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1. Long Term Care Partnership Only Web site, accessed Aug 22, 2011. 32. Guide to long-term care insurance. Washington, D.C., 2004,

America’s Health Insurance Plans. HealtH-Care FinanCing The American health care system, and especially its cost, is out of control, inhibiting access to care for many, lessening quality of care for some, and creating an almost palpable angst among physicians and others concerned with this enormous national problem. Nicholas E. DaviEs, M.D.1 louis h. FElDEr, M.D. Imagine if all doctors and all hospitals in the US had just one type of form to fill out. And all patients had one insurance card. And all patients had health insurance. . . . And now think of the savings in time, money, paper-pushing. Doctors would have more time to care for patients; everyone would have fewer headaches waiting to talk to their HMO to prove their coverage; nurses would be less frustrated with their work. GraMazoN.coM2 The only plausible explanation for the US paradox of spending more and getting less is that the US health care system is enormously inefficient. Marsha aNGEll, M.D.3 © m ed ic al ec on om ic s, 19 95 “Is there a doctor in the house affiliated with the Apex HMO?” Chapter Twenty-Four Part Six Protection of the Consumer488 Skyrocketing costs and inequalities in the distri- bution of services are persistent problems in the U.S. health-care system. Part of the problem is the high cost of new technology. But many critics of our health-care system describe it as choked by paperwork, strangled by bureaucracy, and riddled with waste and inefficiency. Solutions to these problems have been stymied by their complexity and the competing demands of special-interest groups. The National Coalition on Health Care4 concluded that most Americans had little confidence in the health- care system. Its 1997 poll found that 8 out of 10 said that medical care quality was being compromised in the interest of profit. The Center for Health Economics Research5 concluded that the major source of public dissatisfaction was not quality but out-of-pocket costs, and that these costs decrease with better insurance cover- age. Other polls have found that the primary concern is with public access and that satisfaction with the system is far greater among those who are wealthy rather than poor, white rather than nonwhite, and healthy rather than disabled.6,7 Health care finance is the management of money (funds) intended to achieve health care delivery goals This chapter focuses on health-care costs, insurance coverage, insurance fraud, cost-control strategies, pro- posals for health care reform, and the Patient Protection and Affordable Care Act, which was signed into law in 2010. HealtH-Care Costs The annual cost of health care in the United States rose about 11% a year from 1960 through 1990, and about 7% a year since that time. In 2009 the cost totaled $2.49 trillion ($6797 per person).8 As shown in Table 24-1, $2.09 trillion of this was spent for personal health care, and the rest was spent for administration, research, con- struction, and public health activities. In 2011 actuaries at the Centers for Medicare & Medicaid Services (CMS)9 estimated that the total would rise about 5.8% per year and would reach $4.6 trillion (19.8% of the gross do- mestic product [GDP]) by 2020. In 2009, 85.7% ($1.79 trillion) of personal health expenses were paid by third parties (private health in- surers and public agencies) and 14.3% ($299.3 billion) were paid by individuals. U.S. Department of Commerce data indicate that in 2009 personal-consumption expenditures for medical care totaled $1.97 trillion. (The Commerce Department’s medical-care total is less than that of the CMS because it does not include moneys from certain government programs.) This amount exceeded housing ($1.89 tril- lion), transportation ($882.7 billion), recreation ($879.4 billion), financial services and insurance ($747.8 billion), food ($746 billion), personal business ($578 billion), household operation ($403.1 billion), clothing and shoes ($334.8 billion), and education ($234.4 billion).10 Figure 24-1 summarizes how America’s health-care costs were financed and how the money was spent. The reasons for the rise have included (a) increasing use of costly high-tech equipment, (b) the high cost of treating such illnesses as AIDS and cancer, (c) aging of the population, (d) fraudulent practices by some provid- ers, (e) the large number and high cost of malpractice suits, (f) the administrative costs of complying with government regulations, (g) wasteful duplication of services, and (h) the practice of —testing that is medi- cally unnecessary but is ordered to protect the physician against the danger of a malpractice suit. Another factor is that greater insurance coverage (more people insured and greater coverage per person) has led consumers to demand more and better services and doctors to recom- mend more services. In 2008, the Commonwealth Fund compared the health systems of Australia, Canada, Denmark, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States

• National expenditures for health care have risen at an alarming rate.
• An ideal health-care financing system would provide equity, access, efficiency, and high-quality care. Reform efforts have been stymied by competing interests and the inherent difficulty of the problems.
• Individuals can minimize some of their expenses through prudent consumer strategies.

