How “Health Insurance” is often Harmful to Your Health
I know – that’s quite a claim, but bear with me. Don’t get me wrong – we all need health care coverage. It is critical to help cover large health care expenses such as emergencies, surgeries, and catastrophic illnesses (click HERE to learn more – especially about Health Sharing Plans, our recommendation for catastrophic coverage). However, and we know this isn’t news to you, health insurance is quite the debacle. Especially in Primary Care. And, it can often lead to poorer health!
How can that be so? The most obvious way is because most deductibles and copays are so high that, in many instances, they prevent care – unless you try to include your concerns during a “free” (wink-wink) annual physical exam. And unfortunately, trying to do so causes several issues of its own (see The “Yearly” Physical below). In addition, as they are currently performed, annual physical exams are fraught with unnecessary testing. See What’s Wrong with Doing These Tests…, The Whole Body CT Scan, and Cash Cow below to learn why unnecessary testing is harmful.
Health Insurance Must Become Akin to Auto Insurance
Auto insurance isn’t necessarily cheap, but imagine how much more expensive it would be if we expected it to cover preventive maintenance like oil changes and tune-ups, or even when something wears out with normal wear-and-tear. Yes, it would be nice, but if it did cover those things, auto insurance rates would skyrocket. Auto insurance exists to protect us financially in case of accidents – and if health insurance were structured the same way, imagine how much cheaper it would be! Here’s a little parable to illustrate:
The Parable of the Fuel Filter
You take your car in for an oil change, and sit down in the lobby to wait while it’s being performed. In walks the repairman. “Ma’am, would you like us to change your fuel filter? It’s dirty.” Your response?
Scenario 1: It is covered fully by insurance.
“Yes, thanks, that would be great!” Whether it’s truly needed or not – you don’t really care. After all, you’re paying a lot for your insurance. And your insurance costs continue to rise.
Scenario 2: You have to pay for it with your hard-earned cash.
All kinds of questions, e.g.:
“Uhhh, well, how dirty is it (does it really need to be changed)?”
“How much does it cost?”
“How often does it usually need to be replaced?”
Then, after you have carefully considered the answers, you make an informed decision. And your auto insurance rates aren’t affected one whit.
This illustrates how having a third party (insurance) pay for something optional can affect both costs and critical thinking.
The Third Party Piece of the Pie
Another way insurance may be harmful to your health is that high costs are largely driven by “them” (the insurance companies) – preventing those who cannot afford the care from getting the care they need. Whenever there is a middleman, health care providers (including clinicians, testing facilities, and treatment companies) are driven to charge as much as they can – especially to make up for falling reimbursements. The humorous part is when insurance companies then portray themselves as the patient advocate, telling them that they are lowering costs by negotiating a reimbursement that is lower than what the greedy doctors charge. I would be lying if I suggested doctors were not further tempted to provide unnecessary services just so they can bill insurance to further make up the difference (see The Cash Cow below). It is messed up on all kinds of fronts. At TLC Family Health, of course, with no middleman, providers order only what’s right – see The Primary Care Provider (PCP)’s Job below – and what the patient can afford. And few can’t afford something that is at cost, usually 90+% less than the standard!
Another example of how having a third party (insurance) pay for something optional can affect both costs and critical thinking is the…
The CT (Computed Tomography) Coronary Artery Calcium Score Test
In ~2006, due to a remarkable advancement in technology (the rapid spiral CT scanner), it became possible to image the heart – between beats. The technology opened the door to non-invasive coronary artery imaging, allowing doctors to catch calcified heart disease before it “caught” you. Being the #1 cause of death, the value seemed priceless. But it only cost ~$600! Understandably, perhaps not surprisingly, insurance companies figured out pretty quickly that this would be a popular test – and, only partially because the value of the test was still under review, they made an immediate decision not to cover it. As such, it entered the open market, and now you can get it for under $100, cash-pay. I know.
