November 18th, 2010

Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform


Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform
[HTML4][Editor's Note: Dave Chase provides us with another guest post. This time, he focuses on what entrepreneurs can do to reform the US healthcare system. It's an area near and dear to his heart and, as you'll see, where his latest startup is focused.] Imagine a cost in your business or personal budget that grew 3400% faster than all other costs. Would you do something about it? That is what has happened to healthcare costs over the last 50 years. While other goods have gone up 8x in the last 50 years, healthcare has gone up 274x. From friends who own small traditional businesses to my tech entrepreneur friends, most are aghast at how severely they've been hit by healthcare cost increases. It's simply unsustainable. This post will outline an alternative approach to getting your healthcare needs met that may be a better route for you and your organization. My experience initially working as a management consultant to nearly 30 hospitals followed by founding Microsoft's healthcare business has led me to the conclusion that it virtually impossible to reform a fundamentally flawed model (i.e., the payment side of the equation). I outlined this in more detail in my Huffington Post piece entitled "Health Insurance's Bunker Buster." The current health payment system is a Gordian Knot designed by Rube Goldberg. While the new health law addressed Access issues, it does very little to effect the Cost side of the equation created by a convoluted compensation system. Watching the sausage getting made in D.C. leads me to believe that looking to our national politicos to effectively address this is extremely unlikely. As a congenital optimist who has seen entrepreneurs solve intractable issues, I believe the prescription is a do-it-yourself approach from the grassroots. It does require business to dive deeper into something that they could shunt off to their insurance agent in the past as it wasn't a big enough impact on the bottom line to worry about. That has changed. Many businesses and individuals are at a financial breaking point and must take action. Over time, the cost increases have been somewhat masked. One might be told that health premiums are "only" going up 10% in a given year but the real effect is actually more like 20% (or even higher) as co-pays, deductibles, and the like have shifted more of the burden onto the patient. As a country, on average we spend well over $7000 per year for every man, woman and child each year on healthcare. Many people don't realize it as the actual expenditures are spread across many different line items. However, many of us are now experiencing the reality of the proverbial frog that has been in water where the temperature has been steadily increasing. Before we boil, we need to make a change.

The Solution

While writing this piece, we took one of our kids in to a dermatologist for something we were concerned about. That 10 minute appointment resulted in a $158 charge and the outcome was we should buy Head & Shoulders shampoo and a simple prescription. Afterwards, I spoke with their billing department as I had just wanted to pay cash saving everyone time and money (or so I thought) since we're on a high deductible plan. The friendly billing department person said that we'd receive a $158 bill that we should ignore and that the claim would like get rejected the first time. She said we'd likely then receive another bill. She indicated that if it wasn't nearly 40% less, we should call her. She went on to explain how it would work with the deductible and the fact that we were on an out-of-state Blue Cross plan (we just moved so are on our old plan). Rest assured, baked into that $158 charge is all the time their billing department will spend sending out bills, dealing with rejections, etc. all to handle something we are going to pay cash for. While there are good things that can and should be done to address healthcare costs such as malpractice reform, electronic medical records, there is only one way to make a major impact on the cost side of equation. We have to take more personal responsibility for our health via a consumer (rather than provider or payer) driven model. That has two dimensions.
  1. First and foremost, the best "medicine" is taking care of oneself and it's clear with the obesity epidemic, we aren't doing a great job on this front. There are some promising and effective wellness programs. There's truth to Ben Franklin's statement "an ounce of prevention is worth a pound of cure."
  2. The second dimension is becoming savvier healthcare consumers. We have a model that has done anything but encourage that. Rather, it's as though we have an open bar at the healthcare "restaurant." After the co-pays, it seems that we can seemingly get everything for "free" as the costs are so masked.