Keep tHese points in Mind as You studY tHis CHapter Key Concepts Chapter Twenty-Four Health-Care Financing 489 and concluded that although per capita (per person) spending on health care in the United States is far greater than in the other countries, the U.S. system is not de- livering superior results. Its report stated that the major reasons for high cost appear to be substantially higher prices (especially for drugs) and a “more fragmented care delivery that leads to duplication of resources and extensive use of poorly coordinated specialists.”11 sourCes oF Funds For HealtH-Care expenditures, 2009 (Billions oF dollars) Table 24-1 Expense Category Personal health care (84%) Hospital care Physician and clinical services Dental services Other professional services Home health care Prescription drugs Durable medical equipment Other medical nondurables Nursing home/CCRC care Other personal health care Total, personal health care Other expenditures (16%) Program administration and net cost of private insurance Govt. public health activities Research Structures and equipment Total, all expenditures Category Total $ 759.1 (31%) 505.9 (22%) 102.2 (4%) 66.8 (3%) 68.3 (2%) 249.9 (11%) 34.9 (1%) 43.3 (2%) 137.0 (7%) 122.6 (3%) 2089.9 (86%)

163.0 (7%)

77.2 (3%) 45.3 (2%) 110.9 (1%)

2486.3 (100%)

Government Programs $403.5 170.2 9.3 18.4 54.7 84.8 11.8 2.8 77.0 71.0

77.2 –

Out-of-Pocket Payments $ 24.4 47.9 42.5 17.7 6.0 53.0 18.6 40.5 39.8 8.9 299.3 – – – – Private Insurance $265.9 237.7 50.0 24.7 5.0 108.6 4.0 – 10.5 5.8 – – – Other Third Party $65.3 50.6 0.5 6.0 2.5 – – – 4.2 4.9 – – – Source: Health Care Financing Administration.8 Some numbers do not add to totals because of rounding. Where the Money Came From Where the Money Went Other private source Private health insurance Hospital care Medicaid Medicare Other public programs Out-of-pocket Prescription drugs Figure 24-1. How America’s health-care dollars were spent in 2009.8 31¢ 6¢ 20¢ 27¢ 13¢ 22¢ 36¢ 4¢ 7¢ 8¢ 17¢ 10¢ Nursing home care Program administration and net cost Physician and clinical services Other spending Part Six Protection of the Consumer490 Personal health expenditures are very unevenly distributed. Consumers Union13 has concluded that (a) the sickest 10% of the population accounts for 68% of health-care expenditures; (b) for households with a head younger than 65, the percent of family income spent on premiums and out-of-pocket payments ranged from a high of 17% for families with income under $10,000 to 3% for families with income of $100,000 or more; (c) one in six households with a head younger than 65 spends 10% or more of its income on out-of-pocket costs plus directly paid premiums; and (d) half of the households headed by a person 65 or older pay more than 10% of their income on such costs, mainly because Medicare does not cover their prescription drugs. The Health Care Technology Institute12 has pointed out that Americans have mixed feelings about cost-con- trol (see the “Conflicting Attitudes” Personal Glimpse box). Medical Fees Physicians generally base their fees on (a) the nature, extent, and complexity of the service; (b) the time in- volved; (c) the office overhead—rent, heat, lighting, equipment, supplies, and salaries of personnel; (d) the experience and expertise of the practitioner; (e) the area in which the physician practices; (f) the fees customarily charged by others in the community; and (g) in some circumstances, the economic status of the patient. Medi- cal fees are also influenced by the forces of supply and demand. Table 24-2 shows the median fees physicians charged in 2009 for outpatient visits. The FAIRHealth Educational Site (www.fairhealthconsumer.org) enables consumers to estimate the local cost of common medical and dental procedures. Insurance plans pay practitioners in three ways. In the fee-for-service method, they are compensated for each service they render. Another arrangement is a salary from a hospital, group health insurance plan, or governmental or private organization or agency. Some members of group or managed-care plans may also re- ceive a share of the profits at the end of each year, based on the amount of service rendered. The third method is capitation, a fixed monthly amount paid for each patient (per capita) regardless of the extent of services used. Insurance companies generally base fee-for-service payments on what they consider usual, customary, and reasonable (UCR). “Usual” refers to a physician’s own charges during the previous year or years. “Customary” refers to the range of fees charged by all physicians in a given region. “Reasonable” refers to a fee within a given region or area that falls below the 90th percentile of the customary charges. Medicare uses the 75th percentile and pays 80% of this amount. Except for deductibles and co-insurance, physicians who accept assignment are not permitted to bill the patient for the difference between what they bill and what they collect from third-party payers. Federal regulations prohibit medical organiza- tions from establishing fee guidelines or fee schedules, which are considered anticompetitive. A few attempts have been made to influence medical costs by publishing physician directories that include fee information. These publications are not very useful because they quickly become outdated, many physi- cians refuse to provide the information, and fees do not reflect the quality of care, which is generally much more important. Dental Fees Table 24-3 lists the