be defined in advance, the cost would be comparable to co-insurance (and far less than any denied claim), and she could submit paperwork for out of network reimbursement from her insurer.
Alternately, she could rely on her insurance. She didn’t know if her plan covered pediatric neuropsychological examination (many plans do not, especially when there is any question of learning disability or school problems). If it does cover such exams, she would need to find out who to see. Is there an in-network clinic taking patients? What is the wait time for an appointment? Is it a clinic she trusts, with a board certified specialist?
And once she has determined whether she can see one of these covered entities, she wondered, how much would it cost her out of pocket? Well, of course, first you must meet your deductible. And then there is co-insurance. She astutely pointed out that still she could not compare pricing, because coverage and fees could vary quite a bit from plan to plan even within one company. Then she would have to call her clinic of choice to find out how many hours they would bill for such a service and at what rate, so she’d be able to calculate her portion.
If the service was not covered, she could go to another traditional-model private clinic, and plan for very lengthy testing, a report weeks later, and a very high bill.
The absurdity of the situation was not lost on her. It shouldn’t have to be that hard.
There’s no excuse for a healthcare and insurance system that fails to provide transparency, expediency, or simplicity. Customer care should be the same for patients as it is for visitors in the highest-end retail stores, with clear standards for quality, pricing and value.
There is another way. A new way. As coverage of neuropsychological services is evaporating, and access to clinics is becoming more restricted, my clinic model is poised to fill the gap, to be here for you and your patients, for you and your family.