Back to Insurance's Root

The single quickest thing we can do to reduce healthcare costs in the coming months and years without affecting the quality of care is to return health insurance to its roots and make it like all other forms of insurance. That is, with the exception of healthcare, we buy insurance for rare events that we hope never happen (major car accident, house burning down, premature death, disability, etc.). Instead we have burdened day to day healthcare needs unnecessarily with the bureaucracy and profits necessary if insurance companies are going to be involved in the day to day facets of healthcare. This need not be the case. Imagine this scenario: Your car needed to get tuned-up. However, in order to get a tune-up you had to get a referral from General Motors dealer in order to get an appointment and hope to have the tune-up paid for by State Farm (your car insurance company). When you asked for an estimate of what that tune-up might cost, you would have one of two responses. "We have no idea how much we are going to bill you" or "It depends". If you worked for the government or a large employer, it would be one price and if you were with a small business you'd likely pay 30+% more. When the car was done with the tune-up, you'd likely have to deal with a co-pay, deductible, co-insurance (if your spouse had car insurance through their employer). Afterwards, it's likely that there would be a series of bills determining whether your tune-up was covered. You might have to re-submit as they may not have realized GM gave a referral. You would also get a bill from the guy who put your car on the lift vs. the guy who worked on your belts vs. the guy who worked on your transmission. It's not hard to imagine your car insurance policy costing 40% more than it does today if it had to support all of that hassle.That lunacy is exactly what we have in healthcare today. Insurance companies do a terrific job of managing risk for the rare items I mentioned above and most of us feel reasonably good about our auto/homeowner's insurance carriers. We probably wouldn't feel that way if they were involved in every little thing we did with our cars and homes. Once health insurers return to their roots, I believe we'll feel similarly rather than the angst many have towards health insurers. If you only take one thing away from this piece, it is we must get insurance out of day to day healthcare if we want to get our healthcare spending under control. Instead, we should "self insure" for the day to day and have a high deductible insurance plan for the events we hope don't happen such as getting cancer, being in a major accident, etc. This kind of shift doesn't happen overnight but there are steps an individual or organization can take today that can save a massive amount of money. I will explain three items that may be new to you but are important to understand and take advantage of depending on the scope of coverage you want for yourself or your employees.
  1. Health Savings Accounts (HSA): These allow pre-tax dollars to be put into an account that rolls over if they aren't used. Funds in the account can be used to pay for qualified healthcare expenses. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent. HSA funds may currently be used to pay for qualified medical expenses at any time without federal tax liability or penalty. More on them can be found at the federal government's Web site and on Wikipedia.
  2. Health Discount Card: Think of this as a Costco Card for health & wellness services. It's NOT insurance. Your Costco Card doesn't allow you to take Cheerios off their shelf and not pay for them. Rather, they have aggregated the buying power of individuals and small business to save their members money when they purchase something. With the card, you can access everything from Dental to Medical to Vision to Alternative Care to Prescriptions at a significant pre-negotiated discount. Full disclosure: My company is going to be selling these when we go into a limited release in the near future. Contact me if you are interested in participating in this initial rollout.
  3. Direct Primary Care (DPC): A relatively new concept that is a derivation of Concierge Medicine but targeted at the mass market. I have looked into these models and have found them very compelling. They typically cover everything from day to day items (physicals, flu, etc.) to urgent care. The only added charges are for items such as an X-ray ($17 per body part) or lab tests where they pass along direct costs. Because it's completely outside of the insurance model (you pay a monthly retainer not unlike a health club that you can use as much or as little as you'd like), doctors are happy to be available by email and phone. In a typical insurance model, they wouldn't get compensated so it's understandable why they are reluctant to be available for their patients in this manner.
It's no surprise that over 50% of Primary Care Physicians say they'd leave practice if they could. In order to make a good living, they need to get patients in and out of their office in 7 minutes. This leads to a model that typically results in a hurried appointment focused on figuring out the symptoms and prescribing a pharmaceutical. In contrast, a DPC primary care provide is able to practice the way they were trained. In appointments that average 45 minutes they are able to get at underlying causes of the presenting symptom. The "prescription" may well be far less costly than a pharmaceutical. An example of the DPC model worth watching is backed by the founders of Amazon, aQuantive (Microsoft's largest ever acquisition), Dell and Expedia. Reportedly, their Net Promoter scores are in Google and Apple territory and they are reducing the costs of the surrounding medical services they don't cover (e.g., Specialty and Hospital visits). I believe it's worth figuring out how we accelerate the adoption of this model. As I mention in my Huffington Post piece, a little noticed addition to the new health law is the fact that DPC models will be part of the coming insurance exchanges in 2014 even though they are a non-insurance alternative. While you can expect these models to explode in 2014, there are already primary care providers offering this model to their patients today. KGW featured one such practice in Portland in a news segment (NOTE: Opens video file).

