radio show healthy pets healthy people we cover a lot of topics regarding health insurance and health care and the differences and tom is owner of west penn life and health here in washington but you're your national organization right and  your service the whole country correct yeah i have a another another company called new era health plans that is a national outfit in twenty eight states correct you know i think tom there's a big misunderstanding about what is healthcare and what is health insurance so i i would appreciate your expert definition of those terms what is health care and you're thin you will certainly health care is what occurs between a provider which could be a doctor or gynecologist a podiatrist a dermatologist and a patient it is the simplest purest interaction between somebody who has the wisdom skill knowledge in the ability to treat a  somebody with a particular problem whether it's chiropractic i threw my back out of whack or whether it is you know i have a skin rash or whatever that is health care so that's actually going to a provider a condition or a symptom that you have and asking for treatment and helping it to resolve the issues of that condition it couldn't be more obvious health insurance is totally different but somehow there's been a confusion and we seemed to associated the term health care with health insurance i think that happened with one obama care team that perhaps and i might say you could you could go back to the early ninety's i lived in cincinnati at the time in those actually  launching that national organization we were discussing and in the early ninety's there was a clarion call for health care reform and if you recall at that time president bill clinton begin to use health care as a crisis topic the narrative but mediately then the cameras would move over to what health insurance and how we need to fix health insurance in fact several states can duckie being one of them in the ninety's actually was adopted a pilot program that is very similar in many ways to what obamacare was years later in two thousand and ten to fire health insurance for a sure health insurance is nothing more or nothing less than a product that a consumer buy from a third party payer right whether it's a big box insurance company like when you drive through the tunnels in pittsburgh the two largest buildings that you're going to see downtown are both related to insurance companies ok the two tallest buildings i should say but insurance is a product you're buying a contract the that brings a third party into the picture and you're paying this third party a premium which is so much money each month to do for you what you cannot do on your own meaning that if i have some develop some disease that requires surgeries course with surgeries comes hospital stays and great expense correct and so forth so we look to insurance to cover a portion our majority of that cost no different perhaps than car insurance or homeowner's insurance right we have determined that as a society that paying a little bit of money each month into a risk pool where a lot of other people are participating and we share risk in other words if you have one hundred thousand people and these numbers you know are illustrative they're not accurate you know examples if you have a hundred thousand people a certain percentage of them but only a certain percentage of them are really ever going to have a major or catastrophic health event you know especially under age sixty five right over age sixty five in america we have medicare which is a federal program that ensures almost all u s citizens age sixty five to their to the grave and that's where most of the major health risks occur sixty five and over but under sixty five if you have  hundred thousand people not all of those people are going to have major medical event a few of them are so common sense dictated years ago that we the people right we could pull our risks and pay a little bit of money into a risk pool organize an association or a fraternal organization or an insurance company to manage that money ok and if or when something bad happens that is out of the financial reach of the people in that risk pool that third party payer would step in and write a check so the third party payors basically taking a premium from you investing that money hoping to make money and hoping that you don't get sec correct and that way they're they're using as a business to make money you get sick there is there is a fund then that would cover the cost correct but somewhere along the line we used to use that for when we had a major surgery acquirement or major illness that's right accident trauma broken bone something that was out of the ordinary but somehow it's kind of kind of been reduced t fact that you get a sniffle and you run to your physician and you expect the insurance company to pay for it exactly well you know i always like to take people on a journey years ago especially you know folks my age you know i can remember my dad  my grandfather both of them had benefits where they were my grandfather worked for west bend by our my father worked for a branch of the federal government you know and they referred to their benefits doc as hospitalization perhaps our listening audience remembers that perhaps you remember that and that's what early health insurance was it was designed to pay what what i cannot pay ok it makes sense like when you think of your insurance at home you don't have insurance on your lightbulbs like when a lightbulb goes out in your living room you don't call the insurance company and say hey what's this you know going to cost to repair you don't have a co pay on your lightbulb because it's a five dollar item or a three dollar item or what you know whatever whatever it is so we've never attempted to ensure routine things when your carpet wears out in your home or the oil needs changed in your car that's routine what that's maintenance when you purchased your car you assumed that there are going to be certain financial responsibilities you know i'm going to wash the car occasionally i'm going to change the tires occasionally have to rotate the tires  occasionally i don't expect a third party some other entity to pay for this it's not that they couldn't it's not that allstate or state farm couldn't write an insurance product to cover every little  estate that most of these third party payors occupy you have to ask yourself is it expensive real estate or is