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Tuesday, 27 February 2018 11:46

Increased Costs Due to Unnecessary Medical Care and Insufficient Member Education

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Recent articles from Benefits Pro and National Public Radio (NPR) claim that many patients are receiving unnecessary or “low-value” medical procedures, which are significantly increasing health care costs.

According to Benefits Pro, “health care consumers are sinking $25 billion a year on low-value procedures”. The Washington Health Alliance, after reviewing claims for 1.3 million patients in the state, found that 600,000+ patients per year are receiving treatment they do not need. The staggering cost for this unnecessary treatment is estimated at $282 million, and ultimately impacts rising health care costs.

Examples of unnecessary or low-value procedures identified in the articles include:

  • Diagnostic tests performed before a low-risk surgery or before any clinical symptoms appear
  • Screening for vitamin D levels
  • Screenings for cervical cancer for non-risk patients in a 3-year window
  • Heart testing for low-risk patients
  • Prescribing brand-name medications instead of a generic equivalent

Consumers rely on their medical providers to know when these tests should be performed, and when prescriptions should be written, but rarely do patients ask enough questions to be fully informed on whether those procedures or medications are necessary.  

When it comes to out-of-pocket costs consumers are paying, it’s not just that their health plans are less rich in benefits than they used to be. Fall River’s experience is that members do not normally understand their health care policy to the degree they should, leaving them less likely to know when and how to save on healthcare costs. Sometimes members aren’t checking that their providers are in-network with their plan, leaving them with much greater out-of-pocket costs. They are also largely unaware of the tools the carriers offer online, such as provider searches, cost estimators, care comparisons, wellness programs, and prescription libraries.

If providers and consumers become more educated about wasteful spending, we might see a significant decrease in the cost of health care. Our current medical system is one that rewards providers for doing more, but a transition from paying for the volume of services to paying for the value of what’s provided, could have an impact.  A Value-Based Pricing (VBP) model would compensate providers for healthy outcomes rather than the predominant form of payment—fee for service—where providers are compensated based on the number of services rendered. 

Every individual has a responsibility to become their own health care advocate, which in turn can decrease costs as a nation and in our own wallets. Consumers, who are becoming more empowered and savvy in healthcare decision making, want to be more proactive in managing their health, but they also say they need help getting there. 

Tips to consider: 

  • Take the time to fully understand how your plan will cover your care by reading your Summary of Benefit Coverage (SBC)
  • Always confirm the In-Network status of all providers, doctors, facilities, and pharmacies
  • Use your insurance carrier’s cost estimator tool online to compare costs between doctors and facilities
  • Ask questions about care, and be fully informed about conditions, procedures, and prescriptions
    • Is the visit/procedure preventive or diagnostic?
    • What tests are being performed and why?
    • How is the test/procedure covered under your policy?
    • Will a generic medication be just as effective, instead of the costlier and sometimes less-proven brand-name or non-formulary medication?
    • Do you have access to a telemedicine benefit to help you access care for common ailments to help keep you out of the urgent care or emergency room?

At Fall River Employee Benefits, we empower our clients (and their employees) with coverage information and guidance on wise consumerism, not only during benefits open enrollment but also throughout the year. If you’d like more information, please reach out to your Fall River Account Manager. 




Read 2296 times Last modified on Monday, 14 September 2020 16:07
Gaby Baughn

Gaby is our bilingual Client Service Specialist. She provides day-to-day support to our clients and members with billing, claims, eligibility, and system issues in English and Spanish. Gaby also assists the Client Managers with creating communications materials, preparing for open enrollment meetings and quoting.