The Primary Care Provider (PCP)’s Job
It is the job of a PCP (and it is a sign of a good PCP):
To do what’s needed and not what’s not, both in helping prevent (see Types of Prevention below) and treat disease
To know and admit (even if just to him- or herself) what he or she doesn’t know, and when (and to which specialist) to refer (the less he or she knows of these things, the more health care costs rise and possible harm goes up)
To ask the patient to please inform him or her (the PCP) what happened with the specialist and how the experience was; also to ask the specialist to send the PCP a report; and not to go to another specialist without informing you
If a referral is made, it is the job of a Direct Primary Care (DPC) physician to make sure the patient asks if any lab work needed can be done through the DPC membership lab account, and, if applicable, the best price can be obtained for any imaging that is done.
The best PCPs try to ensure at every visit that evidence-based preventive measures are up-to-date or being taken. This is discussed further below, under The “Yearly” Physical. To do so effectively, it is critical for both PCPs and patients to understand that there are four types of prevention:
Primary Prevention: Intervening before health effects occur, through measures such as vaccinations, altering risky behaviors (poor eating habits, tobacco use), and banning substances known to be associated with a disease or health condition.
Secondary Prevention: Screening to identify diseases in the earliest stages, before the onset of signs and symptoms, through measures such as mammography and regular blood pressure testing.
Tertiary Prevention: Managing disease post diagnosis to slow or stop disease progression through measures such as chemotherapy, rehabilitation, and screening for complications.
There is now a fourth type of (“Quaternary”) Prevention, which I really like: “First, do no harm.” Don’t do a test or provide a treatment that may cause more harm than good. Also see the British Journal of General Practice’s take on the subject.
The “Yearly” Physical
Omigoodness, where do I start? I often joke that the phrase “physical exam” is not found under “P” in the dictionary. It’s under “Y” for “yearly” or “A” for “annual physical exam.” Everyone thinks you need a physical exam every year. “Everyone” includes whoever, or whatever agency, was advising the Obama administration, which thought they were doing our health (and health care system) a favor when it mandated insurance coverage of yearly physicals – including “annual” well-woman exams (the latter of which just…won’t…die). How does this possibly cause more harm than good?
“An ounce of prevention is worth a pound of cure,” right?! YES (!) – we need preventive care, but not the way the current “yearly physical” is set up, with a standard set of blood tests, and sometimes a lot more. Preventive care should ideally be updated/addressed at every visit, or when it is due. But there is no preventive test that has been proven to be necessary every year, for everyone. If you have a medical condition that requires follow-up (“tertiary prevention,” described above), or are high risk for other reasons (e,g., strong family history), that’s a whole different story (and those costs are out-of-pocket until you reach your deductible).
Screening tests (“secondary prevention,” described above) that have been proven to be beneficial, or that have at least been examined closely and expert consensus recommends, include (see grade A & B recommendations by the United States Preventive Services Task Force, AKA USPSTF):
Mammogram every two (2) years between ages 50 and 74
Pap smear every three (3) years between ages 21 and 29, then every five (5) years between ages 30 and 65 (by the way, this is one of the few guidelines on which all major authorities agree, including the American College of Obstetrics and Gynecology)
Colon cancer screening between 45 and 75
Yearly low-dose CT scan for ages 50-80 if you’ve smoked an average of one or more packs per day for 20+ years (unless you quit >15 years ago)
One-time hepatitis C screening between ages 18-79 (but repeat if exposed)
You get the idea. You can go through the ~100 recommendations on their list, and nowhere does it even come close to suggesting patients get a “yearly physical,” or even a complete physical at all! Health care advocates, including physicians, could, and do, argue until they are red in the face as to whether or not getting an annual physical exam does more good than harm. Here are the reasons I am not a fan:
The true purpose of a preventive “physical exam” is for prevention. That is what is on your doctor’s mind when you schedule one. However, patients often (perhaps understandably) misinterpret “physical exam” as “comprehensive health care visit,” and prevention is usually the last thing on their minds. Instead, because of the effects of the insurance system and the misunderstanding, they hope, and often expect, to have their (often many) health concerns addressed during the visit. The results are counterproductive. 1) The doctor is distracted from being able to discuss much-needed preventive care, leading to poorer outcomes. 2) Depending on the amount of problems presented, the rushed doctor is forced to address each problem inadequately, further leading to poorer outcomes (or at least to increase costs, as the doctor may be more tempted to “punt” the problem to a specialist).
