Ok, no more teasing... Healthcare: The Real Reasons It Is Broken and How To Fix It

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Originally Posted by Cool Hand Clyde

Need a Cliff Notes version for sure.

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The cliff notes version is: Much higher quality primary care, with correct drivers/incentives for the providers, that is significantly more affordable.

Posts 5 and 6.


BTW, I posted the Cliff Notes version. I am looking at converting my hour long "summary" presentation into a book.

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Originally Posted by nadB

Is this strictly an outpatient wellness/referral/minor treatment (aches, pains, splinters and coughs) service ?? I must have missed it, so where is the info re major surgery, hospitalization, chemotherapy, etc. ?? You know, the Big Bucks items. Is that part of the plan ??

What about prescription drug costs ?? Who pays for that ??

I gather that the rates go up as the customer ages, but are preexisting conditions a factor ??

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1. Yes, but unlike your current traditional primary care practice, as it is wellness and preventive-care focused. Just like my auto insurance analogy, think of your car. Do you drive your car until it breaks down, or do you perform regular mainenance on it, like oil and other fluid replacement? Driving your car until it breaks down and then having it repaired is expensive, and then you will need a new car very soon. You get one shot with your body, and it is infinitely more complex than your car...and most of us do a terrible job of taking care of it. Think of us as similar to a financial planner for your business and finances, but as a partner in your health. This offers the same services you get from your current primary care provider, plus more, and your access is unlimited. Imagine seeing your primary care provider every week if you need to, for 30-60 minute, unhurried consultative visits.

2. We are not selling insurance through this business. We DO have an insurance agent that is a partner. We recommend purchasing a catastrophic major medical policy that can be expanded based on your actual risk...which can reduce your costs anywhere, depending on your current situation, between 20%-80%. Instead of your choices being: insurance or no insurance...and you get to choose your deductible, in our model we work with you to analyze your risk, help you purchase appropriately priced insurance coverage for your actual risk of utilization, and provide unlimited, high quality, consultative primary care outside of insurance...where it should be and where it USED TO BE.

3. I bought 2 prescription drugs for $8.26. My insurance prescription drug plan paid $0, because the amount was less than my $15 copay. The increased cost of my insurance premium, to have a prescription drug plan, was over $60 per month. A WASTE of money. Pay cash. Every moderate to large pharmacy has a $4 prescription drug plan. We give our patients access to over 300 for $3.50 and over 1000 for less than $25. BTW, you can get antibiotics for free at SuperOne in Ruston. Unless you are on 30 medications (you need to come and see us) or if you pay $500+ per month on meds, you don't need a drug plan. Pay cash...especially if we are saving you 20%-80% of your costs. If you do have large prescription expenses, you can increase your major medical plan coverage to include a prescription drug plan and still save tons and get access to higher quality. Most people don't realize that a prescription drug plan typically costs them significantly more than it saves...if it saves anything. Personally, mine didn't save me a dime, and instead cost me tons of money...I checked and did the math.

4. There are 4 age groups. The first is 0-49. If you are interested, I can send you our Patient Services Manual that contains our fee schedule. Our monthly rates are all below $100 a month.

5. Our model is not volume driven, nor is it acuity driven. This means you can be perfectly healthy or a trainwreck...there are NO pre-existing conditions. If you are a trainwreck, we want you here because, chances are, your doctor is throwing pills at your symptoms and not helping you get off those pills. I went to my primary care doctor 2 years ago and got put on lisinopril for high blood pressure. No discussion about what causes it, what caused it in me, my diet (horrible), my stress (high), my weight (100lbs overweight at the time), or how to reverse my condition and get off the pills. A year later, my blood pressure was uncontrolled again. The care plan: increase my dosage. Also did a HgA1c - which tests for diabetes. I was borderline pre-diabetic. The response..."this doesn't mean you are diabetic...just that you might become diabetic 10-15 years from now." End of discussion. No info on how to reverse that trend. Nothing about diet, exercise, etc. So next year, I would return and we would just up my dosage again, and continue until I develop coronary artery disease, go into heart failure, lose my feet because I am a severe diabetic, and die. That is not acceptable to me. Traditional medicine is reactive.

There is also no contract, so you can drop it at any time.

Hey thanks for the questions guys. Our healthcare system is completely screwed up. The model is broken, costs are high, and quality is low. It isn't our doctors' fault. It is the model they are forced to work within. And to "get" it, you have to completely forget what you know about healthcare and start over. When you do take a fresh look at it, and break it down, it becomes very simple, common sense. All you have to do is compare to a peer insurance industry. And the reality of what is really behind the current insurance model, and how "they" have brainwashed consumers and providers into accepting that "this is the only way it can work," really, really ticks me off. And I have enjoyed getting many other very smart business leaders very ticked off about it over the past 3 weeks. One of them told us that he "feels like a fool for wasting his money doing it the insurance way for so many years." This particular businessman/friend is a healthcare professional. He and his entire family signed up with us last week.