average and 95th percentile fees charged for common procedures by general dentists and specialists in the United States in January 2009. This information may be helpful when preparing a budget for dental care or considering the purchase of dental insurance (see Chapter 23). Considerable evidence indicates that self-care and preventive dentistry can save consumers money. More important, however, are the benefits of freedom from pain and discomfort, retention of teeth, and less time spent obtaining dental care. The incidence of dental caries and periodontal disease can be substantially and cost-effectively reduced through the fluoridation of water supplies, topical application of fluorides, and plaque- control measures (see Chapter 7). Conflicting Attitudes Since 1980, Americans often expressed, simultane- ously, two contradictory attitudes on medicine and its costs—they repeatedly wanted unrestricted access to the best medical care and related technology, and, at the same time, they wanted lower medical costs and cited expense as a major shortcoming of the U.S. health care system. During the same period, respondents who were asked to consider cost-stabilizing health insurance plans were unwilling to give up complete access to the latest—even if it was the costliest—medical technology. Respondents were willing to exclude only purely elec- tive care (i.e., cosmetic surgery) from national health care plans for cost control purposes. Health Care Technology Institute12 Personal Glimpse Chapter Twenty-Four Health-Care Financing 491 pHYsiCian Fees For outpatient Visits, 2009 Table 24-2 CPT Code / Typical Time with Patient New patients 99201 / 10 minutes 99202 / 20 minutes 99203 / 30 minutes 99204 / 45 minutes 99205 / 60 minutes Established patients 99211 / 5 minutes 99212 / 10 minutes 99213 / 15 minutes 99214 / 25 minutes 99215 / 40 minutes Data source: Medical Fees in the United States.14 90th Percentile UCR ($) 101 146 209 293 371 54 86 117 177 260 Median UCR ($) 73 105 151 212 268 40 64 85 131 193 Typical Severity Minimal Minor Low to moderate Moderate to high High Minimal Minor Low to moderate Moderate to high High The fees to the right reflect usual, cus- tomary, and reasonable (UCR) fees as determined by insurance carriers in 2009. The applicable CPT code depends on the complexity of the evaluation and management involved. (Table 23-5 explains the coding system further.) The median UCR is the point at which half of the fees are at or below the amount listed and half are higher. Specialists tend to charge more than general practitioners, and fees also vary from one part of the U.S. to another. The fees paid by Medi- care were about 40% to 60% lower. 95th Percentile ($) 150 75 106 85 45 65 163 1000 1150 211 / 300 2420 / 2400 235 / 303 294 / 450 1180 / 1690 1960 / 4485 6000–7000 Services Diagnostic Complete intraoral x-ray series Bitewings, four films Preventive Prophylaxis (cleaning)—adult Prophylaxis (cleaning)—child Topical fluoride plus prophylaxis—child Sealant, per tooth Restorative Amalgam—one surface, permanent teeth Inlay, composite, one surface Crown, porcelain on nonprecious metal Oral surgery Extraction, single tooth Implant placement Periodontics Scaling and root planing, per quadrant Endodontics Therapeutic pulpotomy (without final restoration) Root canal, molar Prosthodontics Complete denture, upper or lower Orthodontics Comprehensive treatment (cost depends on age) Median Fees ($)* 108 43 75 55 30 44 105 688 850 156 / 250 1714 / 1900 135 / 150 150 / 250 850 / 1050 1300 / 2200 4870–5600 Fees For CoMMon dental serViCes, 2009 Table 24–3 *The fees listed above the dividing line are for general dentists. Specialists who do the same services tend to charge more for them. In the listings below the line, except for orthodontic fees, the first number is the median fee for general dentists and the second number the median for specialists. Fees for general dentists and orthodontists are similar. Fees tend to be higher in highly populated areas. Source: American Dental Association, 2009 Survey of Dental Fees.15 Part Six Protection of the Consumer492 Hospital and Long-Term–Care Charges In 2009, the estimated average hospital cost per inpatient day was $185316 and the average length of stay was about 5 days. This is what it cost the hospitals to deliver their services, not what patients or insurance companies paid, which was more. These figures do not include medical and surgical fees. Consumers may be able to reduce hospital and sur- gery costs by (a) getting a second opinion when elective surgery is advised; (b) not extending hospital stays for the sake of convenience; (c) comparing prices when hospitalization is needed (some areas have developed consumer guides that provide information about charges, services, and other matters); (d) choosing providers who have contracts with one’s insurer; and (e) monitoring hospital bills carefully to be certain all charges are valid. Billing errors, which are common, can include charges for unreceived services, as well as overcharges. The cost per day at a nursing home depends on the nature of the care rendered, the type of facility, the region of the United States, and several other factors. In 2009, the average yearly cost for a semiprivate room in a nursing home was $72,270 ($198/day).17 For many people, nursing home expenses are by far the largest health-related out-of-pocket expense. Reducing nursing home expenses may be difficult, but it may help to investigate Medicare and Medicaid