My insurance won’t pay for the doctor I want

As he tries to put to rest several outrageous lies about health care reform, President Obama has said repeatedly that consumers who already have a health care plan they like, can keep it. And you can continue to choose your doctors. No one is going to interfere with the relationship between you and your doctor, he says.

Unfortunately, the president isn’t quite telling the truth. He’s fudging a bit. The simple truth is, he can’t guarantee that you get to keep your insurance. Under certain conditions, you could lose your insurance today, without health care reform. That’s the way the system works.

Nor can he guarantee that you get to choose your doctor. You don’t get to choose your doctors today, without health care reform. That’s the way the system works.

Let me illustrate with a personal example. First off, let me say that The Atlanta Journal-Constitution provides a pretty comprehensive health insurance plan. We are self-insured. The plan is managed by Aetna. And Aetna, like most big companies, negotiates with a group of doctors for certain rates. Those doctors are called “in network.” If you want to go outside the network, that’s fine. But prepare to pay heavily out of pocket for the privilege.

Having just relocated to Washington, I have to find a new pediatrician for my infant daughter. I sought recommendations from several acquaintances, and the same name came up repeatedly. (I’ll just call her Dr. Amy.)

I called Dr. Amy’s office and was given an immediate appointment. But I was also told she is “out-of-network” for Aetna.

Called Aetna. They explained I would pay several hundred dollars a year extra for the privilege of taking my baby girl to Dr. Amy.

So, I called another pediatrician who is “in-network.” She said she could see my baby at the end of October.

I have a choice to make: Pay through the nose for a highly recommended doctor who can see my baby immediately. Or, go to the doctor my insurance will pay for, which would mean my child would run months behind on her vaccination schedule. This isn’t a disaster, but it is certainly frustrating.

I think the president has been fudging on the absolute truth about your relationship with your insurance and your doctors under his proposals because he wants to satisfy those people who have perfect health insurance right now. I wonder how many people that could possibly be.

109 comments Add your comment

Bobby McGreevey

August 25th, 2009
12:27 pm

435, I’m guessing.

Jen

August 25th, 2009
12:45 pm

Congratulations on having your daughter (by however means you expanded your family)! Welcome to the simulataneously terrible and delightful world of Parenthood!

And yes, I knew all that. And, like you, I am covered well enough and make enough money that this sort of thing isn’t a disaster.

But I am lucky.

Joey

August 25th, 2009
12:49 pm

I had an email conversation with Mike King, who was an Op-Ed Page writer at AJC until a couple of months ago. Our discussion was about Health Care and Insurance. I loved my insurance company he hated his, Aetna. He wanted National Healthcare now. I did not.

Why did he and you and everyone else at AJC fail to insist that your employer find a better insurance company? What is wrong with you people?

You all are so good at telling anyone and everyone what they should do. But you cannot even stand up for yourselves.

Why would we take your advise? Why?

norman ravitch

August 25th, 2009
12:54 pm

Cynthia: if you want to go outside your network you should pay more. Some doctors don’t accept payment from certain insurance companies because they get less than they believe they deserve.

stands for decibels

August 25th, 2009
1:28 pm

I loved my insurance company

If you did/do, Joey, you’d be the first human being on the planet that I’ve met who’s said that.

Chris Broe

August 25th, 2009
1:42 pm

My doctor tried to claim he was “out of network” concerning my condition once……….once.

Jim morrison

August 25th, 2009
1:47 pm

Again, another plug for the Socialist & Racist reporter at the AJC.

Songbird

August 25th, 2009
1:49 pm

I also work for a large, self-insured company and have a similar health plan only it’s managed by United Healthcare. You are exactly right about going out of network. It costs you, but sometimes its worth it depending on the doctor and the treatment needed. I would only do it if I felt the doctor/treatment I needed was worth the extra cost, i.e., is it life threatening to wait.

