Episdoe 21 of The Living Life Well Show: Insurance, A necessary evil?
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[00:00:00] Welcome to the Living Life Well Show, the intersection of God's Word, today's science, and healthy living with common sense application, all based on the truth of the Word of God. I'm your host, Dr. Jon Skelton. Now let's get straight to the truth. All right. Welcome back to the living life. Well, show today. I want to talk about insurance. Is it a necessary evil? Do we need it? Are there alternatives that we're not knowing about thinking about. Is there a way to do things better? Well, the answer to all these questions is yes. In my opinion.
So I want to go through kind of where we are with insurance today. Why we are, where we are. [00:01:00] And what you can potentially do to get out of this. Typical insurance model. So. Let's go back to you, how we're trained our medical education system. Is one that is focused on insurance. It is how the hospital gets paid.
It's how the drug company gets paid. It's how the durable medical equipment provider gets paid. It is how your physician gets paid and it ultimately pays for the salaries of your nurses. Your paramedics. All those different people that could be potentially involved in your care. And so it is as you know, a very convoluted system. Well, what's interesting is coming from the world of emergency medicine. It has been a bit eye opening as I have opened my own. [00:02:00] Freestanding Emergency facility. And operated that as an independent. A group of physicians for about five years. During that time, what we saw was really interesting. Insurance companies refusals to go in network. With us, we solicited multiple big name insurance companies. To be able to provide services. At, in network rates.
Well, why did we do that? Well, there was a provision that said that any time there's an emergency condition, that the patient had a layman standard, meaning they did not have to be an expert in medicine and, and they can go and seek medical care for anything that is reasonably worried about.
And so. The complaint may be abdominal pain and the result may be that you're just having reflux. Well, what insurance companies were supposed to [00:03:00] do was use the layman standard, what they ended up doing and what they lobbied and spent money. For time and time again in Texas was to essentially change it to a diagnosis standard completely different.
That's not a layman standard. You cannot diagnose yourself as well as you think Google is. And sometimes it's right, but generally speaking, Google's gonna tell you you're dying. So. Using a layman standard is very important. However, through lobbying and different changes to this original rule. Essentially now insurance companies are denying claims left and right.
Well, what does that do? Well, even if you are at a facility that's in network. With your insurance company. It leaves the entire bill on you. The bill for the facility fee for the physician fee, potentially. And for [00:04:00] any radiologic services that may have been provided or laboratory services that were sent outpatient. They may deny all of it and say that this could have been handled at a primary care physician office or at an urgent care. And so they will deny it because of the diagnosis, not because of the complaint, not because the level of anxiety or fear. That played into the reason that you went to an emergency department. So that, that that's one way that insurance companies will try and increase the burden to the patient, but also the physician and the facility. And all those that, that are working with them, they do this not only at freestanding facilities, they do it at hospitals. They do it at clinics.
They do it at many different places and in many different [00:05:00] ways, depending upon the. The particular type of medicine that you're practicing. It's why you have to get prior authorization for a particular medication. And, or test or procedure that your Dr. May require. So. Insurance companies. Are involved in every aspect of care.
And so what we see with that is that naturally trickles down to how we are trained. It trickles down to medical school. Nursing school paramedic school to some degree, not as much but definitely goes into any type of provider Professional training school. And so. What we see is we see a heavy, heavy focus on drugs.
We see a heavy focus on pharmaceutical treatments. And [00:06:00] very little on alternative lifestyle interventions that could be employed. That would potentially result in no need for medications. No need for drugs, no need for procedures, bariatric procedures. Say so. Those, those things are not valued because they know that the insurance model is what runs everything.
And so they teach to that model. And that then shades a physician's entire career as are coming out of medical school, going into residency. When they are in residency, that's really when they start to uncover the rigors of. Using this traditional insurance system. It necessitates that you document certain things and in certain ways, If you don't document [00:07:00] them this way, they will not reimburse you. That it will then deny the claim. So you had the option of going through multiple hoops trying to get them to make an exception or have to go back re document something in the form that they want you to. And, or you can just slide the bill over to the patient and say, here you go.
