Health Insurance

A Sample of Lab Test Cost Savings

A friend posted this image on Facebook with the notation: "thank God for health insurance". 

2018 Prices for Lab Work.jpg

While it's important to have health insurance, it's also important to understand how it inflates and distorts prices for health care. In the above photo, the insurance price for laboratory testing is shown clearly. What's interesting is if these labs were obtained through our clinic, they would have cost a fraction of the amount reported. Here's a test by test comparison:

 

 

A comparison of lab costs between typical insurance billing and our prices at Plum Health DPC

A comparison of lab costs between typical insurance billing and our prices at Plum Health DPC

What's crazy here is that the person is being billed at a 765% mark-up from the actual cost of the service. This is why health care in America is so much more expensive - hospitals and health care providers dramatically mark up costs and then 'discount' these costs for insurance companies.

This price 'gamesmanship' is bad for health care consumers. It's bad for folks with insurance and even worse for folks who are uninsured. For example, if this person had 80/20 insurance coverage for these labs, they would end up paying $162.20 - the insurance company would 'pay' $658.80 or 80% and the insured person would pay the remaining 20% of costs or $162.20. 

However, if this person were uninsured, they would bear the full brunt of these charges. The uninsured person would pay the entire $811 for labs that actually cost $106. 

Thanks for reading, and have a great day,

- Dr. Paul Thomas with Plum Health DPC

Last Day For Open Enrollment

Hello all! It's December 15th and the last day to sign up for health insurance. Health insurance is different from Health Care. What I provide at Plum Health DPC is health care - visits with the doctor, wholesale medications, at-cost labs, convenience, etc...

But you also need health insurance - this is a financial tool to protect you from bankruptcy in case of major accidents, illnesses, or injuries. If you have cancer, a heart attack, a stroke or are involved in an auto accident, you need health insurance to cover these costs.

The best way to get health insurance? Go to HealthCare.gov and choose a plan that's right for you. 

Thanks for your time, thanks for reading and watching! And, sincerely, if you need help with this, give me a call!

- Dr. Paul 313.444.5630

Don't Further Entrench an Already Broken System

Dear Congressional Representatives, Leaders in the AAFP, and all of those concerned with improving the health of Americans,

I’ve recently become aware of a part of the Alexander-Murray health reform bill that is concerning for the Direct Primary Care (DPC) movement, my practice and the patients that I care for in Southwest Detroit.

The bill includes a provision that mandates all High Deductible Health Plans cover an allotted primary care benefit. As written currently, the Alexander-Murray bill will cover “3 office visits per year” but many organizations, including the American Academy of Family Physicians (AAFP), are pushing to expand that.

While this may sound like a nice perk for patients, it only further traps patients and their primary care doctors in a broken system that undervalues primary care. It reinforces the notion that government and insurance companies must micromanage our dollars and decisions.

Forcing patients to pre-pay for a “primary care benefit” with no out-of-pocket costs will have a few detrimental effects. First, it will almost certainly increase the up-front costs of already skyrocketing health insurance plans. It will also dissuade patients from taking a proactive approach to managing their own health and health care, instead pushing them to be managed by an insurance plan or government programs. Finally, this pre-paid primary care benefit will discourage people from joining Direct Primary Care Practices, a promising practice model that is already achieving the quadruple aim: improving population health, increasing patient satisfaction, reducing per-capita health care spending, and improving physician and staff satisfaction while practicing medicine.

Furthermore, the Alexander-Murray bill fails to address the Health Savings Account (HSA) issue with regards to Direct Primary Care membership fees, something that my DPC doctor colleagues and I have been advocating for over the last few years.

My recommendation at this time would be to advocate for the Primary Care Enhancement Act (SB 1358), which would address the above HSA issue and not further entrench an already broken primary care delivery model.

In closing, Direct Primary Care is an innovative health care delivery model that has promise for achieving the quadruple aim on a nationwide basis. There are nearly 1,000 primary care doctors already practicing or on the cusp of engaging in this model. This is an opportunity to help us grow this DPC movement, to help us better serve our patients in this innovative way, and to potentially heal a broken primary care system in America. Help us reach our goal.

