Posted in Access to healthcare, Direct-Pay Medicine, Direct-Pay Practice Models, Economic Issues, Health Insurance, Healthcare financing, Independent Physicians, Medical Costs, Patient Choice, Price Tansparency, Self-Insured Companies, Uncategorized

Jay Kempton: An Unorthodox Benefits Solution – Healthcare Americana

Healthcare Americana, Chris is joined by Jay Kempton of The Kempton Group and co-founder of the Free Market Medical Association (FMMA).

Chris and Jay discuss novel ways of implementing employee benefits, why there are barriers to change, and the upcoming FMMA conference.

https://healthcareamericana.com/episode/jay-kempton-an-unorthodox-benefits-solution/

Posted in Access to healthcare, advance-pricing, Consumer-Driven Health Care, Direct-Pay Medicine, Direct-Pay Practice Models, Doctor-Patient Relationship, Economic Issues, Health Insurance, Healthcare financing, Independent Physicians, Medical Costs, Medical Practice Models, out-of-pocket costs, Patient Choice, Patient Compliance, Patient Safety, Patient-centered Care, Policy Issues, primary care, The Quadruple Aim, Third-Party Free Practices, Uncategorized, Wait times to see a doctor

More Patients Turning to ‘Direct Primary Care’ | Medscape

Christine Lehmann, MA

February 11, 2020

Having quick access to a primary care doctor 24/7 is very appealing to Mick Lowderman, 56, who is married with two children, ages 10 and 8. He pays a monthly membership fee to AtlasMD, a direct primary care practice in Wichita, KS.

Primary care is built on the long-term relationship between clinicians and patients. A 10- to 15-minute patient visit doesn’t support that relationship, Sullivan says.

When Kevin Boyd, 64, fell on his stairs in Wichita and broke three ribs, he didn’t go the emergency room. Instead, he called Umbehr, who told him to come to his office. He referred Boyd nearby for an X-ray and dispensed pain medications at his office. The total cost was $70.

In contrast, the first time Boyd fell and broke his ribs, he had Blue Cross Blue Shield and drove himself to the ER, where he saw the ER doctor, a radiologist for an MRI, and got shots for his pain. The total bill was $14,000, and he paid $2,600.

“I don’t put off care the way I used to because of the money I save,” says Boyd, who joined AtlasMD in 2015.
For his monthly membership fee of $75, Boyd gets several benefits, including unlimited 24/7 access to Umbehr by text, email, or phone, extended same- or next-day office visits, and free diagnostic tests and office procedures, such as EKGs, DEXA scans, and body fat analysis. If Boyd gets really sick and needs a house call, or if he needs a phone consult when traveling, those are also included in the fee.
Posted in Access to healthcare, Doctor-Patient Relationship, Healthcare financing, Medical Practice Models, Organizational structure, outcomes measurement, Patient Choice, Patient Safety, Policy Issues, Protocols, Uncategorized

How Chaos at Chain Pharmacies Is Putting Patients at Risk | New York Times

They struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies, they said — all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.

“I am a danger to the public working for CVS,” one pharmacist wrote in an anonymous letter to the Texas State Board of Pharmacy in April.

“The amount of busywork we must do while verifying prescriptions is absolutely dangerous,” another wrote to the Pennsylvania board in February. “Mistakes are going to be made and the patients are going to be the ones suffering.”

Posted in Access to healthcare, Crony Capitalism, Economic Issues, Healthcare financing, Influence peddling, Medical Costs, Medical Practice Models, Organizational structure, Patient Choice, Patient Safety, Patient-centered Care, Policy Issues, Quality, Uncategorized

Surgeon Sues Orlando Health Over ‘Forced’ Referrals | Medpage Today

Jay Wolfson, PhD, a health policy expert at the University of South Florida in Tampa, said this case “goes to the heart of physician clinical autonomy.”

Hospitals use various methods to ensure that physicians refer patients to its own entities, including non-compete agreements that prohibit doctors from practicing medicine in a set geographic area around their place of employment during their contract, or even after termination.

