We know that NOT to do with Health Coverage, but what is the Alternative?

We look at all the schemes and figure out which is best or what to do instead.

Introduction

Normally we talk about healthcare and health insurance in this space and today is no different.  

Jim Croce said

You don't tug on Superman's cape

You don't spit into the wind

You don't pull the mask off that old lone ranger

And you don't mess around with Jim

Roger Miller sang

You can't roller skate in a buffalo herd

You can't take a shower in a parakeet cage

Well, you can't go swimming in a baseball pool

You can't change film with a kid on your back

You can't drive around with a tiger in your car

You can't go fishing in a watermelon patch

Today we are going to discuss all the alternatives to traditional health insurance, their strengths, weaknesses and what we should actually do, up to and including just sticking with traditional health insurance.

The Choices

Let’s take a look at what traditional insurance entails and then we will discuss alternatives and the pros and cons of each

Traditional Insurance

Get it from your employer, healthcare.gov or just buy it from the seller.  What could be easier?  Since we are not really going to advocate for traditional insurance, we'll just cover the high spots with bullet points.

Strengths

• It's easy

Weaknesses

• Incredibly expensive
• Deductibles/copays/coinsurance - shifts the burden of payment to the patient in a blatant attempt to dissuade them from actually using the insurance.
• Denials - Your insurance company can just flat say “not medically necessary” and refuse to pay.  
• Networks - intended to dissuade the patient from getting care through geographical limitations.  
• Delays - for every day the insurer delays they receive more interest on your invested premium.

Some of these might not be something that you directly pay for, but they all come out of your pocket either directly or through increased expenses at the practice/hospital level.

Direct Primary Care

This little piece of wisdom is going to enrage a lot of Primary Care Physicians (PCPs) and I hope it does.  You see the problem with healthcare in the US is expense.  Direct primary care plus a catastrophic policy is more expensive than regular old insurance.

Let’s do some math.  I’ll do the math you watch.  I know you all hate the math. The average insurance premium is about $500.  It’s actually a little more, but let’s use that for argument.  The average DPC subscription is about $100 per month.  You save $400 per month, right?  

Wrong.

Primary care is only part of the problem.  You have to be covered for all the things that your PCP can’t do, like certain kinds of tests, inpatient, surgery etc. for those you need a catastrophic policy.  The average catastrophic policy is over $300 but we will use that to make the math easy and for argument.  So $100 +$300 is $400.  You saved  $100 per month. Not great but not bad, right?

Wrong.

The average ACA deductible is about $1790.  Catastrophic plans are simply designed to have a low premium, not actually DO anything so they generally have huge deductibles.  Kaiser documented these deductibles average over $10,000.

If you factor in the deductible for your mandatory catastrophic policy with your DPC subscription you are actually paying FAR more than a regular ACA plan.  Yes, your doctor loves you,  He doesn’t’ have to deal with your stupid, bizdiot run insurance company.  He also decreases his workload by about 80% because he can afford to now.  Here is an article that looks at the DPC scam in depth.

Nationalized Health Insurance

In an earlier article, we looked at various forms of nationalized health insurance.  We discusses the UK’s Beveridge system, that is bankrupting that country.  We discussed Canada's Medicare that is bankrupting that country.  We looked at Germany’s Bismarck system that is doing just fine, but the average German family can no longer afford one of those wonderful cars they make and ze Germanss pay about 56% more in taxes than you on average.  

None of those systems allow the patient to go to the doctor when they like and the vast majority of them can’t hire doctors for the money they have to pay, can’t build and maintain facilities with the available resources and have wait times for care that is simply killing patients

We can’t have nationalized care in the US.

Go tell that to Bernie and Co.  We are just barely affording what we have and allowing everyone to go get whatever they want whenever they want is a sure way to crash the healthcare system.  We would be spending all our time trying to separate the noise from the signal.  That means doing triage and not treating anyone.    

Medical Health Sharing Programs

Basically you have a group of like minded people who pool resources and pay for each other’s medical expenses.  Sounds great until you realize that you have a bunch of people doing exactly the same thing in exactly the same way as the big insurers, except they don’t have the economies of scale or the workforce to get all those nasty manual processes done.

