Copayments
Medical CareA drunken stranger with cousins, dogs, cats, wombats and their families pulls into our office driveway with 10 trucks, a priest, a rabbi, and a backhoe.
HAPPY RETURNS MEDICAL OFFICE PAINTING, RENOVATIONS, JUNK REMOVAL.
“WE’RE HERE TODAY TO HELP YOU MAKE YOUR HERE TODAY THE VERY BEST HERE TODAY IT CAN BE TODAY” LLC. FULLY INSURED
is stenciled on the truck door.
“Don’t worry, we won’t stay long. We brought our own tents to sleep in. The food truck will be along.”
“I wasn’t worried till just now.”
“We’re here to help you paint your office.”
“Didn’t know it needed painting. Inside or outside?”
“Both. Most people let things go way too long. We’re doing the whole neighborhood. It’s cheaper that way. We have metrics. When possible we can do ten or twelve neighborhoods at a time. When’s the last time you had this driveway seal coated?”
“So actually, you’re here to save me money. Have you done this before?”
“We brought our own paint, brushes, three dumpsters, ladders, a backhoe a bulldozer.”
“What’s the backhoe for?”
“We might have to waterproof your basement.”
“Have you ever done this before?”
“It costs you nothing.”
“Like free lunch? I think I’ve heard this one before. Have you done painting before?”
“We do 401K’s, Asthma Plans, information technology, goat entrails. …
“Goat entrails?”
“Goat entrails are new. … did you know that asthma can be the most important thing that can happen to a child? …we do behavioral health, psychopharmacology is new, too. We do Psychopharmacology every Wednesday. We have generous retirement packages for any of your older employees who might be having trouble finding the door. Sometimes we find outdated integrated, quality champion functionality circuits. It can get ugly. Sometimes there isn’t even any huddling or team learning going on. That’s why we have the bulldozer.”
“I was going to ask. What’s this going to cost? Is it part of Medical Home? We do our own behavioral health and I promise we were already on the asthma thing and doing a good job with it.”
“Don’t worry, Doc. We’ll send your behavioral health people to Re-Ed Rehab. They’ll come back with all new coding skills and you’ll get paid as long as you call it CBT oil. It’s free and evidence based and you get a Starbuck’s gift card. And, as an early adopter you’ll be eligible for enhanced REMBER coupons, some people call them Magic Beans and there isn’t any such thing as Medical Home anymore. Don’t you or your scribe even read the NOW’S THE TIME messaging board? We can install a state of the art Asthma Dash Board with optional Diabetes Obesity and Physician Burnout modules.”
“I know your service is free to me today, but what does it cost everyone, you, he/she, we, you, them? Will copayments go up?”
“Don’t worry about that. Everyone gets coupons. You get the gold ones. Maybe not today and maybe not tomorrow but someday not amounting to a hill of beans …”
“They’re painting my house Sea Mist Green and Marshmallow Purple with Habanero Pepper Yellow trim.”
“You sure know your colors. We call it ‘the triple aim’. You can set it and forget it.”
“Catchy. I used to to a little painting myself. Wouldn’t it be cheaper if you just helped people who asked for help? What happens if the triple aim misses? Aiming for three things at once? Couldn’t that be complicated?”
“We can always try aiming better with fewer eyes. Most people won’t ask for help until it’s too late. I had an uncle once who drank and wanted sex all the time.”
“What happened to him?”
“He’s actually the guy running the backhoe.”
“So he’s doing well now?”
“Rehab after rehab after rehab. We still can’t let him work unsupervised. Sex is still a problem.”
“So I guess the best thing I can do is just stand back and let you guys do your work.”
“That’s the deal, Doc. You catch on fast. Some of youse guys hand around and try to help. There’s a Starbucks down the street.”
“Will we be able to work while you work?”
“You’re welcome to try but where are your patients going to park? And what if they’re sick? We’re just painters. There’s high powered evidence based evidence from longitudinal non-inferiority outcome Value delivery models suggesting that phone banks and pre-boxed formatting often out performs traditional care for self limited viral illness and 9 out of 10 of the most popular behavioral issues in school aged children.”
“Good to know.”
“All of your patients will be getting 3 of our best selling books – How you can call doctors less often more often – When should I panic – Am I the worst mother in the world.
For an innovation in healthcare delivery to be of value, the healthcare delivered after the innovation would have to be worth more than the healthcare delivered before the innovation. When Patient A pays a $100 copayment to Payer B who uses the $100 to pay Provider C $200 for Procedure D. How Procedure D is done and its value to patients are not changed by the existence of copayments regardless of denomination. Value and Cost are independent variables. If you take Procedure D, put it in a truck in Boston and drive it to San Francisco, there’s nothing about the truck or delivery process that will increase the value of Procedure D.
Whether patient A does well or not, the question healthcare reformers should be asking is, “Where did Patient A’s $100 go? and when is it coming back?”
Whatever unnecessary care copayments might have eliminated and the dollars that might have been saved are hypothetical. The $100 and science are real. There’s no gold at the end of the rainbow and Tinker-bell isn’t real.
Healthcare workers in the fight against COVID-19 enjoy unprecedented public support. They are doing what they went to school for providing the best possible care to patients while protecting public health. Patients are evaluated and treated without regard to insurance status. There will be negotiations about who pays for what but for now, the cost of care and the value of care are independent variables. Copayments and prior-authorizations have been dropped which might seem like a minor detail but it’s a minor detail that makes care more accessible, a little faster, a little safer, a little more effective, and a little less expensive. The extra value delivered to patients and families thus far is ~$5,000,000,000. Until proven otherwise, it’s possible that lowering copayments might increase the value of care and improve outcomes in other situations.
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