Contributed Editorial
As one who has been a lifelong proponent of practicing a healthy lifestyle, I never quite related to my "disease management" oriented health insurance plans. I found them complex and rather dizzying to read through. Although I was healthy, I knew I needed them in case of some serious physical incident, but because I seldom used health insurance, I wasn't familiar with how it really worked.
Through the years, I became somewhat resentful that I had to pay higher and higher fees for my health care plans, even though I had rarely used them. Quite frankly, I thought it should work like car insurance - at least they give you some credit for being an accident-free driver! What frustrated me even more was that I still had to pay out-of-pocket fees to reach my high deductible for any medical visits I did have. Like other American consumers, however, I believed I had no other options and was stuck with the health insurance status quo.
Fast forward to 2014
The Affordable Care Act, while well intentioned, only served to exacerbate the situation in the following years with government mandates, insurance restrictions and fee cuts for Providers as well as escalating premiums and a dwindling number of medical services in the plans offered to their patients - an increasingly grim situation for both Providers and patients.
As medical consultants, my business partner and I have come to see the growing issues for Providers who are being steadily overwhelmed and demoralized by the insurance industry in terms of shrinking reimbursement rates, complicated contracts, excessive paperwork and lengthy time for receipt of payment. We see Provider autonomy being severely compromised and Providers complaining they have to take on more and more patients to sustain their practices, which translates to a decrease in patient time, focus and quality of care.
The Current Reality for Physicians
In a post by Martie Ross in Healthcare Reform, on May 4, 2016, he notes that after 2016, physicians will not have to report performance measure scores to CMS under the Physician Quality Reporting System to avoid up to a 9 percent reduction in reimbursement fees in the Medicare Physician Fee Schedule. According to the Medicare Incentive Payment System proposed rule for 2017, however, physicians' performance scores in four weighted categories will determine a composite performance score and will be used by CMS to establish physicians' 2019 MPFS payment rates.
Working within these challenging parameters, many Providers find it unfeasible to sustain an independent practice due to repeated decreases in income and to maintain the kind of physician/patient relationship they feel is important to continue providing a high standard of care.
One of our roles as medical consultants is to seek out results-driven therapies and programs for Providers and their patients. One such program we have found that benefits both is called "health cost sharing".
The health cost sharing concept has been successfully utilized by members of several U.S. religious ministries for over thirty years. A health cost sharing organization consists of like-minded healthy people who share each other's medical expenses through a monthly share contribution. These members are considered self-pay patients because health cost sharing is not insurance. One of the best aspects of this co-op approach is that, since candidates for this program must be healthy to be eligible, health care costs are kept to a minimum, therefore, monthly share amounts are also held at minimum levels. Members' lower rates are also attributed to this type of organization's not-for-profit status. Members' contributions are utilized for medical needs with only a small portion allocated to administrative services.
There are five main health cost sharing ministries, each with their own guidelines and beliefs that members are requested to follow for acceptance in to their programs. These organizations differ in the services they provide, therefore, it is strongly advised for patients to research each to see which health cost sharing program would most effectively meet their needs. Health cost sharing is not for everyone. It is best suited to people who take responsibility to follow a healthy lifestyle and make every effort to keep their medical costs as low as possible.
Providers benefit from health cost sharing in several ways. Depending on the health cost sharing program involved, reimbursement rates are generally significantly higher than traditional rates. The billing process is extremely simple (no mounds of challenging paperwork required) and reimbursement is generally received promptly.
The higher the percentage of a Provider's patients who are members of a health sharing organization, the greater the percentage of higher reimbursements the Provider would receive. In addition, precious staff time and money would be saved from all the bureaucratic paperwork required by traditional health plans which, too often, land back in the billing department for required revisions, resulting in longer reimbursement lead time.
With higher reimbursement rates, a savings of overhead in staff time to prepare billing paperwork and quicker receipt of funds for better cash flow, Providers can decrease the excessive number of patients seen per day and spend more quality time and focus on patient care, while easing their financial burden.
One health sharing program, Health Excellence Select, has developed a unique wellness platform in combination with its health cost sharing component. Since this is a national program, physicians' patients throughout the country who are interested in membership can apply. This program promotes investing in one's health through wellness medical visits, preventive diagnostic testing, nutritional and natural therapies to get or stay healthy, as well as other medical services that have a focus on disease prevention.
We will always require disease management medical care. Now, however, those patients who take responsibility to be healthy have the option to choose a program that is better suited to their needs while benefiting their Providers, as well - a win-win for all!
Joan Spadafina Phelps, Certified Age Management Consultant, is co-founder with Jacqueline Russo, RN, DDS, of Wellness Works Group, an age management and wellness consultancy in Delray Beach, FL. They assist Providers with results-driven programs to offer patients in nutrition, weight management and aesthetics. For more information, contact Joan at joan@wellnessworksgroup.com or visit www.wellnessworksgroup.com
