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Are CoPayments Really Necessary?

Updated on June 13, 2011

I have a pretty good PPO insurance plan through my employer. It covers just about anything I need it to cover, with modest co-pay for doctor visits and a double copayment if I have to see a specialist.

I am at the cusp of becoming somewhat debilitated in my older years. I am 54 years old, and I have already been told that I need a knee replacement, and lately because of an injury that I sustained at work, I may need a complete wrist reconstruction. I have been spending a lot of money in copayments recently at my doctor’s office visits (I have more than one doctor). These copayments range from $20 per visit for my primary care physician to $40 per visit for a specialist. I have a $150 copayment if I have an emergency. Sometimes I see two specialists a week.

But what is the copayment for? Is it to offset the office expenses of having a clerk pull your file and make a new appointment? Does the money go into the doctor’s petty cash fund, or used for office payroll? If a specialist’s office (which usually houses more than one doctor) has 100 patients a day, that is $4,000.00 a day taken in through the appointment window, not to mention what the insurance companies pay.

After doing some research, I have learned that the copayment is a payment that is paid by the insured person each time a medical service is assessed (DUH!). Technically, it is a type of “coinsurance”, but it does not usually contribute towards any policy out-of-pocket maximums whereas coinsurance payments do. From what I learned, the copay is quite often a small portion of the actual cost of the medical service, and it is meant to prevent people from seeking medical care that may not be necessary. The idea is that with no copay, people will abuse the insurance coverage more than they would if they had to make a payment each time a medical service is rendered.

But by the same token, copayments can also discourage people from seeking necessary medical care. Unusually high copays can cause people to not seek medical care at all simply because they can’t afford it, rendering someone “uninsured” who in actuality has a good insurance policy. There has to be a happy medium. Policies need a high enough copay so that people will be dissuaded from abusing the system, while maintaining a low enough one to keep the insurance from becoming useless.

Because of my injury, I have missed a lot of work. Worker’s Comp is still fighting it, and I have lost about a month’s wages in the last 45 days. My doctor, a specialist, is billing the co-pays to me in an effort to help me get the treatment I need. But now I have been sent to another specialist, one that is going to determine the extent of my wrist reconstruction. He won’t even say “hello” to me until I pay the $40.

So I wonder to myself, “What about the Hippocratic Oath”?

So I read it. It says nothing about money.

I remember a time several years ago in the Midwest when I needed medical care for my young son. I could not afford to take him to the doctor, so the doctor worked out a deal with me. All I had to do was clear the snow away from his office parking lot, and shovel his personal walk and driveway at his house. It took me all day to do this by hand, and I felt personally rewarded by the experience. The doctor was pleased as well, and had our family over to his home for dinner.

I guess that even though we all have our illnesses, medicine is still big business. Even with the veterinarians. If we have an illness, just like we have hunger, we can’t achieve a remedy at either the doctor’s office or the grocery store until we pay for it in cash.

Such is life.

Copyright 2011 by Del Banks



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