A 2018 survey of 2,000 doctors in five states found that 45% of primary care physicians were bound by this sort of non-compete agreement, though hospital-based physicians are less likely to be restricted by these clauses.

https://www.medpagetoday.com/special-reports/exclusives/84571

Posted in Access to healthcare, advance-pricing, Affordable Care Act (ObamaCare), CPT billing, Deductibles, Dependency, Direct-Pay Medicine, Direct-Pay Practice Models, Economic Issues, Employee Benefits, Health Insurance, Healthcare financing, Individual Market, Medical Costs, medical inflation, Medical Practice Models, Organizational structure, outcomes measurement, Patient Choice, Policy Issues, Price Tansparency, Self-Insured Companies, Self-Insured Plans, The Triple Aim, Uncategorized

U.S. Healthcare: A Case Study of What Happens When “Insurance” Supplants Price-Transparent Markets

By Robert Nelson, MD

Our health insurance-based third-party payer protocols have pernicious and nefarious economic consequences on the cost of medical care; and in many ways has diminished access due to regulatory complexities that accompany these interventions.

The undeniable result continues to be a rampant increase in healthcare prices, which is catalyzed by the economic distortions of the 3rd party payer effect and perpetuated by the price-obscuring distortions of the CPT billing cycle.

We have taken the concept of insurance, designed to pay out rare higher-priced claims on unpredictable events, and turned it into a product whose design promotes an incentive for everyone to use it as often as possible.

Insurance is sustainable only when the financial risks of individually rare events are spread over a large population. When it also becomes a funding source for anticipated and affordable events, combined with a perverse incentive to utilize it to the margin, the result is the creation of a perpetual payout fund.

The costs of sustaining this model are never satisfied, being squeezed by patients who are chasing the benefits and providers who chase the billing codes to achieve maximal reimbursement.

As evidence for the negative consequence of misusing insurance as a pass-through system for virtually every healthcare expense (accelerated by passage of the ACA), we can examine the employer-sponsored group market premiums.

From 2007 – 2017 the average premium for family coverage increased by 55% and employee contribution rate as a share of premium cost increased by 74% over the same 10-year period; while median household income went up by only 3%.

To add financial injury to insult, the percentage of employees with an out-of-pocket maximum of greater than $3,000 doubled, going from 30% to 60% of employees.

“Eighty-one percent of covered workers have a general annual deductible for single coverage that must be met before most services are paid for by the plan. Among covered workers with a general annual deductible, the average deductible amount for single coverage is $1,505.” ~KFF.org

Between 2012 – 2017, the percentage of covered workers with a general annual deductible of $1,000 or more for single coverage has grown substantially, increasing from 34% in 2012 to 51% in 2017. Thirty-seven percent of covered workers in small firms are in a plan with a deductible of at least $2,000, compared to 15% for covered workers in large firms.

In the ACA individual market insurance exchanges, single coverage premiums (unsubsidized) increased by 62% and family coverage premiums increased by 75% just since implementation of ObamaCare!

Our third-party payer system has created a dependency paradox!

The same funding method that contributes to runaway costs also causes us to be more dependent on it for access. This guarantees that Healthcare will cost significantly more than the sum of its individual parts, and will continue to escalate faster than our ability to pay for it.

The costs associated with health plan premiums (aka insurance) have become a surrogate for health-care costs.

Now let that sink in!

In what other market does the cost of an insurance product act as substitute for the aggregate cost of the product or services that it insures?

Now apply a similar scenario to the auto insurance market. It doesn’t take much imagination to extrapolate how that would play out. But if you want some help visualizing the scenario, here’s a brief vignette. https://lnkd.in/eUGeCKv

Self-insured employer health plans are in a unique position to break out of this dependency paradox.

By contracting with a Direct Primary Care practice and re-routing subsequent encounters away from the more expensive insurance-based protocols, Self-insured employers can utilize creative plan designs to cut costs and improve employee satisfaction.

Data from the Qliance experience, and supported by other self-insured employer’s experiences, utilization of efficient primary care via the DPC model reduces unnecessary downstream care by approximately 50%, with the resultant aggregate cost savings of nearly 20%.

The caveat being, as we double the number of primary care visits combined with longer visits to adequately address problems, the need for emergent visits, ER visits and specialty intervention drop significantly.

A similar level of savings for direct-pay lab tests was noted in data published in 2014 by CMT journal comparing lab fees charged to a Direct Pay practice by the lab vs. the CPT billed charges by the lab (assuming patient had no coverage or had not met their deductible). For five common blood tests the savings was 89% by not using insurance, with lab billed charges of approximately $782 compared to a direct pay cost of $80. Plum Health, a direct primary care practice in Detroit, shows similarly impressive lab test savings of 87% on six common blood tests; $811 vs $106.

