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By Mike Scott, NEMOnews Media Group
“Having insurance is not equivalent to getting health care,” said Dr. Randy Tobler, Chief Executive Officer of Scotland County Hospital.
“What a lot of people are doing now is self-rationing,” added Tobler. He explained that high co-pays, high deductibles, co-insurance, all on top of high premiums forces people to make a choice.
“They realize that if they go get checked out, and the doctor orders labs, they’re going to have another thousand-dollar expense. So people delay care, get sicker, and present more acutely. It’s bankrupting people, and in our area, it’s going to be the difference between sustainability or not for hospitals.”
Scotland County Hospital recently hosted a Facebook Live event to present a different idea.
“Care in America is a way to access health care, rather than accessing insurance. It is a plan that allows employers and their employees to have a direct relationship with providers of care, on a subscription basis, with no co-pay, no deductible and no co-insurance. From a statistical standpoint, this accounts for 99 percent of care,” Tobler said.
Every employer in northeast Missouri is eligible to apply for their employees working 30 hours per week or more. Plans are not available for individuals.
“Care in America is a way for people to get health care, and have insurance for the catastrophic things. They get health care with the premium, which also covers a wrap-around insurance plan,” Tobler continued. The plan provides a direct relationship with Scotland County Hospital as a way to access 99 percent of needed care. For other needed care, plans include ‘wrap around’ coverage for catastrophic events, or other services not available at Scotland County Hospital.
The catch, if you want to call it that, is that the health care must be delivered by Scotland County Hospital and Clinics, or at one of the Care in America network providers in St. Louis.
If specialized care is needed that cannot be done at Scotland County Hospital, or if you’re travelling and cannot get to Scotland County Hospital, the ‘wrap around’ policy works just like traditional insurance, with co-pay and deductibles. That plan would also be part of the Healthlink Network, there are a large number of in-network providers in the area.
Tobler shared an example of how the ‘wrap around’ coverage would work. Assume a patient has a heart condition. She is short of breath and fatigued. She’s having visit after visit with her doctor, and paying $30 co-pay for each visit. Then a doctor orders and EKG and a chest x-ray. Under the Care In America plan, she’d have zero out of pocket cost for all of that. If she came in with an event, everything done at Scotland County Hospital would cost nothing. If she had to transfer to another hospital, everything at the other hospital would be subject to deductible and copay, just like a traditional insurance policy.
“Most people don’t use the catastrophic coverage in a year,’ said Tobler. “They use the bread and butter stuff, and that’s’ why it’s a perfect fit for our community.”
Best of all, the average monthly premium is $411 for a single, or $989 for a family plan.
Sounds too good to be true,
“I’m the biggest skeptic,” Tobler said.
The idea works for several reasons. First, Care in America has partnered Iron Workers’ union to provide a much larger group of insured. Employers and employees joining Care In America would need to join the Iron Workers’ union at a cost of $10 per employee per month.
Secondly, since there are no insurance claims to file, and the ‘wrap around’ coverage would only be used for less than one percent of care encounters, insurance companies can provide a lower cost.
In addition, facilities like Scotland County have fixed costs, and using more of those services don’t really cost the hospital more.
“Whether we have 75 babies a year or 125, I have to have doctors to deliver them. We have unfilled capacity. We don’t want our operating rooms sitting empty too much of the time. Why not have people come in and get their hernia fixed, or their gall bladder taken out that they’ve been waiting on because they don’t have $3000 laying around,” Tobler said.
“It works because we take away the part of the premium that goes up in smoke to administrative costs. Every time I go down Hwy. 40 and see those gleaming glass buildings, I get the rage,” Tobler added.
“We’re saving you bucks, and keeping our health care institution alive. It’s a fair deal,” he said.
The Care In America Foundation wants to protect the doctor-patient relationship.
“It’s not the way it used to be. We’re more beholden to the insurance companies than we are to our patients,” said Tobler. “I have to click all the boxes on the EMR (Electronic Medical Records) rather than spend time with the patient, to make sure the bill goes through. It perverse.”
“We know if we restore a trusting relationship between patients and doctors, if I tell you don’t need something, you trust me that it’s not the insurance company saying you can’t have it. And if I tell you that you need something, I’m not nickle-diming you,” Tobler said.
Is it risky?
“HMO’s were a similar concept,” said Steve Simon of Crane Agency in St. Louis, who has worked with Scotland County Hospital to make the Care In America plan available in northeast Missouri.
“It’s an evolution of that type of program,” Simon added.
“The doctors at Scotland County Hospital are not going away. They want to deliver a different care model.” Simon said. “We don’t envision it going away. It’s a win-win for patients and providers.”
Making Care In America available in northeast Missouri is not a done deal yet.
“All insurers are interested in doing this,” said Tobler. “But they want a proof of interest of a 1000 people.”
Tobler hopes to have a census of at least 1000 employees quickly, and encourage employers, large and small, to fill out the plan census, which is available online.
“We could pull the trigger as soon as January 1,” he said. “But if we can’t get it together by then, maybe we’ll have to wait until April.”
If your business is interested in more information on Care In America, or wants to complete an employee census, visit https://www. careinamerica.org/care-in-nemo
For more questions, please call Steve Simon at (314) 206-4158.