1. Section Editor(s): Rodts, Mary Faut DNP, CNP, ONC, FAAN
  2. Editor

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Is it any wonder our patients are struggling with all of the confusion regarding healthcare insurance coverage? Having spent the better part of four decades in the private orthopaedic practice setting, the complexities of insurance coverage have gone from simple to beyond complex. Since the implementation of the Affordable Care Act, being able to understand insurance coverage has become nearly impossible for many. Even healthcare providers who should be able to understand, don't.

Mary Faut Rodts, DNP... - Click to enlarge in new windowMary Faut Rodts, DNP, CNP, ONC, FAAN Editor

Patients who were once able to understand enough of the detail of the various plans to get by now find themselves confused. Plans purchased through the Insurance Exchange have given patients the false sense that they have full coverage and all is well. The patient needs to fully understand the plan and the personal responsibility for deductibles and copays. Merely carrying an insurance card in their wallets is simply not enough in today's healthcare world.


And then there are the concepts of coinsurance, maximum out-of-pocket expense, in-network/out-of-network, high-deductible plans, health savings accounts, and flexible spending accounts. It is the patient's responsibility to understand his or her individual situation, but what advice can we provide? It is very difficult to have a patient faced with thousands of dollars of costs related to care that has been provided.


The two areas that will help patients most are to be sure that they understand the concept of in-network/out-of-network clinicians/facilities and deductibles. When seeking care, it is very important to be sure the patient utilizes providers and facilities that are in network for the insurance plan. The patient, in most cases, still has the choice to seek care by out-of-network providers/facilities; however, the cost to the patient will be increased. This would be a decision that the patient would make based on his or her own ability to incur increased costs.


Deductibles often come as a big surprise to patients after services are rendered. Some plans today have deductibles that could be in the thousands of dollars. This is something that is very important when making a decision about what health plan to enroll in, no matter if it is an employer-sponsored program or purchased through the Insurance Exchange. A higher deductible normally decreases the amount of the premium, which is attractive when looking at monthly premiums but may be a problem if services are required as this will increase the cost the patient needs to pay at that time. Deductibles cannot be written off/excused and will remain the patient's responsibility.


This discussion will not go away. More and more patients are frustrated and angry about their perceived "full" coverage. An increasing share of the cost of healthcare will be transferred to patient responsibility. With this issue, will patients not access healthcare due to the increasing costs that they must bear? Delay in care is not ideal.


We, as the patient advocate and often advisor, must continue to educate patients and discuss the need for them to understand their insurance options. Knowing the details at the time of selection will help the patient be prepared for the potential responsibility and to make appropriate decisions about provider selection. Delaying care is not what was intended in the Affordable Care Act, but it may be a result as more cost is shifted to the patient.