Health Insurers Are Ignoring Big Cost Savings

by Cindy Moy Carr

The US healthcare system was built to treat disease rather than develop and support a healthy population.

It’s often referred to as a sickcare system rather than a healthcare system.

The pandemic is forcing this entrenched way of doing business to look for new cost-effective avenues to deliver services to patients.

Unconscious Bias Impacts the Bottom Line

There are disruptions possible that could save millions of dollars, if only the big stakeholders in the healthcare system, such as health insurers, cared to set aside a few preconceived notions and address unconscious bias.

My own healthcare costs are a good example, and mirror those of many of my friends.

In 2016, my insurer paid more than seven-thousand dollars (equal to $8,131 in 2021 if adjusted for inflation) for treatment of an ongoing condition.

In 2021, my insurer paid $395.

That’s a significant cost savings.

What changed? The way I managed my condition.

What’s ridiculous is that I had to launch a tech startup to develop the product I needed to manage it because the product didn’t exist yet, despite HALF THE POPULATION sharing the same issue.

But I’ll get back to that…

The Science Experiment

The costs go back even further, before I knew I had a condition, when instead I felt like a science experiment.

Soon after I turned forty I had my first migraine, a blinding pain that sent me into a cold dark room for two days.

When I had a second migraine a few weeks later I went to the doctor who said, “What, you think you have a brain tumor or something?”

I didn’t when I walked in, thank you very much. I did when I walked out.

After the fourth migraine I was sent to a neurologist who ordered an MRI.

No brain tumor.

He said it was probably hormones and suggested I ask my mother and aunts if they experienced migraines at my age. See Ask Your Mum: Genetics and the Onset of Menopause

As a person who was adopted as an infant and who has no medical information about my biological family, this was not a possibility.

The Hypochondriac

Thereafter followed doctor visits and treatment for vertigo, dry eyes, anxiety and depression. See Perimenopause and Dry Eyes, Oh My!

I didn’t bother telling the doctor when I could no longer bear the taste of tomatoes or red wine. It seemed so outlandish.

Several doctors suggested the strange symptoms I mentioned were psychosomatic–that I was jealous of

  • the attention I was giving to my young children,
  • my spouse who survived cancer in his 20s and a heart attack at 48,
  • my aging father who was in and out of the hospital for hip surgeries, and
  • my mother who slipped further into dementia every day for seven years before her death.

So I went to a therapist–covered by my health insurance (which was paid for by my husband’s employer) and said I needed to stop being a hypochondriac.

I just didn’t have the time.

“What if all these things you’re experiencing are real?” she asked.

Impossible. All the doctors said so.

I found another therapist who asked the same question.

I quit therapy.

Then things got worse.

Housebound

At one point I was nearly housebound for months with repeated urinary tract infections (UTIs), many requiring trips to Urgent Care or the emergency room. (My co-pay was forty-dollars. The rest was covered by insurance.)

Many days a life lived in constant pain didn’t seem doable.

What was the point of living if it was too painful even to sit in a chair?

A chance encounter with a nurse practitioner changed everything.

“You need to see an ob/gyn,” she said. “This is menopause-related.”

Oh. OH.

The neurologist’s words came back to me. “It’s probably hormones.”

Five Doctors and 18 Months

It took three ob/gyns, two urologists and EIGHTEEN MONTHS of doctor appointments, tests and trial-and-error medications before my life was back on track.

It was a VERY expensive year for my health insurer.

A Normal Life

I now see a nurse practioner who is menopause specialist once a year.

I track my now-manageable symptoms on mySysters, the app for perimenopause and menopause that my startup developed in 2016.

My insurer covers the office visit, lab visits to check hormone levels, and part of the prescription costs for menopause hormone therapy.

That comes to $395.

My out-of-pocket costs are about $500.

My symptoms were extreme.

Only twenty-percent of women will experience significant menopause symptoms.

However, there are 31 million menopausal women in the US workforce right now.

Seventy-five percent of them will experience SOME symptoms.

Information BEFORE Crisis

Most will be able to manage those symptoms with lifestyle changes.

The key to managing symptoms with lifestyle changes, though, is to understand what’s happening to one’s body and what to do about it, preferably BEFORE we’re in crisis.

WIthout basic reliable information, we can’t act.

