The biggest lie ever told to the American people is that if they have health insurance that they will have coverage for health services and be healthy. Many Americans believe that if they have health insurance that it will cover most, if not all services needed at a hospital or clinic. The unfortunate truth is that insurance companies are covering less every year, while charging more on their annual premiums. This has created a crisis because many patients need treatment, but their insurance rarely is going to cover anything so most of the cost will have to come out of their own pocket whether in the forms of deductibles, co-pays or self-payment.
If insurance is going to charge more and cover less every year, we will eventually get to a point that only emergency services are covered under these plans and the rest will be the patient responsibility. With this impending reality, many providers, hospitals and clinics are innovating new ways for patients to receive that much needed care. Some have suggested just moving to an all cash-based practice is the answer, where the patient pays for their services up front and then can file a super bill to the insurance company themselves in hopes of receiving payment from them directly. Unfortunately, many attempts to go to an all cash, fee-for-service clinic has shown many wrinkles in the model and many clinics have gone out of business. So what can be done to address this massive problem in healthcare? Innovate!
At Prototype Health, I have taken it upon myself to innovate how patients receive care in the chiropractic profession. I mentioned earlier that many people say that insurance coverage (or lack thereof) is the main problem in healthcare reimbursement, but I believe that it is what we are paying for in healthcare that is the problem. Let me explain what I mean in further detail.
Traditionally, we are used to paying for services carried out by a provider. If one goes to a cardiologist, they can expect a bill for the exam, lab services, and any other tests or medications that was given while at the office. In chiropractic or physical therapy, the game of fee-for-service is much more convoluted. It is the same fee-for-service model that exists in all of healthcare, but the problem is that this game is not straight forward to the patients. Many times, services are done not out of medical necessity, but because that is the service code that the office will be reimbursed for from the insurance company. Those services could very well not be what is medically necessary to treat the patient’s condition, but those are the ones done because the clinic must be paid for doing something right? The quality of care is diminished when providers have to play this game with the insurance companies to ever be paid. A lot of times those services that they do pay for will be capped at 6–12 visits and then they cease payment to the providers, which then puts the financial responsibility back onto the patient. This game is frustrating for both patients and providers, and is one of the main reasons why healthcare is so expensive.
So what have we innovated to combat this issue? We have a fee for results model in our clinic as opposed to a fee for service model. This means that you pay for the doctor to correct your headaches, scoliosis, rotator cuff tear etc., not the services required to fix the headaches, correct the scoliosis, or rehab the shoulder. The reason this model works so well in chiropractic and physical medicine is because it is very hard to give a truly accurate prognosis for any condition as there are a multitude of variables in treating patients outpatient. For example, if I told a patient that it would take 24 visits to correct her headaches that were caused by a hypo-lordotic cervical spine, she would pay with her credit card for 24 visits at $50/piece in hopes that I nailed it down to the visit when she would be getting better. After all no one wants to overpay for visits they don’t need, but more so, people do not want to have to pay for more visits after the doctor told them that 24 visits would be sufficient. In our office, you pay for the result of wiping away those headaches no matter how many visits or services it takes to get you there. It is a guarantee that you will get to your goals and results instead of hoping that the doctor has prescribed the right amount of services and care.
When doctors are incentivized (paid) to perform services, more services will naturally be performed over a longer period of time because that doctor wants to capitalize on growing his clinic’s bottom line. Well the best way to do that is do more services. We have changed the dynamic to: when doctors are incentivized to get results for patients, then they will only do what is in the best interest of the patient and their goals. This allows doctor’s creativity and abilities to shine through in their patient care, because their only motivation is to get results for that patient. The motivating factor changes from doing services for patients that will get paid to doing services that will get results for the patient. I like that dynamic better!
We believe that patients should pay for the end result not for the winding journey on the road to recovery that many patients are put on by providers. The game of fee for service is costing patients obscene amounts of money and leaves them with no guarantee that they’ll get to their health goals. At Prototype Health, we believe we should be paid for getting patient’s results; isn’t that what people want to pay for anyways?
Dr. Mike Goetsch D.C
Director of Healthcare, Prototype Health