Steps businesses should take today

Ironically, these models will eliminate most of the frustrating quagmire of complicated paperwork and hassle, but in the short term, there will be a learning curve and adjustment. The following are steps you can take to reduce your healthcare costs without negatively affecting quality.
  • Educate yourself and your employees on being wise and proactive healthcare consumers. This is a change from the status quo and it will take patients and providers into new territory. While it should be better for both of them, it's change nonetheless about a topic that can be emotionally charged.
  • Strongly encourage your healthcare providers to go to cash-based practices that allow them to save dramatically on billing and administration and pass along the savings to you. Since the DPC model is new, it may take some additional education and encouragement to get primary care providers to move that direction. Organizations such as professional associations and organizations such as the Oregon Entrepreneurs Network can provide a voice and aggregate market power to accelerate this shift.
  • Consider where on the continuum of coverage you want to get for yourself and your employees. I have laid out some options below dependent on the resources you have.
The following are examples of the range of coverage you can provide to your team. I would always recommend at least having a very high deductible insurance plan.
  • Bare bones: At least offer a Health Discount Card even if you can't cover the employee's High Deductible Insurance Plan. Just be sure to communicate that it is NOT insurance as many will think it is. The Costco analogy helps people understand (i.e., you can't walk out without paying for what's in your cart, it just costs less).
  • Good: Couple a High Deductible Plan with a Health Discount Card
  • Better: Combine the "Good" with a Health Savings Account that you fund with pre-tax dollars. Employers such as Whole Foods have taken this approach and found their employees getting much savvier on spending "their" dollars.
  • Best: Combine the "Better" with a Direct Primary Care membership. Prices vary widely but the DPC model referenced above charges $69/month for a 40-49 year old, for example.
In the follow-on to this post, I will give the new governor of Oregon (who happens to be a physician) a prescription for what he can do to help. The fact is that our state leaders can make a tremendous impact and the governor, in particular, has a bully-pulpit that can help. As entrepreneurs, we are the ones who create sustained job growth so I challenge Salem to lend a hand. Saving us money means more money can go towards job creation.

About Dave Chase

Prior to working in startups, Dave spent 12 years at Microsoft in various senior marketing and general management roles, including his role as Worldwide Healthcare Industry Director and Managing Director for Industry Marketing & Relations for the Digital Media industry. He both founded industry organizations and served on their board that played pivotal roles in the growth of those industries. In the aftermath of the dotcom bust, he was selected to take a leadership role within the online ad industry to grow online’s share of the overall ad market in concert with AOL, Yahoo!, DoubleClick/Google and other market leaders. During his tenure, MSN championed three major initiatives that the industry adopted that led to the turnaround of the online ad industry. Prior to joining MSFT, Dave was a senior consultant with Accenture’s Healthcare Practice working with a wide array of healthcare providers and systems. Dave has also been a successful investor and adviser to several early-stage companies. He can be found on Twitter as @chasedave.
(Image courtesy congaman. Used under Creative Commons.)

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Background that may help (or may not)

19 Responses to “Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform”

  1. Cory Huff says:

    DPC is similar to what happened in some places in ancient China. They paid a monthly fee to the doctor, until they became ill. Then they stopped paying until they got better. The doctor was then incentivized to help them get better.

    I’m going to look into DPC for my family.

  2. Dave Chase says:

    I’m told there are 20 or so MDs doing DPC in Portland. The only one I’m personally aware of is Dr. Lester Baskin. I think his website is baskinclinic. A MD relationship is a very personal decision so I’d recommend speaking to him and others to ensure the fit.

