Aren’t doctors supposed to be working for the patient?
In ancient China, the ideal doctor was the one who was able to teach a healthy lifestyle in order to prevent diseases. Doctors got paid when they were successful (in keeping their patrons healthy), not when the patients got sick (which was considered a sign of failure).
So why is it that in our ‘modern’ health care system, we do the exact opposite? When someone is sick, he suffers both physically and financially, and his employer suffers by lost productivity in the workplace. So it’s completely backwards to think that the healthcare provider actually benefits financially from that illness.
Wouldn’t it make sense if we turned that around? Shouldn’t we change that model so that physicians can more easily work to keep people healthy rather than gain from their illness?
Our health care system would in all likelihood work much better if everyone was aligned to do better with the same outcome and the same goal, to keep our patients healthy in the first place.
How can we get the physician (or nurse practitioner) back to working for the patient?
There is actually a new system that fits this model. It’s growing in popularity all across America, and it was popular even before the ACA was introduced and passed.
You might even argue that it’s more pertinent now, with the ACA mandates focused so much on preventative care.
It’s called Direct Primary Care, and it involves the physician receiving a flat monthly fee, either without any extra payments from an insurance company, or actually directly from the insurance company.
Almost all of the complications and hassles of healthcare payments and insurance are removed. By eliminating copays and deductibles and by providing unlimited visits, Direct Primary Care transforms the patient-physician relationship to that of a trusted healthcare advisor.
Many employers see this model as a real solution to lost productivity due to employee illness. There’s a lot of evidence that this really works.
By keeping employees healthy, this up-front preventive care avoids a lot of what we call ‘downstream encounters’. These are expensive tests such as MRIs and CT scans as well as treatments including hospitalization.
By removing obstacles to care such as copays, deductibles, limited office hours and locations, people will be more able and willing to see their primary care provider.
By connecting up-front, they address concerns before they become serious problems.
Insurance or Medicaid administrator?
Some insurance companies have seen the wisdom and benefit of this model and are offering it as an option when you select your primary care provider.
Fewer downstream expenses benefit the health and financial well-being of everyone involved; the patient, the employer, and even the insurer.
Interestingly, this free-market solution is good for state Medicaid administrators as well.
Some are finding that including a DPC provider produces the same benefits for Medicaid. So by doing so, the state taxpayers also win by saving money as well. This is a solution that`s actually good for everybody.
What is this brave new world of healthcare?
There’s now a lot of focus on preventative health care, rather than curative. Keep them healthy, don’t just wait and fix them when they’re broken.
We can do better.
We should be standing and running for prevention, and not just scrambling for the cure.
More and more people are demanding better access to affordable preventative healthcare, not just expensive and often unnecessary tests that follow the typical 7-minute physician appointment.
Instead, physicians should be spending 30 minutes with the patient, really working out the situation and then finding that they often don’t have to order a special test or refer to a certain specialist.
Sometimes it’s just a matter of having the time to sit down and truly connect with the patient.
You can’t do that in a 7-minute visit.
How can people make such changes happen?
Employers can ask their insurance companyand state legislators can discuss it with the various Medicaid administrators.
Everyone should be asking how can they all get more DPC providers in contract in this kind of model.
When the insurers and administrators see the interest, and when they realize that this actually benefits them too, they will not just listen, they’ll act, because they’ll quickly realize that it’s in their interest to act.
For more information, visit DirectYourCare.com, which is a St. Louis home-grown company.
(KPLR) – Dr. Sonny Saggar stopped by the studio to continue talking about the Affordable Care Act.
In the second segment of his three part series, he discussed money and Missouri.
What’s the same in every state?
When it comes to your health care options on the Marketplace, some things are the same in every state such as basic coverage.
The U.S. government sets basic guidelines for what are called ‘essential benefits’. Every health plan sold in the Marketplace has to offer them.
They include emergency care, pediatric care, maternity care, lab testing,and more.
There are upper limits on how much you have to spend before your insurance company starts paying toward your care. No plan can charge more based on your health or whether you’re a man or a woman.
Four levels of coverage
To make it easier to compare plans, every Marketplace will rank the types of plans according to the level of benefits they offer, from platinum (the most) to bronze (the least). There’s also a special plan for young adults.
What decisions can Missouri make?
Aside from those basic requirements, states that set up their own Marketplaces have a lot of control over what to include in their health coverage.
