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Insurance is not health care. Health care is not insurance.

Health care and insurance are not one and the same. Health care is our doctors, our research, our providers’ tort protection, our approach to health and our own willingness to allocate resources to living another day and in a quality way. Health care is admission to higher education, access to and ability to afford training, affordable liability insurance costs, ease of opening a new business, health care providers’ availability to take time off for continuing education, and the permission to treat each patient as an individual. Health care is our doctors being able to manage businesses without regulatory confusion and the expense of outsourcing compliance and HR. It’s having the ability to simply compensate employees with whatever wage and benefits upon which the parties agree. Health care is affected by the FDA, drug and medical device companies, legislation, campaign finance and lobbyists – and most of all - INSURANCE!

BUT - Insurance alone is not health care!!!

It's simple. Ask any actuary. A premium we pay for an insurance product is a function of at least three things:

1.    The chance of something happening

2.    The cost of that thing’s occurrence  

3.    Overhead/reserves/profit for the issuer (p.s. Lower corporate taxes mean lower insurance costs right?)

In recent years, we've seen the nation demand that preventive care be covered at 100%. That's a recipe for disaster. How can we insure AGAINST something that should definitely be happening!  Insurance is the wrong product for things that will probably happen.

When we insure against expected expenses, we are paying for the covered event plus overhead and capital/asset reserve requirements for the issuer. Imagine if we insured against needing gas, tires or oil for a vehicle! Wouldn’t it be better to just pay for the expected event? Of course it would, but there’s the elephant in the room – or umm Donkey. What if people are not responsible and don’t take care of themselves or their children?

If we start designing a new America built entirely around the expectation that people will fail to meet responsibility, we guarantee they won’t meet it!

What we really need when it comes to expected expenses is a volume purchasing avenue ... the ability to negotiate or drive prices down based on pooled purchasing power of whatever groups band together seeking a great deal, the largest of which should be the free market of Americans with purchasing power and demand. When this happens, providers can compete for our business. Without insurance concealing and driving up the price of expected expenses, something great will happen!

There's a problem few people know exists; it has to do with health care providers, insurance companies and procedure cost. Everybody wants to know ...

Why doesn't my doctor or dentist just tell me how much this costs? In this day and age, why can't I just look on the provider’s website and see, for example, how much is it to get my teeth cleaned?

This is why:

Dental insurance covers teeth cleaning - usually at 100% or close. If a procedure is covered by insurance, that means the insurance company gathers information on the rate charged for that procedure. The insurance companies all go in on independent agencies to collect the data on rates charged by providers for every covered procedure code, considering the lowest published or known rate of each provider – they look on Groupon, providers’ websites, claims filed and even call the providers’ offices and ask! I’m sure I’m not the only one who has experienced some kind of cryptic feel on a call to a provider about cost for a procedure.

The data gatherers aggregate the prices per procedure code. The insurance companies buy data lists with the average costs of each procedure code broken down by percentile grouping and packaged by zip code group (usually by the first three numbers), choose a percentile band to base their fees upon and sell plans with various accepted-rate fee schedules. The most expensive plans allow reimbursement rates in the higher percentile bands of average billed amount, and cheaper plans may allow as low as an area’s 10th percentile amount. Many doctors don’t accept these poorly paying plans. Further, many insurance companies punish providers for not taking all of their plans by instituting an all-or-nothing contract option. We can see here why insured individuals’ access to care continually declines.  

Finally, the patient’s copay and coinsurance is then applied to this already reduced amount, leaving the provider to estimate patient portion, collect partial payment from the patient, file a claim to insurance, adjust the filed amount to the lower, agreed-to amount after the payment is made and issue a credit or act as a bill collector by surprising the patient with a final bill.

There is so much confusion and variance in prices, not to mention labor expense, built into health care expenses and therefore into insurance premiums!

This unfortunate situation is what stops providers from publishing low self-pay prices. It also means that providers must incur an extra labor expense to file claims at higher UCRs (usual and customary rates) and then adjust the paid amount upon payment. Trying to get crafty and filing at the cost the provider has found that the insurance company ties to that procedure code only sets the providers in that zip code up for a lower rate the next year when the agencies review the procedure charge data. In effect, it creates a constantly reducing loop. This is unsustainable!

In reviewing the last 100 visits to an owner-operated, single-dental-practitioner’s office in a Dallas suburb, the following is the breakdown of the dentist’s total revenue per periodic preventive visit, including exam, cleaning and typical x-rays:

16 patients - $0
43 patients - $1 - $5
19 patients - $6 - $20
11 patients - $21 - $80
11 patients - $81 - $156

The average cost was $21.44 with an estimated administrative labor expense directly attributable to insurance verification, estimation, filing and adjustment on the insured patients of this sample of $675. If the total revenue for these 100 visits was $2144, and $675 could have been eliminated if insurance did not cover this expected expense, the dentist’s published price could have been $14.69 This would also drastically reduce premiums for patients and increase the likelihood those who want to seek health care could do so. It would cause greater competition in the health care industry, improving the consumer experience and lowering the cost. It would untie the hands of many qualified scientists and medically minded individuals so that they would be capable of running a business while providing their service, and finally, it would once again attract more our brightest minds to health care careers.

Besides it being absurd to insure against things that will likely happen (immunizations, a broken bone here and there, strep throat, a sinus infection, teeth cleaning, a colonoscopy, a mammogram etc.), we have made it impossible for health care providers to compete in the free market because they can't publish or adjust prices based on the principles America represents. The thing that stops us from fixing this problem is that people don't want to be responsible, and it just sounds “mean” to say no free annual visits, common medical procedures, etc. The truth is that they aren’t free; cost plus some is built into insurance cost. To reduce health care expenses, the move should be from 100% coverage on common expenses to 0%!

Imagine the labor savings, price transparency, procedure cost reductions and premium decreases that would result if we stop insuring against things that are likely to occur!