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Can You Really Choose the Best?

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A letter just arrived in the mail from Aetna, my insurance carrier, telling me that it was ending its relationship with three of my favorite health care providers:

1) Beth Israel Medical Center, the nearest hospital to my apartment;

2) DOCS, a walk-in clinic where I go for emergency antibiotics when I can't get in to see my regular doctors and

3) New York Eye & Ear Infirmary, two blocks from home and where my eye doctor, perhaps the best glaucoma specialist in the city, now does his surgery.'  They are the best around, he says, having moved his business from one of New York's gigantic teaching hospitals that advertises a lot on TV.

Not that I need any eye surgery, but I wanted to know why my doctor ' thought New York Eye & Ear was superior to where he used to practice.'  They have the best operating room nurses and do lots of volume, he explained.'  Hmm!'  Volume'that's what all the experts say is important when you choose a hospital or a physician to perform delicate procedures.'  The more eye surgeries a doctor or hospital does, the greater your chances are for a good outcome.'  I wouldn't want to have someone mess around with my eyes if the hospital performed these surgeries only once in awhile.

But should I need surgery, New York Eye & Ear is now off limits unless I want to pay for the operation myself or request that Aetna pay out-of-network benefits, which they often forget to do when I file the occasional claim.'  After several months of trying to get my reimbursement, I just give up.'  That's probably what Aetna wants.

So here I am caught in the classic consumer health care dilemma.'  You do your homework (standard consumer advice), read the comparative ratings (which still have yet to catch on), get your doctor's take on where he or she thinks is the best place to go (we have to trust somebody), think you've done all the right things, and bingo, the insurance company says no dice.

To get a handle on the out-of-control medical costs, which really do stem from what doctors and hospitals charge, insurers are telling providers they won't pay what they are asking.'  This is what happened with Aetna and Beth Israel hospital's health system, Continuum Health Partners.'  Continuum asked for a 40 percent increase in payments over three years.'  Aetna said no.

All of this shows why a lot of the rhetoric surrounding health reform was just that'rhetoric.'  Consumer choice'it's not there.'  Continuity of care'not there either.

While it's easy to blame insurance companies, and reform advocates and politicos have painted them as the devil incarnate, some actions by insurers do have a legitimate basis.

If insurers bow to humongous rate requests by providers, they will simply pass them along in the form of higher premiums'which is what they are already doing.'  And the public doesn't like that one bit.

This is how the real world of health care works as the marketplace continues to be a battle of the Goliaths'the big insurers vs. the big hospital systems.

P.S.'  I can go to Beth Israel in an emergency, and Aetna says it will pay in-network benefits.'  But exactly what is an emergency?'  I walked over there the day I poked a knife into my hand opening a ketchup bottle.'  Who would have paid for the one stitch I needed'the insurance company or me?

More Blog Posts by Trudy Lieberman

author bio

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.


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Star says
April 30, 2010 at 10:49 AM

It became clear pretty early in the "debate" that the pols didn't get this. They had probably never seen an EOB up close. The president's grandmother got a hip replacement while bedridden with cancer--somehow--and he said he would make sure she got anything else recommended, though I don't think it ended up with his paying from his personal funds (book royalties then). I have had many eye surgeries and believe me, you don't want just anyone messing with that tiny bunch of tissues--they never go back the same way they were. I am blind in my right eye now--or as one doc said, I have a pretty nice-looking fake eye (that would be my "real" eyeball, and it's weird--bigger pupil). These are pretty important decisions. What I always wonder is could I think of someone in my HS class who I would trust to go off and study for a decade and be smart enough to root around in my eyeball? All I can conclude is all medical care is a crapshoot. And you don't want snake-eyes.



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