Free-market entrepreneurialism disrupts the way we do things, providing better goods and services at decreasing prices. It gives us smartphones, laptop computers, ride-sharing, Airbnb, smart homes, self-driving cars, low-flow toilets, flat-screen TVs and an endless array of entertainment products. It creates cars that drive themselves, powered by the sun. Within the lifetimes of Gen Xers, count on entrepreneurs offering routine, affordable round-trip vacations in space.
The profit-funded market constantly solves problems by creating products adults never dreamed of when they were kids.
So imagine an entrepreneurial uprising of disruptive health care businesses solving much of the country’s seemingly intractable health care crisis.
“The solution is not going to come from politicians,” says Dr. Tom Carter, a physician and health care entrepreneur in Monument. “The solution is going to come from individual innovators — the people in the trenches who see the problems and propose nuts and bolts solutions. I don’t know that politicians can ever solve this.”
The public hears incessant talk from politicians about the health care crisis. Surveys consistently show health care costs as the public’s first or second-highest concern, while climate change and immigration rank below education, terrorism, Social Security, the economy and needs of the poor.
Despite bipartisan health care promises and legislation, no one can claim victory in resolving the country’s health care concerns with “reform” or patchwork laws.
Then-President Bill Clinton asked then-first lady Hillary Clinton to propose massive health care reform in the 1990s, but Congress never turned “Hillarycare” into a bill for the president to sign. Obamacare reduced the number of uninsured families and individuals but did little if anything to make health care more affordable and available to the masses. For a high percentage of the fully insured, Obamacare means higher deductibles and lower benefits as the law rations health care consumption among the upper-middle-class and rich to “share the wealth” among those less fortunate.
Republicans have notoriously ignored the country’s health care concerns, offering no big-picture solutions since then-President George W. Bush signed Medicare Part D into law in 2003. Just as insurance does not create health care, it does not produce an adequate supply of the drugs people need.
To help establish Obamacare, Colorado and 32 other states expanded Medicaid by relaxing qualification standards. It made politicians look good. They appeared to give health insurance policies to the uninsured with the ease of printing coupons. There, problem solved. Right? Not quite. Not even close.
Dr. Scotty Bowen, an orthopedic surgeon in Colorado Springs, says most physicians severely restrict the number of Medicaid patients they will see — if any — or they go broke.
“Often a Medicaid patient shows up at a medical practice thinking he is fully insured,” Bowen says. “They want you to take care of them right now, because they are insured. They really are not, and some of them get quite indignant if you suggest you’re going to have to do some balanced billing to help pay for some of it.”
Medicaid reimbursements to physicians are pennies on the dollar relative to the reimbursements paid by private insurers and Medicare. As a deacon in the Catholic Church, Bowen has always treated a relatively high percentage of Medicaid patients out of personal benevolence. But he has to stay in business. He ran the numbers and determined he could not pay for malpractice insurance if he saw only Medicaid patients.
“I could not pay for insurance, let alone pay for nurses, support personnel and the other costs of running an office,” he says.
Medicaid patients do not always know a doctor has rejected them for having a policy that does not pay enough.
“It’s in the business model,” Bowen says. “The practitioner doesn’t even know when someone has been turned away. The Medicaid patient calls, and the scheduler knows to say something like ‘the doctor can’t see you for four months.’ The hope is the person will find another practitioner before waiting four months. You can only see a certain percentage of Medicaid patients or you will go out of business, guaranteed.”
Americans with private health insurance contend with thousands of dollars in out-of-pocket co-pays and deductibles. Insurance companies routinely refuse to cover the costs of treatments and drugs doctors prescribe.
Though “rationing” is often seen as a future dystopian concern, Americans have endured it for decades.
“The co-pays, the deductibles, the co-insurance, step therapy (the insurer demands a cheaper drug). There are all kinds of rules that are, in fact, the rationing of care,” says Sharona Hoffman, a professor of health law and bioethics at Case Western Reserve University.
Nearly 70% of Americans have private health insurance, and nearly that many consider the country’s health care and pharmaceutical markets too expensive.