    I’d never heard about that China story. Where did you hear about that? Pretty clever model.

  3. Diarry says:

    This time, i focuses on what entrepreneurs can do to reform the healthcare system.It was mostly for entrepreneurs and those looking to fund entrepreneurs.FOr a small business ideas check here for more details http://jewelsnistico.com.

  4. Dave Chase says:

    Coincidentally, I read a piece this morning that delved further into the DPC model referenced above. They now have a broad enough patient population to demonstrate meaningful results. Patients in the DPC model compared to the populous at large visited the ER 62% fewer times. Further, hospital days were reduced 26%, specialist referrals 55%, advanced radiology 48%, surgeries 73% and surgery days by 51%. Imagine scaling these savings to all of Oregon. That alone could probably balance the states budget given how much we spend on healthcare out of the state coffers. These kinds of savings should get the attention of Ted Wheeler (Oregon’s Treasurer), Gov-elect Kitzhaber and every public official who touches Oregon’s health system.

    Washington is ahead of us. As their governor stated in a letter to the head of Health & Human Services “Our state law ensures that the services provided by these medical homes run the gamut from routine primary care and preventive care to urgent care and from chronic disease management to wellness education and specialist/hospital care coordination,” she writes. “There are no pre-existing condition exclusions, no disagreements over covered treatments or insurance forms to be filled out, and no deductibles or co-pays. Instead a single low monthly fee covers all costs.”

  5. Tineke Malus says:

    Fabulous article. After spending 20 years working in the standard american model of medicine, I decided that when I opened my Primary Care practice I was going to forgo the abusive relationship with insurance companies that I saw so many colleagues and patients suffering from.

    I am happy to see that the idea of creating more direct provider to client relationship is really taking hold in so many places. Not dealing with insurance allows me to spend more time with my patients.

    Traditionally the insurance companies were the only access to networks of providers and conversely for providers to the patients. Technology has made that scheme irrelevant.

  6. Rian says:

    (Everything I write is from the perspective of a health care provider (pharmacy), and as an economist. I’ve also been a small business owner with a fair number of employees where single-person monthly premiums during year 1 were $520/pp/mo, and by the third year were over $700/pp/mo. It’s also one of the reasons we ultimatly went out of business.)

    My economics thesis was on this problem. Part 1 was on demand side reforms, which is what your ideas are, and Part 2 was on supply side reforms. Demand side reforms, as sexy as they, don’t result in the same bang for the buck that supply-side reforms do, no matter how unintuitive this may feel. Singapore tried similar demand-side reforms in the early 90s (HSAs, shifting the burden of cost to those that could afford it, etc.), and discovered this the hard way. It was only until they implemented supply-side reforms that they were able to contain the inflation.

    Most of the middle class can afford to pay out of pocket for normal maintenance stuff like PCP visits, simple derm visits, occasional meds, etc. What they can’t pay for–and where most of the inflation is coming from–are the big ticket items: heart attacks, cancer, etc. Anything that is technology-intensive. Yes, technology drives health care costs UP, not down. (I’m not talking about health care IT.)

    Health Discount Cards make people feel warm and fuzzy, but have limited impact on overall spending trends. Are you going to get a discount on a $250K bout of cancer? Probably not. You might get one at your PCP’s office, so instead of paying $70-100, you might pay $50-60. That’s cool, I guess, but in terms of overall percentages, it’s tiny. Even if you did get 10% off, you’re still going to go bankrupt and lose your home.

    Supply drives demand in health care. It’s the only industry where this is true, and the reason it’s true is because of the huge information asymmetries, and no, the Internet can’t help in this area. This is, in no small part, why Massachusetts has more MDs per person but also has the highest health spending per capita of any other state in the country. In general, you will find that this phenomenon holds true in other states, too.

    None of this touches on medmal which I’ll cover quickly: the latest numbers indicate that medmal accounts for ~$50bn/yr. If you “solved” this problem perfectly ($0/yr), that would amount to a one-time discount because medmal premiums aren’t inflationary the way health care spending itself is.

