In the United States today, there is one model for healthcare funding and that is fee-for-service. That means that you go to the doctor, get what you need and your insurance company pays for part or all of your visit. In a perfect world, value based reimbursement would be preferable. Your doctor keeps you healthy and you don't have to see him or her as often and you get fewer tests and procedures and everyone wins with lower healthcare costs. In a perfect world. In this world, doctors and practitioners are highly educated, highly paid professionals who won't see their income go down because they have worked themselves out of a job. I can't blame them.
How do we move toward this Utopia of healthcare payment? We create a healthier population consisting of healthier individuals. How do we create this healthier population? We do it the same way we do everything else: carrot and stick. We reward the demonstrably healthy patient with discounts for staying healthy. We reward the less than healthy patients for evidence of good choices: lower weight, lower BMI, better waist/hip ratios, and better HDL, LDL, Glucose and A1c measurements. At Sentia Health
, we call this compliance. If a patient simply doesn't get worse they are compliant and eligible for substantial insurance discounts. If these health measurements get better, the discounts increase. The more healthy you get, the more discount you receive.
In order to make this work, however, we need something that currently doesn't exist: an insurance company that can adjust your rates based on information contained in your medical records. In the old fee-for-service model, the doctor/practitioner dispenses care and documents your patient encounter however they like, then they hire a medical coder to translate the procedures performed into codes the insurance company can then pay. In this new paradigm, the insurance company would have to have access to the entire medical record to qualify the insured patient for discounts. Even better, we can move more toward a value/performance based system since this new insurance company could then pay doctors more for patients who got healthier, in the same way that patients who got healthier would receive discounts for being healthy. Everyone wins. The practitioners get paid more per patient, the patients who are healthy have lower premiums, the unhealthy get healthy and the insurance company has less risk. The costs is even borne by the people who are causing the problems, the ones who refuse to take control of their own health.
Here at Sentia Health
, we actually have the system that would be the basis for this Utopian insurance company. We already have the systems in place to allow the doctor/practitioner to document patient encounters in a free Electronic Health Record (EHR) that we provide and to see what is covered, what is not, and for how much, in real time, for the patient they have in front of them. When a covered procedure is performed, the payment can be sent in near real time to the practice, avoiding all the current insurance monkey motion that goes on with medical coding, adjudication, and everything else that the insurance company does that doesn't need to be done. Further, we have a patient portal so the patient can log in and get his or her medical records, secure email to the practitioner, a secure scheduling system, the ability to see images (like x-rays) that the practitioner uploads, and of course the patient education that we prescribe automatically that instructs the patient on how to get healthier and get those discounts. This patient education is aimed at engaging the patient, showing them what is wrong, how much it is wrong and how his or her lifestyle decisions affect the tested values and there for his or her wallet. Then we show the patient what better choices he or she can make to get that discount back, or increase it.
Sentia can provide this system to the patient (it's free for doctors, remember) for a small subscription fee comparable to Netflix: $10 per month. The insured will pay the total actual cost of the coverage on top of that, and we will handle all those calculations as well. This is the actual cost of the coverage this is not $10 plus what your insurance company charges you now, on average the insured sees a decrease of 1/3 in the total insurance cost and the $10 is about 10% of what the current insurance industry charges for the same service. The average medical specialist in the United States spends about $32,000 per year on his or her EHR. Since we would be providing this, that money can go back into his or her pocket immediately. Hospitals spend sometimes hundreds of millions of dollars implementing an EHR. That money could be better spent on improving care as well.
While the processes we automate as detailed above will save about 1/3 from the total cost of healthcare, that isn't enough. To truly contain costs, we have to have a healthier population. The only way to have a healthier population is to base health insurance premiums on maintaining health. That way, the doctors who service a healthier population can be rewarded with higher payments and by being able to see more patients. The patient who is measurably compliant will also see a decrease in the overall cost of healthcare. For those others, they will have to carry the cost of their own decisions and their doctors will now have some 'skin in the game' as my grandmother says, to persuade patients making questionable decisions to rethink their choices.
The practitioner isn't alone in this quest for healthier patients. As described above, Sentia automatically prescribes patient education, based on lifestyle and measured tests. This education shows the patient how to get healthier and therefore how to get discounted health insurance.
This is the only solution that I see to the skyrocketing cost of healthcare. I think this could be the ONLY solution. I welcome any input, so discuss with me and among yourselves, and maybe we can fix this problem TOGETHER.