coverage, purchase long-term insurance (see Chapter 23), or explore less-expensive alternatives to nursing home care (see Chapter 22). Some people qualify for Medicaid by incurring medical expenses until their net income after medical expenses is low enough to qualify. This method is called “spending down.” Some people transfer assets to someone other than their spouse so these assets will not have to be spent to establish Med- icaid eligibility. Since recently transferred assets are considered part of the applicant’s net worth, the transfer must take place several years before applying.18 This method is controversial but legal. Budgeting Considerations When budgeting for health care, consumers should con- sider that (a) out-of-pocket expenses are likely to occur each year; (b) the 2009 average was $974 per person; (c) health-care costs tend to increase as people grow older; and (d) the appropriate amount to allocate should depend on the number of people in the family unit, how old they are, and the extent of insurance coverage. Table 24-4 provides further details about per capita out-of-pocket personal health-care expenses for 2009. Cost-Control MetHods Most health care provided by practitioners in the United States is paid for on a fee-for-service basis. Health plans generally pay hospitals fixed amounts, either per admis- sion or per day.19 Various strategies are being used to try to control escalating medical and hospital costs. Traditional in- surance companies can use several measures. They can raise deductibles and co-payment amounts, limit what they pay for each service, limit or exclude certain ser- vices, limit maximum total benefits, and exclude people with pre-existing illness. They also can use utilization management to limit payment to medically necessary services. For example, they can require a confirmatory second opinion before authorizing certain types of elec- tive surgery. Managed-care plans can limit their sub- scribers’ choice of providers to those who have agreed to accept lower fees (or capitation) or have exhibited a pattern of providing lower-cost care. These plans also deny coverage of diagnostic tests and the services of specialists unless the primary physician authorizes them. All third-party payers can insist that various diagnostic tests and surgical procedures be done on an outpatient rather than an inpatient basis. Managed-care plans can use additional measures that influence physician behavior. They may require preauthorization from the plan before hospitalizing a patient or ordering certain expensive tests. They may exclude certain drugs from coverage and require that generic drugs be prescribed when available. They use aggressive utilization review programs to detect what they consider medically unnecessary or inappropriate care. They can also reduce costs by creating econo- per Capita out-oF-poCKet personal HealtH-Care expenditures, 2009 Table 24–4 Category Amount Hospital care $ 79 Physician and clinical services 156 Dental services 138 Other professional services 58 Home health care 20 Other health/residential/personal care 29 Prescription drugs 172 Durable medical equipment 60 Other medical nondurables 132 Nursing home and CCRC facilities 130 Total 974 Source: Centers for Medicare & Medicaid Services.8 Chapter Twenty-Four Health-Care Financing 493 mies of scale, reducing duplication of services, issuing treatment guidelines, and using financial incentives to encourage cost-conscious decisions. Managed-care plans usually compensate physicians with capitation fees or a salary. In addition, they typically use incentives to limit use of diagnostic tests, referrals to other physicians, hospital care, or other ancillary services. Many plans pay bonuses that depend on how little the plan has to spend for these services. Some plans withhold a percentage of the physician’s compensation until the end of the year to cover any shortfalls in the amounts budgeted for patient-care expenditures. If there is no shortfall, or if the shortfall can be covered by part of the withheld fees, the remainder of the withheld amount is distributed to the physicians. Since 1983 Medicare has paid for hospital services according to a predetermined schedule for about 500 diagnosis-related groups (DRGs). This system provides an incentive to shorten hospital stays and minimize the cost of providing their services. Hospitals able to provide services for less than the government rate can retain the difference. Thus a hospital that keeps a patient for 2 days receives as much as one that keeps a similar patient for 6 days. To ensure that the quality of care is not affected, hospitals treating Medicare patients must conduct strict peer review. Concerns have been raised that some hospi- tals discharge patients who still need treatment. Patients who believe they are being prematurely discharged can: (a) ask for a written notice, which will be needed for appeal, (b) seek help from their doctor, and (c) appeal to the hospital peer review organization. Many authorities have expressed concern that finan- cial considerations may undermine patient care. Wenger and Shapiro,20 for example, suggested that utilization review programs explore possible underuse of care in addition to overuse. The American Medical Association (AMA) Council on Ethical and Judicial Affairs21 has stated: While efforts to contain costs are critical and while many of the approaches of managed care have an impact, managed care can compromise the quality and integrity