Everyone screaming about keeping the gov’t out of the healthcare and having the decision of treatment be just between them and the doctor is naive or stupid, because the insurance company is making the ultimate decision on what they will pay for. If you want something done anyway, then you can pay out of your pocket if you can afford it.

Duh

August 25th, 2009
2:00 pm

Help. Please. I need my gubment to save me!!! I’m too stupid to do it myself.

theROOSTER

August 25th, 2009
2:05 pm

That is exactly the point. That is called the free market. You are not prohibited in any way from seeing ‘Dr Amy’. You will just have to pay more to do so. The difference is that under the government plan you will not have that option. The government system will likely resemble what is currently in place for our military. You will be assigned a physician based upon your social security number, or some other type of unique identifier. Please talk to some of these Vets that have been in this system. It’s terrible. Most of the military doc’s are great, if you ever get a chance to see them.

Obama is right. Sort of.. Competition does lower prices. So, why not create a marketplace in which we can choose our coverage in the same manner as we choose our car insurance? First we have to get away from the employer provided insurance and go to an individual purchasing system. We let the consumer buy insurance across State lines in order to create more competition in the marketplace. There are literally thousands of providers around the country to choose from. You like government? Great. We will let them come up with three different plans. One that covers only emergencies, another with a PPO type system that covers emergencies + primary and preventive care, and then a third “platinum” type coverage for those who can afford it. The market can decide what price each of these plans will be and the individual can choose based on that price and comparing it with other companies. Higher risk patients, (like higher risk drivers) will pay more.. That’s how it is. How hard is that?

ctucker

August 25th, 2009
2:11 pm

Rooster, I’m a bit confused. Couldn’t a soldier also see the doctor he chose if he paid for it himself? Does the military strictly prohibit its personnel from paying for the own care?

Tea

August 25th, 2009
2:18 pm

Can one of you Einsteins with perfect health insurance explain to me how you have been able to obtain it? I am apparently one of the people who are too frieghtened, intellectually deficient and/or uninformed to be able to obtain it for myself. Either that or I’m just not rich enough to have perfect health insurance. Which is it?

Fitzgerald

August 25th, 2009
2:19 pm

Cynthia:

Thanks so much for describing the exact health care plan that will be in place if the current health care reform is passed. Nothing different, except you will be told by the government who to see, how much to pay, and how long it will be until you see a doctor. Good luck with that.

Tea

August 25th, 2009
2:28 pm

If health care in England (for instance) costs less than half as much per capita as the US, and English people enjoy better healthcare, what’s wrong with changing our system to be more like theirs ? (I’m defining “better” as a longer life expectancy, higher satisfaction rating and easier access to doctors). If we had that system now, the cost savings just THIS YEAR would MORE than pay for all the financial system bailouts. Imagine an extra 1 Trillion dollars a year the government could spend on education, research and tax reductions.

Truth

August 25th, 2009
2:28 pm

WOW…. Mrs. Tucker didn’t bring race into this column!

Deeeetroit

August 25th, 2009
2:29 pm

Hey Rooster you are right but why should I be forced to give up my employer provided coverage where I pay only a couple $$$ per pay and I have great coverage and I can see my DR. when I want, to be forced into some government run insurance where I will definitely recieve less and no doubt pay more. And you can’t compare car insurance to health insurance, Health is much much much more expensive and who has that type of money to pay for higher costs because you may be of a higher risk . Because I some how got cancer I should be forced to pay more obviously I would be considered a high risk through no fault of my own, I did not smoke but I happen to get cancer( which thank god I don’t have I was just using the scenario as an example) be categorized by what they can afford to pay for. There is no way this country can afford to pay for everyone to be insured and it not having any affect on the coverage I receive now with my employer.

RealityKing

August 25th, 2009
2:32 pm

Is Obama going to force Dr. Amy into the government option’s network?

Of course not, she and most other highly recommend doctors are not going to take part in the government option’s network because they will be paid less for their highly recommended services. In fact, they will end up catering to the rich and self-appointed elitists, like Cynthina, who can afford to pay those high out-of-network costs.