Sure you don’t have the big profit motive, but you also don't have a workforce of hundreds of thousands getting your medical care paid for.  All they are doing is to just share the risk, which is precisely what the big insurers are doing.  The big insurers at least have real actuaries and can do the math even if they don’t show it to you.

Great idea.  Well, no, not really.  It isn’t really an idea at all, it is just doing what United Healthcare, et al., does without the resources to do it at scale.

Won’t work.

Health Share Ministries

We wrote an article about health share ministries a few months ago.  We concluded that the big difference between that and health insurance is the ministry part.  We don’t like the thought of the invisible man in the sky telling us what we can and can’t have in healthcare.  If you are smart, you don’t either.  Outside of the invisible man in the sky who loves you and wants to take care of you, this is the same thing as the Medical Health Sharing Programs.  

Health Savings Accounts (HSAs)

Health savings accounts are just another way some government official came up with to coerce the patient into paying for 100% of his medical care.  Sure, we should all be self-sufficient, but unless you want to go down the road with Canada and the UK, you just can’t afford not to spread the risk and shoulder the whole burden yourself.  

What happens if you have an accident and require emergency surgery and don’t have the funds for treatment? What happens if you have a heart attack and don’t have the funds for treatment?  Sure you go to the Emergency room.  Then we all pay for your lack of vision and forethought anyway, just at several times the going rate because EMERGENCY.

Nope, HSAs are a joke

Indemnity

An indemnity policy is one that pays a set price for whatever is covered.          As the patient, you can negotiate the price, the premium and what is covered.  There are no networks, you can see whomever you like, and there are no negotiated rates.  This keeps the lawyers away and therefore the costs down.

Buyer beware, however.  You pay for your care upfront and get reimbursed, afterward.  The price may not be adequate to cover the care you need and what you need might not be covered.    

Catastrophic Coverage

A catastrophic plan, as discussed above, is only available to people under 30 unless you qualify for a hardship exemption or an affordability exemption, which applies when Marketplace or job-based insurance is considered unaffordable for your income.  That puts the DPC above further away from viability.  This plan is for young, healthy people just to have some kind of safety net if something goes horribly wrong, not to provide real coverage to the general populace.  

What TO Do (The Alternative that DOES Work)

Now we know not to tug on Superman’s cape and not to swim in a baseball pool, but what do we do for health coverage?

Sentia has produced a data driven Electronic Medical Records System (EMR) that is data driven.  It is the only one of its kind.  We won’t go into all the benefits here, if you’ve been following along you know already, but we will hit the highlights of how this data-driven EMR is different and how with it, you can automate the entirety of the health insurance industry.

Benefits of a data-driven EMR

Nobody Reads your “Notes”

First, doctor, nobody reads your notes.  I know you are succinct and eloquent and you know that nobody reads them.  Having data will make your documentation searchable and only return relevant results instead of having to read reams of wandering, meandering prose that has little to nothing to do with the case, or that have been copied and pasted and contain wholly irrelevant information.  

Searching

With a data-driven EMR, you can do searches for the thing you are looking for.  Since the complaint is related to the symptoms are related to the lab results are related to the clinical observations are related to the diagnoses, are related to the treatments are related to the outcomes, you could literally pick the complaint and come up with a list of differential diagnoses and successful treatments.  You could start anywhere in that chain and enter new data.  It would condense the eight season, 177 episode, House television series into a five minute EMR search.  

 Aggregating

With a data-driven EMR you can produce population health reports detailing problems and allowing us to come up with overall solutions for any population no matter the size.  We can also produce individual health reports because the care is not hidden in typed in notes.

Integrated Health Coverage

Since Sentia built the world’s only data-driven EMR, we are the only ones who can integrate health coverage right into the EMR.  With reference based pricing, we suggest 150% of Medicare, we can pay for procedures performed in real time.  

This is real coverage with all the inherent actuarial math, just without all the administrative burden of medical coding, verification, adjudication, pre-authorization, denials, delays, insurance networks, rate negotiations and sales/brokers/agents.  That alone saves the patient about half from their premium

Practice/Hospital Management System (PHMS) 

Because we have a data-driven EMR, we can run a profit and loss )P&L) statement for any employee/doctor, room, procedure, piece of equipment, consumable, wing, floor or the entire enterprise for any time period, with the click of a button.  

