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

Over the past several months, I have referenced the real cause of why our healthcare system is broken, and an alternative model that "fixes" it. We can discuss all of the hot-button political talking points all day long, such as malpractice, tort reform, pharmaceutical companies, medical device manufacturers, etc., but they are all symptoms of a much greater problem...a broken foundational model.

I have also hinted that a new business employing this alternative model was about to launch in Ruston, with intent to expand rapidly. That business is, as of last week, operational and seeing patients. We have hosted 5 presentations for local business owners and leaders to solicit feedback on the model, and we have successfully blown them away with it. We are signing up people left and right, and are now really starting to create a buzz.

In the following posts, I am going to...as promised...provide a very summarized conceptual model explaining the root cause of the problems in healthcare and the model that healthcare should employ. It will include a very simplified explanation of why your healthcare is "backwards," and we have angered several very smart people by helping them realize that we have all been fooled.

The information I am posting below constitutes about 20% of what we actually present. Therefore, it likely will prompt you to ask multiple questions. If you arrive at this point and find yourself intrigued and wanting to know more...including having all of your questions answered...please let me know and I will answer them.

If you are a reader, I am considering expanding what we have into a book. We also are hosting weekly presentations. Our team is available to meet with anyone one-on-one. A few of us have also agreed to sit in on a healthcare panel discussion hosted by the local Tea Party group coming up the second week in October at the Ruston Country Club if anyone is interested in attending that. Of course that panel discussion will include healthcare and politics in general, and not just a discussion on what you read below.

I hope that you enjoy reading just a taste of what I can spend weeks discussing, and will be happy to engage in if anyone is interested to know more. I also welcome feedback.

Disclaimer/Disclosure: What I am about to present is very politically charged, but not politically biased. I personally don't believe that either party can fix healthcare. I lean to the right, but when it comes to my career, I use my knowledge, expertise, and common sense, and not political bias. If Obamacare...which does have many good things in it...were the answer, I'd tell you. But its not, and the GOP isn't close either.

<sup>References for Information to Follow:

1</sup>Kaiser Family Foundation. Employer Health Benefits Annual Survey 2010. http://ehbs.kff.org/pdf/2010/8085.pdf

² American Health Insurance Plans Center for Policy and Research, Individual Health Insurance 2006-2007 and 2009: A Comprehensive Survey of Premiums, Availability, and Benefits. (Washington, DC: American Health Insurance Plans, 2007, 2009) http://www.ahipresearch.org/pdfs/Individual_Market_Survey_December_2007.pdf, www.ahipresearch.org/.../2009IndividualMarketSurveyFinalReport.pdf
³ Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2001-2006.
⁴The United States Census Bureau, "Income, Poverty and Health Insurance Coverage in the United States: 2009" http://www.census.gov/newsroom/releases/archives/income_wealth/cb10-144.html
⁵ Kaiser Family Foundation. The Uninsured: A Primer, Key Facts about Americans without Health Insurance. (Menlo Park, CA: Kaiser Family Foundation, December 2010). www.kff.org/uninsured/upload/7451-06.pdf
⁶ The Kaiser Commission on Medicaid and the Uninsured. Snapshots from the Kitchen Table: Family Budgets and Health Care. http://www.kff.org/uninsured/7849.cfm.
⁷ Centers for Disease Control. Personal Health care expenditures, by source of funds and type of expenditure: United States, selected years1960-2009. http://www.cdc.gov/nchs/hus/healthexpenditures.htm

⁸Health Services Research, 2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2254573/

Healthcare Crisis: A Broken System in Need of True Reform

Today’s healthcare industry is in crisis. Access to quality healthcare is diminishing, billions of dollars are being wasted, and millions of people are going without care. These problems are being complicated by the majority of medical students choosing to specialize rather than go into primary care. Healthcare reform legislation is taking steps to address some of these problems, but significant progress remains nonexistent.

What is the cause? Health insurance - a product originally created to cover unplanned serious illnesses and crises – has grown to manage our routine, everyday health needs.
Insurance remains a critical element in the healthcare of Americans - for expensive, unusual, unpredictable events. When health insurance is used as a payment system for everyday healthcare, significant problems arise. When insurance infrastructure is used to administrate the high utilization and low cost of primary care, it actually makes primary care more expensive and less effective.

Americans are paying more, but getting less for health insurance:

· The costs of employer-based health insurance premiums have risen 114% since 2000.¹
· Americans are paying higher deductibles. The average family deductible increased from $1,034 in 2006 to $1,518 in 2010.¹
· American families aren't only paying higher deductibles, but higher copayments as well. In 2004, only one in five people with health insurance through an employer had a copayment of more than $25. In 2008, that number was one in three. In 2009, it was nearly one in two.²
· A middle-income family with individual coverage spends an average 22% of household income on health care while a similar middle-income family with employer based coverage spends about 8% of their income on health care costs.³

Millions of Americans are going uninsured or underinsured because of escalating health care costs, decreased access to health care and gaps in quality of care.

· 86.7 million Americans were uninsured at some point during 2007 and 2008.⁴
· Working families make up 80% of the uninsured.⁵
· Insured Americans are going without needed medical care due to expensive copayments and deductibles.⁶

Primary Care Defined

According to the American Academy of Primary Care, primary care is defined as:

“Care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of healthcare settings. Primary care provides patient advocacy in the healthcare system to accomplish cost-effective care by coordination of healthcare services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in healthcare.”

Take a moment and examine the primary care services you receive. Does the above definition describe what your primary care looks like?



