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17% of Healthcare Execs Said AI Would Affect Financial Outcomes
• 60% of respondents expect AI to impact clinical outcomes. • 17% said AI would affect financial outcomes. • 13% said AI would impact their operation outcomes. • 9% said AI would impact administrative outcomes. • 61% of executives hope to bring about a complete digital transformation in their organizations within three to five years.
Former: CEO and Founder Superior Consultant Company, Inc. [SUPC-NASD]
EDITOR’S NOTE:I first met Rich in B-school, when I was a student, back in the day. He was the Founder and CEO of Superior Consultant Holdings Corp. Rich graciously wrote the Foreword to one of my first textbooks on financial planning for physicians and healthcare professionals. Today, Rich is a successful entrepreneur in the technology, health and finance space.
-Dr. David E. Marcinko MBA CMP®
***
By Richard Helppie
Today for your consideration – How to fix the healthcare financing methods in the United States?
I use the term “methods” because calling what we do now a “system” is inaccurate. I also focus on healthcare financing, because in terms of healthcare delivery, there is no better place in the world than the USA in terms of supply and innovation for medical diagnosis and treatment. Similarly, I use the term healthcare financing to differentiate from healthcare insurance – because insurance without supply is an empty promise.
This is a straightforward, 4-part plan. It is uniquely American and will at last extend coverage to every US citizen while not hampering the innovation and robust supply that we have today. As this is about a Common Bridge and not about ideology or dogma, there will no doubt be aspects of this proposal that every individual will have difficulty with. However, on balance, I believe it is the most fair and equitable way to resolve the impasse on healthcare funding . . . .
Let me start in an area sure to raise the ire of a few. And that is, we have to start with eliminating the methods that are in place today. The first is the outdated notion that healthcare insurance is tied to one’s work, and the second is that there are overlapping and competing tax-supported bureaucracies to administer that area of healthcare finance.
Step 1 is to break the link between employment and health insurance. Fastest way to do that is simply tax the cost of benefits for the compensation that it is. This is how company cars, big life insurance policies and other fringe benefits were trimmed. Eliminating the tax-favored treatment of employer-provided healthcare is the single most important change that should be made.
Yes, you will hear arguments that this is an efficient market with satisfied customers. However, upon examination, it is highly risky, unfair, and frankly out of step with today’s job market.
Employer provided health insurance is an artifact from the 1940’s as an answer to wage freezes – an employer could not give a wage increase, but could offer benefits that weren’t taxed. It makes no sense today for a variety of reasons. Here are a few:
1. Its patently unfair. Two people living in the same apartment building, each making the same income and each have employer provided health insurance. Chris in unit 21 has a generous health plan that would be worth $25,000 each year. Pays zero tax on that compensation. Pat, in unit 42 has a skimpy plan with a narrow network, big deductibles and hefty co-pays. The play is worth $9,000 each year. Pat pays zero tax.
3. The insurance pools kick out the aged. Once one becomes too old to work, they are out of the employer plan and on to the retirement plan or over to the taxpayers (Medicare).
4. The structure is a bad fit. Health insurance and healthy living are longitudinal needs over a long period of time. In a time when people change careers and jobs frequently, or are in the gig economy, they are not any one place long enough for the insurance to work like insurance.
5. Creates perverse incentives. The incentives are weighted to have employers not have their work force meet the standards of employees so they don’t have to pay for the health insurance. Witness latest news in California with Uber and Lyft.
6. Incentives to deny claims abound. There is little incentive to serve the subscriber/patient since the likelihood the employer will shop the plan or the employee will change jobs means that stringing out a claim approval is a profitable exercise.
7. Employers have difficulty as purchasers. An employer large enough to supply health insurance has a diverse set of health insurance needs in their work force. They pay a lot of money and their work force is still not 100% happy.
Net of it, health insurance tied to work has outlived its usefulness. Time to end the tax-favored treatment of employer-based insurance. If an employer wants to provide health insurance, they can do it, but the value of that insurance is reflected in the taxable W-2 wages – now Pat and Chris will be treated equally.
