Denver DPC

When I started my practice back in 2012, I thought I was the only one.  It turns out, Dr. Lisa Davidson (now a friend) was doing the same thing at the same time.  There is actually a whole movement called Direct Primary Care (or DPC).  Dr. Davidson’s practice is now full but a friend of mine recently opened her DPC practice in north Denver (Dr. Brie Seefeldt).  Each DPC practice is uniquely designed to suit the particular physician and her (or his) patient population.  We each have different office hours, different prices, and can provide different services.  But underneath it all, we are all trying to fill a need for a different way of doing medical care.  Both patients and physicians are getting burned out, slipping through the cracks, and hoping for another option.  It’s exciting that DPC is changing from something people have never heard of to something people are looking for.  So if you are hunting for DPC in Denver or DPC in Englewood, you have more choices than ever!

 

Insurance Prices for 2014 Available

Colorado is one of several states that has published the prices of insurance available in October on the health insurance exchange.  This means you can now guess what to expect.  If you have NO insurance available through work (or the insurance for the employee only costs more than 9% of your total income) you will qualify for a subsidy if you buy your insurance on the exchange.

First: Go to Connect for Health Colorado and calculate your expected subsidy.

Then: Look at this chart on the DORA website to see what a monthly premium would be for a 40 year old (the only information currently available).

If you have kids, see if you qualify for CHP+.  (If you don’t, I have no idea how much insurance will cost through the exchange…less than for a 40 year old, anyway.)

Finally, do your math.

So, let’s say you are a stereotypical family of two children and two parents (both age 40 just because that’s the information we have).  If you gross under $32,500 annually (or a little over $2700 a month, based on this year’s data), you will qualify for Medicaid.  So let’s say you make $40,000 (or $3333 a month).

You calculate your federal subsidy, which comes to $572 monthly if you are only buying insurance for the adults (and putting the children on CHP+) or $938 if you are buying insurance for the whole family.

Your children qualify for CHP+ so you pay the enrollment fee of $35 for two children (it’s $105 for two kids if you make over 200% of the federal poverty level).  The two adults can choose a bronze level plan that starts at $186 per month per person up to a gold or silver plan that costs at least twice that.  To understand the different plan levels, look at page 2 of this link, which shows samples.  For instance, a bronze level plan might have a $5950 deductible.  A gold level plan might have a $640 deductible with a 20% coinsurance once your deductible is met (meaning you pay the first $640 in medical bills and after that your insurance pays 80% of the bill and you pay 20% of the bill until you reach your maximum out of pocket).

Let’s say you choose the gold level plan from Rocky Mountain HMO that costs $412.81 a month for each of the two adults.  You use your federal subsidy and end up spending a total of $253.62 a month on insurance for the parents plus $35 annually for the kids.  You still have to meet a deductible and pay co-insurance for everything that is not preventative but for under $300 a month, you have what most people would consider “good” insurance.

Let’s say instead that you choose the Rocky Mountain HMO bronze level plan for $296.41 per person.  You are now paying $20.82 a month for the parents’ insurance plus $35 annually for the kids.  You know your kids are covered.  The parents’ insurance doesn’t provide much beyond your annual exam until something terrible happens…but once something terrible happens, you don’t risk bankruptcy.  It may take a long time to pay off bills in the thousands, but at least it is possible.  I’ve seen patients have a completely unexpected medical bill leave them with hundreds of thousands or even a couple million dollars in bills.  For twenty bucks a month, that’s pretty good.

If you make more money, you’ll be paying more for the insurance, but everyone making under 400% of the federal poverty level will qualify for some subsidy if they do not have insurance available at work.

What if you do have insurance available at work but you don’t like it?  Or what if it’s cheap to buy insurance for the worker but most of your paycheck to insure the rest of the family?  Anyone can use Connect for Health Colorado to shop for health insurance, you just don’t get a subsidy.  So let’s say you are that same family but Mom has a job that provides her with okay insurance for $300 a month but would cost $2000 a month to insure the family.  Technically this counts as “affordable” according to the laws and so the family does NOT qualify for a federal subsidy (yeah, stupid, but there it is).  This family can still get the kids on CHP+ for the same $35 enrollment fee.  The parents can then look at their options on Connect for Health Colorado and choose anything from the Kaiser bronze plan, which would cost $372.40 a month for both of them up to a ritzy $800-1000 a month option at the higher levels (which would still come out to less than buying a family plan through work).