1. Diagnosis and treatment of acute and chronic illness? Check. We all currently get this through our healthcare providers.
2. Health promotion? Does your doctor promote good health to you?
3. Disease prevention? Does your doctor discuss with you and implement methods to prevent disease?
4. Health maintenance? Does your doctor work with you to maintain good health?
5. Counseling? Do you receive counseling from your doctor?
6. Patient Education? Do you receive education during your visit about your body chemistry, physiology, health status, medications, testing, results, or treatment plans?

Do you have the “how” and “why” questions answered, or does the nurse simply pat you on the shoulder and tell you your tests were normal?

Do you believe your healthcare is cost-effective?

· The average person visits their primary care provider 3 times per year, and consumes no other healthcare services.⁷
· The average primary care visit lasts 15.7 minutes.⁷
· The average annual insurance premium is $6,797 per person.⁷

When calculating the average premium cost in proportion to the average consumption, the ratio is:

$2,265.67 per 15.7 minute visit…or $8,658.62 per hour.

Is your healthcare a partnership?

Are you knowledgeable enough to engage as a partner in your healthcare, or do you simply trust whatever your doctor says? Most people blindly trust their doctor. Do you take this approach with your finances, your business, or any other area of your life?

What role does your insurance play in your relationship with your physician? Insurance companies dictate the delivery of care, as well as payment for services rendered.

According to a study by Health Services Research⁸:

· Median visit length = 15.7 minutes
· Median of six topics
· About 5 minutes spent on the longest topic.
· Remaining topics each received 1.1 minutes.

The study conclusion:

Many topics compete for visit time, resulting in small amounts of time being spent on each topic. A highly regimented schedule might interfere with having sufficient time for patients with complex or multiple problems. Efforts to improve the quality of care need to recognize the time pressure on, patients and physicians, the effects of financial incentives, and the time costs of improving patient–physician interactions.⁸

A typical primary care visit:

1. Patient presents with a Chief Complaint
2. Testing may or may not be performed
3. Diagnosis is made
4. Symptoms are treated.
5. Visit ends.

Does your physician perform everything referenced above, or does your physician simply manage and control your symptoms? If you are obese and have high blood pressure, does your physician work with you in a way to resolve your condition, or does your physician simply prescribe medication to control your blood pressure…until it becomes uncontrolled and your physician decides to increase your dosage?

This is a very REACTIVE approach to medicine…and it is failing.

A Clinical Model That is Backwards

There are two drivers in healthcare, and only two: Volume and Acuity


The more volume, the more money a physician makes. The greater the complexity, the more money a physician makes. These drivers cannot work in tandem, as you cannot have volume and complexity at the same time. Therefore, one must win out. In the realm of primary care, the money is in the volume. If volume is the primary driver, then quality suffers.

That then raises an interesting question…


If you have a condition that requires you to visit your physician once a month for a year, and then you are cured of that condition and resume your average consumption of three visits per year, your physician will take a big pay cut.


If physicians need volume to sustain their practice, are physicians incentivized in our current healthcare model to keep us sick?


Example: When you phone your physician’s office for a refill on your prescription, does your physician require you to schedule an appointment to see him? Many do, so that they may bill for a visit.


Our Healthcare Industry is Unsustainable

Healthcare in this country is plagued by the following factual trends:


· Consumer premiums are increasing
· Costs for insurance companies to operate are increasing
· Complexity of the process is increasing for all players
· Industry sustainability is decreasing
· The Patient/Provider relationship is deteriorating
· Access is decreasing


Regardless of your political affiliation, unbiased healthcare experts and industry leaders all agree that “Healthcare Reform” will make all of these symptoms much worse.

A Model That Works

There is a model that has been in place in the US for over ten years, but only in very remote corners of the country, and on very small scales. There is a provision in the Affordable Care Act allowing this model to become eligible for state and federal healthcare exchanges. In fact, the Centers for Medicare and Medicaid are exploring this model…courtesy of the $4.2billion allocated under the Affordable Care Act for a Healthcare Innovation Committee…and have already begun a pilot study. Over the next 2-10 years, this model will grow rapidly across the country.


The Driver: Quality


In this model, success is measured through customer retention, not through volume of patient visits.


The Method: Provide patients high quality through investment of time, with a wellness and preventive care approach to traditional medicine, in a proactive clinical model.


The Incentive: Deliver high quality to get you healthy, keep you healthy, and keep you productive…at home, at work, and at school…and out of the doctor’s office. Not only will we treat diseases, we will also attack the causes of diseases and educate and empower you to attack them also. We want you so healthy and disease resistant that you don’t need to come and see us, unlike traditional primary care practices that simply try to control your symptoms.

Higher Quality For Less Than Half the Cost?

The Health Insurance industry does not function like insurance in primary care. Rather, it becomes a service-delivery/payment-for-service mediator. Let’s examine a peer industry…


It is very likely that you have auto insurance. Why?


Answer: To cover your RISK of large, unexpected out-of-pocket expense resulting from a collision. On average, we pay $65 per month/per car for auto insurance. Your risk of filing an auto insurance claim this year is 2.1%.



Do you file an auto insurance claim to replace a tire or rebuild your transmission?


Do you file an auto insurance claim to change your oil or fill up with gasoline?


Answer: Of course not, and to imagine doing so seems ridiculous.

Attachment 9789

Can you imagine the complexity of your life and the inflated costs of auto insurance if this were the case?


Attachment 9790

This model, one in which insurance administration encompasses the entirety of service utilization, is exactly what occurs in healthcare today:

Attachment 9791

Why Does Healthcare Cost So Much?