That makes it exceedingly easy to find and fix cash leaks and streamline and automate the entire medical enterprise.  The combination of the integrated health coverage and the PHMS should save the enterprise about a quarter.

Health and Wellness

Because we have a data-driven EMR we can automatically prescribe patient education based on the patients procedures and lab results.  We have partnered with WebMD Ignite to provide this documentation.  Not only do we provide the education for the patient but the education includes a ‘temp gauge’ showing the patient graphically how immediate the problem is, plus instructions on how to fix the problem.

To give the education teeth, we offer a 1% discount for simply opening the education long enough to read it.  Then when the education is followed and the lab results come back in line with normal values, we offer an additional 14%, 15% total discount for staying healthy and saving us all money.

Almost 90% of healthcare spending in the US is on behavior-based, avoidable chronic disease. Simply getting us down to the OECD average mortality for behavior-based, avoidable chronic disease would save the US almost a trillion and half dollars on the cost of healthcare.

Conclusion

With the data driven EMR we can completely fix healthcare finance.  We demonstrated a way to save the patient half, the hospital or practice an additional 25%, and the population of the US about 75% from the cost of healthcare.  We do this with streamlining, automation and really thinking about solving the general problem and not just the easiest way possible.

We have shown a way to regulate every financial transaction a practice or a hospital enters into, the Practice/Hospital Management System (PHMS).  Included with the PHM is a workflow elimination tool that extracts more and better work from employees and streamlines and automates every facet of patient care.  All that increases revenue and decreases costs.

We have shown a way to incentivize healthy living in a population and decrease chronic disease and therefore decrease costs for us all in a streamlined and automated manner.  This alone has the potential to save $1.49 trillion or about 25% of healthcare spending in the US

We have shown a way to revolutionize the way medical records are thought of, executed, used and searched.  This eliminates Epic, all the legacy EMR vendors and makes research a simple pick and click operation, saving millions of lives.

We have shown a way to integrate health coverage into the EMR.  The practice or hospital gets paid as the practitioner documents patient care.  That eliminates medical coding, verification, adjudication, pre-authorization, denials, delays, insurance networks, rate negotiations, sales/brokers/agents, money for a third-party EMR, skyscrapers in every major city, hundreds of thousands of employees, all the insurance monkey business and reduces cost by about half. 

It also eliminates Epic/Cerner AND the legacy insurers.

It also makes your facility leaner faster, more efficient and more profitable.

This system includes the automation of the health insurance industry completely, eliminating more than half the costs by Sentia as the coverage company, employer based captive or TPA or by direct payments to doctors and practices.

Here are additional points detailing the costs incurred by the legacy insurance companies that you pay currently, in addition to wasting about half your premium, according to Grand View Research and current as of 2023 and that Sentia would eliminate completely:

Medical Records:

• The average practitioner spends $35,925 annually on electronic medical records
• The average patient spends $106 annually on electronic medical records
• The average patient encounter or visit cost for electronic medical records alone is $32

Medical Coding:

• The average practitioner spends $20,286 annually on medical coding
• The average patient spends $60 annually on medical coding
• The average patient encounter or visit cost for medical coding alone is $18

Compliance and Efficacy Reporting:

• The average practitioner spends $17,165 annually on compliance and efficacy reporting
• The average patient spends $51 annually on compliance and efficacy reporting
• The average patient encounter or visit cost for compliance and efficacy reporting alone is $15

Totals:

• The average practitioner spends $73,376 annually on completely avoidable costs
• The average patient spends $217 annually on completely avoidable costs
• The average patient encounter or visit cost for completely avoidable costs alone is $66

Yes, you read that correctly: $66 per visit. That is probably more than the practice makes on the average encounter.  There must be a better way. There is a better way and Sentia has it.

Remember also that these costs are over and above the 50%+ your insurance company wastes or shoves into their pockets.

Implementing this system should be fairly simple and will completely revolutionize the way healthcare is delivered and paid for, saving countless lives. We have shown a way to use this system to make the best healthcare system in the world also the most efficacious and the most affordable.

If you liked what you read contact us here, on our site, SentiaHealth.com, our parent company SentiaSystems.com, or send us an email to info@sentiasystems.com or info@sentiahealth.com.