of the physician- patient relationship and reduce the quality of care received by patients. In particular, by creating conflicting loyalties for the physician, some of the techniques of managed care can undermine the physician’s fundamental obligation to serve as patient advocate. Moreover, in their zeal to control utilization, managed care plans may withhold appropriate diagnostic procedures or treatment. . . . Efforts to contain health care costs should not place patient welfare at risk. Thus, financial incentives are permissible only if they promote the cost-effective delivery of health care and not the withholding of medically necessary care. Many state legislators have expressed concerns that HMO cost-cutting measures have been too stringent.22 Many states have passed laws requiring HMOs to permit women to remain in the hospital at least 48 hours (or a time recommended by the American College of Ob- stetricians and Gynecologists) after giving birth. Some states have made it harder for HMOs to deny payments for emergency-department visits that turn out not to be emergencies. A few states have enacted laws that require prospective enrollees to be told how HMO physicians are compensated. Many states have banned “gag clauses” (HMO rules that prevent doctors from telling patients about treatment options that the HMO does not cover).24 Provider Strategies Escalating costs and the prospect of greater government intervention have stimulated rapid and sweeping changes in the way in which the health marketplace is organized. Hospitals have merged with other hospitals, forming purchasing alliances, hiring large numbers of physicians, and developing integrated managed-care systems that include the full gamut of medical services. Profit-making organizations have been buying hospitals and physician practices. Physicians have formed independent practice associations and other networks so that they can bargain more effectively with managed-care organizations. Group practices are becoming larger. Some Blue Cross/ Blue Shield organizations have converted from nonprofit to commercial status. Many facilities now use physician assistants and/or nurse practitioners who deliver services less expensively Consumer Health Insight Health Priorities The U.S. spends billions on healthcare services of questionable value while basic, evidence-based pre- ventive services are not getting done as often as they should. Yet the time available to deliver healthcare services is limited. Brief clinician office visits must ad- dress chronic conditions, acute illness, and preventive care. In this environment, prioritization of healthcare services is occurring, but it is rarely systematic or rational. And the consequences of misplaced priorities are high: people die and illnesses worsen because the most important preventive services do not get done. Health outcomes in the U.S. could be improved at less expense if the health care system, clinicians, and patients gave priority to services that were most beneficial and offered the greatest value. — Partnership for Prevention23 Part Six Protection of the Consumer494 Rights and Responsibilities” box and the Consumer Tip box on pages 495 and 496 suggest how to protect your health and avoid unnecessary expense. Some of the suggestions are simple to carry out, whereas others require diligent effort. insuranCe Fraud and aBuse Federal officials and insurance company executives believe that insurance fraud and abuse are widespread and very costly to America’s health-care system. Fraud involves billing for services that are not rendered. Abuse involves multiple services that are not medically necessary, such as a laboratory test performed on large numbers of patients when only a few should have it. Consumers can detect certain frauds by examining in- surance payment reports to see whether they accurately reflect the services rendered. The Consumer Tip Box tells how to spot a criminal scheme known as a “personal injury mill.” Financial Abuse Many insurance companies base their coverage on the physician’s “usual and customary fee.” Some physicians charge insured patients more than uninsured ones but represent to the insurance companies that the higher fee is the usual one, when in fact it is not. than physicians. Electronic medical record systems have the potential to make the delivery of health care safer, more effective, and more efficient.25 There is widespread concern that small organiza- tions will be unable to compete effectively with large ones because large ones can achieve economies of scale. It is also possible that mergers will reduce competition enough to ultimately raise prices.26 Employer Strategies Most health insurance is obtained through employers. As health-care costs have escalated, it has become in- creasingly difficult for businesses to absorb the expense while still remaining profitable. As a result, many have reduced health-care benefits, switched to managed-care plans, cut retiree benefits, or are requiring employees and retirees to pay part of the premium costs. About half of employers now self-insure (assuming the financial risk) but hire an insurance company or other third party to administer their program.27 Today the vast majority of those who obtain health services through an employer are in some form of managed care. Consumer Strategies Health-care costs and benefits can be defined both in terms of dollars and the presence or absence of disease. The National Health Council’s “Principles of Patients’