So either way it happens, it creates a lot of excess work. It creates a lot of excess jobs that aren't necessarily needed, which again, Increase the total burden of cost of care for an individual. And so these types of things are really not helpful and just really tend to create that wall between physician and patient, between health and wellness versus treatment and sick care. [00:08:00] Because you see really what insurance is focused on. Is sick care
they will pay virtually all day long for some sort of, treatment that is related to a condition. Somebody that is just wanting to maintain health and continue to live without the necessity of drugs through. Diet and lifestyle through regular checkups, through a laboratory testing and evaluation. They don't really value this.
When we look at the American college of lifestyle medicine over half of the lifestyle medicine practitioners, and this actually is really talking about PCPs that potentially practice lifestyle medicine to some degree, meaning they are endorsing, different lifestyle practices, diet practices, exercise practices. Different things that would [00:09:00] be non-pharmaceutical non procedure based practices. And over half of them are getting zero reimbursement. A very small percentage are getting some reimbursement that is nearly close to what they would give.
If this physician was then just. Prescribing a, a pill or a procedure and then a few more do get a very minuscule response, a. You know, 10 to 20, 25% of what insurance would, would normally pay if you were treating it in the traditional model. So. As you can see for the physician, for the patient as well, not just the physician, not just the nurse practitioner, the PA. Not just them, but for the patient as well. The, the insurance shifts the burden [00:10:00] on to you. They expect you to be able to diagnose yourself, to know when and how to treat yourself and they expect you to then. I pay for that. If you and your physician, after talking about this, decide to do something that is outside of pharmaceuticals and or procedures. So, this is why we have the system that we do today, because it has morphed over time. To be so heavy on pharmaceuticals and procedures and so lacking in personal education. Knowledge, diet, lifestyle evaluation, and a word treatments that we now have essentially lost control.
Our insurance premiums are increasing every year. And so, increasing tremendously. Every single year that, that that's true. At [00:11:00] my home as well. And so, I know it's true at yours. And so that, that burden just for the insurance premium is increasing. And the coverage that they're providing for that same program that you used to be on is less and less.
They're ratcheting down what they cover. They are increasing that burden to you constantly. So. What are some potential alternatives? Well, one is you could go to a concierge type of practice. Typically what a concierge type of practice is going to be is going to be one in which you pay either a monthly fee or a yearly fee. To either a physician or a physician group, and they agree to provide you with a certain services.
Be it a yearly visit. Sometimes these will be included. Sometimes you just pay an extra nominal fee. [00:12:00] For access, the reason these concierge practices are popular is two fold. There is no barrier to getting into the physician. There is no barrier to what is going to be discussed. There is no barrier to the amount of time the physician is able to spend with you.
So typically these practices are going to be practices that have smaller number of patients, so that. You can have time to discuss and educate and really get into the reason that you're experiencing these symptoms. The reason that you are currently in this disease state or getting to what testing really needs to be done to evaluate why you're having these things. None of this is available. in the traditional health care model, the traditional healthcare model, you maybe spend six, seven. If you're [00:13:00] lucky. 10 minutes. With your physician. When you're spending such a small amount of time and doing that every year or six months how's a physician really going to be able to ascertain what is going on with you.
So, you know, when you're looking for an alternative care provider, you want to find someone that is going to be very extensive. They're going to have at least a 30 minute appointment. The initial appointment needs to be anywhere from one to two hours depending upon what you're, you're going to be meeting for.
Then you want a physician that when they do go in and do diagnostics, that they are going to come back and really discuss those labs with you.
So when we look For alternatives to healthcare. One. Concierge. A model. Now. With that model. I still think [00:14:00] two things are potentially important. I still think that there needs to be some form of insurance. Okay. You know, only God knows if you're going to get hit by a bus or not, or if something else is going to happen.
