As a health insurance broker, and a member of the New Jersey Association of Health Underwriters (NJAHU), I’m often asked by my clients why health insurance premiums seem to be spiraling out of control. The reason the cost of health insurance rises, I tell them, is because the cost of health care keeps rising.
For example, it’s been recently reported that 80 percent of Medicare patients who need a CT scan of their chests are actually getting two of them at community hospitals.
Not only are the extra scans largely unnecessary and extremely expensive, they can also be hazardous to the patient. Two CT chest scans give the patient the radiation of about 700 regular chest x-rays – a powerful dose for even healthy people to sustain.
Are the doctors who order these extra tests looking to make extra money? Are they trying to prevent a lawsuit that might occur if they miss a diagnosis? Or could they simply be apathetic to the health risks of high doses of radiation?
When double-testing has a financial benefit for the physician and the hospital, maybe there is not a significant deterrent to limit procedures. Or perhaps most physicians don’t consciously perform more tests than they need to, but lack standardized best practices and regulations that limit what they can order at a hospital.
One answer to this problem may come in the form of Accountable Care Organizations (ACOs), which are steadily gaining popularity in New Jersey and nationwide. ACOs are networks of doctors and hospitals that work together to provide care for their patients. They are paid a fee for each patient they enroll, not for each test and procedure they perform. They are rewarded based on quality, not quantity. They strive to live up to the credo, “First, do no harm.”
The concept is that if the network is accountable for each patient’s health care at a flat rate, physicians will focus on preventative medicine and won’t have an incentive to perform unnecessary tests and procedures. ACOs reward doctors and hospitals who keep their patients healthy, rather than by treating them once they get sick.
The NJAHU supports the concept of ACOs, as a means to maintain Medicare, which costs $452 billion, or 14 percent of the nation’s budget, each year. ACOs are modeled after some of the best and most cost-effective hospitals in the country, such as the Mayo Clinic.
Until ACOs become widespread and are fully tested, NJAHU members are recommending to their clients to question doctors about prescribed tests, procedures or medicine. Even if you don’t ultimately get the bill, it is your right as a patient to know the risks involved, as well as the costs.
Ray Pokorny, a resident of Brick, is the President Monmouth-Ocean Chapter of the New Jersey Association of Health Underwriters and an Employee Benefits Consultant for FFP Financial Services of Hazlet.