As the web between patients, providers, and insurance companies becomes more and more complex, those seeking quality health care in Colorado—and across the country—must learn to be more judicious consumers. Here’s how.
—Illustration by Marina Muun
This past year, the United States was expected to reach an unfortunate milestone in health care: The National Healthcare Expenditure—stats gathered by the U.S. Department of Health and Human Services—was forecasted to breach the $3.2 trillion mark, which would mean health-care spending per American would eclipse $10,000 annually. The final tally won’t be released until late 2016, but no matter what, that’s a lot of dough to shell out for a system that rates fair to middling in comparison to those in other developed countries. While very few people are likely to be surprised by the fact that health-care spending is spiraling wildly out of control, too many of us are underprepared for the position it puts us in: being held accountable for how we use health care and health insurance. In short, we need to learn to shop for health care like we shop for groceries: Does this place cost less than that place for colonoscopies? Does my kid really need to see the doctor for the sniffles? Why isn’t my insurance approving this claim? Because the answers to these questions might not always be easy to ascertain, we’ve done some of the digging for you. Ready, set, shop!
(Search our 2016 Top Doctors directory at 5280.com/topdocslist)
It never occurred to me that I should know how my health insurance works—until the bills started showing up.
On Sunday mornings, I like to curl up on the couch with a cup of hot tea and a magazine. It’s one of the only times I actually read for pleasure. A few Sundays ago, however, I traded the glossy pages of Backpacker for a detailed explanation of benefits courtesy of UnitedHealthcare.
Six weeks earlier I had undergone minor outpatient surgery. It was such a trivial procedure that looking into what it might run me never crossed my mind—until the explanations of benefits began rolling in. It was only when I saw a line item that read “Provider Billed: $10,485” that I realized I had no idea what my insurance would cover.
“Few people pay attention during those annual insurance re-enrollment meetings their employers offer,” says Patterson McKinlay, vice president at Denver-based Moody Insurance Agency, one of the largest privately owned insurance agencies in Colorado (disclosure: Moody manages 5280’s employee benefits). “But they should.” There are two primary reasons: One, because trying to comprehend your benefits during a health event is never a good idea. And two, because being a consumer of health insurance is just like being a consumer in any other arena.
Until recently, when the insurance industry began shifting toward high-deductible health plans (HDHP) in the wake of the Patient Protection and Affordable Care Act, there was very little financial motivation to be a smart consumer of health care. But with 32 percent of Americans younger than 65 with private insurance enrolled in HDHPs—which means they’ll pay more out-of-pocket expenses before their carriers begin picking up their bills—McKinlay says it’ll behoove us to not only understand our plans, but also to be more discerning customers. “High deductibles should make you question if something is medically necessary, and whether you can find the same quality of care for less someplace else,” he says.
After some Googling, I discovered my insurance plan is not considered an HDHP because the deductible is less than $1,300 for a single person. I also figured out that my plan works like this: First, there is a $1,000 deductible—the amount I must pay before my carrier will pay a claim. Once I’ve satisfied the deductible, my insurance company will pick up 80 percent of eligible claims while I’m responsible for 20 percent—so-called co-insurance—until I reach a $4,000 out-of-pocket maximum. After that, the plan covers all eligible claims at 100 percent. Of course, that’s based on me going to in-network providers. The numbers surge drastically if I (knowingly or unknowingly) select a doctor who isn’t in network.
I might not have an HDHP—yet—but that doesn’t mean my 25-minute surgery was cheap. After UnitedHealthcare factored in its payments and discounts, I wrote checks totaling $1,481.59. If I’d been smart, I might’ve called around to find out how much different in-network surgeons and surgical centers charge for this surgery. I could’ve also checked with my carrier to get a cost estimate ahead of time. But I didn’t. I scheduled a recommended, but not urgent, surgery without thinking about whether I could easily pay for it. It worked out fine—but I sometimes wonder, What if it hadn’t?
Moody Insurance Agency’s Patterson McKinlay offers pointers for navigating your plan.
1. Read your summary of benefits and coverage each year.
2. Be mindful of your in-network and out-of-network benefits; your doctors must be in network if you don’t want to pay more out of pocket.
3. If your family is on your policy, talk with them about its finer points so your spouse doesn’t take Johnny to the ER when urgent care will do—and could cost you $200 less.
4. Take advantage of preventive care and annual check-ups. Many of these visits do noxt require a copay. But be careful: If you ask the doc to look at anything that’s not covered in an annual exam, you could incur charges.
5. HMO plans are trendy, and if you have one, you often need a referral from a GP. Ask if the specialist received the referral before your exam; if not, you could be writing a big check.