So you need some form of catastrophic coverage in my opinion. And so you can look at that for, through a really. Hi deductible. Very minimal service. Kind of traditional insurance company, like blue cross or United Aetna, something like that. That would give you. Coverage pretty much anywhere in the United States, but you know, you're going to have a high in before they're going to start coverage.
Typically these things are going to have, you know, a 10, $12,000 deductible. Something like that. But they're going to be much cheaper on a monthly premium basis. Now you can marry that with a concierge type physician. [00:15:00] And those two things are going to give you a really good coverage. Now. One of the other alternatives. That a lot of people are using these days or the health sharing programs, think things like Medishare Christian healthcare ministries.
There are multiple of these. And so I would invite you to do your research before you enter into one. But typically what that's going to do is you're going to pay. Pretty much everything upfront. And then they are going to come back and then reimburse you. That's typically how these work and so. A little bit different than a traditional insurance.
A little bit more onus on you. But what, you can also negotiate many times with healthcare institutions, especially if it's a plan thing, like say a birth. Or something like that, you can negotiate a, a cash pay price. So if you negotiate a cash pay [00:16:00] price healthcare. Typically, what they're going to do is they're going to give you one price, but you can almost always get it about 40% less.
When you go to a facility that is operating in the traditional model. So you pay that cash pay price. Now your out of pocket is less initially and your overall out of pocket is less when you're using a health sharing type program, because now the 20% that you're ultimately going to be responsible for has been much reduced. Many times they will also allow you to make payments. To them over time, especially if it's something that, you know, that is, that is not an emergent type procedure, anything like that. Ah, In addition. If you are going into an emergency situation They will cover 80% of that.
And then you are going to be responsible for the 20%. So I would recommend really [00:17:00] looking at that that would be an alternative. To the traditional catastrophic type of insurance, you want to look at the different levels of, of service they provide. If there is obviously any. Preexisting conditions. Clauses or things like that with these health sharing programs, many of them. Do have those clauses that would prevent people from being able to participate in them.
So, so that is a potential downside to them. With the current legislation. You should not be denied for a high deductible insurance. Even if you do have some, a preexisting condition. Now, the third thing that I want to talk about that that works really well is HSA. HSA or you know, FSA accounts. Different health savings type accounts. Are really good.
And they've given us a lot of, of great help these days. And I [00:18:00] really love it when a client has an HSA. The reason being is, is that in many concierge practices, even you can pay for your yearly premium. That you're paying to the, to the clinic or physician. Through an HSA, you can pay for your individual visits through an HSA.
Now with lab providers like Evexia and Rupa health. You can get those really key kit testing. That you need at home? By paying through your HSA, which again would give you a credit card associated with it. And so it makes it really easy to be able to obtain all those things. So I think a marrying of at least two of these is going to be important either HSA along with either a health sharing. Program and or catastrophic insurance. Or a a concierge type practice. With [00:19:00] either a health sharing or catastrophic insurance now. The best in my opinion is going to be an HSA. With a concierge type practice. And either the health sharing or the catastrophic insurance. Now. Who really needs kind of more traditional. Insurance, well, people that have a longterm ongoing high cost procedures. That are going to be undertaken.
So primarily the thing that you think about with this is people that are undergoing cancer treatments cancer treatments Can be very expensive. Somebody that is undergoing repeated imaging, some people with different neurologic conditions are going to really, probably need more traditional insurance in that regard. Because of the fact that the treatments may be very, very expensive [00:20:00] and the lifestyle modifications that take place. Again, they, they take time to begin working.
It's not that they aren't useful or art appropriate because there are there's great research with regards to cancer treatment. Ms. Treatment. And multiple treatment that different, different lifestyle modifications and things can occur. To help minimize the symptoms and or exacerbations of that underlying condition. Through diet and lifestyle modifications.
