Funding Your Own Healthcare

Introduction

More folks including both individual adults and families are on their own to provide funding for healthcare. There is a growing trend of being your own freelance business owner, being a contract employee or being employed by a business that does not offer a health insurance benefit. Many people make the mistake of buying price instead of value in a healthcare funding plan. This article provides an overview of options for funding healthcare with both advantages and disadvantages of each strategy.

How Much does Healthcare Cost?

Understanding what healthcare costs is important to deciding the best strategy for funding your own healthcare needs. Buying based only on price and not value (price vs. benefits) is a common and very grave mistake. Some examples of what healthcare can cost will help illuminate the importance of value and risk transfer (insurance) in funding your own healthcare.

Routine Care: Having an ongoing relationship with a medical doctor is important value and can help you avoid much more costly illness and improve your overall health outcome. I am an example of the benefits of routine medical care with the goals of avoiding cardiovascular disease, diabetes and managing my sinus allergies. My recent doctor visit including blood test = $248 Well Baby Check (price from local pediatrician) = $160 Annual Physical = $500? Cost depends on how elaborate a physical you get.

Rx Drug: Prescription drugs are approximately 10% of total healthcare spending [1]. Prescription drugs can be a large component of treating a major or chronic illness. These are drugs that I take with the list prices from my local drug store. OTC Claratin (equivalent house brand) = $10 / month Crestor = $137.99 / month Astelin = $115.99 / month An example of a more expensive medicine that my wife takes regularly for her chronic migraines: Topamax (generic equivalent) = $566.99 / month

Diagnostic Tests: Diagnostic tests are an important part of most disease identification, management and treatment and are a large component of healthcare costs. My recent blood test (three panels) = $152 X-Rays = $100+ Mammogram = $150+ MRI = $1000+; a complex MRI can cost several thousand dollars

Emergency Care: ER Visit = $1000+; this is based on my experience – I have never had an ER visit that was less than a $1000 in billed costs

Hospital Admission About 30% of healthcare costs are for in-patient hospitalization. The average length of a hospital stay is five days [2] with costs highly dependent on treatment. Heart Arrhythmia (irregular heartbeat) – Example from one of my clients = $45,000 including an ER admission and then three days in the hospital

Major Illness: Cancer (Lymphoma) – My brother over two years of treatment = $500,000+; It is hard to tell the actual total but when I called to see if my brother was close to exceeding his $1 million lifetime limit the expectation was at least $500,000 in paid benefits to complete his cancer treatment.

Chronic Illness: A chronic illness is defined by a medical condition lasting a year or more that requires ongoing treatment. Examples are Diabetes, Asthma, hypertension and Depression. Approximately half of all Americans have some kind of chronic aliment [2]. Type 2 Diabetes – Average Annual Cost = $5949 [3] Asthma – Average Annual Cost = $3192 [4]

Put all of this in a gigantic pile and the average cost of healthcare in Texas according to the Texas Department of Insurance in 2006 was $7110 per person. That is $593 per month per person. Admittedly that includes a lot of unhealthy and high healthcare uses but it provides some perspective on what healthcare costs. If you have not had a close relative, family or friend with a serious illness or injury, it is hard to imagine the high cost of healthcare. Value in funding healthcare is more than helping with the cost of routine care. Value to me means grappling with the risk of a major illness or injury.

Choices for Funding Healthcare

Cash – Just buy it when you need it and pay what it costs out-of-pocket. The big disadvantage of the “Cash” or what I call the “If we are Lucky Plan…” is that you have no protection of the risk for a major illness or injury. We have over 24% of Texans uninsured for healthcare with a fourth of the uninsured on the “Cash” plan by choice — about 6% of the entire population.

