An insurance company's worst nightmare

I’m enrolled with the largest health insurer in Oregon, which was given permission last week by the state Insurance Division to raise rates on individual premiums an average of 12.8 percent—about half the 22.1 percent the company was seeking.

We haven’t heard directly from Regence BlueCross BlueShield yet about our policy, so my response to this news is muted. I’m relieved to know the state gave Regence a 50% haircut, but can’t feel great about an increase that’s still about 10 percentage points higher than the CPI. While our financial resources aren’t endless, we’re fortunate in that 1) we have private insurance and 2) that we can afford co-pays and expenses before our high deductible is covered ($7500/person). My family’s out-of-pocket health expenses so far this year are on a trajectory to exceed our earned income. When people talk about how the escalating costs of Medicare and Medicaid may bankrupt the country, I can relate.

In a manner of speaking, I’m every insurance company’s worst nightmare: a heavy consumer of medical services who is dying very, very slowly. I was first diagnosed with melanoma five years ago, and have needed considerable treatment in four of those five years—almost every cent of it related to cancer. I’m otherwise healthier and fitter than most men I know. I have the resting heart rate of a teenager. Prior to 2006, the only time I ever saw a doctor was for my annual physical. It’s funny how a renegade melanocyte can wreck your reputation for medical frugality.

So when my insurance premium increase comes through in the next few days, I will greet it with ambivalence. I will hate that I have to pay more at a time our income is pretty meager, but will also be grateful that the increase is not as horrific as was threatened. The public scrutiny that insurance regulators in Oregon are giving to rate increases is a positive development. Everyone needs to better understand how health insurance companies do business with medical providers and why costs are going up the way they are. Shining a light on this process with public hearings is good consumer protection.

Sadly, regulating the rates of insurance policies doesn’t control healthcare costs; it only controls the cost of insurance policies. As the ultimate consumers of healthcare, we—meaning you and me—need to have skin in the game to bring costs down. Our utilization of healthcare is possibly more out of control than the premium increases for health insurance. It’s hypocritical to complain about the price of services and then expect your insurance carrier to cover everything you think you need when you’re sick or injured. The question to ask is: How do we genuinely change our expectations about the volume and complexity of the healthcare services we receive?

Let's face it, if a procedure or pill has any chance to make us or our friends or family members better we all want it, we want it now, and when we’re insured we don't care what it costs. We pay but a small portion of services through co-pays and deductibles.

Until we change our cultural expectations for how healthcare is provided, utilization will expand infinitely, to the ultimate ruin of everything else in our economy. Controlling the price side of the ledger will have only a limited impact on total healthcare cost. If we focus solely on identifying and rewarding the lowest cost services, we will ultimately threaten the quality of the care we have become accustomed to receiving.

I may be willing to shop for the cheapest oil change for my car, but I don’t shop for my own cancer care on the same basis. I want to make sure my surgeries are performed by someone who does a couple hundred of them a year, who uses the best practices with the best outcomes, and who has nurses and support staff of the highest quality. Because I have experience as a medical editor, I know how to find such a provider. And it’s almost certain that by meeting these criteria, my surgical care is not in the bottom quartile on price.

The political right will respond that we need medical malpractice reform in order to root out defensive medicine and that without it, we can never control utilization. I agree. And the political left will say that healthcare is a constitutional right and should be ratified as such. Therefore we should have access to what we need when we need it. I agree with that too, but only under certain circumstances.

But none of this changes the fact that if my son were to have a bike wreck and bang his head, my first instinct is that I want him in an ambulance headed to the ER. I want a full workup and a CT scan—and I want it stat. This makes me part of the overall cost problem because I expect immediate access to the best technology and the brightest minds. I know that and I know that I must change my ways to be a part of the solution. Are others willing to do the same? Who among us wants to do with less or to wait a little longer for certain tests or procedures and use only those that have been proven to be the most efficacious versus the first thing our doctor recommends? I can state bravely now that I would refuse a drug treatment that extends my life by only a month at the cost of, say, $60,000, but should that time come and should my insurance plan cover the cost, my decision might be quite different.

If we can’t or won’t change, then we may be expecting too much from all the other players in the healthcare system. It doesn’t help to vilify the insurance companies and the rest of the medical establishment. We need a way to educate and engage the public in a broad sense around the questions of our own role in the utilization equation and begin the cultural shift immediately. If we don’t, we may never crack this nut called the healthcare “system.”