And don’t bet on keeping your private plan either. Because companies shop around for the most cost effective coverage each year. And you can bet that most companies will be forcing their employees onto the cheaper government option to save themselves few bucks. Especially liberally run organization that are prompting it like the AJC. The government option is the only option in their progressive eyes. And if you don’t like it you can just find another job(Good luck in Obamaville).

Which means Obama is telling nothing short of a bold face lie when he repeatedly says that Americans can keep their current plan and doctor if they so choose. Because the fact is, the average American will be forcefully scuffled into a government controlled HMO by emploers looking to save a few bucks, Where costs, and therefore quality, are regulated by politicians, not doctors.

Good to see you finally realizing this Cynthina..

dr oz

August 25th, 2009
2:38 pm

this is all moot. President Obama and his boys are about to fold on this whole deal. The insurance companies just haven’t hit the majic number yet. $$$

Tea

August 25th, 2009
2:46 pm

That’s what I think too oz. Rather than healthcare reform we’re just going heavily subsidize the existing system with tax dollars. Big Pharma has kicked in their nickle. Maybe it’ll cost HC ins companies half a buck. From where I sit, Obama has sold us out on HC reform.

RealityKing

August 25th, 2009
2:50 pm

Next time you in town Cynthina, you should take you new baby down to the Grady emergency room and see how long it takes you to see a qualified pediatrician. That’s what Obamacare will certainly bring to the majority of Americans. Which of course doesn’t include you or me, the self-appointed elitists among us who can afford the high out-of-network costs. But you should still experience what you’re advocating.., at least once.

Daniel

August 25th, 2009
2:57 pm

The key phrase is, You get to choose. Find a doctor that is willing to accept what you are willing to pay for your child’s care. Ask yourself this question, where do you get your hair cut? It is your decision. If someone is at the top of their field, why should they expect to be paid less than what they are worth? This conversation actually has nothing to with insurance, but your ability to provide the best care for your child. Find an employer with the best networks, but look inside yourself first

Tired of BS

August 25th, 2009
3:01 pm

Mrs. Tucker I am surprised that you would choose Obamacare. You think it’s difficult to deal with finding a pediatrian now…. just wait ’til your man controls everything. You will have a nice long wait before you are able to see a doctor. Go ahead and keep wishing…. and pray your baby never gets sick.

Tea

August 25th, 2009
3:05 pm

Well, in traditional capitalist system that would be true Daniel, but like many, many American industries, the Healthcare industry does not provide enough competition to support “normal” supply and demand market behavior. This is a fundamental point that is not receiving enough focus in our country’s healthcare debate. The reason HC is so expensive is because our system has many unnecessary layers of non-caregiving middle men who inflate the overall cost. We are paying for their profits, not for healthcare. If we were just paying for healthcare the cost would be orders of magnitude less that what it currently costs us.

bob

August 25th, 2009
3:07 pm

Tea, you said we could save a Trillion by switching to gov healthcare and then tell us what GOV could do with that money. What is the use of putting my healthcare in the hands of gov if they are going to spend the money anyway.

bob

August 25th, 2009
3:10 pm

Tea, you asked what your problem was in finding good healthcare and gave a few examples. After reading your posts, I would go with the intellectually deficient.

theROOSTER

August 25th, 2009
3:37 pm

ctucker,
Yes, in most instances military members are allowed to seek private care if military care is unavailable. Some remote locations do not have military hospitals, or may not provide some specific type of assistance the member needs. There is also nothing to stop a military member from purchasing their own private insurance. However, if a military member were to seek out a private doctor on their own, the would likely have to pay out of pocket for that care, unless the visit was pre-approved by Tricare or the member’s PCP.

D-troit,

You are missing the point entirely.. You don’t want to be dependent on the gov’t for healthcare, yet you are totally dependent on your employer. Why can’t you be self-sufficient and research and purchase your own plan. Maybe your employer would let you keep your plan.. That’s fine. But, why is your health the responsibility of anyone but you? Does your employer pay your homeowners insurance?

