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I shouldn't say they're 100% mutually exclusive, but they tend to be for most routine services. They're probably still going to file a catastrophic claim if the

I shouldn't say they're 100% mutually exclusive, but they tend to be for most routine services. They're probably still going to file a catastrophic claim if they find cancer, etc... >it seems like you can gain only so much by bypassing them. You do, but self-insuring on it's own saves a big chunk, so what's left is really just the complicated paperwork. The only reason it exists is to complicate insurance dictated rate structures, so get rid of the complicated rate structures for the 80-90% most common visits by contracting a doctor directly and there just isn't the need to pay someone else to manage it anymore. Then the real gain is paying the doctor based on a simplified negotiated rate, and in return he gets a whole company of regular patients, and can send just one summarized bill to the company for everyone he sees in a week. Not having to file any additional billing paperwork per patient is just a happy side-effect, for both the doctor, the patients, and the sponsoring company. >And why would you want to eliminate medical records? It's not to eliminate medical records, it's just a matter not being forced to do them in a certain way. I think most doctors would have loved to start by scanning paper charts at the end of the day, then let some data people convert that into something the computer understands. But the way it's setup (and mandated), the database is the official record (not the attached notes) so it all has to be done personally by the doctor, or signed-off by the doctor if a nurse or mid-level or medtech enters anything. They basically make the doctors responsible for data entry QAQC, with their malpractice insurance at risk for a screw up. Doctors are used to mostly freeform notes with a few fill-in-the-blanks and check boxes for orders or standardized info like heart rate, bp, etc. Most software tries to cram 99% of this into a mess of a structured relational database. These also have freeform typing boxes for notes, but getting paid depends on duplicating most of the note information across a huge range of screens and tables so that the billing software understands what was done, and understands it in such a way that is covered by the patient's provider. They are probably a 6-digit number of ways to code for giving the patient aspirin, but half might not be covered, and the other half might range in price from free to thousands of dollars of copay. And this changes with every different insurance policy, and every different doctors office/hospital system, (depending on negotiated rates with insurance) so that even the most expert billing tech might not know the correct way to bill a particular patient the first time. And oh, if they need to change it later to get insurance to cover it, the doctor usually has to sign-off on it again as if he performed a different exam than was recorded the first time. It's a lot easier to just scratch down on paper (or in a computer) "gave patient exam and aspirin, bill for a level 2 and rx" or something similar, and then your receptionist knows what to collect or bill. All of a sudden you don't need a staff of billing techs on the phone with insurance companies all day, or a software support contract that your billing depends on. Now imagine getting all the doctors approaching retirement and working in small practices that switching is worth the expense and hassle. So it's not being against medical records, but the freedom to do them as you see fit, while avoiding the hassle of compliance. And one of the few remaining ways to do that is go for the market that can pay cash, which overlaps nicely with both the concierge market and self-insured employers. (and some niche co-op style wellness "clubs", but I'm not familiar)

perl4ever 7y ago
"You do, but self-insuring on it's own saves a big chunk" That doesn't save money because then you don't have insurance! The part of your premium that covers unexpected events can't be saved; only the part that pays for routine care. The word that comes to mind is "optionality" although I'm not sure it is the right jargon. People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about. It costs essentially zero to transfer money from one account to another, so just because you don't gain anything by having insurance pay, you (on average) shouldn't lose anything either. There can't be any fundamental problem with them providing a payment service.
- beerandt 7y ago
  >That doesn't save money because then you don't have insurance. The employees are still insured, it just means the employer absorbs the risk instead of the insurance company. At a certain point, this becomes cheaper than paying the insurance company. But then the company might take out a separate catastrophic policy that covers anything over $X million in a year. >The part of your premium that covers unexpected events can't be saved This is just wrong. A significant portion of that amount can be saved. Some of it is statistics, and some financial structuring. The insurance company isn't going to absorb a company's risk for free, but there are savings beyond the profit and (overly conservative) risk margins. Segregating your risk pool allows additional control over it, then you can reduce risk in a number of ways, but especially with wellness programs. (My premium contributions at work were cut 75% for participating in the company wellness program.) I think" a company is also able to hold it's own reserve assets that are backing their risk, and there are additional tax savings with how money changes hands fewer times, but I'm fuzzy on the details. Anecdotal, but my last two employers were extremely eager to qualify to self-insure, even while still using the insurance company to manage policies. (There's a multi year process to qualify involving financial stability, risk pool evaluation, and sometimes even reorganizing the company structure or re-incorporating.) >People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about. They say that because it's no longer medical insurance, it's pre-paid health care plus medical insurance packaged together. The biggest problem people have with the pre-paid routine care is that it's basically pooled just like the insurance part, and what's routine for me might not be routine for you. Nonsmoker's, even if they're priced as tobacco-free, have to pay for a policy with smoking cessation coverage. Nuns and 80 year olds must have coverage for birth control. There's mandatory coverage for prenatal visits and labor/delivery, even if you never want to (or can't) have kids. Insurance is meant to mitigate high cost risks, not be a bureaucratic middle-man for every routine cost. Affordable "risks" shouldn't be insured. Insurance that covers expected* costs isn't insurance. It's just quasi-socialized healthcare with the word "market" attached for political deniability. In the non-segregatated pools, there's no incentive to keep costs down. You'll be paying for a portion of the weekly doc visits of the bored little old lady who goes and gets every little bruise and goosebump checked out, because why not? It's a no-cost routine visit for her. Also, you have to pay for coverage for services you might already have free access to. Like if you work for a clinic and they offer employees free visits. You still have to pay for that coverage. Or I want to see a particular doctor that's out of network. I've got to pay out of pocket for a service that I've already paid for. If you forget to get pre-authorization before going to get a mole removed by the dermatologist? Same thing. They might not pay it, because you did it without their permission. All of these "routine" costs are built into the price of your policy, and for most people it would be cheaper and much less of a hassle to pay-as-you-go for everything thats not catastrophic. >It costs essentially zero to transfer money from one account to another Except your money got thrown into slush fund shared with thousands of strangers, and you'll never get as much out as you put in (Unless you're talking about the case of a self-insured employer paying 100%, which is rare.) >There can't be any fundamental problem with them providing a payment service. If that was all they did, and you got rid of the pooled routine costs, and got rid of the billing-code/ coverage roulette, and got rid of the copay/ deductable/ out-of-pocket calculation hassles, and if it would just work as constantly as a debit card, then I think people wouldn't have a problem with it. But that's sort what an HSA does (which is through the bank, not the insurance company.) In practice they're restricted to certain policy types, and don't really eliminate any of those problems, just reduces them.