Thank you for your time and consideration,

- Dr. Paul Thomas, MD with Plum Health DPC in Detroit, Michigan

2017 Plum Health Family Medicine Doctor AAFP.jpg

Drew and Mike on Health Care

I was listening to the Drew and Mike Podcast from September 26th, and Drew and his Crew were talking about how health insurance costs are outrageous! Early in the episode (time 1:16), one of the co-hosts admonished Drew Lane, "you can barely afford insurance for yourself!" This set off a conversation about the cost of health insurance, the little coverage that it affords and Drew Lane's displeasure with the overall system. 

Drew's first reaction (minute 1:28), "I don't know how people my age, in my position," not yet covered by Medicare, "and self-employed... ...that's a big chunk of money." He goes on to say that his insurance costs roughly $18,000 - 19,000/year and if you were to make $50,000/year, it would cost roughly 30% of your gross income. 

Because of this extremely high cost, Drew and his co-hosts speculate that some folks just choose to "roll the dice," i.e. go without insurance and hope for the best. They do mention that those folks earning less may be eligible for subsidies or tax breaks from the Federal Government. But, still - a huge chunk of our income is going directly to health insurance and health insurance companies. Even worse, the quality and service levels can be low because care is dictated by third party payers like insurance companies or the government. 

Because Drew's dog recently had eye surgery, Drew was talking about how veterinarians discuss charges before providing care, and how that concept should be applied to the human medical field. "Wouldn't that be something?" Drew asks rhetorically. 

Well, it doesn't have to be a rhetorical question. It doesn't have to be a pipe dream. I'm here to tell you that Direct Primary Care doctors make their prices clear and transparent, and it may revolutionize primary care!

Here's how it works: Direct Primary Care (DPC) is a membership model for health care. Prices vary between different DPC practices, but our prices at Plum Health are $10/month for kids, $49/month for young adults 18 - 40, $69/month for adults 40 - 65, and $89/month for older adults 65 and up. 

With that membership, patients or members can come in and see the doctor any time! They can also call, text or email the doctor anytime. 

Further, patients or members can have access to wholesale medications, at-cost labs, and at-cost imaging services. So far we've saved our members tens of thousands of dollars on these ancillary services. 

I shot a video explaining these concepts in more detail, here:

Thanks so much for reading and watching. I hope that I've opened your eyes to the possibility of better health care services with a transparent pricing structure.  Finally, have a wonderful day!

- Dr. Paul Thomas with Plum Health in Detroit, MI

2017 Plum Health DPC Drew and Mike Podcast.png

Opinion Published in the Detroit News

Our opinion regarding Health Insurance and Health Care was published in the Detroit News last night, and it is currently on the front of the Opinion Page

 

Our opinion made the top of the page for the Detroit News Opinion section on June 5th 2017. 

Our opinion made the top of the page for the Detroit News Opinion section on June 5th 2017. 

Here's our opinion in full: 

Health insurance does not equal health care. As Americans, we often conflate these two entities. But they are in fact separate.

Health care is when you see your doctor. They listen to your story, empathize, perform a physical exam, make a diagnosis, and discuss treatment options. They can also order tests and give you medications. The compassion, the sincerity, the relationship — that’s health care. Health insurance is what covers you in the case of a medical catastrophe, like if you’re involved in an accident, have a heart attack or a stroke. Health insurance is a financial tool to prevent you from going bankrupt in case these catastrophic events occur.

These may seem like obvious statements, but we’ve grown accustomed to a system in which health insurance covers everything, from flu shots to ICU. This may not be a terrible thing; we all need flu shots, and some of us may end up needing ICU care. The problem exists in how we pay for these services.

If we continue to ask insurance companies like Blue Cross Blue Shield and government entities like Medicaid and Medicare to pay for all of our health care services, from blood pressure medications to cardiac bypass surgery, costs will continue to be inflated.

So if you’re paying $10 for your lisinopril each month, know that it actually costs $0.37. If you’ve paid $120 to check your cholesterol this year, know that it actually costs about $6.55. If you’ve ever paid $150 for a chest X-ray, it actually costs about $40. When we use our insurance cards to pay for the basic, routine health care services, prices are inflated. Fortunately, we now have a choice, an opportunity to use free market principles to save money on our health care services. More Direct Primary Care clinics are popping up in Michigan and across the nation.

Direct Primary Care doctors ask that patients pay a monthly membership, which allows them unlimited visits with their doctor and the ability to call, text or email the doctor any time. These doctors also provide wholesale medications, at-cost labs, and at-cost imaging services. By cutting out the middle man and asking consumers to pay for their basic services, the cost of these basic services decrease. Typical savings for medications, labs and imaging services range from 50 percent to 90 percent.