And yes, you can compare them. The free market way we buy auto insurance is a great template. The govt could still play a roll by mandating coverage for each specific plan. For those below the poverty line, a tax credit is given for the amount equal of the basic care plan.

Duh

August 25th, 2009
3:38 pm

Your choice, if you are a decent parent, is to sacrifice something else so you’ll have the extra “several hundred dollars a year” to see the doctor you want in the timeframe you want.
Just cancel your cell phone, don’t eat out so much, don’t get your hair and nails did. It’s easy, really.

The Last Believer

August 25th, 2009
3:38 pm

Dang, I wonder how civilization survived up until now. How did they manage it for all these centuries? What? What was that I just heard someone mumble under their breath? “Be responsible for yourself?” “Act mature?” “Work hard?” “Accept the consequences of your stupidity and move on with your life?”

What do these mean, insensitive statements mean? I need a handsome, smooth talking politician to help me figure out my life and to make everything okay for me. After all, I deserve to be taken care of. Other people have more than me, and it’s not fair.

So, somebody go fix my healthcare, because it’s not my responsibility to get an education, a job with benefits or take any responsibilty for my actions.

There, I feel better now.

Jackie

August 25th, 2009
3:40 pm

Cynthia’s dilemma is why a single-payer system is needed.
If everyone were part of the same risk pool, then it would not matter which doctor you choose because they would be compensated by the system for services rendered.

HMO, PPO and HSA are methods set up to provide a means of selection by the insurance company to help “control costs.” The insurance company has negotiated with the doctors and hospitals for the amount the will be compensated for specific services. If someone with another carrier that has negotiated a different rate will be charged for the negotiated rate of that carrier.

Essentially, doctors and hospitals are sub-contractors of the health insurance companies.

Larry

August 25th, 2009
3:53 pm

Don’t let the facts get in the way people, just keep spreading the GOP lies!

No one can say what is in the new heath care bill, because there is NO bill. Several proposals are floating around, different bills but nothing you can say is final. How can another choice be so bad?

We know the insurance companies have been raping and robbing us for the last 50 years and it will never get any better without some competition. Why are the insurance companies so afraid of competition? What happened to the Free Market System? If we have the best system in the world how could a public OPTION hurt anything?

I have what is considered a good employer provided policy, but it cost more and covers less every year. The insurance companies have had their chance and failed miserably!

RealityKing

August 25th, 2009
3:53 pm

The funny thing is that I too have Aetna with my company. An insurance that is accepted by our highly recommended doctors. In fact, insurance that worked well for us the Sunday before last when my 3 year old woke up at 4 am with a very high fever. We cooled him down a bit with ice chips and immediately called the 24hr on-duty nurse. Yes, private insurance provides that service. And she was great, graciously calling us back twice for updates before finally calling at 8:30 with a 10 am appt, for our highly recommended pediatrician. Needless to say.., we had a prescription for antibiotics by 10:30, filled and administered by 11. You see strep throat is a nasty virus for young children, one that can be very debilitating if not treated quickly.

But I am not fooled by a nurses graciously soothing voice. I know high insurance premiums are the only thing that enables this type of quality service, for 85% of America. A quality of service no government controlled entity could/has ever afforded in any format. A quality of service that Obama can now only hollowly promise with words elegantly read from his teleprompter. No.., I am not a fool for Obamacare.

theROOSTER

August 25th, 2009
3:56 pm

Jackie,

Why are we all apart of the same risk pool, when we do not all carry the same risks. Why should you you be forced to pay for someone elses rehab, when it was their own bad decisions that landed them there?