• Participants in minor accidents are advised that they may have been injured more seriously than they think.
• Participants are advised that their care won’t cost any- thing because insurance will pay for it.
• The diagnostic evaluation process is set up by a lawyer who refers to multiple practitioners.
• Multiple professional appointments take place at the same facility or on the same day. There is no real consultation in which one doctor advises another. The original physician is never seen again, and subsequent physical examinations are cursory.

√ Consumer Tip How to Spot a Personal Injury Mill28 Personal injury mills are conspiracies to provide unnecessary services in order to create large insurance claims. This en- ables providers to profit and attorneys who represent injured clients to get higher settlements (and therefore higher fees for cases taken on a contingency basis). Large mills can involve hundreds of participants and steal many millions of dollars, causing higher insurance premiums and higher taxes. In many cases, insurance claimants are advised that they can make money by doing what is recommended and that failure to participate could adversely affect their legal case. However, false reports of medical diagnoses or loss of functionality can cause trouble for patients who later seek employment, apply for insurance, or actually become disabled and apply for disability. Knowledgeable participants can be prosecuted for fraud. The scenarios that should arouse suspicion include:

• Many patients get the same treatment on a similar schedule.
• Multiple diagnostic tests are recommended with little or no explanation of the results.
• Patients are said to have suffered significant injury even though they have few or no symptoms.
• The treatment remains the same—with multiple modali- ties—whether or not the patient is feeling better.
• Practitioners are willing to forego the deductible or co- payment, and payment reports are coded and go to the attorney rather than the patient.