Ideally, people will pair DPC services with a health insurance plan that fits their needs and their budget, and covers them in case of a catastrophic event.

Paul Thomas, M.D., is a family doctor at Plum Health Direct Primary Care.

A screenshot from our Opinion in the Detroit News on June 5th, 2017. 

A screenshot from our Opinion in the Detroit News on June 5th, 2017. 

Thank you for reading and have a wonderful day,

Dr. Paul Thomas with Plum Health Direct Primary Care in Detroit, Michigan

How Many Direct Primary Care Practices in Michigan?

The number of Direct Primary Care doctors in Michigan is difficulty to quantify. A reasonable place to start is with a definition of what Direct Primary Care is and is not. Philip Eskew is both a lawyer and a DPC physician over at DPC Frontier, and he sets forth a good criteria: 

FOR THE PRACTICE TO QUALIFY AS A DIRECT PRIMARY CARE, IT MUST:

1) CHARGE A PERIODIC FEE 

2) NOT BILL ANY THIRD PARTIES ON A FEE-FOR-SERVICE BASIS, AND

3) ANY PER VISIT CHARGE MUST BE LESS THAN THE MONTHLY EQUIVALENT OF THE PERIODIC FEE

I wanted to apply this definition to the State of Michigan, my home state, to see how many "DPC" practices meet this criteria. As far as pure Direct Primary Care offerings open to the public, there are two: Chad Savage, MD with YourChoice in Brighton and Plum Health DPC in Detroit. 

There are other Hybrid DPC offerings within clinics that also bill third party insurance companies: Dr. Younes in Dearborn, Dr. Tindle in Grand Blanc, and Dr. Kevin Roy in Saginaw. I take issue with the Hybrid practices, because you lose the accessibility piece that makes DPC such a great delivery model - these doctors are still seeing a significant number of insurance-based patients and offering DPC to a subset of patients. So if a DPC patient needs to be seen, they "jump the line" and are seen ahead of the insurance-based patients. This is less than ideal.

Premier Private Physicians offers what I would define as Concierge Care or Concierge Medicine. The membership is $200/month or $2400 for the year and some labs and vaccines are billed to insurance companies. Visits are included, but they do not have contracts for at-cost meds, labs, or imaging because their patients are typically high income earners/wealthier people who are not as cost sensitive. 

The other category of "DPC" in the State is employer-based DPC. Some large employer groups like United Shore have contracted with a "DPC" provider like SALTA or ProactiveMD to have on-site doctors to care for their employees. These practices are not open to the public and people who are not employees at these companies cannot access these services.

Because the access to care is limited, this operates more like a third party structure as the large company finds that it saves money to pay a capitated rate for each employee to an on-site doctor, rather than the patient using their employer-provided insurance to seek out urgent care or emergency services. Unfortunately, employees may start to use the "DPC" doctor more for urgent care type visits and less for primary care, chronic care, or preventive services. 

If you wanted to include all of the above practices in the definition of DPC, there are roughly 8 "DPC" providers in the State of Michigan. My argument is that there are only 2 "pure" or authentic DPC practices in the State of Michigan. Sincerely, I would love to see more doctors taking the plunge into authentic DPC medicine, and am here to inspire, encourage, and consult other doctors to do just that. 

If you want to add to the conversation or debate, please send me a message or write a comment below!

Thanks for your time,

- Dr. Paul with Plum Health DPC 

Health Coverage for your Employees

With changes looming for healthcare in the United States, many individuals and employers are on edge and uncertain of what may come down the legislative pipeline. In my community small business association, in Corktown Detroit, a few questions were asked about the Affordable Care Act and the mandates set forth therein. 

Question #1: at what size does your business need to offer health insurance for your employees?

For now, if you have 50 or more full-time equivalent employees, you must provide health insurance coverage, or you have to pay a fine. This is known as the "employer mandate" in the Affordable Care Act, aka ObamaCare. This coverage must apply to at least 95% of your full-time employees and their dependents up to age 26. Spouses are not included in this mandate. More information on this topic can be found here

Question #2: What if one of your employees already has their own health insurance coverage?