perl4ever 7y ago

"You do, but self-insuring on it's own saves a big chunk" That doesn't save money because then you don't have insurance! The part of your premium that covers unexpected events can't be saved; only the part that pays for routine care. The word that comes to mind is "optionality" although I'm not sure it is the right jargon. People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about. It costs essentially zero to transfer money from one account to another, so just because you don't gain anything by having insurance pay, you (on average) shouldn't lose anything either. There can't be any fundamental problem with them providing a payment service.

beerandt 7y ago
>That doesn't save money because then you don't have insurance. The employees are still insured, it just means the employer absorbs the risk instead of the insurance company. At a certain point, this becomes cheaper than paying the insurance company. But then the company might take out a separate catastrophic policy that covers anything over $X million in a year. >The part of your premium that covers unexpected events can't be saved This is just wrong. A significant portion of that amount can be saved. Some of it is statistics, and some financial structuring. The insurance company isn't going to absorb a company's risk for free, but there are savings beyond the profit and (overly conservative) risk margins. Segregating your risk pool allows additional control over it, then you can reduce risk in a number of ways, but especially with wellness programs. (My premium contributions at work were cut 75% for participating in the company wellness program.) I think" a company is also able to hold it's own reserve assets that are backing their risk, and there are additional tax savings with how money changes hands fewer times, but I'm fuzzy on the details. Anecdotal, but my last two employers were extremely eager to qualify to self-insure, even while still using the insurance company to manage policies. (There's a multi year process to qualify involving financial stability, risk pool evaluation, and sometimes even reorganizing the company structure or re-incorporating.) >People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about. They say that because it's no longer medical insurance, it's pre-paid health care plus medical insurance packaged together. The biggest problem people have with the pre-paid routine care is that it's basically pooled just like the insurance part, and what's routine for me might not be routine for you. Nonsmoker's, even if they're priced as tobacco-free, have to pay for a policy with smoking cessation coverage. Nuns and 80 year olds must have coverage for birth control. There's mandatory coverage for prenatal visits and labor/delivery, even if you never want to (or can't) have kids. Insurance is meant to mitigate high cost risks, not be a bureaucratic middle-man for every routine cost. Affordable "risks" shouldn't be insured. Insurance that covers expected* costs isn't insurance. It's just quasi-socialized healthcare with the word "market" attached for political deniability. In the non-segregatated pools, there's no incentive to keep costs down. You'll be paying for a portion of the weekly doc visits of the bored little old lady who goes and gets every little bruise and goosebump checked out, because why not? It's a no-cost routine visit for her. Also, you have to pay for coverage for services you might already have free access to. Like if you work for a clinic and they offer employees free visits. You still have to pay for that coverage. Or I want to see a particular doctor that's out of network. I've got to pay out of pocket for a service that I've already paid for. If you forget to get pre-authorization before going to get a mole removed by the dermatologist? Same thing. They might not pay it, because you did it without their permission. All of these "routine" costs are built into the price of your policy, and for most people it would be cheaper and much less of a hassle to pay-as-you-go for everything thats not catastrophic. >It costs essentially zero to transfer money from one account to another Except your money got thrown into slush fund shared with thousands of strangers, and you'll never get as much out as you put in (Unless you're talking about the case of a self-insured employer paying 100%, which is rare.) >There can't be any fundamental problem with them providing a payment service. If that was all they did, and you got rid of the pooled routine costs, and got rid of the billing-code/ coverage roulette, and got rid of the copay/ deductable/ out-of-pocket calculation hassles, and if it would just work as constantly as a debit card, then I think people wouldn't have a problem with it. But that's sort what an HSA does (which is through the bank, not the insurance company.) In practice they're restricted to certain policy types, and don't really eliminate any of those problems, just reduces them.