Daniel H.’s Post

Can’t we just make health insurance work better? Sorry, but No. This was a question recently posed to me on a LinkedIn thread. Please see my response. There is no saving the current system because it’s inherently flawed. The only time we should be reliant upon insurance is for catastrophic things like hospitalizations and surgery. That would allow insurance to work like every other insurance model where they cover catastrophic and uncommon events. By relying on insurance every time we see our primary care doctor, we increase the cost of healthcare because we are using the most expensive mechanism to pay for care. Primary care doctors can manage more than 80% of the average patient needs. If you were at My Practice, you would pay $1800 per year for full primary care services. However, we’re spending $12,000 per year per American and getting worse health outcomes. I recently had a patient decline to join My Practice because she wanted to use her insurance. She is paying$1800 per MONTH (remember, that would be a year worth of care with me), but she cannot find a physician to see her in a timely fashion. It’s time to change the whole system and our thinking about how we pay for healthcare. #dpc #healthcare

Who do you want making your medical decisions? Do you want your physician who has a relationship with you, and actually sees you to make them? Or do you want your health insurance company who saves money on denials making the decisions. Obviously we all want our physicians making our medical decisions, and physicians obviously are the ones who want to make them. No one wants a health insurance company denying them care that their doctor thinks is necessary. In orthopedics, we mostly get focused on MRIs and elective surgeries. But this is happening in oncology too, where a health insurance denial could contribute to your suffering and perhaps early death. It is happening across the board, as health insurance denials become automated. I think that we will see increased denials as time goes by because health insurance companies make money from them, and have no legal accountability if harm comes to a patient. At the very least, health insurance companies should have medical liability for denying a claim that caused a patient harm. #healthcare #medicine #healthinsurance

25 million Americans were uninsured in 2023 according to HHS. 11% of Nevadans were uninsured in 2023. If you make more than $20k annually, you don't qualify for the State Medicaid Program. The average food service worker in NV makes $47k annually, $39k net. In this example, using the NV Health link website to compare plans, this individual can expect to pay between $130 - $180 for monthly health insurance. The least costly plan comes in around $130 monthly, $7,500 annual deductible and $45 copay for office visits. I think a state funded secondary insurance program that covers out of pocket costs such as deductibles and copays could improve access to care for millions. #healthcare

(STAT) - "Biden Admin Rule Forces Insurers To Not Dilly-Dally On Prior Authorization." A new rule now applies to health insurance companies that offer Medicare, Medicaid, Children's Health Insurance Program, and Obamacare plans. It forces insurers to explain specifically why they denied coverage, and to speed up the pre-approval process. Find A Better Health Insurance Plan At: HI4E.org #MedicalProcedures #MedicalClaims #PreCertification #MedicalPreAuthorization #BidenHealthcare #BidenPreSertificationRule #HI4E.Org #MedicaidPlans #PriorAuthorizationOfMedicalSvcs #Stat #HealthInsurance4Everyone #HealthAndLifeSolutions #UnscheduledMedicalProcedures #MedicarePreCertification #MedicalBilling #CHIP #ObamacarePreCertification #PreApprovalProcess #PriorApprovalRuleForObamacare #HI4E.Org #ObamacareRestrictions #TrumpHealthcareReforms #PreAuthorizationRequirements #HealthInsurersPreCertification

Excellent thoughts by Dr Paull! I would like to add a thought. DID YOU KNOW: Approved prior-authorization is not a binding agreement that insurer will cover the procedure/imaging in question?!?! I’m not even talking about meeting the deductible so the insured may be responsible for some or all of the cost according to their health plan. I mean, it is not a guarantee of coverage AT ALL. How many physicians schedule the requested procedure or imaging once prior authorization is approved? Answer: Nearly every one! I had a patient, who also happened to be a physician, I requested prior authrization for viscosupplemention knee injection. PA was approved and injection was performed. 4 months later they recieved a bill for the entire amount of the injectate (>$1100)!!!! I immediately called my billing/coding department. They informed me “Approved prior authorization is NOT a guarantee of payment or coverage.” This patient had also never heard this absurdity in their 15+ years of practice. WHAT. THE. HELL. IS. THE. POINT.

Perfect explanation of the value of Direct Primary Care!

Here is an irony: someone gets health insurance with massive monthly premiums, only to never want to use it, and instead pay cash for care as it saves them money. So they purchase insurance for coverage, and then are too scared to use it because when they go in system, they have no idea how much they are going to have to pay. This is especially true if they have a high deductible. In this case, their health insurance is really for catastrophic care only. Patients like these are often the ones that find direct care. They have insurance, but direct care is still the most economical option. This goes against the notion (which is false) that direct care only caters to the healthy and wealthy. Direct care caters to those who don't have insurance, or who have a high deductible insurance. It is the most economical option. These people are not being taken care of well by the current system. Not to mention that the quality of care with Direct care is usually much higher for any given doc as much more time is allotted for appointments. I was lucky enough to be on a virtual panel last night to explain direct care to medical students. Things are changing! #healthcare #medicine #healthinsurance #directcare

We hear all the time that our healthcare system is broken. But it depends who you ask. For physicians and patients, it certainly is broken. Not much emphasis is actually placed on the doctor patient relationship, and the system has created a high volume low quality standard of care. Patients are unhappy and physicians are burnt out and miserable. But, if you are a large hospital system or a health insurance company things have never been better! Large hospital systems gobbling up everything they can while not paying taxes! I wish I didn't have to pay taxes so I could buy every property and practice I see! Health insurance companies raking in billions while denying necessary treatment for those patients who pay their premiums. Stock prices going up up up! Time are very good if you are a health insurance company. So for those who actually use the healthcare system, it is indeed very broken. But for those large corporations that profiteer from it, it is working just as intended. #healthcare #medicine #healthinsurance

Read this... important work that opens up the possibility of returning to a rational health insurance structure. Paying $24k in premiums and another $14k in out of pocket expenses before having coverage is ridiculous. When you think about the fact that only 20% of individual meet their deductible (not their full OOP responsibility) in a given year, a cash based structure with an insurance plan for catastrophic coverage makes sense. Thanks to Ge Bai and colleagues for raising awareness of this critical issue.

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