Step 2 is to consolidate the multiple tax-supported bureaus that supply healthcare. Relieve the citizens from having to prove they are old enough, disabled enough, impoverished enough, young enough. Combine Medicare, Medicaid, CHIP, Tricare and even possibly the VA into a single bureaucracy. Every American Citizen gets this broad coverage at some level. Everyone pays something into the system – start at $20 a year, and then perhaps an income-adjusted escalator that would charge the most wealthy up to $75,000. Collect the money with a line on Form 1040.
I have not done the exact math. However, removing the process to prove eligibility and having one versus many bureaucracies has to generate savings. Are you a US Citizen? Yes, then here is your base insurance. Like every other nationalized system, one can expect longer waits, fewer referrals to a specialist, and less innovation. These centralized systems all squeeze supply of healthcare services to keep their spend down. The reports extolling their efficiencies come from the people whose livelihoods depend on the centralized system. However, at least everyone gets something. And, for life threatening health conditions, by and large the centralized systems do a decent job. With everyone covered, the fear of medical bankruptcy evaporates. The fear of being out of work and losing healthcare when one needs it most is gone.
So if you are a free market absolutist, then the reduction of vast bureaucracies should be attractive – no need for eligibility requirements (old enough, etc.) and a single administration which is both more efficient, more equitable (everyone gets the same thing). And there remains a private market (more on this in step 3) For those who detest private insurance companies a portion of that market just went away. There is less incentive to purchase a private plan. And for everyone’s sense of fairness, the national plan is funded on ability to pay. Bearing in mind that everyone has to pay something. Less bureaucracies. Everyone in it together. Funded on ability to pay.
Step 3 is to allow and even encourage a robust market for health insurance above and beyond the national plan – If people want to purchase more health insurance, then they have the ability to do so. Which increases supply, relieves burden on the tax-supported system, aligns the US with other countries, provides an alternative to medical tourism (and the associated health spend in our country) and offers a bit of competition to the otherwise monopolistic government plan.
Its not a new concept, in many respects it is like the widely popular Medigap plans that supplement what Medicare does not cover.
No one is forced to make that purchase. Other counties’ experience shows that those who choose to purchase private coverage over and above a national plan often cite faster access, more choice, innovation, or services outside the universal system, e.g., a woman who chooses to have mammography at an early age or with more frequency than the national plan might allow. If the insurance provider can offer a good value to the price, then they will sell insurance. If they can deliver that value for more than their costs, then they create a profit. Owners of the company, who risk their capital in creating the business may earn a return.
For those of you who favor a free market, the choices are available. There will be necessary regulation to prevent discrimination on genetics, pre-existing conditions, and the like. Buy the type of plan that makes you feel secure – just as one purchases automobile and life insurance.For those who are supremely confident in the absolute performance of a centralized system to support 300+ million Americans in the way each would want, they should like this plan as well – because if the national plan is meeting all needs and no one wants perhaps faster services, then few will purchase the private insurance and the issuers will not have a business. Free choice. More health insurance for those who want it. Competition keeps both national and private plans seeking to better themselves.
Step 4 would be to Permit Access to Medicare Part D to every US Citizen, Immediately
One of the bright spots in the US Healthcare Financing Method is Medicare Part D, which provides prescription drug coverage to seniors. It is running at 95% subscriber satisfaction and about 40% below cost projections.
Subscribers choose from a wide variety of plans offered by private insurance companies. There are differences in formularies, co-pays, deductibles and premiums.
So there you have it, a four part plan that would maintain or increase the supply of healthcare services, universal insurance coverage, market competition, and lower costs. Its not perfect but I believe a vast improvement over what exists today. To recap:
1. Break the link between employment and healthcare insurance coverage, by taxing the benefits as the compensation they are.
2. Establish a single, universal plan that covers all US citizens paid for via personal income taxes on an ability-to-pay basis. Eliminate all the other tax-funded plans in favor of this new one.
3. For those who want it, private, supplemental insurance to the national system, ala major industrialized nations.
4. Open Medicare Part D (prescription drugs) to every US citizen. Today.
According to One Survey, only 4% of People Understand the Basic Insurance Terms of Deductible, Co-Insurance, Copay and Out-of-Pocket Maximum.