it for you know it's usually prime real estate so the brick and mortar and the costs and the labor and the taxes and everything that goes into running that business it becomes very expensive for me to let's say a doctor visit let's say a chiropractic visit that i could pay cash twenty five dollars for why would i pay a third party payer over here in the big city why would i pay them to pay you when in fact the simplest easiest most affordable way to exit cute that transaction would say would be here's the twenty five dollars you know it's interesting i am a client of yours and you've saved me a ton of money and maybe we can address that a little bit later a little later but i called up to make an appointment mean it was just kind of like so strange to hear that you know the first thing i want to know what was minds are very common and i think that in lies the problem because i know some people and i've had conversations with them tom where they they test for everything it's almost like they're looking for something they want to find something wrong with them and i'll say what are you doing on that for why have the insurance i'm sure it covers it right well so what you know and i say you're getting all these x rays and all that's almost an abuse of the system certainly well you know i've raised four children ok and one of the things that i've noticed is that the kids had a lamborghini diet growing up when dad was paying the bills but now that they're all on their own and they're writing the check for their car or their house or their shoes it's a little different ok in what i mean by that is when you're insulated or isolated from the cost of anything it's very difficult for you to understand the value a dollar ok and insurance actually creates a problem in many cases and that problem is when a consumer in a normal economy when you bought your house or you buy a pair of shoes or you buy tickets to a concert somewhere in the negotiation you ask the question what is this cost only in health care are we not asking that question and the reason consumers are not asking that question is what are they care somebody else is paying in there in lies another problem for example this is where we can discuss after the break how that if an m r i through a large hospital in washington county nearby ospital and m r i of run through traditional billing you know the big box method you have insurance etc is going to be two thousand two hundred fifty dollars  same consumer the same m r i the same hospital if they said look i don't have insurance it's cash pay they would get an immediate seventy percent discount that two thousand two hundred fifty dollars m r i immediately becomes nine hundred fifty bucks why because it never cost two thousand two hundred fifty to begin with it's they're using phony baloney billing that is run off of what is called in the business a charge master which is usually behind closed doors nobody knows what the billing is in fact what we're finding is that a lot of the billing is different it may be different for you if you have this health plan versus it made be different for you if you have that health plan or as i indicated and this is provable a large  hospital in washington county has just come out and said for cash pay clients if you negotiate we will knock off seventy cents on the dollar on products and services rendered here for cash bakelite swan because so many people have big high deductibles today even with insurance ok they're becoming more consumer aware and that's what i was observing i was watching my premium going escalating to three threefold carette almost every year and i wasn't using it because frankly i take care try to take care of myself and i want to stay away from all of these doctors i say that and just a little bit of course but i do you know i think health care is it starts with you and what you're doing the insult you're bringing to your body how you're supporting your body the nutrients the type of physical activity you have you know the do's and don'ts and being well i don't look at as health care to keep me well i look at health care ok i broke my arm ninety i need health care you know i got a pain in my side let's go find out why the pain is so i came to you saying my my my premiums are skyrocketing i don't use it we did was we bought a hospital surgical policy that is designed to cover you if you're in the hospital outpatient surgery professional fees including surgeon assisting surgeon radiology path ology your attending physician and then it has limited outpatient testing and therapy for you know it will help you with a doctor visit or whatever it will cover up to twenty per year but what we do is we teach people just what you describe pay cash for the small stuff by insurance for the for the big our ways you know the fifty thousand dollar bill the seventy thousand dollar bill we just paid out a claim unfortunately for a gentleman in atlanta georgia over two hundred thousand and he didn't make it and was sad but just paid a claim here for a local gentleman in mcdonald over fifty thousand had a heart attack walked away with zero out of pocket with when all the moving parts to my plan kicked in the man had no no deductible no out of pocket in fact with his crisis recovery benefit has over two thousand cash extra following his  recovery for indirect medical costs which is often missed when people build a risk management strategy see what insurance really is is a risk management strategy if you had fifty million dollars in a trust fund would you need health insurance most likely not you are the insurance company why pay somebody thousands of dollars why pay ten thousand dollars a year for the next ten years if you're fifty five aging into medicare that's one hundred thousand dollars that could be in your cookie jar you wouldn't do that if you had fifty million in the cookie jar so we want to train people to look at insurance as a risk management you bra the risk tolerance like i often say to people if we had a crystal ball and you knew that you were never ever ever ever ever going to have a claim that exceeded ten thousand dollars would you buy insurance no you'd you know because i think they're confusing on their own and they are and then and talk about the proper what's changing and health care health insurance yes i would be careful to use that term and how we go about saving money and getting proper coverage over these things  that's why it's important to wash