Advantages:

No Monthly Premium / Fees
Ask for Cash discount from healthcare providers
Available to all
Disadvantages:

No financial protection from the risk of a major illness or injury
Difficulty in accessing cares without insurance; some healthcare providers may require advance payment
You pay the whole bill for medical treatment
Discount Health Card – Buy it when you need it and pay less with an “Affordable Healthcare” discount card. Essentially, you access contracted network rates without a Health Insurance policy for an annual or monthly fee. I look at this plan as a variation of the “Cash” plan since you have no protection of the risk for a major illness or injury. “The FTC and many states have found that although some medical discount plans provide legitimate discounts that benefit their members, many take consumers’ money and offer very little in return.” – Federal Trade Commission

Advantages:

Low Monthly Fee
Discounted care from some healthcare providers
Normally available to all applicants
Disadvantages:

No financial protection from the risk of a major illness or injury
Difficulty in accessing care without insurance; Some healthcare providers may require advance payment
After any offered discount, you still pay the whole bill for medical treatment
Limited Benefit Plan – Pay a monthly premium for a defined-benefit insurance policy. Also often marketed as “Affordable Healthcare,” these mini-med health insurance plans typically offer a set payment amount for a specific healthcare treatment and a maximum benefit limit under $100,000. These plans don’t meet the “my brother test” – would this type of plan coped with the healthcare costs of my brother’s lymphoma? – No, so I won’t sell them. The healthcare discount cards and limited benefit plans are aggressively marketed on the internet. Just Google “affordable healthcare” or “low-cost health insurance” and you will see bunches. There just is no free lunch in health insurance. If the plan is cheap, then the benefits are limited.

Advantages:

Less expensive monthly premium
Discounted care from some healthcare providers
Limited insured benefit payments for medical procedures
Improves access to care
Few enrollment restrictions
Disadvantages:

Incomplete financial protection from the risk of a major illness or injury
Due to benefit limitations, some healthcare providers may require advance payment
After any offered discount and benefit payment, you pay the remaining balance of the bill for medical treatment
Major Medical Policy – This is your “Traditional Medical Insurance” policy for individuals and families. You pay a monthly premium for an insurance policy covering a wide range of healthcare risks with a substantial benefit limit, often $1 million or more. Most Major Medical Insurance policies now sold use a network concept called a “PPO” or Preferred Provider Option. Most plans feature co-pays for doctor visits and prescription drug purchases which reduce the out-of-pocket cost of these routine healthcare expenses.

Advantages:

Protection from the financial risks of a major illness or injury
Provider discounts if “in network”
Improves access to healthcare providers and treatments
Encourages preventive health treatments
Reduced out-of-pocket costs for routine healthcare
Disadvantages:

High monthly premium costs
Applicants must qualify based on health screenings
Generally, no maternity coverage
Must use “in network” providers for lowest out-of-pocket costs
High Deductible Health Plan (with optional Health Savings Account) – This is a “Major Medical Policy” to grapple with a major illness but only after an annual deductible is exceeded. An optional tax-advantage savings account (H.S.A., “Health Saving Account”) is available to set money aside for healthcare costs prior to reaching the deductible. A family insurance plan that qualifies as a prerequisite for a Health Savings Account in 2009 can have a deductible of no less than $2400 and no more than $11,900.

Advantages:

Protection from the financial risks of a major illness or injury
Provider discounts if “in network”
Improves access to healthcare providers and treatments
Access to optional Health Savings Account to save toward future medical bills with a tax advantage
Disadvantages:

Monthly premium costs (lower than Major Medical Plans but still substantial)
Applicants must qualify based on health screenings
Generally, no maternity coverage
Requires making more choices on healthcare
Larger deductible and no expensive reducing co-pays
Additional Advantage of Optional Health Savings Account:

Reduced taxable income by amount saved in H.S.A. account
Use it or keep it — any funds not used are retained for future medical expenses
Funds saved are available for broad range of healthcare expenses while retaining the tax advantage
David W. Crump, Ross Gray Insurance Agency

I specialize in Business, Health and Personal Insurance sales and service.

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Evolving Healthcare Trends

The model trends in the healthcare system have been changing over the period of time. The old trend gave importance to the individual patients and the emphasis was on treating illness. The goal of the hospitals was to do inpatient admissions, fill up the beds and more emphasis was given to acute inpatient care. The role of managers in the old paradigm was to run the organization and coordinate services. In the old system, all providers were essentially the same. The hospitals, physicians and health plans were separate and not integrated.

The newer trends that evolved gave importance to the population as a whole. It not only treated illness, but emphasized on promoting the wellness of the people. The goals of the healthcare system after being transformed over the years is to provide care at all levels which is continued. The role of managers in the new paradigm is more broad. They see the market and help in quality and continued improvement. They not only run the organization, but also go beyond the organizational boundaries. In the evolving system, the providers are differentiated according to their ability. The hospitals, physicians and health plans have formed an integrated delivery system.