In Another Survey by United Healthcare Itself, Only 9% Understood the Terms Premium, Deductible, Co-Insurance and Out-of-Pocket Max.
This Lack of Understanding is Not the Fault of the Employee Benefits Professionals or the Employees… Rather, the Health Insurance Plan Designs Are Just Too Complicated.
In case you missed it: If you or a loved one are 50 or older, or are moderately or severely immunocompromised, you can get an additional Pfizer or Moderna COVID-19 booster shot at no cost to you.
The CDC recommends an additional booster shot for certain individuals to increase protection from severe disease from COVID-19. People over the age of 50, or who are moderately or severely immunocompromised, can get an additional booster of Pfizer or Moderna 4 months after their last dose.
This is especially important for those 65 and older who are at higher risk from severe disease and most likely to benefit from getting an additional booster.
Learn More: Remember: Medicare covers the COVID-19 vaccine, including booster shots, at no cost to you. Find a COVID-19 vaccine location near you.
A survey was recently conducted by Centivo of 805 US adults ages 18-64 with employer-sponsored private health insurance. The survey found that respondents were willing to accept the following conditions in exchange for significant cost savings:
• 50% would accept referrals for specialists as a requirement. • 47% would select a primary care physician (PCP) from a defined list. • 30% would give up their current PCP. • 28% would stop seeing a current specialist.
1) Traditional Medicare: Health Insurance for Seniors 65 and older. Medicare Part A is coverage for hospital services. Medicare Part B is coverage for doctor, physical therapist and other provider services and for outpatient services such as labs and imaging.
2) Medicare Advantage: Health Insurance for Seniors 65 and older administered through a private health insurance company. It is sometimes referred to as Medicare Part C. It can be chosen instead of Traditional Medicare and often includes Dental Insurance, Vision Insurance, Hearing Aid Insurance and Prescription Drug Coverage.
3) Medicare Part D Prescription Coverage: Additional insurance for people on Traditional Medicare to cover their prescription medications as well. Medicare Part D is administered by private insurance companies.
4) Medicare Supplement Plans: Insurance that can be purchased in addition to Traditional Medicare to cover the expenses that Traditional Medicare does not cover, such as hospitalization deductibles and Medicare Part B co-insurance.
5) Medicaid: The health insurance program administered by each state for it’s economically disadvantaged residents. It is funded in part by the Federal Government and in part by each state. It is administered by private health insurance companies.
6) Affordable Care Act (ACA) Exchange Plans: Health insurance for people under 65 who make too much money to qualify for Medicaid, but do not received health insurance through their employer. ACA Exchange Plans are subsidized by the Federal Government and administered by private insurance companies.
A stop-loss health insurance policy covers claims above a health insurance plan’s retained claims. The claims fund of a self-funded employer will pay claims up to the predetermined deductible for each of the company’s covered employees. The role of the stop-loss is to cover all claims above these deductible levels.
According to RoundStone Insurance, aggregate stop-loss insurance is designed to protect an employer who self-funds their employee health plan from higher-than-anticipated payouts for claims. Stop-loss insurance is similar to high-deductibleinsurance, and the employer remains responsible for claims below the deductible amount.
An individual stop-loss insurance carrier determines the average expected monthly claims per employee / per month PEPM based on the employer’s history. Then, this figure is multiplied by a percentage ranging from 110%-150%. That determined amount is then multiplied by the enrollment on a monthly basis to establish the aggregate deductible.
An accumulator is a running total of money you’ve paid towards your out-of-pocket max for covered services. This includes any copayments, coinsurance, and other health care costs, but not your monthly premium payments.
A Professional and Personal look at Health Insurance, with Karl Albrecht
Rich talks with the president of Action Benefits, Karl Albrecht about the state of Health Insurance.
Albrecht also gives a candid insight to his personal fight with pancreatic cancer and how being a Health Insurance executive as well as a patient, has given him a unique perspective on how things work, and how they could improve.