Ask Your Pharmacist
For 19 years, registered pharmacist Michael Godcharles has been caring for patients at Saint Joseph Hospital in Uptown. Because being a clever consumer is especially challenging when it comes to medication, we had a few questions for the veteran druggist.
5280: What’s the most common misconception about your profession?
Michael Godcharles: That we just count pills.
Wait…that’s not what you do?
Nope. We identify, resolve, and prevent medication-related problems. We assist with recommending drug therapy, tailored for the individual, including financial considerations such as insurance coverage and out-of-pocket payments. For example, there may be times when your insurer won’t cover a prescribed medication but covers an alternative that will work just as well. Or, surprisingly, sometimes it’s less expensive to just pay for the meds instead of paying the copay.
So I can ask my pharmacist these things?
Definitely. I think people feel like we’re unapproachable, shielded behind a wall of glass. But I encourage questions. You need to make sure you’re taking the right drug at the right dose for the right reason. If you don’t know these things, ask. Ask why the doctor prescribed it. Ask how you will know if it’s effective. Ask how often and when to take it. Ask about side effects and interactions with other medications. Get to know your pharmacist by name. And remember: You don’t need to be filling a prescription to ask a question.
When I go to Walgreens to purchase over-the-counter drugs, what should I keep in mind?
You should be thinking about taking a medication as prescribed, for the shortest amount of time necessary. Also, don’t forget that all drugs have side effects. Advil, Motrin, and Aleve can actually make headaches worse if taken on a daily basis over long periods of time. These drugs—all NSAIDS—can cause intestinal bleeding and kidney damage and increase risk of heart attack and stroke. With prolonged use, heartburn meds like Prilosec, Nexium, and Prevacid are associated with pneumonia, infection, kidney problems, and bone fractures. Decongestants can raise blood pressure and risk of heart attack and stroke. OTCs are not benign.
Yes. Brand-name medications are not superior to generic medications. Seriously. Save yourself money and get the generic stuff.
Doctors seem to be prescribing opioid-based pain meds pretty liberally these days—what should people understand about drugs like Vicodin or Percocet?
These drugs are not meant to make you pain-free. There will be pain after surgery; these meds are meant to reduce, not eliminate, pain. Doses should be gradually reduced as your pain level improves and your body heals. Regular (several times a day, for several weeks or more) or long-term use or abuse of opioids can lead to physical dependence and addiction problems.
Are there any online resources consumers should know about?
MedlinePlus (nlm.nih.gov/medlineplus) is a good website for medication information, and scriptyourfuture.org is a great resource for helping patients improve medication adherence.
Why is UCHealth the only medical system in Colorado giving patients access to their doctors’ notes?
Dr. C.T. Lin is a little like a traveling salesman these days. He’s been all over the state to speak with his UCHealth colleagues about OpenNotes, a novel way for health-care providers to give patients full access to their electronic medical records (EMRs). Although Lin, UCHealth’s chief medical information officer, has spent the past two years in meetings about OpenNotes, he still gets nervous. “Sixteen years ago, when I first started studying this idea,” he says, “I got shouted out of the room.”
OpenNotes isn’t a fancy software program; it’s an initiative being promoted by a growing consortium of U.S. health-care providers. The basic tenet of OpenNotes is that patients should have access to every part of the EMR that’s relevant to them, not just the parts a provider deems fit for consumption. Whether patients know it or not, most doctors digitally “hide” the part of the EMR containing their notes—which means when you log on to the patient portal to get lab results, you’re not seeing whatever it was the doc was scribbling in the exam room. “Up until recently,” Lin explains, “most doctors believed—and some still do—that the EMR was only for the physician.”
However, study upon study has proved transparency with notes is a good thing. “Patients who have been given access to their doctors’ notes say they feel empowered; they feel like they can ask better questions,” Lin says. “And they say being able to read the notes makes them trust the provider more.” These are just a few of the many reasons UCHealth—which has five hospitals and about 400 clinics—implemented OpenNotes in May. At press time, it was the only system in the state to have adopted the practice.
It didn’t come easily. Detractors voiced concerns about how EMR data entry was already causing exhaustion; about how they’d have to change the way they wrote their notes; about how short-handed notes might confuse patients; and about how notes about sensitive subject matters could agitate patients.
“I think the hesitations are mostly fear of change,” say Dr. Jean Kutner, chief medical officer at University of Colorado Hospital. “Physicians will find it’s mostly a nonevent. It’s just one more tool in the toolbox for patient engagement.” One that patients of other health-care systems in Colorado might consider asking their doctors about.