A single payer system leads to rationing. That is simple supply and demand. There will be way too many patients and not enough providers. That’s the hard truth. Can you imagine having the swine flu in a single payer system? Everyone with free healthcare? Everyone with a sniffle will be lined up outside an emergency room preventing those who actually need treatment from getting it.

gttim

August 25th, 2009
4:00 pm

Funny, my dad has government insurance. It is called Medicare. He chooses what doctor he wants to see. He has had all his treatments covered. He has supplemental insurance from a private company to pay for whatever Medicare does not cover- deductibles, co-pays and excess. Never once has the government dictated treatment to him or his doctor. After having private insurance for decades, he loves his government insurance.

The military system somebody is tossing around here is not what the public option will be, The public option will pretty much be Medicare for everyone, which is an idea I love! My work provided insurance pays very l little, refuses to pay for people’s treatments, has outrageous deductibles and is overly expensive. I will gladly pay premiums for the pubic option, while you will be free to keep your private insurance and you own doctors.

Cutty

August 25th, 2009
4:01 pm

Some of you people are absolute morons. Some of you don’t even have health insurance but will defend the industry to the end. Costs have risen, people pay premiums for years and then get dropped when they become sick, yet some of you would rather do nothing. Republicans are now opposed to any cuts whatsoever to Medicare even though that is the fiscally correct thing to do so the program will be around when I retire. So no you people were against socialistic medicine before you were for it. Nothing but politics. Republicans have been in control of Congress and the White House for much of the last 20 years and have done nothing to curb the skyrocketing costs. I have employer-based insurance and pay over $500/ mo for a family of four. In the span of a year, we may go to the doctor a total of 10 times. Its a complete rip off and you turds are defending it. Then will complain in 2012 that Obama didn’t try to do anything to address the problem. Enjoy you increasing health care costs, which surely will rise in the next few years if nothing is done. You people deserve it.

gttim

August 25th, 2009
4:03 pm

Of course, can anybody tell me what the private insurance company ads to the health care equation for their 30% take of medical spending? What do they do to make people better? What do they do to make health care more affordable? What do they do to health care more available? What do they do to earn 30% of health care dollars?

rdh

August 25th, 2009
4:07 pm

Do you really believe that, under a government option, you will get to see any doctor you want? And what if all of us want to see the same, best doctor in a given geographic area or specialty? (Who is the best doctor in Atlanta? That is the guy I am going to see under a government plan!) We can’t all go to the same heart specialist or pediatrician. There will be rules and limitations, and anyone who can’t see that is dreaming. Cynthia, everyone will want to see Dr. Amy when this is all said and done, so her time and patients will be determined by a government panel.

rdh

August 25th, 2009
4:11 pm

gttim – Medicaire is broke. Spare us using IT as a model for a government run plan

Cutty – The Republicans don’t get a say in this. They were told by the president that he doesn’t want to hear from them, and their ideas are not allowed on the House floor. You can’t blame the Republicans for lack of support if you won’t even listen to what they have to say

the evil rich

August 25th, 2009
4:25 pm

Cynthia, how much does the DNC pay you for this propaganda?

tj

August 25th, 2009
4:38 pm

Medicare is going broke, what to you think will happen to a public option ?? Say NO to healthcare Reform!

Joey

August 25th, 2009
4:54 pm

Jay "Numbnuts" Bookwoman

August 25th, 2009
5:47 pm

Hmmm, I find it hard to believe there are only two pediatricians in DC. Furthermore, I find it hard to believe that you can’t find a DR. (to your liking) within your network, that can get your baby in sooner. Here’s a novel idea – refuse your coverage through your employer and Aetna and GO BUY YOUR OWN INSURANCE. YOUR BABY IS WORTH IT RIGHT?!?!?!?!?

Jay "Numbnuts" Bookwoman

August 25th, 2009
5:54 pm

Here’s another thing to chew on… What makes you think that those highly sought after doctors are going to stay in the governments network? After a few times of the government telling the doctors what to charge – they will bolt. You will see many not excepting any insurance period and we will have to pay out of pocket. So guess what? Those sought after doctors will still be out of reach for you SINTHIA.