Answer: 1) The costs of administrating high utilization of low cost services in primary care inflates the costs of insurance companies to operate. This would be the same as filing auto insurance claims for changing your oil…

…combined with…

…2) the high costs of major medical services typically utilized at the end of life spread across an all-inclusive risk pool of consumers. The high shift in utilization from primary care to major medical and specialty services is partly caused by the poor quality of primary care services.


Attachment 9792

Imagine your healthcare utilization and proportional costs as being similar to the auto industry:

Attachment 9793

As you age, or if you develop chronic conditions such as diabetes, you may need to increase the amount of insurance coverage that you purchase. However, as long as basic services are not included under insurance administration, the cost savings can be significant.

Forty cents of every one dollar spent in healthcare is spent on the insurance administration process. This does not include costs associated with fraud, abuse, or errors. The total amount is actually closer to sixty cents per dollar.

That is 60+% of healthcare costs that can be converted into savings for you and your provider.

We can take that 60+% and pass much of it along to you in savings, and use the rest to provide you with much higher quality care that includes:

· Unlimited access for one low, monthly payment
· 30-60 minute office visits
· Appointments with unhurried providers who are focused completely on your health and wellbeing
· Phone appointments and e-visits
· Healthcare support in person, by phone, or by email
· Disease prevention and wellness education
· Same or next-day appointments

· Chronic disease management
· Specialist care coordination
· Hospital care coordination
· Ancillary Services
· Office Procedures

...and much more.

Consider your patient experience now:

1) You know you will pay a co-pay at the time of visit. The amount is usually printed on your insurance card.
2) Do you know what your exam charge will be? No.
3) You know your insurance will pay something. Do you know how much? No.
4) You know you have a deductible. Do you know what your deductible is? Many people don't. Do you know if you've met it? Do you ever meet it? Do you know how much for today's visit will be applied to it???
5) Do you know what co-insurance is? Most people don't, and millions of people have it.
6) You know you will get a bill. Do you know how much it will be for before you get it? No.
7) Do you know if the bill is actually correct? No.
8) You will get an Explanation of Benefits from your insurance company. Can you read and understand it? For most people...No.
9) Do you know if your insurance company paid correctly? No. They pay correctly, on average, 20% of the time.

A flow model of your visit looks similar to this:

The yellow is you, the blue is your provider, and the red is insurance administration processes.

In our model, your patient experience looks like this:

You have:
NO copayment.
NO Exam charge.
NO Insurance to file.
NO Deductible.
NO Co-insurance.
You will NOT receive a bill from us.
You will NOT receive an Explanation of Benefits from us, as you know your exact costs everytime.

Your new flow model looks like this:

Notice there are no red squares...

A typical insurance-based primary care practice has a minimum of 2,500 patients. We tell our clients 3,000, and some in Ruston have 10,000-15,000, but we will go conservative with 2,500.

2,500 patients per provider x avg. 3 visits per year = 7,500 annual visits.

5 day workweek = 29 visits per day
4 day workweek = 37 visits per day

29 visits per day = 18.62 min/visit (9 hr day with no breaks)
37 visits per day = 14.59 min/visit (9 hr day with no breaks)

Some providers in Ruston see 45-75 a day.


In our model...

500 patients per provider x avg 3 visits per year = 1,500 annual visits.

5 day workweek = 6 visits per day

6 visits per day = 1.5 hrs per visit (9 hr day with no breaks)

This is why we can offer quality and investment of time. If you need an hour, you get it. If you need a same day appointment, you likely will get it.

Plus, primary care providers don't have time to provide you with the list of components that define primary care, and in most cases they don't get paid to.

Just like you can't have volume and complexity at the same time, you also can't have volume and quality at the same time.

As a consumer...

Would you prefer to be in a model that incentivizes your provider to keep you sick, or a model that incentivizes your provider to provide you quality in order to retain you as a customer?

AND, we can save you money...

If you'd like more information, let me know. I'll answer any questions posted. I'd love any feedback that you have. We are open for business in Ruston right now, and will be expanding very soon.

Thanks for all the info, very interesting. Trying to digest for now maybe ? later.

The healthcare/Obamacare debate rages for years on this board, and I get crickets in this thread. Too much info I guess? Probably should have posted before football started. :laugh:

Quote:

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Originally Posted by RhythmDawg

The healthcare/Obamacare debate rages for years on this board, and I get crickets in this thread. Too much info I guess? Probably should have posted before football started. :laugh:

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Need a Cliff Notes version for sure.

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 ??

Quote:

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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.

Quote:

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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.

Quote:

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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.

Quote:

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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.

Quote:

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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.

Quote:

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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.

Quote:

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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?

Quote:

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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

Quote:

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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!

How does your system work for someone that needs several surgeries?

Major medical insurance covers that. If you don't currently have insurance, you won't get it unless you can get it through your employer's group policy. However, according to Obamacare, there will be no exclusions in 2014. Originally, we were saying: sure, but nothing says insurance companies can insure you with no exclusions, but make it so unaffordable that you can't get it anyway. Now, apparently there will be a limit on the premiums. You think that will out them out of business?

If you do currently have a policy, you should keep it, reduce your benefits, increase your deductible, add our primary care, and you save between 20-80%, get unlimited 30-60 minute visits with your provider, and if your appt is at 10am, you get in at 10am.

And if you are a small business owner, be afraid. Example: there is a business in monroe with 500+ employees. Obamacare will make the business unsustainable, forcing them to close. 500+ jobs. Thus the reason we are approaching small businesses first.