In addition, because deductibles are so high and insurance usually covers this visit fully as a “preventive” visit, patients often delay much-needed follow-up of their chronic medical conditions – sometimes for a full year – until it’s time for the “yearly physical” again. This delay, of course, leads to poorer health outcomes.
All of these problems are driven by the negative effects of insurance. Do I mind doing physical exams, or seeing patients who schedule physical exams, even if they try to combine the visit with several concerns? Of course not – but because of my practice model I don’t get paid any differently based on the purpose of the visit. And we are able to take the time needed to address everything thoroughly – if we run out of time, another appointment is made with little added cost.
So how often do you need a preventive visit? Babies and toddlers need preventive visits regularly, primarily for vaccines and to ensure healthy physical, mental, and emotional development, so I recommend getting them as often as the CDC recommends to obtain them. After age two or so, other than getting a yearly flu shot (and who knows where CoVID vaccine recommendations are going to end up), the next important check-up/in is between ages is 4-6. After that, I’d say every 2-3 years until age 18 (making sure one occurs around age 11-12), then every 3-5 years afterwards. Obviously, if concerns develop before a planned preventive visit, make sure you seek care.
Also see:
“What’s Wrong with Doing These Tests More Frequently – or Other Tests That Aren’t Recommended for Screening – Especially if I’m Paying?”
Patients and physicians love tests. We all want to know more. However, because not all testing is benign, and can cause more harm than good [perhaps the best example is illustrated under The Whole-Body CT Scan (or MRI) below], it is imperative to go through an educated decision-making process (usually guided by an experienced health care professional) before assuming it’s smart to order. And of course cost must be weighed into the decision-making process. One must also be aware that the more testing one has/does in an individual whose symptoms or risk factors don’t warrant the test, the more likely false positives will be encountered. False positives usually lead to further testing, some of which may be invasive, and that increases the risk for infections, harm, and even death (not to mention the added cost) – all of which could be avoided had we not done the test in the first place.
To explain another way, although all tests have normal and abnormal ranges, some unaffected individuals may have abnormal tests (i.e., false-positives, especially if results are barely outside of the normal range) and some affected individuals may have normal tests (i.e., false-negatives). The lower the pre-test probability (likelihood of having a disease based on symptoms and risk factors), the higher chance for a false-positive result. False-positive results have multiple negative consequences, such as causing undue stress (very common in the “worried well”) and driving up health care costs, as additional consultations and testing are needed, much or most of which are paid for by insurance, if you have it, since all of a sudden you have a diagnosis. Ask your local insurance company CEO what he or she thinks of patient-driven testing. Again, all of these issues can be better understood by consulting with a qualified physician.
The Whole-Body CT Scan (or MRI)
You may have heard the advertisements and the testimonials: “Find cancer early!” “It saved my life!” Who wouldn’t want to find cancer early and have their life saved? Sounds smart to me, too. However, unfortunately, the grand majority of “lumps” found on self-referred whole body CT (or MRI) scans are benign, often referred to as “incidentalomas.” If the person interpreting the images (which I hope is a well-trained radiologist) isn’t 100% sure it is benign (which is common), you will end up getting another scan (and if another CT scan, it will expose you to even more unnecessary radiation) and/or possibly a biopsy. Depending on where the lump is, there may be severe risks for doing the biopsy (such as internal bleeding, infections, and death), and again you end up with increased morbidity and mortality – all of which could have been avoided had you not had the CT (or MRI) in the first place. Before deciding to get that done, again, consult with a qualified physician.
The Cash Cow
I once heard of a primary care doctor who ordered every test that could be ordered (for which he had determined the insurance might pay) at every physical exam – and accepted what the insurance paid, but wrote off the rest. Patients were (maybe are) perfectly fine with him doing so, because again, we all LOVE tests (as long as they don’t hurt physically or cost us anything)! However, you now know unnecessary testing is unwise, as it hurts both the patient and the system, sometimes fatally. This doctor generated so much money (way more than most family physicians) that he was able to shower his large staff with gifts, including a cruise! Our healthcare dollars at work.