Jay "Numbnuts" Bookwoman

August 25th, 2009
5:57 pm

“accepting” not “excepting”

Eddy

August 25th, 2009
6:19 pm

If there is a doctor that you want to see Cynthia but is not in the network, pay for the doctor’s visit out of your pocket. I had Cigna. My oncologist referred me to a surgical-oncologist for a consultation. Doctor did not take Cigna. I escalated this to the patient advocate within Cigna to no avail. So I called the surgeon’s office, explained what I wanted (a consultation for cancer surgery) and asked what the cost of visit was going to be. I went, had the consult and paid for the visit. What’s so hard to figure out? You are supposed to be the adult. Your baby is the infant. Act like an adult and quit making a fuss over a non-issue. If you believe that Obama’s plan is going to be the answer, you should seek help immediately. Dr. Amy could refer you to an in-network shrink or one that is out of network and you can then choose. Only two choices…in or out. One’s cost is a copay the other’s cost will be significantly more.

In the Middle

August 25th, 2009
6:26 pm

If the status quo is the way to go, then what’s wrong with this picture:
Laid off a year ago (real estate/architecture), go on COBRA. Still no jobs around, so we start new businesses (great! – how American, right?). COBRA will run out so we shop for individual coverage (because we’re willing and able to work and pay for it, and the new businesses don’t qualify for group insurance). Only to find out that company after company refuses to cover our 7 year old daughter. At all. Why? “Too many UTIs”. WHAT??? There’s nothing wrong with her. We even paid ourselves to have her kidneys tested to prove this. We are told that the companies calculate that the cost of her going to the doctor a couple of times a year to get a prescription for antibiotics exceeds the premiums they would collect. So we say “fine — we’ll pay for her UTIs”. And they say, “No, sorry. No insurance for her.” This goes on for nearly a year. So we faced having to let her go without insurance for 6 months until she becomes eligible for PeachCare. Thankfully, we found a company to take her. Never mind the fact that we could pay a healthy mortgage with the premium.
The problem with the “individual private market” is that the risk pool is not large enough to entice them to accept even healthy children. People are hopelessly tethered to getting their health insurance from an employer. Way to stifle entrepreneurship! Why would anyone jump from a McJob to start their own company if they had a family and knew that it potentially meant health care calamity? Someone who supports “the current system” needs to address this scenario with a compelling argument.

I Report/ Vast White Wing Conspirator (-: You Whine )-:

August 25th, 2009
6:39 pm

Wait a minute, I thought babies were a wanton destruction on the “environment?”

Now a lib wants to care for one?

I’m so confused.

Mine

August 25th, 2009
6:47 pm

“He’s fudging a bit.” Cynthia – how dare you speak negative about “The One”. One can now only surmise that you’re racist!!!

luckydog

August 25th, 2009
6:54 pm

There are only 2 pediatricians in DC? Only 1 on your plan? You got a sorry plan!

tonya williams

August 25th, 2009
6:57 pm

I wish this was the biggest problem I had. Thanks to the wonderful insurance commissioner of Georgia, I have an “enhanced conversion policy” which means that since I came off Cobra in July, and the fact I can not get private insurance due to pre-existing medical conditions, I am not eligible for the state mandated plan which would cost me around $500 a month. Instead, my “enhanced” coverage cost me $26,000 a year, and no that’s not a typo. Also, I get no benefit of a prescription drug card or reduced benefit costs from doctors or hospitals. How convenient, that way I’ll reach my lifetime limit of 2 million dollar much quicker. Who was the policy enhanced for? Cigna. Just ask our insurance commissioner how much he received from them in political contributions. People have no idea the turmoil that is going to happen when Cobra expires for so many of the people who have relied on it, or what will happen to the people who have been forced to take early retirement and won’t be able to purchase health insurance. If you don’t think this problem is going to affect everyone, you are in for a big surprise.

Arthur Blank

August 25th, 2009
7:13 pm

Wheres the father? He cant help pay? Do you know who the father is?