• 34% of physicians report that PA has led to a serious adverse event for a patient in their care. • 24% of physicians report that PA has led to a patient’s hospitalization. • 18% of physicians report that PA has led to a life-threatening event or required intervention to prevent permanent impairment or damage. • 8% of physicians report that PA has led to a patient’s disability/permanent bodily damage, congenital anomaly/birth defect or death.
An annual study of over 1,500 U.S. consumers, shows:
• 55% of consumers find it stressful paying a healthcare bill. • 53% of consumers find it stressful understanding their plan’s coverage and benefits. • 53% of consumers find it stressful comprehending what they owe. • 59% of consumers find it stressful reconciling a bill issue with their payer.
Average Annual Growth Rates of Spending, Utilization, and Prices
• Spending per person: commercial insurers (3.2% per year); Medicare fee for service (1.8% per year) • Utilization per person: commercial insurers (0.4% per year); Medicare fee for service (0.5% per year) • Prices paid to providers: commercial insurers (2.7% per year); Medicare fee for service (1.3% per year).
Notes: For hospitals and physicians’ services, 2013-2018 Source: Congressional Budget Office – January 2022
On December 15, 2021, the Centers for Medicare & Medicaid Services (CMS) released a report detailing healthcare spending in the U.S. in 2020, which confirmed the outsized impact the COVID-19 pandemic has had on the nation’s healthcare industry and on federal spending. Overall, healthcare spending increased 9.7% in 2020 (to $4.1 trillion), double the 2019 increase of 4.3%. Healthcare spending also became a larger share of the U.S. gross domestic product (GDP) in 2020. This Health Capital Topics article will review the notable findings included in CMS’s report. (Read more…)
42.7% of physicians in practices that participated in a commercial ACO
An AMA survey of 3,500 physicians finds steady growth of physician participation in accountable care organizations (ACO) and medical homes:
• Nearly one-third of doctors worked in practices participating in medical homes in 2020, up from 23.7% in 2014 • 42.7% of physicians were in practices that participated in a commercial ACO in 2020, up from 31.7% in 2016 • 29.5% of physicians were in practices took part in a Medicaid ACO, up from 20.9% in 2016 • Share of physicians in practices involved in Medicare ACOs has risen from 28.6% in 2014 to 36.7% in 2020 • 32.3% of doctors worked in practices participating in medical homes in 2020, up from 23.7% in 2014
With 43 Million Americans Having Lost Their Job at Some Point During the Pandemic and About 1/2 Those Jobs Providing Health Insurance… the 1st Group–People Who Do Not Have Health Insurance–Needs to Be Aware of How These Programs Work.
In this Video You Will Learn the Patient Assistance Program Process for:
1) 2 of the Most Common Types of Insulin
2) The Highest-Revenue Medication in America: Humira
**Note: At the Time of the Video’s Recording, the Unemployment Rate in the US was 15%. As of November 2021, the Unemployment Rate is 4.2%.
31% of Americans Don’t Know How They’d Pay for Severe Illness
A recent survey by HealthcareInsider that polled 1,062 adults aged 18 and up asked, “If you were to experience a severe illness how would you pay for treatment?”
• Don’t know: 31% • Credit card: 26% • Non-retirement savings: 17% • Borrow money from family: 16% • Retirement savings: 11% • Health Savings Account: 9% • Borrow from a finance institution: 8% • Crowdfund online: 6%
Wendell Potter is a Famous Ex-Executive from Cigna Who Left His High Paying PR Job in 2007 to Reveal the True Story Behind Health Insurance Carrier Public Relations.
Health care in the US is technologically advanced but expensive, costing about $3.6 trillion in 2018, which was 16.9% of gross domestic product (GDP) (1). This percentage is significantly higher than in any other nation.
According to the Organization for Economic Cooperation and Development (OECD), in 2018 the next highest spending countries were Switzerland (12.2% of GDP) and France, Germany, Sweden, and Japan (each about 11%), while the average of the 35 OECD countries (OECD35) was 8.8% (2).
