Posted in Access to healthcare, Affordable Care Act (ObamaCare), American Presidents, big government, Consumer-Driven Health Care, Direct-Pay Medicine, Direct-Pay Practice Models, Economic Issues, Free-Market, Government Regulations, Health Insurance, Health Reimbursement Arrangement (HRA), Health Savings Accounts (HSA's), Healthcare financing, Individual Market, Individual ObamaCare Market, Insurance subsidies, Medical Costs, Medical Practice Models, News From Washington, Patient Choice, Patient-centered Care, Policy Issues, Price Tansparency, primary care, Subsidies, Uncategorized

Fund the Money Pit or Move to Sustainable Patient-Centered Care: Rethinking Health Care Policy | RealClearHealth

Despite proposals from Biden to double-down on the current dysfunction, the Republicans have not coalesced around one plan, though many market-friendly reforms have been floated. Given the obvious fatal flaws of the Affordable Care Act and lack of political will to confront the real cost-drivers, many have lost faith in a government solution for a problem that government largely caused.

Fortunately, the private sector has brought forward new ideas for health care reforms, and these promise access to affordable and innovative care on our terms. Alternative market-driven options exist that improve access, reduce costs, and move patients into closer relationships with their doctors instead of with government bureaucracies.

https://www.realclearhealth.com/articles/2020/11/30/fund_the_money_pit_or_move_to_sustainable_patient-centered_care_rethinking_health_care_policy_111144.html

Posted in Access to healthcare, advance-pricing, Economic Issues, Health Insurance, Healthcare financing, Independent Physicians, Medical Costs, Medical Practice Models, out-of-pocket costs, Patient Choice, Price Tansparency, primary care, Uncategorized

Wealth Extracting “Insurance” Bureaucracy vs Real Value-based Care: #DPC

From Dr. Lee Gross, Epiphany Health:

“New patient in the office today had a CT scan ordered by his urologist for presumed symptomatic kidney stones, which was denied by his insurance for 2 months. I ordered the study stat, cash pay. Done 30 minutes later, $220 cost paid by the patient. Stone identified, results given same day. Treatment and care plan initiated. Now that we have a diagnosis, the urologist has the insurance logjam relieved to proceed with a care plan if our conservative therapy is ineffective. Insurance is frequently an obstacle to health care.” #DPC

https://www.facebook.com/groups/DPCdocs/permalink/3473547759342175/

Posted in Access to healthcare, Consumer-Driven Health Care, Defined Contribution Benefit Plans, Direct-Pay Medicine, Direct-Pay Practice Models, Economic Issues, Employer-Sponsored Health Plans, Health Insurance, Healthcare financing, Independent Physicians, Medical Costs, Medical Practice Models, Policy Issues, Tax Policy, third-party payments, Uncategorized

Who Pays for Your Healthcare Matters

By Robert Nelson

Zero co-pays. No co-insurance. No surprise medical bills! Considering the inflated prices we pay for healthcare, who could pass up that deal, right?

Are the new generation of value-based employer-sponsored Direct Contracting Health Plans, which often include Direct Primary Care, a great deal and more efficient use of our healthcare dollars? Absolutely yes!

real-health-care-expenditures-and-third-party-largerBut we can’t lose sight of the economic reality that individuals always pay the cost of benefits, either directly or indirectly.  And linking benefits to employment has been a colossal policy mistake and the genesis of job-lock and our 3rd-party payer system, which has been the source of runaway costs for 50 years. As the graph illustrates, insurance (3rd party payer) is now a near surrogate for total healthcare costs!

Don’t be fooled. Within the modern paradigm of healthcare financing, employers don’t pay for our healthcare. Our healthcare expense, no matter how it is structured, IS part of our compensation and a huge portion of of it.

images-223535545945618981307.jpgFACT: Every dollar of tax-favored benefits paid by our employer reduces our take-home pay.

The beauty of Direct Primary Care is the portability (no job lock) and affordability which can exist independent of the size or benefit package of the employer. But the foundation which aligns the incentives is based on the identity of the customer. This is why we have to be careful to match the buyer with the recipient of care whenever possible. To insert another 3rd party, even the employer, undermines the sovereignty of the patient and the independence of the physician.

The supply side of healthcare has served the wrong customers for far too long. DPC should not make that same fatal error by exchanging its essence for a pipeline of patients.

This linkage highlights the importance of policy decisions regarding use of HSA funds; the importance of allowing HSA dollars to pay premiums AND DPC fees can’t be overstated.

