Tuesday, September 8, 2009

Healthcare on the Roam

People often ask how we handle healthcare while traveling for months at a time, and it's one of our largest expenses, so I thought I'd share our experience.

Individual Insurance

When we gave up the pursuit of the weekly paycheck, we also gave up access to group health plans. We purchased an individual family policy and a dental plan from a major insurer with a national presence. It's a PPO, or Preferred Provider Option, meaning that if we use a provider in the network, the provider will bill the insurance company a contracted amount, and we will pay a portion of that, as outlined in our policy.

We elected a higher deductible/lower premium option, and we have a co-pay for office visits, a different co-pay for accidents/ER visits, free vaccinations, and free routine dental care. There's a separate deductible for labs and imaging, and probably a hundred other cost details that I won't know until I come up against them.

The premium has changed over the four years we've had it, actually edging down the first year, later bumping steadily up. It took a giant leap this year, we think because Joe turned 45, putting our policy into an older age-based risk pool. We might pay more for routine healthcare than if we self-insured, but having insurance makes the overall cost more predictable by reducing our upside risk if we incur major medical expenses.

Along with higher premiums and no employer subsidy, individual policies are less generous than group plans in other ways. There's no employer with the power to terminate hundreds or thousands of contracts negotiating benefits with the insurer. There's often a health questionnaire and physical exam as well as blanket exclusion of pre-existing conditions. In a typical group policy there's no waiting period for specified conditions, if you join as soon as you're eligible (or within a larger employer's annual "open season"). As soon as you sign up you can go to the ER and be fairly certain you're covered.

Our waiting period covered a specified group of bodily systems and diseases. Unfortunately, Joe had his most severe (and first clinically diagnosed) gall bladder attack within that waiting period. So we learned how much gall bladder removal costs, including the primary care clinic, the surgeon, the hospital (images, labs, OR, and patient room), and the anesthesiologist, all of whom billed us separately. It's enough to bankrupt a family that lives from paycheck to paycheck. And this was a minimally complicated case of a very common condition. That event confirmed my resolve never to attempt to self-insure for healthcare.

Rather than wait for the bills to start coming in, a week after Joe's surgery I went around to the various medical offices, asked what discount I would get for immediate payment, and made full and final payments then and there. I was so prompt that the hospital departments hadn't finished posting all their charges, but we settled on a figure and I wrote up a quick contract for the business manager to sign that showed my obligation as satisfied. The discounts were all 30-35%. Think of that. They spend so much trying to collect, and they write off so much bad debt, that the 30-35% was reasonable to them. Does this mean we're all being charged 30-35% more for healthcare because of the administrative cost of collection?


Because our insurance company has subsidiaries across the country, we have no problem finding in-network providers. So far all of our routine care has been close to our home base. Now that we have no home base and we're changing our state of legal domicile, we'll either return to our old stomping grounds for annual check-ups or we'll find providers on the road.

We've sought urgent care in Kansas, Maryland, Mississippi, and California, and every facility we've contacted participates with our insurance company. Once or twice we've been to an ER at an in-network facility, but the doctors staffing the ER weren't in-network, so we had to pay them out-of-pocket. Again, not hard for us, but I feel for the folks who don't have a rainy-day fund for such things, or easy access to temporary credit. One healthcare resource we are just becoming acquainted with is Departments of Public Health, which offer various clinical services and health education. The clinics charge reasonable rates for routine services such as vaccination, and they also accept insurance.

We've been generally pleased with the quality of care we've received, from a small-town clinic in the Mississippi Delta to a large hospital in populous (and prosperous) Orange County, California.

Tomorrow I'll write about our approach to wellness and prevention.

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