“Coverage” Isn’t “Care”

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By Keith Smith, MD: http://surgerycenterok.com

If you are following health-related topics on social media you have likely encountered “coverage is not care,” as a theme or #hashtag. This phrase/quip should be viewed as an opportunity and lens through which the dysfunction of the crony-dominated “healthcare system” in this country can be viewed.

Not only is “coverage” not equivalent to “care,” “coverage” can and many times does create a barrier to “care.”

It might shock you to learn that the “cash” price for many medications at your local pharmacy is less than the co-pay if you are using your “coverage” to buy these same medications. In other words, you are better off claiming to be uninsured when you buy certain pharmaceuticals! Why is this? Your “coverage” represents an additional, contracted layer—a toll booth—through which the exchange between you and the pharmacist must take place. This toll to pharmacy benefit companies/wholesalers is removed from the purchase if you represent yourself as uninsured. The presence of this middleman/distributor can and does increase the price of pharmaceuticals dramatically, representing as much as 50% of the purchase price for a large number of medications.

The same goes for the care at many physician offices. Any physician who is contracted with insurance companies labors under their fee schedules, any departure from which risks expulsion from the “network.” Physicians who waive all or part of deductibles for patients or treat cash-strapped patients free of charge run the risk of running afoul of these same “network” contracts and may also face legal action. What gives?

Waiving deductibles or co-pays for those short on funds lowers the barrier upon which the insurance carriers rely to protect their own corporate wallets. After all, a patient who cannot muster their deductible represents little or no financial risk to those providing the “coverage,” and the higher the deductible—or barrier to care, the greater the likelihood the “insurance” companies will pay nothing at all. The courts have been no friend to those well-intentioned physicians and facilities that have waived deductibles/co-pays in an attempt to help their patients. Once again, if you have “coverage” and are low on funds, you should always ask the “cash” price for a service before revealing that you actually have “coverage.”

Do you have “coverage” and have no trouble meeting your deductible? Do you therefore think you can safely access the care that you need? Think again. “Insurance” companies employ hidden techniques that deny various types of care to those who have “coverage.” Intentionally paying physicians below an acceptable rate for certain treatments and procedures serves as a powerful rationing tool, leaving certain treatments in short supply. Moreover, if a treatment is theoretically “covered” but is denied in your case, say because the insurer deems it “unnecessary” or “inappropriate,” the physician cannot accept payment from you because of the “hold harmless” clause in his provider contract. Thus, he must either provide the care at his own expense, or agree with the insurer that you shouldn’t get it.

Perhaps the only gift of Obamacare was that the deductibles were very high and very few physicians or facilities actually signed contracts with these plans. This created a vigorous cash market, where patients who are “covered” but without benefit, could negotiate cash prices with physicians and facilities for the care they needed. At the Surgery Center of Oklahoma we continue to see a large number of patients who are attracted to the pricing on our website (www.surgerycenterok.com) that is a fraction of their Obamacare or other “coverage” deductible.

Fans of “universal coverage” should keep in mind the countless “covered” Canadians who buy their care in the U.S. or overseas due to long access lines. Canadian provinces balance their budgets by stringing patients out on long time lines, extracting a painful and merciless “time tax” from their citizenry. Fans of “Medicare for all” should know that while violating a private “insurance” contract can be a hassle for their physician, violating the terms of a contract with Medicare is a crime. Unless a physician has opted out of Medicare he is not at liberty to waive deductibles or co-pays or charge less than the amount Medicare allows. In short, Medicare has criminalized charity, as demonstrated in a recent case of a Medicare beneficiary with a broken ankle who is stuck in a wheelchair because she can’t come up her $2000 deductible.

Leave it to government to force the purchase of this “coverage.” All who have been victimized by this cronyism have earned a seat on the #metoo bandwagon.


Author / Contributor bio:

Dr. G. Keith Smith is a board certified anesthesiologist in private practice since 1990.  In 1997, he co-founded The Surgery Center of Oklahoma, an outpatient surgery center in Oklahoma City, Oklahoma, owned by over 90 of the top physicians and surgeons in central Oklahoma.  Dr. Smith serves as the medical director, CEO and managing partner while maintaining an active anesthesia practice.

In 2009, Dr. Smith launched a website displaying all-inclusive pricing for various surgical procedures, a move that has gained him and the facility, national and even international attention.  Many Canadians and uninsured Americans have been treated at his facility, taking advantage of the low and transparent pricing available.  His most recent effort is the launch of the Free Market Medical Association which provides a platform where those seeking to obtain high quality and affordable health care can find free market-minded providers, both physicians and facilities.

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