What does this mean for my patients?  First, according to federal law, everyone in the country will be required to have insurance in January unless you have Medicaid/Medicare/Tricare, a religious exemption (such as a Christian cost sharing plan), or certain other exemptions.  So get some.  Second, if you end up with a high deductible, it still makes sense for most people to keep seeing me…you’re paying out of pocket anyway unless something really terrible happens.  I’ll help keep your bills down in the meantime.  Finally, if you end up with really good insurance and go elsewhere, I won’t get my feelings hurt.  Congratulations on hitting the health insurance jackpot.  I want everyone to be able to have coverage that good but until that happens, I’ll keep doing what I’m doing.

Any questions?  Yeah, we’re all a little confused at this point.  But we’ll work together to figure out the new system.  It’s not perfect, but it’s a huge improvement over what we have right now.  Please contact me if you have any questions.

Insurance Terminology

Everyone has heard that under the ACA, everyone is required to have insurance.  I do recommend that everyone acquire an insurance plan.  At that same time, I do not for a moment want you to confuse insurance with medical care or the legal definition of “affordable” with a reality definition of affordable.  Many people buying “affordable” insurance will not be able to afford to use it.

All those topics are for another post though.  First, I want to start by reviewing some basic definitions so that as we get into more detail down the road, you will know what I’m talking about.  As you shop for insurance, there are a lot of confusing terms out there that can make it difficult to know what you are looking at.  When I was a kid and first married, it was easy.  The insurance premium was dealt with behind the scenes through your employer and the most you’d see was your portion on your pay stub; at the doctor’s office, you paid a small flat rate copay, often $5 or $10.  Nowadays, you have to sift through a mishmosh of deductibles, coinsurance, copays, premiums, and tax credits.  So what does it all mean?

Premium: This is the amount you pay every month in order to have insurance.  It is similar to (but more expensive than) the premiums you pay for your car insurance, life insurance, or homeowners insurance.  For instance, you might pay $1000 a month for insurance for a family of 4.

Deductible: This is the amount you have to pay for your own medical expenses before your insurance starts paying.  For instance, our car insurance has a $500 deductible.  This means that if we are in a car crash, we have to pay the first $500 of the bill before the car insurance picks up the rest.  With health insurance, the deductible is usually more like $2000 to $4000 before it starts paying.  Under the ACA, insurance policies that are not “grandfathered in” are required to pay for certain limited preventative services without a deductible.  In layman’s terms, your well visit is free.

Co-insurance: This is usually a percentage of the bill you are still responsible for, even after you have met your deductible.  For instance, you might have a 70/30 plan with a $3000 deductible.  What this means is that after you have spent $3000 on your medical care for the year, your insurance will foot 70% of the bill and you are still responsible for 30% of the bill up to a maximum out of pocket expense for the year.

Copays: These are increasingly obsolete.  If you happen to have a “comprehensive” plan, you are paying copays instead of a deductible.  Occasionally with the high deductible plans, you are still charged a “copay” for certain services such as a trip to the emergency room.

Out of pocket maximum: The law dictates that at some point you don’t have to keep paying your percentage co-insurance.  For a family, the legal limit in the small group and individual market  is $12,500 for a year.  So let’s say something totally dreadful happens and you rack up hundreds of thousands of dollars in medical bills and you have a 70/30 plan with a $3000 deductible and a maximum out of pocket (also referred to as a cost sharing limit) of the legal maximum $12,500…you would pay the first $3000 in bills, then 30% of the bills until you’ve doled out a total of $12,500 and then you’re done.  Your insurance will pay 100% your bills for the rest of the year.

HSA (Health savings account): Certain HDHPs (high deductible health plans) can be combined with an HSA; they are designed to work together.  An HSA is a tax-deductible savings account that can only be used for medical expenses.  In 2013, an HSA compatible plan has to have a minimum deductible of $2500 for a family and the maximum contribution to an HSA is $6450 for a family.  Here is a list of medical expenses you may pay for from your HSA.