ASSESSMENT: Of course, the absolute amount and the rate of increase of health care spending in the US are widely regarded as unsustainable. Consequences of increased US spending on health care include the following:
In this episode the Entrepreneur MD is joined by Dr Robert Pearl, MD, to talk about his latest book Uncaring and the need to stand up against the current healthcare model.
Uwe Reinhardt PhD was a Princeton Healthcare Economist Who Passed Away in 2017. He Was Possibly the Most Well Known Healthcare Economist in America and Even the World.
Claims Adjudication Occurs between a Healthcare Provider Submitting a Claim to a Health Insurance Company and the Insurance Company Making a Payment Back to the Provider.
Health Insurance Business Harms Doctors, Patients and Hospitals –Inside Healthcare with Nate Kaufman–
Rich Helppie brings back healthcare expert and consultant, Nathan Kaufman, Managing Director of Kaufman Strategic Advisors.
Rich and Nate talk about the current policy issues surrounding healthcare, and why the United States’ approach to health insurance, care and finance are woefully inadequate in today’s landscape.
To keep up with the ever-changing field of health care, we must learn new and re-learn old terminology in order to correctly apply it to practice. By bringing together the most up-to-date abbreviations, acronyms, definitions, and terms in the health care industry, the Dictionary offers a wealth of essential information that will help you understand the ever-changing policies and practices in health insurance and managed care today. For Further Information.
Review
The Dictionary of Health Insurance and Managed Care lifts the fog of confusion surrounding the most contentious topic in the health care industrial complex today. My suggestion therefore is to ‘read it, refer to it, recommend it, and reap’.” —Michael J. Stahl,PhD, Physician Executive MBA Program, William B. Stokely Distinguished Professor of Business, The University of Tennessee, College of Business Administration
“The Dictionary of Health Insurance and Managed Care lifts the fog of confusion surrounding the most contentious topic in the health care industrial complex today. My suggestion therefore is to ‘read it, refer to it, recommend it, and reap’.”
—Michael J. Stahl, PhD, Physician Executive MBA Program [William B. Stokely Distinguished Professor of Business]
The University of Tennessee, College of Business Administration
Health Insurance Carriers Are Misaligned by Owning PBMs That Make More Money in Rebate Kick-Backs When the Employee Health Plan Spends More Money on Expensive Prescription Drugs.
Doctors Are Misaligned When They *Are Employed by Hospitals That Tie Test and Procedure Ordering Volume to Doctor Compensation.
Hospitals are Misaligned When They Buy Physician Practices and Raise the Prices for In-Office Testing and Procedures by 300%… Even Though NOTHING Has Changed Other Than the Sign on the Door.
Accordingly, True Employee Health Plan Innovation is ALIGNMENT Innovation That Provides Care Outside the of the Status Quo Fee-for-Service System.
Onsite Clinics, Near Site Clinics, Direct Primary Care and Capitated Virtual Care All Provide Real Alignment Innovation for Employee Health Plans.
Specifically, Forrester Research Says That Customer Service is ‘Poor’ at Blue Cross of Texas and Illinois, Blue Shield of California, CareFirst Blue Cross, Anthem, United Healthcare, Cigna and Aetna.
Hospital Billing Customer Services Is Bad Too.
Hospital Billing Complexity is So Troublesome to Patients, that 40% Say They Avoid Preventive Care and Screening Tests Just to Avoid the Billing Headache.
Healthcare Customer Service is Terrible Because Health Insurance Companies and Hospitals Do Not Need Good Billing Customer Service to Be Successful, As Demonstrated by High and Rising Health Insurance Stock Prices and Large and Growing Hospital System Revenue.
For Health Insurance Companies and Hospitals, Not Fixing Their Poor Customer Service May Be a Calculated Business Decision.
Implications:To Help Make Their Employees’ Lives Better, Employers May Need to 1) Hire a Healthcare Navigation Company or 2) Deliver More Care to Their Plan Members Outside of the Traditional Health Insurance and Hospital Systems… and Avoid the Terrible Customer Service All Together.
Disclaimer: Dr. Bricker is the Chief Medical Officer of Virtual Care Company First Stop Health and is the Former Co-Founder of Compass Professional Health Services.
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