Which insurance companies get to sell on their Marketplace and how many
States can choose insurance companies and can set tougher rules for coverage than the federal guidelines require.
Some states, like California, are limiting the number of insurance companies selling on their Marketplace. They hope it will improve the quality of the plans offered. Other states are taking a different approach. For instance, Colorado will allow any insurance company to sell plans.
Treatments that are covered
States running their own Marketplaces can tell companies that they must make the essential benefits more generous than the federal guidelines.
For example, some plans may pay for weight loss surgery, but others may not. Some plans may cover fertility treatments to get pregnant under maternity care, but others may not.
One plan may only cover a few drugs for your condition, like medicine for high blood pressure, while another plan may cover many brands.
What complementary and alternative treatments count as essential benefits
For instance, some states, like California, Maryland, New Mexico, and Washington, are including acupuncture as an essential health benefit. Many other states probably won’t.
How to promote the Marketplace
States are in charge of advertising for their Marketplaces and encouraging people to use them. That matters. If a state is very successful in getting lots of people to buy plans, the costs of insurance in that state could go down for everyone.
State Marketplaces may offer extra coverage for health problems that are more common in that state. For instance, if a state has high levels of diabetes, its Marketplace might include more plans that have special programs to help people with that condition.
Coverage for more people with low incomes
One way health reform was supposed to help more people get medical care was to expand each state’s Medicaid plan. Medicaid is the free or low-cost health program for people with very low incomes.
However, states can decide whether or not to expand Medicaid. If a state doesn’t expand Medicaid, some low-income people won’t be able to afford coverage. To find out whether you qualify for Medicaid, check out the insurance finder on HealthCare.gov.
Things to know about Missouri’s Marketplace
Plans will vary state-to-state. If you’re trying to help an out-of-state relative buy a plan, remember that their options will be different from yours.
We don’t know all the details yet. What exactly will Missouri offer? Presently, nothing. Missouri has so far decided not to participate in any way in the Affordable Care Act.
The Federally-facilitated Marketplace (FFM) will be offering health coverage in Missouri in 2014. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant’s account to the state agency for a final eligibility determination. Missouri is not expanding Medicaid coverage to low-income adults effective January 1, 2014.
Physician’s point of view
The healthier our citizens are, the more productive they are. It is as simple as that. You can’t contribute much to society if you are crippled with a foot broken years ago and never repaired properly.
You can’t contribute much if you are burdened by depression or an untreated psychosis or lupus or rheumatoid arthritis. We benefit from the productivity of healthy people.
Furthermore, we benefit from their health itself.
If poor people don’t get checked for tuberculosis, the rest of us are at risk. If poor people don’t get treated for addiction, we all suffer from petty theft to secure them a supply of drugs.
If mental illness isn’t diagnosed and treated early, that burden is for all of us to bear. We pay a lot more to care for the mentally ill in prison than early treatment would cost. And it’s cruel as well as expensive.
Medicaid expansion will benefit those of us who don’t need it, who have health insurance, as well as benefitting those who cannot afford insurance.
But most important as a matter of law, caring for the poorest among us, ensuring that they receive the benefits of good healthcare, is a measure of the quality of our society. Do we harden our hearts and turn our backs? Or do we provide quality care to everyone who needs it?
The important thing to note is that the Affordable Care Act is not as much health care reform as it is insurance reform.
St. Louis Urgent Cares presently has 4 locations in St. Louis, and all 4 are active participants in Direct Medical Care: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care. We are planning even more facilities in the near future.
In the state-run health insurance marketplaces, the government-approved health insurance plans are divided into five tiers: platinum, gold, silver, bronze, and catastrophic. Analysts expect young adults to gravitate towards the bronze and catastrophic plans, which are the lowest-cost options.
Both the bronze and the catastrophic plans cover basic preventative health services including cholesterol tests, immunizations and screenings for depression and alcoholism (a full list is here). Both also cover, to varying degrees, all 10 categories of “essential health services”: hospitalizations, emergency services, ambulatory (outpatient care) services, some maternity and newborn care, pediatric care, vision and dental care for children, mental health and behavioral health treatment, rehabilitative and habilitative services and devices, laboratory services, and chronic care services.
There are some key differences between these two tiers, however. This chart can help you decide which plan may be right for you.