I’m an attorney and journalist. I’ve written a book on healthcare law (among others.) I have access to some of the best healthcare resources in the world.

Yet I was completely uninformed about perimenopause and menopause.

When I talked to my friends about menopause, they acted as though they’d never heard the word.

We were all in our late 40s or early 50s by then.

The stigma around menopause is still firmly entrenched in the US, which is unfortunate.

By 2025, there will be over one billion women worldwide experiencing menopause. That’s twelve-percent (12%) of the world’s population. By 2030 it will be a quarter of the world’s population.

Health Insurer Could Have Avoided Costs

Here’s the irony: After the neurologist told me it was probably hormones, I asked my health insurer to approve an endocrinologist visit. It refused.

I understand the reasoning–by the time the significant costs came along my insurer believed I would be another insurer’s problem. But I wasn’t.

I was still covered by the same health insurer, and the health insurance premiums were still paid by the same employer.

The practice of delaying coverage and hoping to pass the costs on to the next insurer is, of course, counterproductive to all insurers.

When one employee leaves another arrives–possibly from a company using the same insurer–with one or more potential health issues.

Eventually the bill comes due.

High Costs of Being Reactive

My case is not an anomaly. See The High Cost of Perimenopause

Yale’s School of Medicine conducted a study in 2014 on the high costs associated with women with untreated hot flashes.

The lack of treatment showed the demands placed on healthcare and how it drives up insurance costs.

Using data from 500,000 women, half with and half without hot flashes, the study found that over a 12-month period the women with hot flashes had 1.5 million more healthcare visits at an additional cost of $340 million dollars.

Further, during that same period the cost of work lost was another $27.7 million dollars.

Women in the VMS group had $1346 higher all-cause annual direct costs ($1,641 in 2021 adjusted for inflation) and $423 higher annual VMS-specific direct costs than the non-VMS group ($515 in 2021 adjusted for inflation).

Benefits of Being Proactive

Why should health insurers take a leading role in providing menopause education and tools?

Health insurers that have the most influence on employer decisions and behaviors that impact employee wellbeing.

The US lags other nations in seeking ways to keep women ages 40-65 in the workforce–a short-sighted gamble in light of the current labor market.

Women in this age group account for eleven percent of the workforce in the Group of Seven most-industrialized nations.

The UK set up an all-party parliamentary group to overhaul “menopause rights, entitlements and education” after it discovered nearly a million women had left the workforce due to issues surrounding menopause.

Several large companies in India, where maternity leave is only a decade old, are also taking steps to retain its female workforce by offering education and medical awareness around menopause for both men and women, medical coverage, leave policies, sensitization of managers, and workplace flexibility.

The Ripple Effect

Health insurers also have the ability to offer consumers integrated healthcare options that focus on skills for improving health, rather than disease management.

Half the counties in the US lack a single ob/gyn.

For those of us with access to ob/gyns, we don’t know to mention at annual checkups that we’re suddenly having migraines or joint pain or tinnitus or a metallic taste when we eat certain foods, such as tomatoes.

Frankly, even if we did mention it, fewer than twenty-percent of ob/gyns receive any menopause training in medical school, so it probably wouldn’t do any good if we did.

Most importantly, it’s health insurers who benefit financially from a consumer base empowered to take care of their own health and wellbeing.

According to the U.S. Department of Labor, women make 80 percent of health care decisions in the United States.

Primary care teams know conversations with women about preventive topics have a significant impact on the health of the entire family.

When I was well I was meal planning, cooking from scratch and taking the kids on hikes.

When my symptoms were unmanageable the kids were eating frozen waffles and watching cartoons and my mother was making signs telling the cats to wipe their feet before coming into the house. (There were no cats in the house.)

Women in midlife are caring for children, spouses, aging parents and at times even siblings, friends and coworkers.

Our wellbeing has a ripple effect on those around us.

When we’re healthier, everyone us around is healthier.

If health insurers include perimenopause and menopause in their coverage, they’ll see a healthier bottom line as well.

mySysters is a free mobile platform that provides a way for women to track changes in their bodies over time so they can make lifestyle changes and/or better advocate for themselves. Good Housekeeping named mySysters the Best App for Women in Perimenopause and a Must Have App for Women.