I usually refrain from these type discussions regarding healthcare (mostly), but since the questions are coming, I'll gladly answer whatever you got...It'll prep me for the panel discussion with the local Tea Party I have coming up.

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Originally Posted by RhythmDawg

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.

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I like your model, RD. I'm not sure it's THE solution, but our current "one-size-fits-all" system certainly needs viable alternatives.

And not to pick on physicians, but they aren't completely blameless in some of the grind the healthcare system is experiencing. They have done an incredible job of promoting themselves and placing themselves at the center of the healthcare universe. Unfortunately, at times they have done this by seeking to unfairly diminish the scope of practice of other healthcare providers. Fortunately, there are trends in healthcare to create more collaboration among providers, and this is definitely in the best interest of patients. But, one of the big barriers to the growth of this is the (sometimes apparently willful) ignorance of physicians regarding the training of other healthcare specialties (particularly of other doctoral-level healthcare providers).

At the heart of the issue is the dominant healthcare model. In the late 19th through the 20th centuries, the disease model (upon which current physician training is predominantly based) exploded, and with amazing results: even looking at advancements in vaccinations and antibiotics alone, the top diseases in morbidity of the 19th century have nearly all been virtually eradicated. The disease model is predicated on a focus on the biochemical functioning of the body, and this constitutes the vast majority of physician training. This has been their strength, and what rightfully put them at the center of healthcare throughout the last century and a half. They become experts in the biochemical, biomechanical, and other biological functioning of the human organism, and are immersed in biochemical (and mechanical, for the surgeons) interventions for that system through pharmacology.

As the dust settled from the victories over the diseases that responded well to biochemical approaches, it became clear that the top killers that emerged to succeed them required more than just biological interventions. Toward the end of the 20th century, a successor model was developed in medical science, which attempts to account for the additional factors that lead to the development and maintenance of ailments such as heart disease, obesity, and diabetes. It is the biopsychosocial model, and research continues to point to the need for systemic interventions that address biological, psychological, and social aspects of human functioning if we are to effectively deal with these diseases that do not respond fully (if much at all) to purely biochemical interventions.

Physicians still play a vital and centrally important role in health care, and their specialized training in the biochemical and biomechanical functioning of the human organism is absolutely essential. But the days of the solo (and all-knowing?) GP who makes house calls and fixes everything that ails you is gone. Collaborative teams that pull from specialties across not only the biological, but also the social and psychological, clinical sciences are going to provide the best systemic solutions to systemic problems.

Sorry to interject my own agenda into your agenda, RD. To try to connect this to anybody still reading, as patients I encourage folks to recognize that a) not every health problem can or will be solved by a pill (and many that can may be solved as well or better by other means) and b) educate yourselves on how your physicians are trained, and what other types of providers may be able to add to what your physician provides in your treatment.

And to physicians, I encourage you to not only know what you know and to know it well, but also recognize where the boundaries of your knowledge exist. Then educate yourselves on the training that other healthcare folks have received and the expertise they offer that can truly extend the care you provide your patients. (And, for the most self-serving piece of the whole argument, consider the possibility that many other doctoral-level clinicians actually had to work for their doctorates, too. :icon_wink:)

Brian, I absolutely 100% agree with your post.

Are these unlimited 30-60 minute sessions with a licensed M.D. ?? Does the customer see the same person each visit ?? Can the customer choose ??

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Originally Posted by nadB

Are these unlimited 30-60 minute sessions with a licensed M.D. ?? Does the customer see the same person each visit ?? Can the customer choose ??

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MD or midlevel, patient's choice.

What is a midlevel ??

So what is your target market - individuals, small businesses, or both. What size businesses are you targeting?

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Originally Posted by nadB

What is a midlevel ??

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Nurse practitioner or physician assistant

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Originally Posted by RhythmDawg

Nurse practitioner or physician assistant

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Tks., that was my guess.

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Originally Posted by glm47

So what is your target market - individuals, small businesses, or both. What size businesses are you targeting?

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Both. The business model works such that, if you have, between employees and dependents, 500+ individuals, we can actually consider putting a clinic and provider(s) on sight at your place of business, if you have space. At the moment, because we are a startup and currently operate one location, the only real challenge arises right now with targeting large businesses with multiple locations. But expansion will remedy that over time.

Specifically, we have already found that the quality and tremendous convenience is extremely appealing to men.

Wow, that unlimited 1-hr. visits should help you sign up every hypochondriac within driving distance once word gets around. I know one person who would probably be there every day, twice if they could. :icon_wink:

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Originally Posted by nadB

Wow, that unlimited 1-hr. visits should help you sign up every hypochondriac within driving distance once word gets around. I know one person who would probably be there every day, twice if they could. :icon_wink:

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Lol, yes, we have discussed that scenario. :laugh:

I suppose everyone else on here knows who you are since no one asked, but is that a deep dark secret?&nbsp; You say you already are in business in Ruston.&nbsp; Where?&nbsp; What's it called, etc.?&nbsp; Or are we not supposed to know who you are?&nbsp; I suppose I could go to the country club if I really wanted to find out that way.&nbsp; And I did read your entire posting, and it sounds interesting.&nbsp; Almost too good to be true if it actually works.

I have no earthly idea what the &nbsp deal is in the above post. Sorry about that. Just skip over them.

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Originally Posted by CutiePie72

I suppose everyone else on here knows who you are since no one asked, but is that a deep dark secret?&nbsp; You say you already are in business in Ruston.&nbsp; Where?&nbsp; What's it called, etc.?&nbsp; Or are we not supposed to know who you are?&nbsp; I suppose I could go to the country club if I really wanted to find out that way.&nbsp; And I did read your entire posting, and it sounds interesting.&nbsp; Almost too good to be true if it actually works.

