Thank you for the consideration of a vision of a new Health Care System. After your review, please comment how your experience has been with the current healthcare system. If you can see the vision as well to a new system please comment. Lastly, if you see a potential obstacle please comment your solution.
The Problem: Current ‘System’
I pay $400 a month for Healthcare insurance. I have to pay a $4,500 deductible before my insurance will pay 80% of my medical bill. That is $4,800 a year just to hold a special card to get discounts ( contractual agreement) from a select line of providers. My insurance does pay for my free preventive exams once a year at 100%. This kind gesture ranges from $200-$500 when using a preventive diagnosis. I find it hard to meet my deductible each year. often paying $2,000-$3,000 for services didn’t provide any significant care for my family.
Lets sum this up. I pay $4,800 a year to have a card for ‘special access’ + $4,500 out of my pocket before my insurance pays. That is $9,300 each year before the insurance pays a portion on my claim. Please note, they do pay for your $500 preventive exam and services at 100%. This exchange does not seem like a win-win solution.
Now, lets go over a real example of the claim process. I visited the ER in 2020 and due to a clinical error spelling my name, I received a bill to pay $176 for the facility charge as a self pay patient. It took 2 years and multiple calls to update my name and insurance information. Once corrected my insurance was billed $2,000 for the ER facility charge and my responsibility was $400. Just to clarify, I am paying $400 a month to pay a higher rate? But what about my insurance discount?
This process doesn’t seem fair to me as a patient, but it also doesn’t seem fare to the provider. The provider who assisted me works who knows how many hours each week, spent countless hours bettering his medical decisions, and it took 2+ years for payment. During this 2+ years my claim had been touch by numerous administration reps. Coding to Billing to Insurance- Customer service calls- back to billing- statements sent ( mail room and paper cost)- to the patient… me. this cycle happened 4 times during these 2 years. This seems like a complex process for just my ONE claim. Can you imagine how many claims one provider sends a month. Then imagine how many claims an insurance company receives in a month. Then imagine how many insurance companies there are in the U.S.A. My brain is about to explode with the thought of volume in one month.
Lets sum this up. I could have paid $176 at the time of service as Self Pay. But, by utilizing my $400 a month card I was able to pay $400 costing the facility administration burden utilizing time, salary and other resources for a 2 year delay.
This system is not a win for the patient, and it doesn’t sound like a win for the provider. So who is winning?
I have shared my experience by the prospective of the patient and the provider. Now let me explain how I have obtained this view. I spent 5 years working for facility and mental health providers. During this time I was able to work with the patients collecting payments, processing financial assistance, and appealing with insurance companies any denials received. I then spent 5 years working for the facilities sister insurance company as a medical coding analyst. During this time I would manually work claims, process provider appeals, while keeping up with the ever changing guidelines, internal and external. I then spent 5 years working for a medical tech solutions company as a Client Policy Specialist. During this time I sold edits within the company software to high level insurance executives on how we can offer solutions to ensure up to date payment/coding guidelines are met, prevent overpayment, and identify signs of FWA. This software addition is needed due to the cost of replacing the insurance’s ancient processing system. It is cheaper to hire a company to ensure proper responsibility rather than buying, training and implementing a new system.
Half of my life has been experiencing each step in our current system. The one constant is the people. Patients, providers or administration all wanted to do their best in their department. Often due to unrealistic expectations due to ‘the system’ most are in a constant state of stress or anxiety. Again, who is winning with this system?
THE STARTING POINT OF A SOLUTION:
I purpose a patient to provider payment system. This could be something as simple as an app. This is not an insurance. This would be free for the people to use basic services.
Basic services would include a variety of office and preventive care services listed of providers, their current cost of service and availability. The cost of services would utilize industry standard rates that can be adjusted at providers will. By empowering the patient with transparency of the cost prior to service, they are able to pay same day or set up a payment plan. The administrative burden is reduced significantly. With a plan like this I would be able to utilize my $400 I spend in premiums just for the card, for services and directly pay the provider.
Advance services would have a reasonable monthly fee that gives additional coverage for more reactive procedures such as In-patient, ER or other unexpected services. Depending on the additional services the associated fees would balance the fees of teams to update and manage the additional services.
With this straightforward system we would be able to transition the system to working for us rather than against us. This would then open up opportunities for additional advancements in healthcare. The analytics alone could correct and transform how we ‘practice medicine’. Alongside AI we would be able to advance medical technology/devices.
Thank you for reading to the end. If you want to see a change, I thank you for your vote.