Use of Out-of-Network Services May Explain Higher Health Care Costs For Women

Women generally have been paying higher health care costs than men for many years, and this trend appears to be continuing or worsening since the major economic downturn began in 2008, according to Susan Busch, associate professor of health policy in the Yale School of Public Health.

Busch believes women’s use of out-of-network services might explain, at least in part, this discrepancy.

In many insurance plans, most health care expenses are more generously covered if a patient uses a provider that is part of the insurer’s network, while he or she is charged a greater out-of-pocket expense for using providers outside that network.

Susan Busch. Image credit: Yale University

Busch, and Dr. Kelly Kyanko, a physician who trained with Busch as a Robert Wood Johnson Clinical Scholar at Yale, set out to determine whether men or women are most likely to use out-of-network health care services and, if the latter, whether women were doing this intentionally or unintentionally.

“This is clearly an area where we felt that policy could be informed by good research, given how much we spend on health care and health insurance,” Busch says. “Not enough was being done to look at it.”

Busch and Kyanko created their own nationally representative survey of 700 privately insured adults, ages 18 to 64, in order to study this phenomenon. Their study was supported by a Women’s Health Research at Yale Pilot Project Program grant, along with additional funds from the Robert Wood Johnson Clinical Scholars Program.

The researchers’ preliminary results suggest the rate of out-of-network use is approximately 60% higher for women compared to men.

Some women deliberately choose out-of-network health care providers — perhaps because they are following the advice of family or friends to use a particular provider, or because they continue to use a provider when that provider no longer is within their insurer’s network, note the researchers.

In the mental health area in particular, women are much more likely than men to use an out-of-network provider, notes Busch, who has done extensive research on mental health care financing and accessibility. This may be because their insurance does not cover such services, or the women are more comfortable with a particular provider — regardless of the network status, she says.

However, in other areas of health care, women may receive unexpected charges from out-of-network providers — even when they use emergency rooms or hospital facilities that are part of their insurer’s provider network. Examples of these unexpected charges include billing by anesthesiologists who provide epidural anesthesia for women in childbirth, and neonatologists who provide pediatric intensive care.

“This adds clear data to what I see as a major consumer advocacy issue,” said Kyanko, who is now an instructor in the Division of General Internal Medicine at New York University School of Medicine.

Most people who need medical services know to ask if a provider is within their insurer network, Busch says. However, in some cases, Kyanko notes, patients might assume the physicians attending them are part of their network, or the patients might be so immersed in dealing with their medical problems that they simply “don’t think of asking each doctor who comes to their bedside.”

To follow up on their pilot study results, the researchers will conduct in-depth telephone interviews with patients who have had experiences with the use of out-of-network health care services, exploring financial or other personal consequences.

“We will be looking to obtain more detail for the reasons patients use out-of-network health care, intentionally or unintentionally,” says Busch. “We want to get more of a flavor for why it happens.”

One hypothesis that the researchers are exploring is that a significant share of unexpected charges for out-of-network care involves medical emergencies.

If this proves to be the case, notes Busch, some help for solving this problem is on the way via a little-known provision of the Patient Protection and Affordable Care Act, enacted by Congress and signed into law last year by President Obama. This provision requires insurers to cover emergency care services regardless of whether the care was provided by an in-network or out-of-network physician. This means that patients who receive emergency care in or out of their insurer’s network will not have to provide higher co-payments or cost-sharing expenses to their insurers.

This provision, however, does not prevent an out-of-network health care provider from billing an emergency care patient the difference between what the insurer covers and whatever the health care provider might charge — so-called “balance billing” — notes Busch, pointing out that some states prohibit this practice. Furthermore, she adds, the provision, which took effect in September 2010, applies only to new health insurance plans, not previously existing ones.

Overall, says the Yale researcher, the new federal health care law represents a major step forward for women’s health. New federal rules will ensure that women, for the first time, have access to a range of preventive health services without having to pay insurance co-payments or deductibles. These include well-woman visits, contraception methods approved by the U.S. Food and Drug Administration, breastfeeding support, and domestic violence screening and counseling. These rules will require new health insurance plans to cover these services without out-of-pocket charges beginning Aug. 1, 2012.

In addition, the new federal law will go a long way toward helping women gain insurance coverage and access to health care once it is fully implemented over the next several years, Busch says. An estimated 15 million women would gain insurance coverage through expansion of Medicaid and the offering of health insurance plans through state health insurance exchanges to be established under the new law.

Although larger solutions to the problems of out-of-network costs will have to come from federal and state legislation, and the medical and insurance industries, there are some things that consumers can do for themselves, Busch notes.

First, “try always to ask if a provider is in-network or out-of-network,” Busch says. “Second, if a patient receives an unexpected bill for out-of-network charges, try to negotiate with the provider and try to get the insurer to cover the charge or reduce it.”

– By Daniel Jones

*Source: Yale University

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