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Thanks for asking. I didn't want to come out wearing my résumé on my sleeve, but for credibility purposes, I certainly don't mind you asking.

The business is Seasons Primary Care (which may be rebranded soon). I am one of 4 owners. I am also the CEO of a local hospital (not NLMC), and COO of Impact Healthcare Solutions, where we provide a range of services including hospital and physician practice consulting, hospital and practice management, practice startups, billing and collections, credentialing, operational and financial assessment, business process outsourcing, and special projects too numerous to list.

The purpose of starting this thread was to initiate enough interest to either meet with me or our team personally, or attend one of our weekly presentations. I have already had several requests, which I appreciate. And thanks for taking the time to read it and post.

And yes, it really is that simple. Just look at peer industries...auto insurance, home insurance, life insurance, etc. and it is working right now. We have over 40 members in less than two weeks by simply inviting people we know to presentations. We have a dozen or so companies we are running numbers for right now. We will be in Monroe and Shreveport within 6-12 months.

You will start hearing about us on the radio shortly.

If anyone wants more info, I'm free at lunch today.

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Originally Posted by CutiePie72

I have no earthly idea what the &nbsp deal is in the above post. Sorry about that. Just skip over them.

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It's HTML code for a space. I have no idea why it would be showing up in your post.

Quote:

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Originally Posted by CutiePie72

I suppose everyone else on here knows who you are since no one asked, but is that a deep dark secret?&nbsp; You say you already are in business in Ruston.&nbsp; Where?&nbsp; What's it called, etc.?&nbsp; Or are we not supposed to know who you are?&nbsp; I suppose I could go to the country club if I really wanted to find out that way.&nbsp; And I did read your entire posting, and it sounds interesting.&nbsp; Almost too good to be true if it actually works.

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To further expound on this...what we are doing is not new, as there are over 100 practices across the US, the oldest being in operation for 10 years with 5 locations. They have two investors helping them fine tune their model (doctors are running it, not business people), and you may have heard of them: Jeff Bazos and Michael Dell. Yes, we'd love to have those kind of investors, too! There is also a prevision in Obamacare that directly addresses this model. We are expanding our scope of practice to meet all of the requirements for Obamacare in 2014 so that you, as an individual or business, don't have to pay your tax or penalty, however it applies to you. I talk details about this in our presentation.

As a side note, through 10 years of data, that company has shown a 54% reduction in absenteeism from work with their patients and their respective jobs. I am not claiming we will do that! :D. But I think it is interesting.

http://www.breitbart.com/system/wire...14-232724-6523

Do you know of anyone who sells insurance that simply guarantees that the hospital will charge you at some negotiated reduced rate. It seems to me that the premium on a such a policy would be really low but would allow a lot of people to obtain all the health care they need by paying cash for everything.

Quote:

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Originally Posted by RhythmDawg

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.

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Quote:

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Originally Posted by LT

Do you know of anyone who sells insurance that simply guarantees that the hospital will charge you at some negotiated reduced rate. It seems to me that the premium on a such a policy would be really low but would allow a lot of people to obtain all the health care they need by paying cash for everything.

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You are close to describing what HSAs do for the insured.

Unfortunately, thanks to Obamacare, there are no low premiums.

Quote:

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Originally Posted by maddawg

You are close to describing what HSAs do for the insured.

Unfortunately, thanks to Obamacare, there are no low premiums.

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Aren't all the HSA's that are offered simply part of an insurance policy that has a higher deductible - say $3,000-$5,000?

What I'm asking about is a policy that would offer NO coverage at all - that would simply require the health care provider to accept the discounted payments for procedures that they accept from the major insurers? I would think that the premium on such a policy would indeed be low - maybe $50/month or even less.

I wonder if those who cry about the Affordable Care Act requiring everyone to purchase insurance would be willing to sign a legal document agreeing not to receive any government health care aid in exchange for not having to buy insurance. Would they give the hospital the right to garnish wages and go after assets if they have an operation but don't have funds to pay for it?

Quote:

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Originally Posted by LT

Aren't all the HSA's that are offered simply part of an insurance policy that has a higher deductible - say $3,000-$5,000?

What I'm asking about is a policy that would offer NO coverage at all - that would simply require the health care provider to accept the discounted payments for procedures that they accept from the major insurers? I would think that the premium on such a policy would indeed be low - maybe $50/month or even less.

I wonder if those who cry about the Affordable Care Act requiring everyone to purchase insurance would be willing to sign a legal document agreeing not to receive any government health care aid in exchange for not having to buy insurance. Would they give the hospital the right to garnish wages and go after assets if they have an operation but don't have funds to pay for it?

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Sounds like the way a bank operates. I like it. What does the bank do if you can't/don't make you payments? They claim the assets for their own to offset at least a portion of the debt. If you are going in for surgery and don't have cash or adequate insurance, then you must present collateral before the procedure.

Of course that would not work for emergency procedures. I would be okay with routine/scheduled procedures being handles this way.

Okay, so I thought about it for a minute and that would never work. If you don't have cash, and you don't have insurance, you probably don't have stuff either. At least not stuff that is free and clear. I guess I will keep paying for everyone else's healthcare. It's what I am uses to anyway.

Quote:

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Originally Posted by LT

Aren't all the HSA's that are offered simply part of an insurance policy that has a higher deductible - say $3,000-$5,000?