One of the current trend in the healthcare delivery model is that continued care is emphasized. The key professionals are not only treating patients for their illness, but they are promoting and managing quality of health. For example, a patient with high cholesterol visits a doctor. He is not only given one-on-one medical treatment, but he is also offered to attend a group session where information is provided on how lifestyle and behavioral change can help. The patients learn from the clinicians and also from each other. Another current trend is to take care of the health of the defined population and not only individual patients. All the health needs of the population as a whole are identified and served. It is emphasized that the community uses the health and social services provided. Healthcare has become more population-based. Another trend that has evolved is that the hospitals, physicians and health plans have got connected and have formed an integrated delivery system. More investments are being made with a goal of providing services to the customers and retaining them.

There is a beneficial impact in the transformation of healthcare towards emphasizing continued health. The way healthcare has been viewed in the past has been changing. The shifting of care from treating acute illnesses to providing continued care is resulting in enhancement of the health of the people. The only appropriate and feasible model is to provide a continuum of care with the emphasis firmly on the family and community. The health of the population and community is considered as a whole. This is advantageous as it creates value in the healthcare delivery system. The healthcare providers work with the community as a whole and consider to improve the health of the general population. Even though this requires new kinds of ways of organizing and managing healthcare services, it helps in understanding the health needs of the target population. By studying their needs, the right health and social services could be provided to them. Examples of promoting wellness of the whole community are organizing health campaigns and providing preventive education to the people in general. Another example is providing awareness about flu vaccines and encouraging people to get the vaccination.

Integrating the healthcare delivery system has led to certain advantages to the patients. For example, they can be offered alternative sites of care depending on their convenience. It helps in meeting the needs of the customers and their preferences which is taken into account. The number of providers are expanded and the patients get to have a choice. The relationship between providers and health plans are organized in the current trend and this ensures that the right care is provided in a convenient way to the customers.

There are defined budgets and expenditure targets for the populations which implies that there is a need to be efficient and productive. The formation of strategic alliances, networks, systems and physician groups can also add value. There are capitated payments and budgets allotted to the healthcare organizations. These are used to provide care to the defined population. The organization might like to improve on the payments and budgets as the expenditures of the companies increase. This results in the management to make decisions like forming strategic alliances with other organizations and increase the total resources. The growth of such networks will help in providing better care to the customers. Financial resources greatly influence the efficiency and productivity of the organization.

The aging population is influencing the healthcare delivery. There is increased demand for primary care of people over 65 years and for chronic care of people over 75. The ethnic and cultural diversity is also influencing the healthcare delivery. This provides a challenge in meeting patient expectations on one hand and diverse workforce on the other. Biological and clinical sciences have met with technological advances and have led to new treatment modalities. This has led to open new treatment sites and manage across the organization. External forces change the supply of certain areas of health professionals like physical therapy and some areas of nursing. The management needs to compensate for such shortages and they need to develop different teams of caregivers at different work sites. Changes in education of health professionals implies that the management be more creative in offering healthcare services. With an increase in diseases like AIDS and morbidity from drugs and violence, there is more and more need to work with community agencies, form social support systems and there is a need for more chronic care management. Advances in information technology is another area where there is a need to train the healthcare employees in new advances. They also need to manage issues of confidentiality and rapid information transfer. Increasing expansion of world economy has led to more competitive management of strategic alliances, care of patients across the nations and of different cultures.

Current environmental trends impact the healthcare delivery model. Organization’s success depends on its external and internal environment. The complex environments made up of uncertainties and heterogeneity of components leads to different organizational designs. The current environmental trends influence managerial and organizational decision making. The unique challenges facing the healthcare delivery organizations should be analyzed in order to develop and implement new and effective operational processes and strategies. As an impact of current environmental trends, the healthcare delivery system needs to improve individual, team, and organizational accountability and performance. The impact of advances in medical knowledge and information technology on the process of healthcare delivery should also be examined, and it should be leveraged to improve quality of care, process and cost controls, and revenue. New strategies would need to be identified and implemented for learning and performance improvement to create a culture that supports accountability, safety, and high-quality care. Innovative models in healthcare delivery would also be required in order to develop and implement strategies that promote organizational success and competitiveness.