Chapter Twenty-Four Health-Care Financing 495 national HealtH council’s PrinciPles of Patients’ rigHts and resPonsibilities

• All patients have the right to know what provider incen- tives or restrictions might influence practice patterns. Patients also have the right to know the basis for pro- vider payments, any potential conflicts of interest that may exist, and any financial incentives and clinical rules (e.g., quality assurance procedures, treatment protocols or practice guidelines, and utilization review require- ments) which could affect provider practice patterns.
• All patients, to the extent capable, have the responsibil- ity to pursue a healthy lifestyle. Patients should pursue lifestyle factors known to promote positive health re- sults, such as proper diet and nutrition, adequate rest, and regular exercise. Simultaneously, they should avoid behaviors known to be detrimental to one’s health, such as smoking, excessive alcohol consumption, and drug abuse.
• All patients, to the extent capable, have the responsibil- ity to become knowledgeable about their health plans. Patients should read and become familiar with the terms, coverage provisions, rules, and restrictions of their health plans. They should not be hesitant to inquire with appropriate sources when additional information or clarification is needed about these matters.
• All patients, to the extent capable, have the responsi- bility to actively participate in decisions about their health care. Patients should seek, when recommended for their age group, an annual medical examination and be present at all other scheduled health-care appoint- ments. They should provide accurate information to caregivers regarding their medical and personal histories and current symptoms and conditions. They should ask questions of providers to determine the potential risks, benefits, and costs of treatment alternatives. Where appropriate, this should include information about the availability and accessibility of experimental treatments and clinical trials. Additionally, patients should also seek and read literature about their conditions and weigh all pertinent factors in making informed decisions about their care.
• All patients, to the extent capable, have the responsi- bility to cooperate fully on mutually accepted courses of treatment. Patients should cooperate fully with pro- viders in complying with mutually accepted treatment regimens and regularly reporting on treatment progress. If serious side effects, complications, or worsening of the condition occur, they should notify their provid- ers promptly. They should also inform providers of other medications and treatments they are pursuing simultaneously.

Endorsed by the National Health Council, March 22, 1995.

• All patients have the right to informed consent in treat- ment decisions, timely access to specialty care, and confidentiality protections. Patients should be treated courteously with dignity and respect. Before consenting to specific care choices, they should receive complete and easily understood information about their condition and treatment options. Patients should be entitled to: coverage for qualified second opinions; timely referral and access to needed specialty care and other services; confidentiality of their medical records and communica- tions with providers; and respect for their legal advanced directives or living wills.
• All patients have the right to concise and easily un- derstood information about their coverage. This infor- mation should include the range of covered benefits, required authorizations, and service restrictions or limi- tations (such as on the use of certain health care provid- ers, prescription drugs, and “experimental” treatments). Plans should also be encouraged to provide information assistance through patient ombudsmen knowledgeable about coverage provisions and processes.
• All patients have the right to know how coverage pay- ment decisions are made and how they can be fairly and openly appealed. Patients are entitled to informa- tion about how coverage decisions are made (how “medically necessary” treatment is determined) and how quality assurance is conducted. Patients and their caregivers should have access to an open, simple, and timely process to appeal negative coverage decisions on tests and treatments they believe are necessary.
• All patients have the right to complete and easily un- derstood information about the costs of their coverage and care. This information should include the premium costs for their benefits package, the amount of any pa- tient out-of-pocket cost obligations (e.g., deductibles, co-payments, and additional premiums), and any cata- strophic cost limits. Upon request, patients should be informed of the costs of services they’ve been rendered and treatment options proposed.
• All patients have the right to a reasonable choice of pro- viders and useful information about provider options. Patients are entitled to a reasonable choice of health-care providers and the ability to change providers if dissatis- fied with their care. Information should be available on provider credentials and facility accreditation reports, provider expertise relative to specific diseases and dis- orders, and the criteria used by provider networks to select and retain caregivers. The latter should include information about whether and how a patient can remain with a caregiver who leaves or is not part of a plan network.