Many Self-insured companies are beginning to discover the value and savings in this approach, while breaking free of the coverage trap and the myth that health insurance equates to health care; and the realization that so-called “access” to inflated pricing and the phony discounts used to fleece the buyer is no longer a conversation they are willing to have.

Posted in Economic Issues, Education, Free-Market, Job loss, Liberty, Patient Choice, Patient Safety, Policy Issues, Uncategorized

Watch “Second Chance DENIED” on YouTube

Implicit in the mission of this blog is to support independent professionals, not just medical professionals, and the unencumbered ability to pursue their chosen profession; and to do so without excess gov’t restrictions.

Posted in British National Health Service, Economic Issues, FDA, Health Insurance, Healthcare financing, outcomes, outcomes measurement, Patient Choice, Patient Safety, Policy Issues, Protocols, Quality, Technology, Uncategorized

Should access to life-saving medicines be determined by economic evaluations? | TheHill

“My opportunity finally came. In April 2018, I was one of a few hundred cystic fibrosis patients to dose in a pivotal phase III clinical trial to evaluate a new drug designed to correct CFTR, the dysfunctional protein responsible for CF. The medication, two pills in the morning, and one at night worked almost immediately.

Within a few hours, the viscosity of my usually thick, sticky mucus changed; within a week, the constant cough I had lived with for my entire life nearly vanished, and within a month, my pulmonary function tests skyrocketed. I could finally breathe.

Instead of heading towards end-stage illness, disability income, and an end to my fight with cystic fibrosis, Trikafta, as the drug came to be named, saved my life.

A disturbing trend is washing over the United States, though. Insurers are using economic analyses based on a discriminatory cost-effectiveness metric called Quality-Adjusted Life Years (QALY) as negotiating leverage to limit access to life-changing medications.

A 2018 article in Health Affairs said, “QALY calculations inherently privilege treatments that extend the lives of those who can be restored to perfect health, and disadvantage the many who seek life-extending treatments despite having a disability or chronic condition that is not curable.”

But, QALY is not adequately able to quantify what happened in my own life — my journey from near end-stage illness and no hope for a future to correctly managed CF and entrance into an elite graduate program. Living in a world where I would not have had the chance to dose Trikafta sends a shiver down my spine.

That world, however, has existed in countries where QALY has been used to justify not covering CFTR modulators for people with CF. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) makes QALY calculations to determine which medications are covered by the nation’s National Healthcare Service. In 2016, NICE decided that Orkambi, a previous CFTR modulator iteration, was not cost-effective for its citizens.”

https://thehill.com/opinion/healthcare/477547-should-access-to-life-saving-medicines-be-determined-by-economic

Posted in Access to healthcare, advance-pricing, Consumer-Driven Health Care, CPT billing, Defined Contribution Benefit Plans, Direct-Pay Medicine, Direct-Pay Practice Models, Economic Issues, Government Regulations, Health Insurance, Healthcare financing, Patient Choice, Policy Issues, Uncategorized

Why Value-based Payment Methods Won’t Fix Healthcare

I’ve read several posts today on so called “Value-based payment” strategies and I couldn’t resist adding my 2-cents.

VBP can’t fix these fundamental problems because it is still based on a price-opaque shell game I like to call Fee-for-Coding, which results in:

1) Price insensitivity on the utilizer’s part.

2) Misaligned incentives on the provider’s part.

3) Lack of important price signals between buyers and sellers due to lack of advance pricing capabilities.

VBP utilizes the same fundamentally flawed economic system as our current billing model.

Moving to value-based care will require…

1) A system where prices are known in advance of care (not trauma or emergency care where extent of injuries or illness are unknown at onset – but even still a lot of those can be estimated ahead of time based on scenarios).

2) …that physicians be paid to be available to solve our problems, where payment is not tied to documenting work in a chart.

3) …that we move to a system that is based on defined contributions as opposed to defined benefits. As John C. Goodman is fond of saying, “money should follow people”, not programs and insurance policies.

Value will be elusive until we let the discipline of the market work in healthcare.

https://www.linkedin.com/pulse/why-value-based-payment-methods-wont-fix-healthcare-robert-nelson-md/