Democratic politicians on the far left want Medicare for all, which would require at least $34 trillion in additional federal spending in the program’s first decade. No one serious, including most Democratic contenders, considers this a financially viable option.
U.S. Sen. Michael Bennet, D-Colo., pitches a plan he calls Medicare X. It would create a Medicare buy-in option for the small percentage of uninsured Americans — a demographic of about 10%, give or take a few digits in individual states. If implemented, this would do nothing to address the health care complaints of most Americans.
Nearly all other political rhetoric about fixing health care begins and ends with regulatory tweaks to private and public insurance that ignores the big problems. It’s a shell game of who should get a higher or lower priority when distributing and rationing a relatively fixed supply of health care facilities, providers and pharmaceuticals.
“People need to understand this is a multilayer problem that is extremely complex,” Hoffman says. “If we really want to make medical care in this country as good as it can be we need to attack it from all angles. It’s not enough to say we’re going to provide access to a few more people, or we’re going to get a few more nurses on the market. You need to deal with access, absolutely. But you have to deal with costs and insurance, and physician shortages. The problems are numerous and we have to pay attention to all of it, especially as the population ages.”
Hoffman and other health care experts refer to increasing medical needs of an aging population as the “Silver Tsunami.” Carter says about 10,000 baby boomers join Medicare each day. Meanwhile, physicians are retiring earlier than in the past. Fewer young adults are embarking on medical careers. It adds up to rapidly increasing demand on a system losing capacity. That means consumers can expect more control of supply through rationing in the form of high out-of-pocket expenses, denied coverage of prescription drugs, and longer wait times to see general practitioners and specialists.
“There just aren’t enough doctors,” Carter says. “The time and investment it take to become a licensed physician is nuts. We have young residents who rotate through the hospital who owe $300,000 or more in student loans at 7%-to-8% interest. I don’t know who can do this. It’s a noose.”
To slow or reverse the physician shortage, Carter says politicians need to work on the cost of medical school and student loans. If they don’t do that, he says, the country won’t graduate nearly enough physicians to meet demand.
Bowen describes a health care system mangled by perverse incentives of insurance companies and corporate hospital chains. It’s all about billing, with health care an afterthought. He tells an urban legend he has heard among doctors, in which a clinic in the 1960s charged an average of $50 for chest X-rays. Then came Medicare, in which doctors billed government.
“Instead of writing $50 for the chest X-ray, a billing person wrote $500,” Bowen says. “And the government paid it. According to the anecdotal story, physicians learned they could put down almost any number and the government would send a check.”
Of course, that did not last long. The government began balking and adjusting the reimbursements physicians requested.
“Then practitioners were in this situation where they had to bill as much as possible knowing they would get only a fraction of what they requested,” Bowen says. “It’s a situation of constant bargaining between payers and providers.”
Major hospital systems, which buy up private practices and urgent care clinics, get larger reimbursements than do solo clinics.
“The fundamental issue is, the system really has not cared about health care for years. It cares about billing and costs,” Bowen says.
It’s a giant, garbled mess no one fully understands. Not even professor Hoffman, who has wrestled with untangling health care since graduating with a juris doctor from Harvard, a master of laws from the University of Houston, and a doctor of juridical science from Case Western. She has written articles and books, lectured and studied the problem and concluded there is no legislative reform package that can fix it.
“You can tackle one problem at a time,” Hoffman says.
Carter agrees the country’s health care dilemma can seem intractable, but he believes market entrepreneurialism poses the greatest hope for solving the nightmare one problem at a time. He began visualizing a disruptive revolution as an early adapter in the telemedicine trend. For $45 paid on a credit or debit card, patients interface with Carter from smartphones, tablets or personal computers. He can prescribe common drugs over the internet. No patients travel to a clinic or subject themselves to a germ-infested waiting room. Once a cottage industry of solo practitioners, telemedine has caught on among insurers, employers and major hospital systems as a benefit to customers.