What I'm asking about is a policy that would offer NO coverage at all - that would simply require the health care provider to accept the discounted payments for procedures that they accept from the major insurers? I would think that the premium on such a policy would indeed be low - maybe $50/month or even less.

I wonder if those who cry about the Affordable Care Act requiring everyone to purchase insurance would be willing to sign a legal document agreeing not to receive any government health care aid in exchange for not having to buy insurance. Would they give the hospital the right to garnish wages and go after assets if they have an operation but don't have funds to pay for it?

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HSA's with a high deductible don't, for the most part, offer coverage on the deductible or out of pocket amount. The insured is agreeing to "self insure" for that amount. In return the insured gets the discounted rate offered by the provider. In network and pre-approved is a set rate. Out of network and/or no pre-certification can get expensive.

You are describing a pooling of healthy individuals which, by definition, is not insurance. Try to imagine an auto policy or home owners policy with your scenarios plugged in.

Quote:

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Originally Posted by LT

Do you know of anyone who sells insurance that simply guarantees that the hospital will charge you at some negotiated reduced rate. It seems to me that the premium on a such a policy would be really low but would allow a lot of people to obtain all the health care they need by paying cash for everything.

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the answer is no. The only way anything like what you described will happen, or because of Obamacare the model I have outlined earlier in this thread, will become mainstream is if the healthcare system implodes and we start over...and that isn't out of the question.

By the way in case anyone is wondering, we did make the direct primary care model work in Ruston. Problem is insurance companies won't write group castrophic coverage because the ACA is set to enforce a $2,000 deductible maximum. There is a proven model that works, it fixes every backwards incentive for physicians, patients, and insurance companies, it aligns health insurance to mimick every other area of the insurance industry, we have shown as much as 80% savings, we have achieved behavioral change in some cases, and the government is regulating it out as an option. In fact the are rubber stamping the very thing that is wrong. I may write a book and send it to my rep.

Quote:

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Originally Posted by techman05

Sounds like the way a bank operates. I like it. What does the bank do if you can't/don't make you payments? They claim the assets for their own to offset at least a portion of the debt. If you are going in for surgery and don't have cash or adequate insurance, then you must present collateral before the procedure.

Of course that would not work for emergency procedures. I would be okay with routine/scheduled procedures being handles this way.

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Have you ever gone in to have scheduled surgery or a routine procedure without having adequate insurance or even your deductible? That is how it's handled. If you can't pay, they don't play, at least in my experience.

Just read this all the way through. Really interesting and interested. Unfortunately, I don't know that it would work for me in my condition now, but I can see it working for my wife and son. How does this work for women and their "types" of visits like breast screenings, pregnancies, and other stuff like that? Would they need an OB/Gyn separate from this group? As far as my situation or someone that has already developed a disease or diseases that have no cure, how would this model work? I still need the primary care model physician for bumps and bruises, etc..., but how would I incorporate the other care I need such as routine visits to cardiologists, pulmonary, GI, etc...?

Quote:

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Originally Posted by Dirtydawg

Just read this all the way through. Really interesting and interested. Unfortunately, I don't know that it would work for me in my condition now, but I can see it working for my wife and son. How does this work for women and their "types" of visits like breast screenings, pregnancies, and other stuff like that? Would they need an OB/Gyn separate from this group? As far as my situation or someone that has already developed a disease or diseases that have no cure, how would this model work? I still need the primary care model physician for bumps and bruises, etc..., but how would I incorporate the other care I need such as routine visits to cardiologists, pulmonary, GI, etc...?

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Regarding the OB/GYN, if you aren't of childbearing age, do you really need one? OB/GYN is a specialty within Primary Care. If you are getting breast screening and paps, a primary care physician can do that.

For someone in your condition Dirty, my response would be...

This model allows each individual's costs to be proportional with their risk of consumption. If you are very healthy and a low utilizer, your costs will be much lower. If you have a chronic condition like diabetes, COPD, heart disease, cancer, etc., your healthcare costs will be proportionally higher, as it should be, because you are a high utilizer. Your healthcare costs more.

In your case, I would say to you, you need fully comprehensive health insurance coverage because your risk of utilization is extremely high. If I were trying to get into the white house, I would be saying...if the government wants to get involved in healthcare, subsidize end of life care, terminal illness, etc. by mandating/paying for catastrophic insurance coverage. Leave primary care and intermediate specialty care to us. The amount of money that would be available to care for you in your condition, and that could go to research, if the model was flipped would be unreal.

Everyone gets mad over the "everyone pay their fair share" tax argument. Its been happening in healthcare for decades. Everyone is dumped into the same pool and we all subsidize each other. Obamacare is taking it even a step further. This is no better illustrated in healthcare than group policies for businesses.

RD, how is this going?

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Originally Posted by Brian96

RD, how is this going?

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Politicians have the only power to fix it and they aren't capable. Some are starting to listen though. Honestly, right now...if I can ignore the insane amount of money it will cost everyone and the massive regression of access to care...I'd rather keep the ACA in place and let the healthcare insurance industry collapse. The problem is the healthcare industry itself would fall apart. Hospitals would close all over the country. Technology and pharma companies would go out of business. People would stop going to medical school. But at this point everything needs to be wiped out and rebuilt.

Trying not to be pessimistic, but everything realistic that the government might do with healthcare is nothing more than shifting the degree to which the same problem exists.

Other than that it's going pretty well.

I'm surprised there has not been one comment in this thread about balance billing. The #1 cause of bankruptcy in the US is medical bills and allowing doctors to charge patients whatever they want to in emergency situations and insurance companies paying only to a certain point is what causes most of these bankruptcies.

