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2016 Presidential Town Hall: Enlarge the ACA v. Repeal the ACA. You're Both Wrong, and We Know How To Fix It.

10/10/2016 10:08 AM

I'm watching the debate last night and Anderson Cooper lobs out the baseball that we all want to see knocked out of the park:

"Affordable Care Act, known as Obamacare, it is not affordable. Premiums have gone up. Deductibles have gone up. Copays have gone up. Prescriptions have gone up. And the coverage has gone down. What will you do to bring the cost down and make coverage better?"

We all knew what Secretary Clinton was going to say because she already said it in her open response to the New England Journal of Medicine in her article titled "My Vision for Universal, Quality, Affordable Health Care."  Basically, she wants more of the same thing that Mr. Cooper was complaining about: More ACA giving us higher premiums, higher deductibles, higher copays higher drug costs more regulation, more oversight, more government and decreased coverage.

What we didn't know was how Mr Trump would change healthcare.  He gave us the same old saw about increasing competition by selling insurance across state lines that has become the Republican mantra.  Margot Sanger-Katz wrote about that in the New York Times last year in response to Mr. Trump making similar comments during the republican debates.

“The barriers to entry are not truly regulatory, they are financial and they are network,” said Sabrina Corlette, the director of the Georgetown University Health Policy Institute.

In 2012, Ms. Corlette and co-authors completed a study of a number of states that passed laws to allow out-of-state insurance sales. Not a single out-of-state insurer had taken them up on the offer. As Ms. Corlette’s paper highlighted, there is no federal impediment to across-state-lines arrangements. The main difficulty is that most states want to regulate local products themselves. The Affordable Care Act actually has a few provisions to encourage more regional and national sales of insurance, but they have not proved popular.

My analysis of this situation is that we can't go forward with the Affordable Care Act, and we don't have anything viable to replace it.  I know it sounds pedagogic, anyone who follows this blog has heard it, but we here at Sentia Health have the answer: Health Insurance as a subscription.  Health insurance is nothing more than data management.  Insurance companies take data in, in the form of claims, and send data out, in the form of payments or denials.  The rules are well known and well understood and can be completely automated.  Where everyone misses the boat is first that the patient encounter has to be coded in ICD-10 codes before being sent to the insurance company  for payment and the fact that nobody knows what is going to get paid for in advance.  

At Sentia, we have a better way to run that insurance company.  First, WE provide an Electronic Medical Records Management System (EMR) for doctors and practitioners to use free of charge.  This EMR is sufficient to document the patient encounter completely, and in English (or any of several other languages) without needing a medical coder and shows what procedures are covered and for how much at the time of care delivery and encounter documentation.  This eliminates several processes and their associated costs: medical coding, third party EMRs, and the billing department.  The average practitioner spends about $32,000 per year on the EMR part alone.  Additionally the traditional health insurance company is allowed by the ACA to wad up 20% of your insurance premiums and do whatever they want with it.  As long as the claims are paid they can stick the whole thing in their pockets.  With the average policy running about $300/month for the individual, that equates to about $60 per month per policy.  In rough numbers 270,000,000 insured people in the United States paying traditional insurance companies $60 each per month to be completely wasted equates to $16,200,000,000 per month or $194,400,000,000 per year.  Let's reiterate that $194 BILLION wasted.  A billion here, a billion there and pretty soon you are talking about real money.  That doesn't count all the ancillary costs we outlined above.

We estimate the total waste associated with paying for healthcare to be about 1/3 (conservatively) of the amount paid.  We as a nation spend about $3,000,000,000,000 (yes, trillion with a 'T') on healthcare so that means that one trillion dollars of that goes to waste.  We at Sentia propose to replace that whole system with our EMR-as-a-Service (EaaS) that pays claims automatically as the patient encounter is begin documented in near real time.  For the privilege of managing the insurance data, we will charge a $10 per month to the insured.

Yes, we can do that.  We've already done it.  That $10 per month would eliminate over 95% of the waste and the monkey motion that goes on with healthcare finance and payment.  More of the same and unviable political solutions aren't gong to get the job done.  This isn't a shameless plug for our company either.  The plan is laid out right here.  If big insurance wants to do this, go ahead.  The Cerners and Epics of the world can't build and install a working EMR (for hundreds of millions per installation, no less), and the insurance sompanies can't automate their own processes, so I'm positive that nobody can do both, like we have.  

We need leadership, we need innovation and we need what Sentia Health provides:

Real Solutions

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