Part Six Protection of the Consumer496

• Acquire a primary physician, preferably before you are ill. Chapter 5 will help you find one and to communicate efficiently. Don’t attempt to seek care from one specialist after another without a primary physician as a coordinator.
• Use the preventive measures described in Chapter 14. Do not smoke, eat sensibly, maintain optimum weight, exercise sufficiently, avoid excessive intake of alcohol, keep immunizations up-to-date, wear a safety belt in automobiles, and have a smoke detector and possibly a carbon monoxide detector in your home.
• Have periodic health examinations as recommended in Chapter 5.
• Find out in advance about fees and payment policies. If you have insurance, ask whether the doctor will accept assignment. If paying for particular services may be a problem, discuss it with your doctor or the doctor’s of- fice staff. Some fees are negotiable, and most doctors will permit payment in installments. If you expect costs to be a problem, indicating this may also encourage the doctor to increase consideration of costs when ordering services or prescribing medication. The Healthcare Blue Book (www.healthcarebluebook.com) can help you estimate out-of-pocket expenses.
• Use the telephone discriminately to obtain needed infor- mation about your concerns. However, do not expect this procedure always to be a substitute for an office visit. Re- member that provider time is valuable; have your thoughts well organized before telephoning.
• A local health department clinic may provide certain tests without cost and will inform your physician of the results. Keep in mind, however, that isolated tests are not a substitute for an overall diagnostic evaluation. The local health department may also provide immunizations and other health services without charge.
• Take advantage of outpatient services, including surgery, whenever possible, since these are much less costly than inpatient services.
• Visit your doctor during regular office hours except in emergencies. Avoid unnecessary use of hospital emer- gency rooms, which are far more costly than physicians’ offices or ambulatory care centers.
• Do not press to remain in a hospital longer than neces- sary. Avoid entering the hospital on a weekend if tests or procedures you need will not begin until Monday.
• Check your hospital bill carefully and dispute errors. If faced with a large bill that is not covered by insurance, it may be possible to negotiate a lower cost.29
• Become familiar with local health facilities and organiza- tions. (For example, the American Cancer Society and the American Lung Association have brochures and programs for people who want to stop smoking.) Know ahead of time what to do and whom to call in case of emergency.
• A dental school clinic may be able to provide dental ser- vices at lower cost.
• Mental health care may be less expensive through group therapy, self-help groups, or clinics.
• When elective surgery is recommended, seek a reasonable explanation of what it entails, why it is recommended, and what the risks are. Ask if a medical alternative is available and consider getting a second opinion (see Chapter 5). Your primary physician’s opinion may be as valuable as that of a second surgeon, or even more valuable.
• Appropriate home-care services, where available, are generally less expensive than hospital and nursing home care. Medicare, Medicaid, and insurance companies are often willing to pay for these services.
• Attempt to purchase prescription drugs by generic name rather than brand name. Compare prices in several phar- macies and follow the other suggestions presented in Chapter 17.
• Do not waste money on dietary supplements. Unless you have a specific concern that makes supplementation advisable, sensible eating can provide the nutrients you need (see Chapter 11). If you wish to take a multivitamin, tablets are available for 5¢ a day or less. Never ingest doses exceeding 100% of the Recommended Dietary Allow- ances (RDAs) or Daily Values (DVs) without competent medical advice.
• Read product labels and adhere to any instructions or warnings.
• Learn the names of all medications you use; take them as prescribed.
• Brush and floss your teeth at least once a day. Invest in periodic dental checkups at intervals recommended by your dentist. Support fluoridation of local drinking water, and use other types of fluoride supplementation if recom- mended by your dentist.
• Make sure you understand how to determine whether to self-treat and when to contact a physician if a health problem arises (see Chapter 14).
• Be cautious about health information unless you are sure that its source is trustworthy. Chapter 2 and the Appendix identify many useful sources.
• Purchase health insuran

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