Appreciate you taking the time to post all of this. I won't waste anyone's time by rehashing the issues re: healthcare. I have always thought that such steps as tort reform, being able to buy health insurance (like we can for all other insurance) across state lines, and a true market environment of competition where doctors/hospitals publically posting pricing, would all lead to better and more affordable HC for all. I could even see promotional campaigns, like hey! have a gallbladder removed and get a tonsil out for free! Or, buy one knee surgery and get another at half-price!

I can't complain about our insurance issues, however.

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Originally Posted by dawg80

Appreciate you taking the time to post all of this. I won't waste anyone's time by rehashing the issues re: healthcare. I have always thought that such steps as tort reform, being able to buy health insurance (like we can for all other insurance) across state lines, and a true market environment of competition where doctors/hospitals publically posting pricing, would all lead to better and more affordable HC for all. I could even see promotional campaigns, like hey! have a gallbladder removed and get a tonsil out for free! Or, buy one knee surgery and get another at half-price!

I can't complain about our insurance issues, however.

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There is a reason why this can't happen...one that I can fully explain if you wish...but it is because of insurance payers.

We can and do, however, fully disclose 100% of our pricing to our patients...and can because we are operating a cash model. We have taken the $ going to the middle men (insurance companies) and 1)invest in services and time with patients and 2) pass a ton of it along to you as savings. This then puts the power back in the hands of you and your partnership with your healthcare provider, and not in the dictatorial relationship of your insurance company on your healthcare.

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Originally Posted by RhythmDawg

There is a reason why this can't happen...one that I can fully explain if you wish...but it is because of insurance payers.

We can and do, however, fully disclose 100% of our pricing to our patients...and can because we are operating a cash model. We have taken the $ going to the middle men (insurance companies) and 1)invest in services and time with patients and 2) pass a ton of it along to you as savings. This then puts the power back in the hands of you and your partnership with your healthcare provider, and not in the dictatorial relationship of your insurance company on your healthcare.

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Why would insurance PAYERS object to patients saving money on procedures?

Example: say, I was planning to have a procedure done at the local hospital/and surgeon. The posted price is $18,000. But, I see that I can get the same procedure 50 miles away in the next town for $13,000. My insurance company....well, in fact, I would think INS companies would maintain an on-line database of such pricing, and even offer to cover hotel stays if their customers agreed to travel somewhere. Like for me, they might say, we'll pay for a hotel and provide a stipend for meals, if you'll agree to travel to Dallas to have this done. Then it might be an extended stay of one night for recovery and/or an ambulance ride back home. Something like that.

Mind you, I am not poo-poohing your model. I am sincerely throwing out scenarios for the sake of discussion and a study of alternatives.

I believe in the power of a free market.

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Originally Posted by dawg80

Why would insurance PAYERS object to patients saving money on procedures?

Example: say, I was planning to have a procedure done at the local hospital/and surgeon. The posted price is $18,000. But, I see that I can get the same procedure 50 miles away in the next town for $13,000. My insurance company....well, in fact, I would think INS companies would maintain an on-line database of such pricing, and even offer to cover hotel stays if their customers agreed to travel somewhere. Like for me, they might say, we'll pay for a hotel and provide a stipend for meals, if you'll agree to travel to Dallas to have this done. Then it might be an extended stay of one night for recovery and/or an ambulance ride back home. Something like that.

Mind you, I am not poo-poohing your model. I am sincerely throwing out scenarios for the sake of discussion and a study of alternatives.

I believe in the power of a free market.

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Because insurance companies don't give a crap about how much a hospital or physician charges. All that matters is their negotiated, contractual fee schedule with that entity. Every contract, for every payer, for every provider, is potentially different and can be negotiated. BUT, a provider by law has to charge everyone the same thing. As a consultant, if I walk into a provider's facility, and see a charge that was paid at 100% by an insurance company, I immediately tell them their charge is too low. In order to capture 100% of what is collectible from every insurance contract, you have to inflate your charges. Typically, physician offices actually collect only about 60-65% of their charges.

If you don't have insurance, sucks to be you because they still have to charge you the inflated price. If you negotiate it, you can usually get an adjustment as a cash payer on the back end...but not always. Because contracts are individually negotiated, pricing cannot be standardized. PLUS, hospitals and clinics are funded differently, meaning some are fee-for-service, some are prospective payment, some are charity care, some are cost-based, etc., which affects Medicare, Medicaid, and charity care patients...which I could also write a book on, but won't...but it translates into: everyone's costs are different depending on how they are calculated. this leads to charges varying greatly, especially between urban and rural hospitals, for example.

This is how you end up with the $15 bandaid and the $20 piece of gauze.

Bottom line is, the healthcare market isn't driven by the prices...it's driven by the reimbursement rates in this insurance model we have all grown to love and cherish.

None of what you describe is the free market: "a provider by law has to charge everyone the same thing."

Anti-trust laws prevent companies in other industries from price-fixing. But, in HC, the opposite is true, the law requires providers to price-fix. So, again, create a true free market, with laws designed to punish those who collude in pricing for services, insurance, etc...

