Justified

It's Past Time to Call Everyone Out

A recent Wall Street Journal article reported that up to 45% of home insurance claims are denied. They described this finding as the equivalent of “tossing a coin” when filing a homeowner claim.

In 2024, Kaiser Family Foundation reported that 19-20% of health insurance claims are denied over a steady 10-year analysis.

I personally stopped counting how many times a day or week a prescription sent out to a pharmacy is denied or results in a request to change my recommended management. I have documented for readers the absolute sham Medicare Part D is.

One of our local radiology groups has confirmed that the cash price they offer is truly a mutually beneficial (not a poverty/compassionate care list price) transaction. The explanation is that trying to use the insurance payment mechanism results in point-of-care denial of service and last-minute cancelation of a scheduled procedure.

This real world story absolutely validates why a free market approach to health care is the answer to our country’s quest to health care access. This means despite the patient having their test delayed in scheduling for 2-3 weeks as the radiology company attempts to get payment authorization, the process fails. The patient gets denied service upon arriving for their appointment. No billable event occurs, and therefore all the overhead and costs for that appointment get zero payment. The price for future studies gets higher to compensate for the lost opportunity of actually keeping that appointment. This real-world system artificially drives costs up and crushes efficiency for delivery of care.

Just today, I got a cash price quote of $258 for a cervical MRI for a patient. She is happy, and the procedure is scheduled tomorrow (price quote today). Both she and the radiology company experience a different type of opportunity cost.

This week I provided the national magazine, the Washington Examiner an op-ed pointing out that our government and the involved hospital and health insurance lobby have us in the financial death grip of preferential hospital location payment for the same services physician offices provide. This is resulting in the predictable demise of physician private practice, market consolidation, and rising overall health care and health insurance premium costs. In the op ed, a call to action to addressing this is also offered.

So Why Do We Keep Pretending Mandating Health Insurance Is The Answer To Getting The Most Citizens Health Care?

Not long ago, I stated that Government Usurped Its Authority When It Started Medicare and Medicaid. I know that sounds “crazy,” but I contend these programs, as presently operating, pale in comparison to what is possible for how healthcare could be getting accessed. Every step of the way for the past 30 years, these programs, through government regulatory policies, have put the axe to what connects doctors with their patients. Consider it intentional or not, ask yourself where we find ourselves and what is possible.

My op-ed recommends immediate action that would place a necessary punch on the nose to the hospital business model.

Broad site-neutral reform could save taxpayers roughly $150 billion over the next decade, and even narrower proposals have scored tens of billions in savings.

This is something some in the present congress are proposing. I would favor action ASAP and for me, the time for more debate is over.

Other Policy Options That Would Free Us From This Morass

Economist John Goodman has written on this topic extensively and I concur with many of his suggestions.

When it comes to Medicare, seniors consider Medicare a fait accompli. Sadly most physicians have the same mindset. My profession has been browbeaten towards acceptance. Mr. Goodman has offered a way forward for Medicare reform. He suggests:

• Funding Direct Primary Care via Roth HSAs: HSA stands for Health Savings Account. Goodman explicitly proposed allowing Medicare Advantage plans to make after-tax deposits into a beneficiary’s Roth-style Health Savings Account. Seniors could then use these tax-free accounts to pay for direct primary care (DPC) physicians or custom wellness arrangements without administrative interference.

• Expanding Medical Savings Accounts (MSAs): Goodman has pushed to lift restrictions on Medicare MSAs, specifically allowing them to offer prescription drug coverage on a level playing field with standard MA plans.

Going Deeper

I would suggest this is clearly an initial step forward. I would propose things be a bit more liberating while also getting the government out of its mounting debt obligations piling up from political promises to the Medicare and Medicaid Programs.

• While his recommendations were applied to Medicare Advantage plans, I would suggest the idea of an HSA path for ALL Medicare beneficiaries. This could be implemented immediately. One option to provide personal funding for this would be to allow the transfer of current IRA (Individual Retirement Accounts) or Pension monies into an allowed, tax deferred HSA for seniors and retirees. If health care expenditures are incurred by an individual with such an account, the expenditure remains untaxed. The amount of benefit can be set at present average dollar expenditures from historical costs.

• For those who don’t have an HSA structure, allowing a dollar-for-dollar tax deduction up to an annual cap would be another way to allow individuals to fund health care costs directly and without the use of a government agency to hold payments.

• Going further, allowing all tax-paying citizens an annual Health Savings Account savings incentive is the only fair way to provide equal incentives and costs across the board. Given how poorly health insurance is working, there should be NO requirement to have an insurance plan to qualify for a U.S. health savings account.

• Require the current Medicare coffers to balance. No more government borrowing for Medicare or Medicaid. Instead of trying to apply price-fixing to all codified health services or product and agreeing to cover all present and future health service inventions to Medicare beneficiaries, limit Medicare coverage to the budget. This means not all health services are going to be eligible for Medicare reimbursement. Return to essential services as the priority.

• Expand subsidized coverage as funding allows BUT END PRICE CAPS. Let the market determine the demand and price for innovation. Two present examples that we are experiencing in our practice are the Galleri cancer detection test and the coronary CT angiogram with plaque characterization. Medicare and insurance don’t presently cover these innovations BUT price discovery is ongoing. There are buyers for these services and frankly the market participation is increasing.

• Recall Medicare A is for hospitals inpatient care and skilled nursing care. Over time, Hospice and Home Health services got added to the ledger. Medicare B is for the rest of the market. Stop allowing Hospital systems to bleed into the part B money pool. This is where the call to disallow special billing to hospital owned outpatient services is coming from.

For starters the aforementioned HSA expansion suggestions could be applied for only Part B Medicare. This would allow all non-institutional care and services to enter a transition into a free market health care economy. Actual brick-and-mortar hospitals will not need to expand going into the future due to the advance of healthcare technology, personal health monitoring and the movement towards health and wellness and away from sick care.

A marshal arrives at the scene of the crime: a health care system where patients are robbed through denied care, inflated charges, opaque billing, and profit-first i