    I could go into more detail on what supply-side reforms are, but the first link below covers it pretty well. It has very little to do with the payment side of the equation.

    Further reading:

    Health Care in Singapore: What’s the Secret?
    http://www.healthbeatblog.org/2008/07/health-care-in.html

    Anderson, Gerard F., et al. “Health Spending In The United States And The Rest Of The Industrialized World.” Health Affairs (2005): 903-914.

    Arrow, Kenneth J. “Uncertainty and the welfare economics of medical care.” American Economic Review (1963): 141-149.

    Gawande, Atul. “The Cost Conundrum.” 1 June 2009. The New Yorker. 16 October 2009 .

    Testing, Testing by Dr Atul Gawande
    http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande

    Kwak, James. “You Do Not Have Health Insurance.” 5 August 2009. The Baseline Scenario. 16 October 2009 .

    Monsivais, Pablo and Adam Drewnowski. “The Rising Cost of Low-Energy-Density Foods.” Journal of the American Dietetic Association 107.12 (2007): 2071-2076.

    Sheehan, Aiden. “Junk food costs 10 times less than healthy option.” 21 October 2009. Independent.ie. 17 November 2009 .

    “National Health Expenditures Data.” National Health Expenditures Data. Centers for Medicare & Medicaid Services, US Dept of Health & Human Services, 2009.

    Shang, Baoping and Dana P. Goldman. “Prescription Drug Coverage and Elderly Medicare Spending.” NBER Bulleting on Aging and Health (2007).

  7. Dave Chase says:

    Dr. Malus – If you are comfortable doing so, it would be interesting to hear more about your practice, how you’ve built it, how it works, rough monthly costs (assuming a monthly retainer) etc. This is new terrain for most people so it would shed light for many if you can share that info.

  8. Rick Turoczy says:

    Just so folks know, there is also an interesting discussion on this topic taking place over on Hacker News.

    http://news.ycombinator.com/item?id=1921935

  9. Dave Chase says:

    Rian – Excellent reading recommendations. I wish the other articles were available online as the piece on Singapore and the New Yorker article were outstanding. As the New Yorker farming analogy showed, there’s no one silver bullet.

    I don’t believe it’s an either/or on the demand side vs. supply side. I believe demand side adjustments will lead people to become more educated and proactive on the cost issues that our fee-for-service system has created on the supply side. There’s studies that demonstrate that a doctor group that invests in imaging equipment results their patients utilizing the extremely expensive imaging equipment at 2-3 times the rate of doctors who don’t have a financial interest in imaging.

    Further, if pricing transparency is brought into the mix, people will learn that there can be a 2-3x variation in pricing from one facility to another for the same procedure with the same outcome. Example: within one hospital system I know, there is a 8x variance for the cost of a lab procedure simply because the lab manager at one facility has been in place for 17 years and chose to increase his dept charges 4% every year for no direct cost reason.

    The reason I am keen on people starting with the day to day (yes, lower cost) items is it puts them on a journey to becoming educated and empowered consumers and ultimately moving towards the Direct Primary Care (DPC) model referenced above. Further, there are few families who wouldn’t appreciate saving several hundred dollars on their healthcare. My wife is going in for a preventive procedure that the discount card will save us a minimum of $450. That’s material.

    Here’s an example of the power of the DPC model: As ref’ed in the link below, a DPC model has shown that its patients visited emergency rooms 62 percent fewer times than the benchmark per 1000 patients. In addition, hospitalization days were reduced by 26 percent, specialist referrals by 55 percent, advanced radiology
    by 48 percent, surgeries by 73 percent and surgery days by 51 percent. In other words, while I agree that middle class families can afford Primary Care visits, these aren’t disconnected from the expensive bankruptcy-inducing items you mentioned that could be avoided if one is proactive/educated.