For DPC, and Direct Contracting at-large, to dig us out from under the boot of the 3rd party apparatus it must remain accessible to the sole proprietor, independent contractor and very small businesses that don’t have “health plans.” And moving to defined contribution plans and away from defined benefit plans will help get us there.

third-party-2Getting first dollar decisions in hands of consumers will also be deflationary and spur competition; and essential to the goal of eventual portability & ownership of benefits. To do otherwise, with too much focus on a new & improved generation of employer-sponsored healthcare plans, will lead us right back to where we started.

Posted in Access to healthcare, advance-pricing, Direct-Pay Medicine, Direct-Pay Practice Models, Entrepreneurs, Healthcare financing, Independent Physicians, Medical Costs, Medical Practice Models, out-of-pocket costs, Patient Choice, Patient Safety, Patient-centered Care, Policy Issues, Price Tansparency, Quality, Uncategorized

Transparent Pricing for Medical Emergencies | The Emergency Center

What the status quo apologists and the naysayers said was impossible, is a reality:

Emergency services with transparent pricing and NO surprise bills!

“Always staffed with board-certified physicians, ICU- and ER-trained nurses, X-ray technologists and helpful administrative personnel, The Emergency Center offers the same comprehensive emergency care and treatment as a hospital ER, without the wait. State-of-the-art CT, ultrasound, x-ray, and lab services on-site combined with compassionate care provides an unparalleled patient experience.

The Emergency Center and OnDEC Health have partnered together to offer direct contracts for emergency room visits, urgent and primary care, plus telemedicine. OnDEC Health’s innovative direct contracting opportunities save employers significant dollars on ER claims, while offering their members 24/7, no-wait access to premier concierge style freestanding ERs and more.”

Peyton Vooletich

Director of Business Development

https://www.theemergencycenter.com/fort-worth-er/

Posted in Access to healthcare, advance-pricing, Direct-Pay Medicine, Direct-Pay Practice Models, Entrepreneurs, Healthcare financing, Independent Physicians, Medical Costs, Medical Practice Models, out-of-pocket costs, Patient Choice, Patient Safety, Patient-centered Care, Policy Issues, Price Tansparency, Quality, Uncategorized

Transparent Pricing for Medical Emergencies | The Emergency Center

What the status quo apologists and the naysayers said was impossible, is a reality:

Emergency services with transparent pricing and NO surprise bills!

“Always staffed with board-certified physicians, ICU- and ER-trained nurses, X-ray technologists and helpful administrative personnel, The Emergency Center offers the same comprehensive emergency care and treatment as a hospital ER, without the wait. State-of-the-art CT, ultrasound, x-ray, and lab services on-site combined with compassionate care provides an unparalleled patient experience.

The Emergency Center and OnDEC Health have partnered together to offer direct contracts for emergency room visits, urgent and primary care, plus telemedicine. OnDEC Health’s innovative direct contracting opportunities save employers significant dollars on ER claims, while offering their members 24/7, no-wait access to premier concierge style freestanding ERs and more.”

Peyton Vooletich

Director of Business Development

https://www.theemergencycenter.com/fort-worth-er/

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, 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 trap!  The same financial tool we rely on to pay our healthcare providers also contributes to runaway costs; making us 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 Access to healthcare, Affordable Care Act (ObamaCare), Direct-Pay Medicine, Direct-Pay Practice Models, Economic Issues, Health Insurance, Healthcare financing, Individual Market, Insurance subsidies, Medicaid, Medicaid Expansion, Medical Costs, News From Washington, Patient Safety, Policy Issues, Reforming Medicaid, Subsidies, Uncategorized

Options Will Increase, Sky Will Not Fall, If ACA Ends

For example, the AMA complains that hundreds of millions would be at risk of losing “coverage.” In fact, only a net 1.7 million people gained private coverageunder ACA, after subtracting the nearly 6 million who lost it, at a shocking cost of $341 billion or $200,000 per newly insured person. Most of the claimed increased coverage came from expanding Medicaid to childless, able-bodied adults. This reduced access to services by the sickest patients, and at least 21,904 patients died on Medicaid waiting lists according to a 2018 report.

Without ACA and its unaffordable requirements, Americans would have many more options to buy affordable insurance. Instead of paying as much as a mortgage payment for “coverage” they are unlikely to use, they might join a DPC (direct primary care) practice and get preventive care and routine medical treatment for at as little as $50/month. They might buy catastrophes-only major medical insurance that ACA outlaws for persons over 30 years of age. Congress might enact Health Freedom Accounts as proposed by Rep. Chip Roy (R-Tex.) and liberalize Health Reimbursement Accounts.

https://mailchi.mp/aapsonline/aca-standing-639035?e=f50410ece3