Due to the current environmental trends, more emphasis is given to the customers and there is more of a patient-focused care. The healthcare delivery model has been shifting to the community based care. There has been an increased modification in care processes. The traditional ways are being challenged and more experiments are being performed to fulfill the demands to improve the quality of care. Due to the shift in the environmental trends in the healthcare delivery model, more emphasis is given to quality improvement. This will help improve the performance levels of key processes in the organization. The performance levels are being measured, the defects are eliminated and new features are being added to meet the customer’s need efficiently.

There is a new emerging contemporary trend in the U.S. healthcare system. Presently, the management research and assessment have been offered increased recognition. The emerging trend seen is that this is slowly forming an integral part of managerial and organizational effectiveness. With the emerging efforts in information management, it is leading towards clinical and financial networking. The trend seen among the physicians and nurses is that they are being increasingly involved in managerial activities. The managerial trends are also changing with respect to role performance and changing values. The managers role is getting more and more recognized in managing finance and human resources. Management training, lifelong and distance learning is being offered in preparing future managers.

The healthcare executives and managers will be faced with the major responsibility and challenge in the years ahead. They will be working with other healthcare providers and will be creating a competitive future for their organizations. They will not only be managing organizations but also a network of markets, services and joint ventures. Formation of more and more strategic alliances and partnerships will lead the management to manage across boundaries. The management will change from managing a department to managing the continuum of care. The management will be following a community-based approach. Trend in management is also shifting from just coordinating services to providing improvements in quality.

As the demands in healthcare are increasing, the management is responsible for forming performance standards. The management is also challenged to maximize the productivity and quality to serve the health needs of the community. The management is looking after the demands of the external environment as well as attending to the performance of the internal environment. The management is responsible for the performance of the organization.

Healthcare organization leadership will be responding to new trends and competitive forces. It will respond to continuum of care, overall health status of the population and more complex organizational structures. These emerging trends in the healthcare system will effect the organization’s leadership. The future managers would need leadership skills and vision to integrate the organizations and help in providing the best care. The managers will have to be committed to leadership and work on giving their organizations the best place and help their organizations adapt to the changing circumstances. More value will be given to leaders who will be able to lead the change process. As changes are inevitable for the betterment of the organization, the leaders should be able to identify how the change is to be received and how it is to be communicated at all levels of the organization without damaging the implementation process. The leaders might have to deal with increased pressures due to organizational complexity.

The leader in the organization provides strategic direction to the organization, manages diverse stakeholders, becomes mentors for management, is willing to take risks, helps the organization interact with the external environment and attends to the internal needs as well. Where required the leader will involve physicians in governance process and align physician and organizational interests. There will be a need for formation of learning organizations. Transformational leadership will create the required vision for the organization. Leaders will have a greater role complexity and they themselves will have to adjust rapidly to new situations. The healthcare organization leadership will have to live up to the values of the organization and will help in fulfilling the mission of the organization.

Individuals and groups within the healthcare organizations require more and more competencies. An enhanced lifelong learning is required due to the fast, changing environment. The individuals and groups within the healthcare organizations will be benefitted as there will be rapidly developing medical technologies which will result in increased services. More sophisticated health services will be provided to the consumers. The range and quality of services provided will be regulated for the benefit of people requiring home care, long term care and ambulatory care. The anticipated future development will also result in the increased competition among the health services organization. The individuals and groups will be involved more and more with the community for issues like drug abuse, teenage pregnancy and violence.

Individuals and groups will be faced with increased strategic planning and management in the healthcare organizations as there will be ever increasing involvement by the trustees and physicians. As the future environment in the organizations will be more complex, the individuals and groups in the healthcare organizations might feel more pressurized. They will need to serve the changing demands of the community as the population of elderly patients will increase. These individuals will require more professional training, increased levels of education and should be taking part in continuing education programs.

Due to the anticipated future development in the healthcare organizations, those individuals and groups will be valued, who are adaptable, committed, are able to add value and embrace change. These individuals will be required to experiment more and help in redefining the mission and goals of the healthcare organizations.

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