Such a Deal

Like it or not, health care is changing--and not always for the better.

Since 1980, health care costs have tripled. Coverage is scantier: More and more insurance companies are denying coverage of procedures they deem unnecessary.

And insurance options are shrinking: More and more companies offer coverage only through health maintenance organizations (HMOs), whose members frequently aren’t covered for mental health, vision care and prescription drugs.

Only the savviest medical consumer will get the most from this changing system.

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Here are 11 ways to get more of what you want: better health coverage at a lower price.

1. Make Sure You Need a Doctor

If you get sick or have some strange symptom, consult a book before you consult an M.D.

A good self-care book can help you decide whether you really need a doctor, and if you don’t, give you basic steps to take care of your problem. After consulting a reliable book (ask your doctor, librarian or bookseller for titles), if you’re still not sure what to do, call your doctor and ask if an office visit seems appropriate.

2. Negotiate With Your Doctor

The idea may seem daunting, but there are a few easy ways to get into the habit:

* Find out what your insurance company pays. Many insurers reimburse you based on “reasonable and customary” fees for a doctor’s services. If your insurance company will reimburse $500 for a procedure but your doctor charges $700, ask if he’ll accept the lower amount. Or you may be able to arrange an interest-free payment plan on the amount not covered.

* Find out what other doctors charge.

* Work out fees for regular treatment. If you require allergy shots, for example, try to negotiate a deal to pay only for the injection, not the price of an office visit.

* Try to get flat rates. Negotiate a single price to have several moles removed, rather than the typical per-mole rate. Ask about having stitches removed at no extra charge.

3. Question Diagnostic Tests, Especially Routine Ones

In traditional fee-for-service medicine, the more tests, office visits and special examinations a doctor performs, the more insurance companies pay the doctor. While you shouldn’t assume your doctor is out to gouge you, it’s reasonable to ask whether every test is necessary, especially tests performed as part of an annual physical. The information provided by chest X-rays, for instance, and blood chemistry panels (which include tests for blood sugar, sodium potassium and calcium) is often of little use when the patient is healthy.

Consumers who are in managed-care plans have the opposite problem. HMO doctors are often paid a flat fee per month for each patient, meaning that they make more money if they order fewer tests, schedule fewer visits and arrange for fewer procedures. In fact, some HMOs withhold 10% to 30% of a doctor’s compensation until year’s end, paying it only if the doctor has met targets for limiting tests, referrals and hospitalizations. In this case it pays to be assertive.

4. Request Itemized Bills

Whether it’s an office visit, outpatient surgery or a hospital stay, ask for an itemized bill. Accounting errors and questionable charges are far more common than you might think.

To protect yourself, ask your doctor for the names and billing codes of the procedures you’ll be receiving, so you can compare them with your itemized hospital bill. Ask the hospital’s billing department for room rates and hourly charges for operating and recovery rooms. During your stay, ask for a daily bill so you or a relative can keep track of what’s been ordered. When you get your final bill, compare it with your notes. If you find an inconsistency, ask the hospital for an explanation.

5. Don’t Go to an Emergency Room Without Calling Your Doctor First

An emergency room visit costs about three to five times more than an office visit--which is fine if it’s necessary but a waste of money if your doctor could have seen you right away at her office. If you do need hospital treatment, your doctor may be able to meet you in the emergency room. That way, you won’t have to go through the triage and long waits that most walk-in patients endure.

HMOs won’t pay for “unnecessary” emergency room visits, so it’s worth your while to know the rules before the unforeseen arises. Call your HMO before you head for the hospital--you may get some medical advice that will help. If you can’t get through, leave a message that you will have the hospital contact the HMO when you arrive.

What warrants a trip to the emergency room? The American College of Emergency Physicians recommends prompt medical attention if you have any of the following symptoms:

* difficulty breathing, shortness of breath;

* chest or upper abdominal pain or pressure;

* sudden dizziness, fainting, weakness or change in vision;

* sudden, severe pain anywhere in the body;

* bleeding that can’t be stopped;

* severe or persistent vomiting;

* coughing up or vomiting blood;

* suspected poisoning or drug overdose;

* significant or severe crushing injuries;

* high fever (for adults, over 103 degrees Fahrenheit).

Your insurance company may have a slightly different definition of a true medical emergency, but most insurers will pay if you meet one of these conditions.

6. Be Smart About Prescriptions

You can’t postpone taking medications you need, but you can reduce the cost involved.

* When your doctor writes a prescription, ask if it can be filled generically. Many doctors check the DAW (dispense as written) box out of habit but have no real objection to a generic version of the drug.

* Comparison shop. Drug prices vary from store to store. Remember that you pay for convenience in filling prescriptions--hospital pharmacies or those adjacent to doctors’ offices usually command premium prices.

* Fill your prescription part way. You can’t return unused medications, so if you have a history of reacting badly to drugs or to a certain class of medications, ask the pharmacist to partially fill your prescription. After three or four days, you should be able to gauge your tolerance to the drug. You can then have the rest of the prescription filled or ask your doctor about switching to a different compound.

* Ask your doctor for free samples. Drug companies give doctors samples as a way to promote new products.

* Use mail-order services. If you have an ongoing need for a prescription (such as birth control pills, insulin for diabetes or medication for any chronic problem), look into ordering by mail.

7. Ask for Outpatient Surgery

The cost of outpatient surgery is generally 25% to 50% less than inpatient--with identical safety and effectiveness. If your surgery does require hospitalization, there are still ways to cut your bills. Don’t check in on a Friday because most nonemergency tests and procedures are done Monday through Friday mornings, so you’ll just be waiting--and paying. Preoperative tests (X-rays, blood work, urinalysis, electrocardiogram) will be cheaper if done before you check in because you won’t be paying for the hospital’s overhead.

8. Keep on Top of Your Insurance

Be strategic. Once you’ve met your annual deductible, schedule a routine exam before the end of the year. That way, you won’t have to apply its full cost to the next year’s deductible.

9. Use Your Insurance Company as a Resource

Many insurers offer an information line staffed by nurses or other health professionals to help you in a number of areas, including understanding the risks, benefits and alternatives to medical treatment for major health problems--free of charge.

10. Get a Second Opinion

Many insurance companies now encourage or require (and pay for) a second opinion before you undergo surgery. Take advantage. Even if you foot the bill yourself, the cost of an extra office visit is outweighed by avoiding the possibility of unnecessary surgery. Don’t feel that seeking a second opinion is disloyal; good doctors expect it.

11. Don’t Waste Your Time Waiting

The American Medical Assn. estimates that the average obstetrics or gynecologic patient waits 15.4 minutes to be seen by a doctor. Many of us spend much longer.

To avoid wasted time, get the first morning appointment or the first one after lunch; unless there’s an emergency, you won’t be kept waiting. Monday and Friday are the busiest days in a doctor’s office. Before you leave for your appointment, call ahead to ask if the doctor is on schedule and plan accordingly.