    Read more about how Washington’s governor is lobbying the HHS Secretary to formally adopt what is already in the new law as well as more on the stats above here – http://qliance.com/pdf/Qliance%20+Wash+Gov+Asks+HHS+IHP+10-10.pdf

  10. Dave Chase says:

    Rian – One other point I left out that speaks to your supply side focus yet is tied to our flawed fee-for-service compensation scheme. The article on Singapore mentioned that they capped Specialists at 40% of MDs. I can’t see that ever happening in the U.S. as it would be so easy to demonize whoever suggests capping anything. This is why I advocate “do it yourself” as part of the health reform equation.

    Many people don’t realize that our financial reward system for medicine has created a situation where over 70% of MDs are Specialists (rest of the world, it is less than 50%). Worse, more than 90% of Med School grads are Specialists as we pay our “special teams players” like “Quarterbacks” and our “Quarterbacks” (i.e., Primary Care Providers) like little used “special teams players”. If you think we have a Primary Care Provider shortage today, you haven’t see anything yet given where things are headed if they aren’t shifted.

    Those utilizing Specialists (which is perfectly appropriate in many, many instances) simply need to be aware of the old adage “When you have a hammer, everything looks like a nail”. An educated health consumer also recognizes that for every $1 Pharma spends on R&D, they spend $2 on marketing. A primary care provider who has more than 7 minutes to spend with a patient can spend time to better understand the root cause of the symptom that is presenting itself and the patient might be able to avoid taking the drugs altogether.

  11. [...] Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform (tags: business economics healthcare insurance oregon startup) [...]

  12. Tineke Malus says:

    My model is pretty simple. (That might be why it is hard to fathom for many people.)
    I have a patient base of a small and slowly growing number of people. They all pay a “premium” to me. Because my community is somewhat marginalized, I offer a sliding scale. But even the top of the scale is only 100$/mo. For this, people get an annual wellness & screening exam, and I am on call for them 24/7. (I only do house calls. All visits are in the homes of my clients -thus cutting the cost of me maintaining an office in my high rent area of town).

    I have a network of other practitioners that I can hire to take calls for me should I go on vacation. Some of my patients require more attention from me that others, but it is never overwhelming for me, and so far everyone has had a good experience with it.

    This is a primary care model that take the insurance companies out of the picture and both I and my clients benefit from that. I am negotiating to find an insurance company that will take a chance on this model to give accident and disaster coverage for a lower (100$/mo. max) for those that can afford and want it.

    At this point with the low premiums, my clients have to pay cash for labs and medications, but this never costs as much as the total of most PPO/HMO premiums.

    I don’t spend any money on marketing. I am staying small so that I can make sure the clients I take care are getting the best service possible from our long-term commitment.

  13. [...] In earlier guest posts here on Silicon Florist, Dave Chase has written some thought provoking pieces that have generated quite a bit of dialog here and offline. He has shared why he chose Portland over Seattle and Silicon Valley and how Oregon’s Athletic & Outdoor, Software & Clean Tech clusters should meet. Then in the first part of a two-part series on healthcare, he put out a call to action for entrepreneurs to employ what he calls Do-it-yourself Health Reform. [...]

  14. [...] Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform (13) [...]

  15. [...] Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform (14) [...]

  16. [...] Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform (15) [...]

  17. [...] Calling Oregon entrepreneurs to action: Do-it-yourself healthcare reform (16) [...]

  18. Bonsoir chers lecteurs quel est votre point de vue de mon nouveau site sur le diagnostic immobilier?

  19. Sadly, the only thing health care reform has done for me is jack up the costs. Access has never been an issue for my small business. What I do not understand is how our representatives did not take into account that high costs mean lower access (we had to switch from a flexible plan to…kaiser as a result).

    For example, colonoscopies are now covered under preventative care, however if doctors find anything, the procedure is then considered diagnostic, and you are stuck with the bill – if you have Kaiser, check it out. People who believe they could be stuck with diagnostic costs will then be less likely to pursue it to prevent an actual problem.

    I am probably one of the more conservative readers here on SF, but Ive also experienced life in a country where anyone with a job can get onto one of two plans for the extended family and have pretty much everything covered. Thats because each of the three legs of the stool: insurance, medical services and pharma are all appropriately regulated, not just half a leg, like we’ve legislated.


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