Tax credit for health insurance (also known as premium subsidies): This is part of the ACA that is supposed to make insurance affordable.  Based on your previous year’s income, the government will pay a certain amount directly to the insurance company to help you buy insurance.  The amount is determined by calculating how much subsidy you would need in order to pay a certain percentage of your income (the exact percentage is determined based on what percent of the federal poverty line you fall at) for a silver level plan (a silver level plan is one that has an actuarial value of 70%…I’m still a little unclear on what that means but just know it’s one plan up from the worst plans that are still legal).  You can then use that subsidy amount towards whatever level of insurance you want.  If you want to spend less on your premiums up front but also get less coverage, you can opt for a bronze level plan.  If you want to have better coverage, you can use the subsidy towards a better plan such as a gold or platinum level plan.  Here’s a brief going into the details.

Cost sharing subsidies: This is an acknowledgement that lower income families and individuals will have trouble paying the higher deductibles and coinsurance associated with the cheaper plans.  This subsidy will help defray those costs.  There is also a lower maximum out of pocket based on income.

Only time will tell if there is any correlation between access to insurance and access to care.  My guess is that while there may be fewer people who are uninsured, there will be many more who are underinsured.  What does underinsured mean?  Come back for the next installment to read about how to determine if you will be able to afford to use the insurance you buy individually or through your workplace.

Summary of Expanded Care in Colorado

C4HCO (1)

 

Click on the table to see the full summary sheet.  Nearly everyone in the practice will be eligible for one of these programs.  If your workplace starts to offer “affordable” insurance that isn’t actually affordable, you can still use Connect for Health Colorado to find a better plan but will not be eligible for the financial assistance.  Please let me know if you have any questions!

ACA and CSFM

Many people have asked me why I am continuing to not take insurance even though everyone is going to be required to obtain some.  I think this question stems from a basic confusion…a belief that insurance means access to care.  Current estimates are that 40% of the cost of primary care is in dealing with the insurance companies.  Which means that by eliminating the insurance companies from my practice, I can make care more affordable and accessible to families and individuals whether they are uninsured or underinsured.

Spend just a moment reading the examples on page 3 of this document from the American Cancer Society.  I’d like to break down the first example a little bit more.  I don’t feel that talking percents or annual incomes really explains the situation very well.  The first example talks about Juan, who spends 18% of his income on his medical expenses.  What they are actually saying is that Juan is earning $1750 a month and will receive a hospital bill for over $3000 about a month after he gets home from the hospital.

Let’s say he didn’t get appendicitis but instead had trouble getting his diabetes under control.  His doctor wants to see him every month, does labs every three months, tells him he needs to join a gym and “work on lifestyle,” and prescribes a couple medications including one that is brand name only.  So now he is paying $150 per visit, doing $120 worth of labs every three months, buying food that he thinks might be a better choice but is a lot more expensive than what he was eating before, pays gym membership fees, and is spending over $200 a month on his medications.  So now of his $1750 a month, he is spending over $500 a month just on his medical condition.  This leaves $1250 to pay his insurance premiums, rent, car payment and insurance, and other basic living expenses.

While I can’t help much with the hospital bill that is almost twice what he earns gross in a month, I can help with the theoretical situation in the next paragraph.  As a member in my practice, he would be paying $30 a month to see me.  The same labs when run through my account would be under $20.  I have the time to spend an hour teaching Juan how to eat a diabetes friendly diet on a budget and discussing affordable options for increasing his fitness level.  I am used to working with people who pay out of pocket for their care so either know already or make sure to research which medications are the most affordable…I also encourage him to call around to get the best price.  He can continue to have his insurance, both to be legal and to limit his hospital bill in the event of appendicitis to something he may eventually pay off.  He gets the care he needs while buying insurance as required.

This solution is not for everyone.  Some people would prefer to pay higher premiums, obtain more comprehensive medical insurance, and go to someone who takes insurance.  That is fine with me and will not hurt my feelings.  I’m sure most of us would do the same if we could.  But for everyone who is going to continue to pay for the majority of their regular medical care out of pocket, CSFM is still here and I’m still offering the same care and prices as ever.