And so, however, sometimes you still need that traditional healthcare model. To help when you get in a crisis. And that's where I think someone in that realm may want to move over to more kind of traditional healthcare. So. The thing that I really love about the HSA is, and I want to get into that a little bit more. And even [00:21:00] the, the health sharing aspect. Is because when you go to your physician virtually all the blood work. That is ordered is going to be covered in some form or fashion from your insurance.
So when I bring a new client into my practice, I give them the option of paying directly. To one of these labs where they're going to give you that functional report, those optimal ranges or using their insurance and going to a place like lab core quest, having blood drawn there, they file the insurance, whatever insurance. Allows then they're responsible for the rest.
So just to give you an idea of kind of what we're talking about and kind of how insurance works and how traditional. Medical institutions work. Let me give you this example. So recently I had a client. That wanted to [00:22:00] use their insurance and wanted me to order all the labs through traditional parameter.
So we did that. They went to the lab to go and get the lab drawn and, and they had a very high deductible plan. Their, their plan really didn't give a lot of coverage for labs. So while they were there and they were discussing they were told. They would need to pay a $4,000. Well, I can guarantee you that lab company was not getting reimbursed $4,000 for the labs that I ordered by the insurance company. They're probably getting reimbursed us somewhere between the insurance company and the client responsibility or patient responsibility. Four to $700 probably is. Is somewhere that, that, that lab company was going to come in at. Well, so, my client contacted me, told me about this.
And so we elected to then [00:23:00] order them through I believe it was Evexia at this time. And we used Evexia and had all that same $4,000 worth of blood work done for about $450. So there are ways that you can get prices. Down that you can negotiate for yourself. And sometimes going through these different lab companies is going to be really great. The other thing that insurance typically won't do, they won't pay for these kit testing. Things that I do like the GI map the Dutch test and there's many other kit tests that you can do for different. Potential disease states. They don't really cover these.
Now, when you have an HSA or FSA, you can use that through these different lab companies like Rupa health or Evexia. And pay for that out of the HSA and have it covered. Sometimes with traditional [00:24:00] insurance, you could submit what you've paid for these kit tests. To your insurance and they may reimburse you something many times not. But needless to say, insurance of some type, I believe absolutely is a necessary evil. If you are otherwise healthy. And a family is otherwise healthy.
I really recommend that you look into the HSA and, or the, the health sharing aspect. I think you get more bang for your buck. You have a better relationship. With the physician. When you go into a more concierge type practice, typically a HSA can pay for that. Sometimes the health sharing. We'll pay for that as well.
And so. All those are things that I would recommend to you to try and get out of that traditional model. [00:25:00] It is a fraught with nothing but pharmaceutical treatments and or procedures. Things that aren't going to get you well, that isn't going to cure or reverse disease. It's going to manage you. Manage your symptoms.
And as for me, I don't want to be managed. I want to manage what God gave me well, and I want to have direction as to how best to do that and to live free of disease. So I hope this is been enlightening for you. I hope you've learned a little bit about insurance and why it is so complicated.
Hopefully if this applies to you. As someone who's otherwise pretty healthy, doesn't have any you know, current serious medical issues going on, or a history of serious medical issues that you would consider these alternatives that I've put forth for you. Thanks. And God bless.
That's it for this episode of the [00:26:00] Living Life Well Show. If you like what you've heard and want to learn more, or want to know how to put this into practice for yourself, go to livelifewellclinic.com. Until next time, this is Dr. Jon Skelton saying, go out and live the truth so you can live life well. The preceding is for entertainment and educational purposes only. It is not meant to be used to prevent, diagnose, treat, or cure any condition. The information contained in this show does not substitute the need for a qualified medical professional, nor is it meant to provide medical advice or services.
If you feel information presented in this show may apply to you, we recommend you seek out the help of a qualified medical professional who can evaluate and treat your specific concerns.
