Health Equality

#tomitschhealthcare #tomitschhealth

HEALTH is a human right and the healthcare supports that goal.. The United States can afford to ensure health for everyone.

PROBLEM:

  1. Medicare for All (M4A) is problematic for the following reasons

    1. Just like the Affordable Care Act (ACA), it can be changed (or attempted to change) by any administration as is with the case of the current administration's court filings trying to remove protections for pre-existing conditions among others.

    2. The medicare billing model is problematic because it causes a huge bloat between price and cost. This billing model is also what private insurance companies use. This model is nonsensical. Essentially every element is charged like a standalone service, there are no economies of scale of combined services.

    3. It also negates the patient/doctor relationship

  2. Insurance companies are public-good companies and should not be publicly traded because of the conflict-related to making the stock prices go up vs patient care. The upside of publicly-traded companies, however, is the oversight component. If private, then there needs to be a complete audit yearly.

  3. The patient has more cost-share than ever before. Just years ago most plans were copay plans, which were reasonable. Therefore, it didn’t matter what the provider-insurer payment agreements were since it was largely taken care of. Now, we have significant premiums (whether personally paid or shared with the employer) and significant deductibles. The insurer, even though paid by patient/employer and in service of the patient *does not* work in our behalf. 

  4. Insurance companies absorb so much money that could pay for care/prescription subsidies. For example in 2018, CIGNA collected $36,000,000,000 (36B) in premiums resulting in a Net Income of $2.64B. They spent $11,934,000,000 ($12B) on administrative and marketing. The shareholder net income is stated at $2,700,000,000 ($2.7B). Therefore, lost care cost efficiency is $14,700,000,000. And this is just *one* insurance company https://www.cigna.com/static/www-cigna-com/docs/about-us/investor-relations/annual-reports-and-proxy-statements/cigna-2018-annual-report.pdf (page 72)

    Also, bear in mind that every doctor’s office, hospital, other medical service providers have billing specialists, another absorber of funds that could go direct to care.

  5. Then, reported winter 2020 - https://www.stopsurprisemedicalbills.com/post/united-s-14-billion-year

 

PLAN:

We need to get back to a cash basis, where the patient has the pricing leverage and control of their own health services. (Some of my experience is delineated below.)  We can get that by modifying the Health Savings Account (HSA) program.

Instead of paying premiums, people and companies can choose to pay into a personal HSA without an insurance plan. This account builds from year to year (and is also a retirement vehicle) and by not spending on premiums and deductibles, the balance can become substantive quickly. The HSA would also have an HSA-fee/tax that goes to a general fund so when you have an event that requires more than your HSA savings, you can still file against the general fund. HSA debit cards are restricted to approved providers and drugs, whether prescription or over the counter.  Some of the general fund would be used to subsidize critical prescriptions/services like birth control, insulin, etc.

Clearly, we have ACA in place now and it is not possible to abandon it. But if we add a cash-based component then we can give people options and then have proper market drivers to make the cost basis more in alignment with real costs as compared to what the medicare billing model is offering.

Another benefit to going to a cash-basis system it’s much harder to defraud since the patient is paying directly on a cash basis.  https://www.justice.gov/opa/pr/four-detroit-area-physicians-found-guilty-health-care-fraud-charges-role-over-150-million

MY STORIES

  1. I have been on a corporate policy, bought on the market place as a single person, and been on a cash basis.

  2. The corporate insurance was a co-pay only plan. Super generous, so I never had a worry about medical needs being covered.

  3. I bought CIGNA plans for two years and came to the realization that it was a waste of money. I was spending $5,000 in premiums and had to expend $5,000 in deductible before I got any care, which was difficult to do. It also removed my choice if I wanted to pay cash it is not allowed.  It takes all pricing leverage and control away from the patient that pays and the patient that is served.

  4. 2016, I had a balloon sinusplasty. (yes, it’s terrible). When I talked to the billing person for the quote, she stated it was $4,000. What she meant is it was $4,000 PER SINUS of which they did 3 of them. My bill was $14,000, after deductible was expended, I still owed about $5,000, which took me more than a year to pay off.   It was very frustrating that it was done during the same 1-hour office visit, with the same team, same device and they charged per sinus like it was three individual appointments. The Medicare/insurance billing model doesn’t allow for economies of scale. They also charged me twice to cauterize each side. Additionally, I tried to negotiate it and there is no wiggle room to do much in discount because the provider can be audited by the insurance company and lose billing priveledges. This 1-hour procedure was billed at far more than my son’s actual surgery in a hospital with anesthesia.

  5. One time, I needed to see my orthopedic surgeon. I had written orders for the x-ray from the operating surgeon. However, the insurance required a referral. I didn’t have to go in because the doc was familiar but still needed a referral. He called one in. I go to the imaging center will the written orders in had. They try to x-ray the wrong side. They wouldn’t listen to me, they wouldn’t use the operating surgeon’s written orders, they insisted that they needed to call the GP, who did not operate, to fix the order. I was livid that I, or my operating surgeon didn’t have the authority to change the order. A GP’s that hadn’t done treatment order took precedence.

    And these plans interfere with my ability to make my own decisions about my health and my medical needs. Most of the plans available now require referrals from the general practitioner (GP). This just wastes time by having to schedule a GP appointment, that might take weeks and cost additional money to have the extra appointment.

  6. Over the last several years, I gave up on buying insurance because of the aforementioned $10,000 per year I was paying before I got services (and that’s just one year). My experience has made much more sense to go to a cash-based system. Granted, I don’t have a chronic illness and do not expect to need major surgery for awhile.  That being said.

    1. I can go to any provider I choose without a referral.

    2. I can pay the cash price, which they can tell me with certainty what that is before we do anything. There is never the ala-carte billing like you get with insurance. (I once got charged for the use of a pulseox when I had bronchitis)

The benefit became obvious when I got a new set of tear-duct plugs on a cash basis. Typically, the doctor is required to charge a $200/tear duct ‘surgical’ charge and $50 each for the plug. There are four tear ducts so this is a charge to insurance of $1200, including the doctor visit fee. The insurance paid about $200 and I was stuck with a $1,000. On cash, I only had to pay $200 all in for all 4.

©2020 by Melanie Tomitsch. Proudly created with Wix.com