hands surfaces and fresh  produce keep raw meat poultry and seafood separate from many to eat foods like fruits and vegetables and to proper temperatures using a food thermometer should be utilized actually and why we need it there are some terms i'd like you to explain what is primary care sure primary care is the care that you would receive or expect to receive from your p c p your primary care physician primary care might include a doctor visit for a cold or little johnny has the flu so that's the primary care physician is basically your gatekeeper to any of the specialties in the medical good primary care physician has the capability in some cases to read an m r i to look at my my primary care physician looked at you know heart e k g and everything and a s a good idea of where we're all trying to train the same way with the way i look at it is i think there's too big of a compartmentalization of health services and everybody wants to put you into that little compartment and nobody knows doesn't no one takes a holistic approach to what the body is doing and that's in lies a lot of problems because you have this position medicating you with this this one medicating it with this and everybody wants is referring out and i think that needs to be addressed but that's a whole nother topic so what is a co pay ok a co pay is if a client has a traditional major medical p p or an h m o plan when you go see your primary care physician or a specialist  usually you have some flash in the game meaning there is usually some cost to you the consumer even though you have an insurance product you will have to render a certain amount of money at claim time in that office be it twenty dollars twenty five dollars fifty dollars that is a co pay that means presumably your insurance company behind the veil is paying so much to that p that provider and you're paying so much you know what you're paying twenty or the twenty five but you don't know what they're paying their pain and what is out of pocket out of pocket is what a consumer is paying out of their own checkbook or out of their own wallet so that could include a co pay plus other fees that's correct when you when you look at a traditional major medical policy they usually have co pays for things like office visits or specialist p c p s or specialists they may have a co pay at the emergency room they may have higher co pays for various types of testing or therapy if you're hospitalized usually there's a big high co pay known as a deductible which means that is the ducted from the amount bill ten thousand dollars hospital bill a five thousand dollars deductible  that ten thousand dollar bill five thousand of it is on the consumer so and then out of pocket another out of pocket or way that the consumer participates in cost is what's called co insurance many people have heard of like an eighty twenty plan or a ninety ten plan what does that mean well that means that even after your deductible the insurance company may not be paying one hundred percent of those claims the insurance company is paying a percentage of them so you're paying your deductible and co pays plus co insurance and that all goes together into this this big way i mean called the out of pocket or the maximum out of pocket expenses so there's a general lower your monthly premium sure the more risk you take the less you're going to pay the third party insurance company what's a p p o a p p o is a preferred provider organization that is where you have a group of doctors and hospitals over here that have joined a preferred provider organization that preferred provider organization contracts to these doctors and hospitals with this insurance company here and there is a relationship that relationship is if either consumer go to these contracted doctors and hospitals this insurance company has negotiated fees  rates so they don't get hosed so that they're not paying retail or being overcharged by unscrupulous providers these providers have agreed to the terms of the relationship therefore they accept the insurance right years ago you never you never heard of does a doctor accept this or doesn't accept it right and that that term acceptance usually relates to the contractual relationship either as a p provider and e p o which is an exclusive provider organization or and h m o which is a health maintenance organizations and that's originally what started from the traditional health insurance the h m o started first and then the p p o s came afterwards and my correct and well traditional health insurance when i got into the business in one thousand nine hundred eighty five was mostly basic hospital surgical plans where you could go to any doctor any hospital anywhere there was no agreement between the doctors and the insurance company the insurance companies agreement was with me the consumer or you the insurance company simply said go see anybody you want  and you have a deductible and after that deductible we'll pay eighty percent of your hospital or doctor or testing fees to maybe a thousand out of pocket then we'll pay a hundred percent they had no relationship there was no p p o or h m o or e p o so there was all to mitt freedom of choice and frankly i think it was a safer environment for everybody today with managed care and keep in mind  the p p o the the exclusive provider organization which means a p p o by the way going back to that if you seek treatment from one of these doctors everything is hunky dory it works just the way you think but if you don't want to see one of these docs or hospitals you still have coverage with a p p o just less you might be penalize you might have to you you have more flesh in the game but at least you have freedom with an e p a it's exclusive provider ok what does that mean that means c v s doctors and have coverage or you don't have coverage if you go outside of the network you're not covered same thing with an h m o by the way and that's a scary proposition because if you  comfortable with the position that you are seeking help from there's a problem there i agree and to be dictated this who can see is an issue and often in those organizations you never see the same physician twice and i i hear the horror stories and this is you know i've never been a part of one personally so i can't speak to that but what i can say is what i see happening with these relationships ok the contractual relationship between the third party payer let's look at the insurance company as