• Patients say they better remember what was discussed during exams
• Patients say they feel more in control of their care
• Patients are more likely to take medications as prescribed
• Patients can share notes with their caregivers, better equipping them to help enact treatment plans
Sidestep the Billing Bombshell
How to avoid surprise medical bills.
Susan Zalatan is a rule follower. She’s also an expert documenter. The Littleton resident learned how valuable these skills were when her husband acquired an infection after heart surgery, which ultimately left him in a wheelchair. “Dealing with his health insurance wasn’t fun,” she says, “but I’ve never had so many hoops to jump through as I’ve had for this silly little drive-by surgery.”
For years, Zalatan (pictured above) had put up with bunion pain, but in late 2015 she decided it was time to remedy the problem. After making sure she didn’t need a referral, she found an in-network surgeon on Anthem Blue Cross and Blue Shield’s website and scheduled the procedure. The operation went according to plan. The billing process didn’t. “Two weeks after the surgery,” Zalatan says, “the surgeon’s billing department called me to say that my insurance denied the claim because the doctor wasn’t in network.” Zalatan thought she was on the hook for $34,000.
In industry parlance, Zalatan was experiencing a “surprise medical bill,” a scenario in which an insured individual inadvertently receives care from an out-of-network provider. This can happen in a variety of ways, but these bills are often the result of receiving planned care from an in-network provider or facility when other providers—such as radiologists, surgical assistants, and anesthesiologists—brought in to help with the patient’s care are out of network. In Zalatan’s case, her carrier insisted the surgeon she chose was out of network, even though he appeared on Anthem’s website as an in-network provider.
Colorado state Senator Irene Aguilar (D), who also happens to be an internal medicine doctor, says Zalatan’s situation is not a one-off. According to Consumer Reports, 30 percent of privately insured Americans have received surprise bills in the past two years. “I’ve heard from so many people with surprise-bill stories,” Aguilar says. Which is why she sponsored legislation in 2015 and 2016 that endeavored to protect consumers from unexpected expenses. Both bills died swift deaths. Fortunately, the demise of those bills isn’t a tragedy for the 26 percent of Coloradans whose health plans are regulated by the Colorado Division of Insurance (DOI). “Since 2005, we’ve had a law that says a consumer who incurs out-of-network charges for care received at an in-network facility must be held harmless by the carrier for those charges,” says Peg Brown, the DOI’s chief deputy insurance commissioner.
That’s all well and good; however, two issues remain. First, not all insurance carriers are quick to hold consumers harmless, which means people must know the law and be willing to contact the DOI for backup if necessary. Second, 74 percent of insured lives in Colorado are not protected by the “hold harmless” law because their plans are not regulated by the state.
So what’s a consumer to do? First, look at your insurance card to see if your plan is regulated by the state. If it is, the letters CO-DOI will appear in the corner. Then do your due diligence: Check that your surgeon and anesthesiologist are in network before your procedure. Ask your surgeon if she’ll be using an assistant and if that person is in your network. “When you go to the admission desk on surgery day,” Brown says, “tell them you only want in-network providers. Being proactive can help.”
But as Zalatan knows, sometimes you can do everything right and still get left holding the bill. In that case, Aguilar says this: “If you get a weird bill, don’t just pay it; call your insurance company. If it isn’t helpful and your plan is regulated by the state, call the DOI. If your plan is federally regulated and your insurance is giving you the runaround, call the provider—tell him insurance isn’t covering the bill and you’d love some help.”
Fortunately for Zalatan, Anthem figured things out. “There was an incorrect explanation code,” says Anthem spokesperson Joyzelle Davis, “and this physician’s bills were being mistakenly denied.” As of July, Anthem had covered Zalatan’s claims. Still, it took about five months for things to shake out. “I work for a living,” Zalatan says, “and this became a full-time job.”
Hire Some Help
We spoke with Mary Scroggin-Harris, founder of Denver’s Lifelong Wellness Advocates, to learn who benefits most from securing the know-how of a professional patient advocate.
If you: Have a loved one who needs support but lives in another state
An advocate can: Attend doctor’s visits (and take notes to send to you), coordinate at-home care, and help your family member take advantage of free resources
Which means: You’ll be better informed about your loved one’s medical situation—and you won’t feel so guilty about not being there.
If you: Are dealing with billing nightmares with your insurance carrier or health-care provider—or both
An advocate can: Wade through the EOBs and bills, make phone calls, document everything every customer service rep says, and (hopefully) help you get the ammo you need to file an appeal or write a smaller check
Which means: You won’t be trying to make frustrating phone calls at work.