A co-worker screams, hey! my computer has crashed. I need a new computer! That'll be $2,000! Like other things (healthcare) always look for the simple answer first. Turned out to be a $100 battery back-up system that crashed. The expensive 'puter is just fine.

I'd like to try some simpler solutions to HC first. Ones that are cost-effective and don't completely overhaul the whole system. Of course, in my ideal world, there is plenty of room for new ideas, such as your model. That's what a true free market would encourage and enhance.

Some examples of my last post...

If you go to your doctor and he runs a CBC on you, he will charge your insurance company $25-$50. Your insurance, depending on which one you have, will reimburse him anywhere from, say, ~$4(UnitedHC) to ~$15(BCBS) to ~$40(OGB). It costs, literally, about $1.00 to run a CBC. Build in the reference lab's profit margin, and we at our business, for example, negotiate a $1.25 CBC. You, the patient, in our model get this CBC included in your services at no extra charge because we have removed the middle man.

Your doctor will charge your insurance company ~$100 to do an EKG on you. They will pay your doctor anywhere from about $25 - $70. The variable costs associate with doing an EKG, that stores images electronically and doesn't print on paper, is $0 (not taking into account 5 seconds of electricity). In our model, we can do an EKG on you EVERY DAY and it costs you, the patient, nothing.


In the insurance model, in a tradition provider practice, you will pay a co-pay associated with that lab test or EKG, and then get a bill for the balance that either 1) goes toward your deductible or 2) is the remaining patient balance after your insurance forced an adjustment on your physician, paid a percentage according to their contract, and assigned a remaining patient balance for the physician to collect from you. It is up to the doctor on if, how and when to collect the balance.

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Originally Posted by dawg80

None of what you describe is the free market: "a provider by law has to charge everyone the same thing."

Anti-trust laws prevent companies in other industries from price-fixing. But, in HC, the opposite is true, the law requires providers to price-fix. So, again, create a true free market, with laws designed to punish those who collude in pricing for services, insurance, etc...

A co-worker screams, hey! my computer has crashed. I need a new computer! That'll be $2,000! Like other things (healthcare) always look for the simple answer first. Turned out to be a $100 battery back-up system that crashed. The expensive 'puter is just fine.

I'd like to try some simpler solutions to HC first. Ones that are cost-effective and don't completely overhaul the whole system. Of course, in my ideal world, there is plenty of room for new ideas, such as your model. That's what a true free market would encourage and enhance.

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I agree. But I'm telling you, it can't happen in the current model without the industry collapsing. The fix requires a change in the clinical and financial model.

There are a lot of very smart people in healthcare, that fully understand how healthcare works, and are trying to make changes, and it ain't working because the system is broken. those of us in the industry have a hard time understanding why decision makers can't see what to us is completely common sense. Politics. Votes.

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Originally Posted by RhythmDawg

I agree. But I'm telling you, it can't happen in the current model without the industry collapsing. The fix requires a change in the clinical and financial model.

There are a lot of very smart people in healthcare, that fully understand how healthcare works, and are trying to make changes, and it ain't working because the system is broken.

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By "industry" do you mean the insurance industry, the healthcare provider industry (doctors et al), or both? What's gonna collapse?

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Originally Posted by dawg80

By "industry" do you mean the insurance industry, the healthcare provider industry (doctors et al), or both? What's gonna collapse?

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Industry meaning licensed healthcare providers and healthcare business experts/leaders/business owners.

The healthcare industry will collapse, likely through one or more of the following: a collapse of the health insurance industry because of costs, leading to the consolidation of insurance companies (which has already started), drastic cuts to Medicare and Medicaid (which has already started), all leading to decreasing access from hospital closures and physician shortages (which has already started). The current industry is unsustainable, for some of the same reasons our national spending is unsustainable and why we saw a housing crisis.

From your work do you find this latest to be true? I really haven't look at it in great detail enough to know this one.

Obamacare: Families Pay $3k More for Insurance; Pres. Promised $2.5k Decrease


Joel B. Pollak

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Originally Posted by TYLERTECHSAS

From your work do you find this latest to be true? I really haven't look at it in great detail enough to know this one.

Obamacare: Families Pay $3k More for Insurance; Pres. Promised $2.5k Decrease


Joel B. Pollak

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Yes, businesses are seeing 10%-30% premium increases.

http://facts.kff.org/upload/jpg/larg...%20Exhibit.jpg

http://www.kff.org/insurance/ehbs091112nr.cfm

The day that the Supreme Court ruled on the individual mandate, Blue Cross sent out a letter stating 1) this is what the decision was, 2) this is what it means, and 3) this also means your premiums will increase.

Our partner that is an insurance agent daily tells us of communication he has with and of the insurance industry, and the entire business is a nightmare right now. I have heard things from him that are coming down the pike that will absolutely freak all of you out if they are implemented.


BTW, the chart above is for individual polices, not group policies. Group policy premiums are much more expensive.

Thanks!