For example, in 2008 on Thanksgiving Day I had to go to my Blue Cross Blue Shield in-network hospital due to severe abdominal pain. I had to have my gall bladder immediately removed per the ER doctor. Long story short- I was in the hospital for about 28 total hours and the entire cost of a routine gall bladder removal was ~$60,000! I had to pay out of pocket about $13,000. The ER doctor was not "in network" with the largest and arguably best health insurance provider in Texas. Why? Because he (and several other medical pros) REFUSE TO BE IN IT! They can make HUGE SUMS of money by not being limited by the insurance companies' agreed max payment amounts. The doctors, hospitals, etc just 'balance bill' the patient and this practice is illegal in several states. Also, hospitals negotiate with these "not in any network" doctors to give them exclusive rights to treat all emergency patients who arrive during their day on ER call. If a patient asks for an 'in network' doctor there will not be one, because he/she did not outbid the "not in network" doctor for the right to see ER patients for that day.

We are now repeating this same 'balance billing' process again with my son's ER visit which will cost at least $5,000 out of pocket (again with BCBS of Texas). Balance billing keeps coming up in many state legislatures to make this illegal in MEDICAL EMERGENCY situations where the patient has no choice to prequalify every entity to see if they are 'in network' or not. Every year the AMA lobbies to kill the bills that seek to kill balance billing.

Balance billing is a crooked and predatory practice that is destroying people financially. That is unless you are one of the doctors, hospitals, ambulatory service providers,... who are part of this activity.

Quote:

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Originally Posted by DogsWin

I'm surprised there has not been one comment in this thread about balance billing. The #1 cause of bankruptcy in the US is medical bills and allowing doctors to charge patients whatever they want to in emergency situations and insurance companies paying only to a certain point is what causes most of these bankruptcies.

For example, in 2008 on Thanksgiving Day I had to go to my Blue Cross Blue Shield in-network hospital due to severe abdominal pain. I had to have my gall bladder immediately removed per the ER doctor. Long story short- I was in the hospital for about 28 total hours and the entire cost of a routine gall bladder removal was ~$60,000! I had to pay out of pocket about $13,000. The ER doctor was not "in network" with the largest and arguably best health insurance provider in Texas. Why? Because he (and several other medical pros) REFUSE TO BE IN IT! They can make HUGE SUMS of money by not being limited by the insurance companies' agreed max payment amounts. The doctors, hospitals, etc just 'balance bill' the patient and this practice is illegal in several states. Also, hospitals negotiate with these "not in any network" doctors to give them exclusive rights to treat all emergency patients who arrive during their day on ER call. If a patient asks for an 'in network' doctor there will not be one, because he/she did not outbid the "not in network" doctor for the right to see ER patients for that day.

We are now repeating this same 'balance billing' process again with my son's ER visit which will cost at least $5,000 out of pocket (again with BCBS of Texas). Balance billing keeps coming up in many state legislatures to make this illegal in MEDICAL EMERGENCY situations where the patient has no choice to prequalify every entity to see if they are 'in network' or not. Every year the AMA lobbies to kill the bills that seek to kill balance billing.

Balance billing is a crooked and predatory practice that is destroying people financially. That is unless you are one of the doctors, hospitals, ambulatory service providers,... who are part of this activity.

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The ER doctor removed your gall bladder???

In most ERs, the physicians fall under one of two categories...employed by the hospital or employed by an ER staffing company contracted by the hospital. In the first scenario, the hospital would bill globally and your services would have been provided in network. In the second circumstance, the hospital might, depending on their arrangement with the staffing company, either bill the same way and pay the ER staffing company, or bill technical components only and allow the staffing company to bill the professional component. In the second scenario, if the staffing company is not in network with the same insurances as the hospital, that is negligence in my opinion on the hospital. I do see it...in fact it happened not long ago in Ruston...and a hospital should never allow that. Similar scenarios happen with remote radiology, lab, and pathology services.

If your gall bladder was removed by an employed surgeon, it would have been billed globally...and should have been under an emergency situation. If the surgeon was not employed, he/she might also have billed pro fees themselves, and the same issue could apply.

Payment depends on both the patient's policy and the contract between a provider and the insurance company. The hospital or physician may set whatever price they want to...because in a contracted in network scenario, the price usually isn't going to matter for the patient. A payer will reimburse the hospital based on their contract with the hospital. They will require the patient to pay their portion based on the policy you purchased from them. They will contractually adjust the rest. Balance billing this contractual adjustment is insurance fraud. Any huge payments required by a payer of the patient is going to be determined by your policy you purchased toward a deductible.

Out of network payments and self pay is another ball game, because there are no contracts in place to govern these rules. In these cases, a provider can balance bill. I agree, it should not be allowed in these cases without an adjustment to the price because the price was artificially inflated for an in network arrangement. All hospitals should have a mechanism in place to deal with this. Patients also have a right to negotiate.

I have always wondered how much people would be willing to pay for a consulting/advocacy service in cases like this. I bet I could have gotten your fees at least cut in half. I've done it pro bono a few times for friends in the past, and even found major billing errors hospitals and physicians made that kept insurances from paying and the hospita/physicianl passed the responsibility on to the patient to pay...and they hospital/physician had no idea they made the error. The patient certainly couldn't have figured it out. But we got it rebelled and paid by the insurance.

A word on price inflation...