Employees with their own insurance plan can keep their current insurance plan. They can also cancel their plan and sign up with their employer's coverage plan. As long as you the employer offer coverage, you won't be fined. But, the employee can't get a marketplace subsidy if the employer's coverage meets affordability and minimum value guidelines. 

Question #3: If your employee switches coverage, can they still see their own doctor?

On choosing to keep your own doctor, you can still go to your doctor, but you may have to pay an out of pocket fee. For example, if you have NGS (or Oakwood Hospital Insurance), you are typically pushed to Oakwood doctors. If you decide to see a doctor at Henry Ford, you will not be forbidden from seeing them, you just will have to pay more out-of-pocket because they are not an "in-network" doctor. HAP is the insurance typically coupled with Henry Ford. Blue Cross Blue Shield allows for greater flexibility in terms of choosing doctors as it is accepted by most physicians. 

Question #4: How do you find services, doctors, and specialists covered by your insurance?

For finding doctors that accept your insurance, the easiest way is to look up the doctor online and see if they accept your insurance. Alternatively, you can call their office and ask, "do you accept HAP/NGS/Cigna/BCBS?" Finally, you can call the number on the back of your card and ask for your choices for primary care doctors or specialists that are covered by your plan in your neighborhood/area. 

Question #5: Our company has less than 50 full-time employees, We aren't making enough money to cover our employees with health insurance, but we would like to provide some sort of health care. What options do we have?

This is the ideal situation for Direct Primary Care practices like Plum Health DPC and many small businesses find themselves in this situation Because we offer an affordable, accessible health care service at a known cost, you as the employer know exactly what you're getting and the price you will pay. For $49/month for adults under 40 and for $69/month for adults over 40, you have access to our doctor and our primary care services when you need it. 

Question #6: So, under your plan at Plum Health DPC, what is covered and what isn't covered?

We can take care of 80 - 90% of your health care needs, including coughs, colds, cuts that need stitches, preventive care, and disease management for conditions like high blood pressure, diabetes, asthma, eczema, etc... We also offer wholesale medications, at-cost labs, and at-cost imaging services.

What we can't cover are things like heart attacks, strokes, and auto accidents that are severe. For these issues, you need to go to the hospital or the emergency department for immediate care. This is why we recommend that all of our customers have some sort of catastrophic coverage plan that covers emergency and hospital care. 

If you have any further questions about what we do, don't hesitate to reach out!

- Paul Thomas, MD

Plum Health at DNewTech Q&A

We were invited to pitch at DNewTech on Wednesday night, and after our pitch, we had 5 minutes to answer questions about Plum Health DPC. Here's the video of the event! 

You can see the original Pitch Video here, and you can see our original blog post here

One of the biggest barriers for people learning about our model is the difference between health care and health insurance. You need health insurance to protect you against the unknown or unforeseen: cancer, stroke, heart attacks and car accidents. Your health insurance should not cover your primary care services, because it introduces a middle man (or several middle men) between you and your doctor, driving up the price of those services. 

Health care is what we deliver at Plum Health. As your primary care doctor, I'm not that expensive and you're really paying me for my time. This allows me to answer your phone calls, texts, and emails in a timely fashion. It also allows me to get you in for an appointment when you need it, rather than having you wait for weeks just to be seen. 

Health care delivers the basics, like office visits, meds, labs, stitches when you cut yourself, and advice/counseling on lifestyle changes when you need it. Health insurance covers the unforeseen circumstances that are beyond our control. 

An analogy is auto insurance. We all have auto insurance, but we almost never use it, unless we're in an accident or our car is stolen. However, we don't expect our auto insurance to pay for the routine maintenance of our vehicles, like oil changes, tire rotations, and gas at the pump. If we did require our auto insurers to pay for these things, it would drive up the prices and make these basic services a hassle. Could you imagine long lines at the pump, prior authorizations to drive to Chicago, and auto insurance that only covers the basic oil, not the Valvoline. 

This would be an absurd way to take care of our cars. And I know that cars and people are different, but the way we've structured our health insurance coverage has caused very similar stress points to the imagined scenario above: long wait times to see your doctor, prior authorizations to get imaging studies like CT scans, and health insurance coverage that only covers some medications, but not others. 

In Direct Primary Care, we get rid of all of these middle men to deliver excellent, affordable services without the hassle. 

Thanks for reading and watching,

- Paul Thomas, MD