If you: Receive a scary diagnosis you aren’t 100 percent sure about
An advocate can: Do the legwork to find specialists—within your insurance network—who are qualified to give second or third opinions you can trust
Which means: You aren’t having to do mind-numbing research when you’re worried about a life-altering illness.
If you: Have a progressive disease like Alzheimer’s or dementia
An advocate can: Help you prepare for the journey ahead by doing advanced planning like securing support services for your family; finding a safe living arrangement; and researching hospice care ahead of time
Which means: You and your family can focus on each other instead of on the inevitable.
If you: Have a life-threatening disease and you’ve exhausted all traditional treatment options
An advocate can: Research and make the necessary calls to inquire about your eligibility for ongoing clinical trials
Which means: You have someone continuing to battle for you, and you don’t have to give up hope.
Check It Out
Does the state think your doctor is as competent as you do?
There’s a saying common among those in medical school, where 28-year-olds are still given report cards. It goes something like this: Know what a D stands for? Doctor. The joke is meant to be funny—but it should give consumers of health care pause. Just like there are bad attorneys and bad engineers and bad teachers, there are bad doctors. And while it’s impossible to avoid subpar physicians entirely, it makes sense to do your homework. The Colorado Department of Regulatory Agencies (colorado.gov/dora) makes that task easy with two online tools.
Verify A Professional Or Business License
To use this tool, prospective patients will need to know the spellings of the first and last names of the health-care provider they are researching. Knowing what type of license—medical doctor or physician assistant or registered nurse—your provider has will also help. Once you’ve filled out the form, hit search. After locating your provider, click on the blue “detail” box next to his or her name. A form will pop up, which shows things like the licensee’s public address and credentialing information. What you’re looking for is a box entitled “Board/Program Actions.” If the words “There is no discipline or board actions on file for this credential” appear in that box, your provider has not received any disciplinary actions against his or her license. Alternatively, if you see phrases like “Letter of Admonition,” “Stipulation,” “Voluntary Surrender,” or “Revocation” in that box, your provider has, in one way or another, been reprimanded by the state. To learn more about the action, look farther down the document to see if there is a “Link” box. In some cases, documents related to disciplinary actions are available.
Healthcare Professions Profile Program
Since 2008, when the Michael Skolnik Medical Transparency Act took effect, every licensed physician in Colorado has been required to maintain a profile available to the public via the Colorado Medical Board’s website. These profiles, which are updated by physicians every two years or less than 30 days after an aspect of their profile has changed, require doctors to reveal previously held medical licenses, board certifications, hospital affiliations, board of director positions, direct business ownership interests, employment contracts, criminal convictions, malpractice settlements/judgments,* disciplinary actions, and any refusals from insurance carriers to issue liability insurance.
*One of every 14 American doctors is sued each year. Just because a doctor is sued or her insurance company settles doesn’t mean the physician did anything wrong.
Be More Assertive
Broomfield mom Maria Hopfgarten talks about having a medically fragile child, health care in America, and learning how to speak up.
I had no idea Jacob was sick before he was born. When he did arrive I just thought I had a fussy baby. But when he was two and a half months old we went to the ER for the first time. The words “failure to thrive” are not good words to hear. I didn’t know it then, but that was just the beginning of Jacob’s health issues. He was later diagnosed with a mitochondrial disease.
We’re from Sweden. We moved to the United States in 1996. We were clueless about everything here. Coming from Sweden, I always thought U.S. health care wasn’t good. What it was was scary and overwhelming.
When Jacob started having seizures when he was about one, I thought, I need to quit my job. But then you realize you can’t quit your job because you have to have the private insurance to pay for this. You can’t even imagine the bills and explanations of benefits we were getting. We made spreadsheets just to stay on top of it all.
We thought we were going to lose Jacob in 2009. He had been in the hospital for about 130 days that year. At one point, I had a very clear moment. I wondered, almost simultaneously, how I’d be able to live after losing him and, if I lost him, how I was going to lose Children’s Hospital Colorado at the same time. The hospital had become our home; the people there were our family. That’s when I decided I needed to figure out a way to stay connected to Children’s even if I didn’t have a child there.
When you get involved with a place like Children’s Hospital Colorado, it snowballs. I got involved with the special-care clinic to help children with epilepsy. I have been a chair for the Family Advisory Council, which promotes family engagement in the hospital, for five years. And I’m on the quality and safety committee, where my job is to essentially give the people on the board who don’t have sick children a reality check.
Without a doubt, my involvement at the hospital outside of Jacob’s care made me a better advocate for him. By being involved, I understood things better.