More recently, Carter created Vested Health Care Partners. He contracts with companies to provide on-the-job checkups and routine health care. Employers pay for the service because it helps prevent employees from developing serious health conditions that create downtime and stress company insurance pools. Think of the adage “an ounce of prevention saves a pound of cure.” Carter wants to grow the business and believes the model will catch on throughout the country, providing workplace health care that reduces demand on hospitals and clinics.
Two of Vested Health Care’s three clients are employers in rural areas of Colorado considered “health care deserts” devoid of clinics, hospitals and physicians.
“These employees have health insurance, but it’s almost impossible to use for routine health care,” Carter says. “It’s a 90-minute drive each way to see a doctor and many of them have neither the time nor the money. So, they bring me to the workplace for anyone who wants to take advantage of the service.”
Other health care innovators are quietly creating concierge health care clinics, such as the soon-to-open Flying Horse Medical Center in downtown Monument. It will be the second major clinic opened by Dr. Aaron Fraser, offering general medicine, aesthetic medicine, and psychiatry. Patients, whether insured, pay a membership fee in return for routine medical coverage. The clinic circumvents the tangle and expense of dealing with big insurance. Patients encounter no co-pays or deductibles. The clinic’s patients need insurance only for catastrophic events involving hospitalization, making the prospect of a tax-exempt Health Savings Account more attractive and viable. Patients can put pre-tax earnings into the accounts, use the money for routine medical expenses, and rely on catastrophic, high-high deductible insurance for potential crises.
Much like Flying Horse, PeakMed Direct Primary Care offers a concierge model with three clinics in Colorado Springs and two in Denver.
PeakMed’s website boasts “a simplified and smarter approach to better health without the stress and limitations of third-party insurance companies. Our membership provides unlimited office visits with plenty of one-on-one time with your doctor, allowing you the opportunity to take proactive steps toward a healthier life.”
Bowen tells of a physician friend in Dallas who recently quit dealing with insurance companies. He reduced the cost of his services by 50% and takes only patients who pay him out of pocket. Given the high deductibles of their insurers, most consider the arrangement a savings. Carter explains how cash transactions can save patients money.
“When you get an MRI and you give your insurance card, you get the cost the provider has negotiated with the insurance company,” Carter says. “I tell patients to skip the insurance and pay out-of-pocket because it will cost them a fraction. Otherwise, because of their deductibles, they pay the higher price billed to insurance, but not paid by insurance unless the deductible has been met.”
Carter points to RubiconMD as another disruptive innovation that helps patients circumvent the traditional health care model’s morass of expenses and waiting times. Traditionally, general practitioners have referred patients with complicated medical conditions to specialists. An arthritis patient gets referred to a rheumatologist, then waits weeks for an appointment and pays another big fee that goes toward a deductible of thousands before the insurance kicks in.
Rubicon, by contrast, facilitates primary care providers in quickly accessing specialists with “eConsults.” The consultations often lead to immediate treatment by the primary physician and eliminate the need for a specialist visit.
“We will always have patients who need a one-on-one, in-person examination by a specialist,” Carter says. “But this works well for common things that traditionally required a visit to a specialist. That might include a weird rash the general practitioner does not recognize. We can send a snapshot to a dermatologist and get advice on what to prescribe, without a visit to the dermatologist.”
Medical experts tell us shortages of health care professionals and entrenched dysfunctions of the traditional system — problems getting worse, not better — open enormous opportunities for an entrepreneurial revolution that routes around the mess. Innovators will succeed by providing more and better health care access at lower prices. Politicians can help them by eliminating tax obstacles and regulations deemed unnecessary to protect the public’s safety and health.
“It’s about finding ways to give more attention to the patient and less to the paperwork and billing,” Carter says. “It’s about accessibility. It’s about finding ways for experts in health care to answer to their patients, no longer beholden to the traditional health care systems and their administrative nuances. It’s about innovations that put patients first.”
Politicians will continue offering free and low-cost insurance, taking from Peter and giving to Paul. In doing so, they will think short-term and small. They will do nothing to create more and better health care. Market innovation, by stark contrast, can go big. A free-market tsunami of innovation, deregulation and more care directly to the people might solve most of America’s health care crisis.