It seemed unthinkable, but I decided to think about it anyhow. Would it be possible to have a hospital birth without maternity coverage? I had time and I had options, so I decided to figure it out. I have to start by being transparent. As the title implies, I am a physician, specifically an ob-gyn. I know many people will think that affords me a significant advantage over the general population, or hand-shake discounts, but this is not the case. My main advantage was knowledge of codes, which can be requested from providers or even searched online, and knowledge of the existence of the self-pay discount, which is what I want to share with my readers. The whole idea behind this article is to convince you of a few things:
1. You have options.
2. Health insurance is not the same thing as health care - your insurance carrier is not in charge of your health care, you are.
3. With enough patience, anyone can learn to navigate this system, and in so doing, may help to improve it for all patients in the long run.
The group health insurance plan available to my family would be ~$1,000/month and covered 80% after a $3,000 deductible. Without knowing the plan's contracted rate with the hospital, I assumed I was already in for the full $3,000 deductible plus 20% of this not insignificant as of yet undetermined amount (this 20% is referred to as coinsurance). Then I factored in the additional cost of the monthly premium (something many forget to do as it cleverly sneaks out of their bi-monthly paycheck). If I chose to insure my family with this plan for the duration of the pregnancy and postpartum period, yearly premium alone would be ~$12,000 (If I chose coverage for only myself, ~$5,500). My next move was to go to the hospital financial office to inquire about the self-pay charge for a maternity stay. They were a little caught off guard by my inquiry, but I got an answer after one call and one in-person visit, and was pleasantly surprised. For an uncomplicated maternity stay, they quoted between $3,100 and $3,300 (representing a 70% self pay discount), with the latter charge being for a cesarean. So again, with just a reasonable guess at the 20% coinsurance, I'm spending roughly $10,000 on premiums and patient responsibility ($5,500 in premiums + $3,000 deductible + a guesstimate of $1,500 coinsurance) for the maternity stay if I insure only myself, and roughly $16,000 (same math as above but with $12,000 in premiums) if I'm insuring my family for the year. Even without factoring in the separate physician fees (which would also incur 20% patient responsibility coinsurance) it seemed like a no-brainer. So I decided to go the self-pay route. I was even more surprised when my hospital offered me 2 options: an additional 5% discount for payment in full within 30 days OR an extremely reasonable payment plan. When all was said and done, the payments I made to the hospital and the fees I negotiated with my physicians, totaled around $6,000.
Most large health care organizations are like any other marketplace - they are willing to negotiate rates with anyone who is willing to pay and I believe that they have begun to appreciate the self-pay population for the liquidity that the arrangement offers (keep in mind that if you are using insurance, it is in violation of the insurance contract for the hospital or physician to negotiate rates, though payment plans may still be an option). If you can plan ahead for a medical event (elective surgery, maternity stay, etc.), and even in some cases that aren't predictable, being self-pay gives you the opportunity to take an active role in negotiating your fees.
Health insurance is not the same thing as health care. I feel like I want to say that again... Health insurance is not the same thing as health care, but the middle-men (that add little to no value) have spent a lot of marketing dollars (your insurance premiums) to convince us that these two things are equivalent or interchangeable. They've also somehow convinced us that we can't exercise any other option.
By convincing consumers that health care comes from being insured, rather than it being a skilled service provided by medical professionals, these middle-men are commoditizing the doctor-patient relationship, and they are profiting at the expense of your health care. Every dollar in the pockets of no-value-added intermediaries is a dollar less towards your health care. In essence you are loaning them money, in the hopes that they will pay you back when you need it. Publicly traded health insurance companies have much more incentive to satisfy their shareholders than they do to maximize the dollars paid toward patient health care.
BUT if, as patients, we recognize that we are consumers of the health care industry and WE are in control of our healthcare, there is power in that. The slowly burgeoning "direct-to-consumer" health care movement seems to demonstrate this, and has asked the middle-men to wait in the parking lot. We are patients, people, human beings. Our health care should not be a commodity to be bought, sold and publicly traded.
Before beginning this journey, it is important to note that the self-pay health care market still has a long way to go. Smaller facilities or physician practices may not have a self-pay fee schedule or any comfort level in managing self-pay debt so it takes a lot of research and pavement-pounding to create your "network." I am currently navigating this in my own practice, and with less boldness than I would like to admit. Just like leaving the matrix as a patient was nerve-wracking, doing so as a provider is also scary. My hope in writing this is that more people feel empowered to take control of their health care and, in doing so, foster the creation of this patient-centered marketplace.