Over the years, Children’s—and probably hospitals in general—has gotten better at listening to a parent when he or she says, “I have a gut feeling about my child.” I had a nonverbal son. I knew him best. Doctors bring the medical knowledge, but I brought the knowledge of him. I knew his baseline. I had a perspective no one else did. If I don’t speak up when I have a gut feeling, how are they going to know?
We need to meet doctors halfway—but they need to meet us there. Doctors need to learn to draw out questions from hesitant patients and family members. And we need to understand it’s our responsibility to ask questions when we don’t understand.
Editor's note: Just weeks after 5280 spoke with Maria Hopfgarten, 10-year-old Jacob died. His mom says she will remain involved at Children’s Hospital.
Eyeball The Numbers
The case for checking a hospital’s clinical outcomes.
Before we make major purchases, a good many of us do a little bit of research. We consult TripAdvisor before we book a week’s vacation. We peruse Consumer Reports in advance of buying a new car. Hell, we read a dozen comments about how a pair of skinny jeans from J. Crew fits total strangers before typing in our credit card numbers. Yet rare is the person who researches which hospital is best before scheduling surgery.
Why do we forego the investigation in this area and not others? “People don’t know to look for this data,” says Daniel Hyman, chief quality and patient safety officer at Children’s Hospital Colorado. “They don’t know it exists.” But it does exist, if you have the patience to seek it out.
There are certain data sets almost all health-care facilities are required by law to collect and report, such as, say, health-care-facility-associated infection rates. In Colorado, those statistics are compiled and made available online to the public by the Colorado Department of Public Health & Environment. However, those facts and figures aren’t the only ones available. Many hospitals, including Children’s Hospital Colorado, voluntarily gather other internal data in the name of facility improvement—and publish some of them on their websites for public consumption.
“We think our patients are entitled to know how we’re doing,” Hyman says. Children’s posts clinical outcome results online for a variety of its departments, including the Center for Cancer and Blood Disorders (bone marrow transplant survival rates), the Heart Institute (heart transplant survival rates), and the Orthopedics Institute (length of stay after spinal fusion). “People who are looking for highly specialized care—like surgery for a congenital heart defect—often learn to look at these statistics,” Hyman says. “But everyone would do well to look at them before planning any hospital stay.”
It’s sage advice, but the reality is not all hospitals publish outcomes information, and even if they do, it can be challenging to find (try key words like “quality data” or “measured outcomes”) and understand. Downloading spreadsheets from unwieldy state agencies can be even more frustrating. “Looking up something as simple as infection rates,” explains Adam Fox, director of strategic engagement at the Colorado Consumer Health Initiative, “can be shockingly difficult. Those things are not consumer-friendly.”
Still, if you have the motivation (avoiding an infection in your bloodstream! not paying for extra nights in the hospital!), there is a good amount of information out there. To start, Hyman recommends hospitalcompare.gov, but he also says searching for facilities that do any internal improvement research—even patient-satisfaction surveys or hand-hygiene reports—is a good idea. “If a hospital is working to improve in one area,” he says, “it is likely looking to improve in other areas as well.”
Find The Power Position
Why you should feel comfortable asking who’s in charge of your care.
Whether you’re in a clinic for an appointment or in the hospital with a complex health issue, it is in your best interest—and well within your rights—to ask staff members about their titles or levels of experience. You are not being rude; you are acting as a responsible patient. “If you ever feel not listened to,” says Dan Hyman, chief quality and patient safety officer at Children’s Hospital Colorado, “it’s always appropriate to go up the chain of command. It’s fine to say, ‘Thank you for your help, but I’d like to speak with the attending physician as well.’ ” The attending physician is the doctor in charge of your care. The other health-care providers—some of them doctors, some of them students, some of them professionals in other disciplines (like physician assistants or nurse practitioners)—you’ll encounter operate under the attending’s authority and direction. If you’re experiencing issues with the nursing staff, keep in mind they have an independent chain of command. A savvy patient will first go to the charge nurse—instead of the fellow or attending physician—when a problem arises with the bedside nurse or nursing assistant. Remember: Titles and types of health-care providers can change depending on the hospital. Here, a basic list of who’s who when it comes to physicians.
Attending physician: a physician who has completed all training; he or she is in charge of your care
Fellow: a physician who has completed residency but is continuing to train in a specialty or subspecialty of medicine
Resident: a physician who has completed medical school but is in the middle of training
Intern: a physician who is in his or her first year of residency training
Medical student: a person who is studying to be a physician; under the supervision of attendings, fellows, and residents, students sometimes interact with patients
—Photo credits (from top): Morgan Rachel Levy (2), courtesy of Mary Elizabeth Graff