I'll use hospitals as the example, but these things apply equally to all healthcare providers. Hospitals are required to charge everyone the same price for a service. But they negotiate...usually poorly...and contract with insurance companies for reimbursement rates. Rates are different from one payer to the next for the same service. Also, the same payer will pay differently to different hospitals for the same service. All payers will pay the hospital its price or its contracted rate, whichever is less. Thus, if I see a hospital getting paid 100% of their price, I recommend them to increase their price for that service because they lost money by getting paid the lesser of the two. Some payers will also pay a percentage of the price instead of a negotiated flat rate. Sometimes they put a cap on it, and sometimes they don't.

This all means that a hospital must assign a price that 1) is higher than every negotiated payment rate for that service, and 2) maxes our the caps for any percentage rate payments. This is what makes a piece of gauze cost $25 on your bill. Each payer pays their contracted rate...and requires you to pay your portion based on the policy you bought...and they contractually adjust the balance.

So. If BCBS pays $100 for a service...

Your hospital charges $125, you according to your policy pay a $15 copay, BCBS pays $85, and BCBS requires the hospital to contractually adjust $25. If your hospital charges $1000, same scenario and the contractual adjustment is $900.

If you do not have insurance, you get the same inflated bill. You have to understand how all this works and negotiate it. Usually a hospital will have a self pay discount...and often they make more on you than they would have from an insurance company because your self pay transaction is based on the inflated price influenced by all payment rates. The insurance transaction is based on a much lower contracted rate that you are not privy to.

All of this is also why prices are so different from one hospital/physician to the next. If you have insurance, and depending on your policy setup and if your provider is in network, price doesn't matter.

All of that reeks of antitrust price fixing. Anyone so engaged should end up in federal prison.

The solution is pretty simple- MAKE BALANCE BILLING IN EMERGENCY SITUATIONS ILLEGAL IN ALL STATES!
There is a very good reason these bills keep getting written EVERY YEAR and there is a very good reason they keep being killed by (arguably corrupt) politicians in committee ($$$$$).

A $60,000 routine gall bladder removal, a $1,600+ out of pocket ambulance (just the patient's portion) expense,... These things have got to stop!

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Originally Posted by DogsWin

The solution is pretty simple- MAKE BALANCE BILLING IN EMERGENCY SITUATIONS ILLEGAL IN ALL STATES!
There is a very good reason these bills keep getting written EVERY YEAR and there is a very good reason they keep being killed by (arguably corrupt) politicians in committee ($$$$$).

A $60,000 routine gall bladder removal, a $1,600+ out of pocket ambulance (just the patient's portion) expense,... These things have got to stop!

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Medicare pays $450 for an ambulance transport, all inclusive.

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Originally Posted by dawg80

All of that reeks of antitrust price fixing. Anyone so engaged should end up in federal prison.

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countless judges and lawyers disagree. But...it IS what is wrong with healthcare.

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Originally Posted by RhythmDawg

Politicians have the only power to fix it and they aren't capable. Some are starting to listen though. Honestly, right now...if I can ignore the insane amount of money it will cost everyone and the massive regression of access to care...I'd rather keep the ACA in place and let the healthcare insurance industry collapse. The problem is the healthcare industry itself would fall apart. Hospitals would close all over the country. Technology and pharma companies would go out of business. People would stop going to medical school. But at this point everything needs to be wiped out and rebuilt.

Trying not to be pessimistic, but everything realistic that the government might do with healthcare is nothing more than shifting the degree to which the same problem exists.

Other than that it's going pretty well.

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More specifically, how is the clinic in Ruston with the model you described working out? How does something like that fit into (or not) ACA?

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Originally Posted by Brian96

More specifically, how is the clinic in Ruston with the model you described working out? How does something like that fit into (or not) ACA?

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The ACA regulated it out of existence. We are currently running it at a Louisiana hospital through its multiple clinics, but it is slightly altered from the original.

There are now over 2500 of these clinics across the country. Ours was different because we addressed intermediate and catastrophic care and not just primary care. It required a catastrophic policy with a high deductible. The law (ACA) deemed a policy with a deductible greater than $2000 to be illegal...but the government is not enforcing it. Nevertheless...insurance companies are basically not writing those policies.

I was afraid of that. When will we learn that health insurance does not equate to health?

Keep up the fight!

In summary, greedy reedy doctors, lawyers, insurance and drug companies are the cause.

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Originally Posted by TYLERTECHSAS

In summary, greedy reedy doctors, lawyers, insurance and drug companies are the cause.

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Not a very good summary

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Originally Posted by TYLERTECHSAS

In summary, greedy reedy doctors, lawyers, insurance and drug companies are the cause.

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Actually, no. Politicians, lobbyists, and regulation are the causes.

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Originally Posted by RhythmDawg

Actually, no. Politicians, lobbyists, and regulation are the causes.

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True, by not making balance billing illegal as Dogswin described. That's nothing more than price gouging and taking advantage of those in desperate situations

Quote:

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Originally Posted by DogsWin

The solution is pretty simple- MAKE BALANCE BILLING IN EMERGENCY SITUATIONS ILLEGAL IN ALL STATES!
There is a very good reason these bills keep getting written EVERY YEAR and there is a very good reason they keep being killed by (arguably corrupt) politicians in committee ($$$$$).

A $60,000 routine gall bladder removal, a $1,600+ out of pocket ambulance (just the patient's portion) expense,... These things have got to stop!

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That's insane and what is the point of insurance if a practice or doctor can just balance bill someone

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Originally Posted by longdawgview

True, by not making balance billing illegal as Dogswin described. That's nothing more than price gouging and taking advantage of those in desperate situations

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This also is only a symptom of the actual disease.