the person with the bucket of money that's really what the insurance company is right they have a big bucket of money and they're the knight in shining armor that ride in over the hill and write the big check when you can't that's what they're but now what's happening is because they have contractual relationships between doctors and hospitals unfortunately now many private practice doctors are being swallowed up and they're becoming defacto employees of the insurance company of the hospitals and the insurance banga because now in some cases the hospitals are being absorbed by the insurance company so it's so now you have what i consider to be a dangerous relationship there's a commingling of the people writing the check now through the carrot and the stick can control the provider and either reward or penalize the provider as it relates the care given to the patient ok and this to me this managed care that the rabbit hole that we're going down is creating a lot of problems that we're seeing surface today not only for the patient but i but can i say this that a lot of doctors are experiencing burnout ok because they are spending so much time today with things such as medical billing codes and compliance we all grew up you know we all remember not all of us but many of us remember dr marcus welby m d member that the television show those were the good old days right where the doc had a little broader scope of authority as a primary care physician he or she had a great relationship with the pro with the patient may i submit to you that the patient provider relationship cannot be overstated in its importance you mentioned earlier a good primary care physician or in my case i use a direct primary care physician which hopefully we can talk about later  but my particular primary care physician treats the whole person she gets over into you know what's cooking in my life emotionally or relationally or exercise or diet all of these types of things and the last thing she wants to do is push pills the other issues you develop this relationship and they provide you with time their time yes what's happening with these hospital and physicians and that's a simple way of saying that they have a quote of the me during that i haven't given any given day and they spent five ten minutes with you as a runner from room to room and it's very difficult to develop a relationship and often as i said you don't get to see them a second time the second time you're in there you're seeing somebody else who's ever there that day and you need that that relationship with your physician they need to know you and understand you because you know we could take all the x rays we want we can take all the blood work tests we want those are just pictures of a moment in time you come in to your provider with symptoms and signs and any good physician should be able to type a she just met that alone if you don't have but five minutes with them there's no way that they can do that you know and those those pictures and those blood the blood work test results are confirmations but i always look at it as you should be able to diagnose a condition by just listening to the patient w well you know in this is what i'd like to see health care reform taking place by the way what's new health care and this what's going on and i know when i came to you one of the big things at the time was we've got to we've got to satisfy the law and  with tax year two thousand and nineteen not too far away right so the individual mandate is gone all right and that was a major component in the affordable care act going back to the carrot and the stick right  was suspect of the affordable care act because it required a stick period ok what i what i've learned in relationships or negotiation if somebody shows up to the negotiating table and they have a big stick to buffet you into this decision it's probably not a decision that in my best interests you know it seems to me when the government uses the term it's just the opposite is what really made it so when they said affordable it was opposite of what affordable meant right on because it was coming difficult for me to afford it in the individual mandate was was something that was it was very contested in the united states and that is one of the first times if not the first time that the federal government passed a law that forced consumers to buy a commodity from a private insurance company such as health insurance right if you didn't buy it you suffered a penalty which is like ok imagine the struggling self employed person who doesn't have health insurance because he or she can't afford it and the government thinks it's a good idea since you can't afford it i'm going to penalize you even more you know that impacted businesses because they cut down employees so they didn't have them to qualify that and there were there were a lot of like anything people read the law they get legal counsel how do i maneuver to avoid the teeth here or whatever so you know going back to central planning is a very i'm very skeptical of central planning in a nation as big as the united states because there so many differing pockets and socioeconomic differences and you know if you travel from alabama to california to maine to pittsburgh you're going to see a lot of difference so so the affordable care act changing right we're going to see a mass exodus beginning january first two thousand and nineteen from the affordable care act also known as obamacare to more traditional forms of insurance where a company like mine is probably set to blossom even even more and we had a record year last year new era health plans and wes peden life and health you know in what the other thing that we're seeing new and i say this to my associates  sales reps and team leaders i've got a team leader in georgia chicago philadelphia cincinnati draper utah were all over the united states now and they have agencies and sub agents that work with them but my message to all of these people is this the number one thing that we have to offer the american people is education ok yes we sell a product and that's what pays the bills but the thing that we're doing right is we're educating the consumer and talking with them about common sense ideas like why buy insurance to pay for the small stuff you know part of our education is teaching people about direct primary care direct primary care another thing that we're educating people about is accessing cash pay opportunities with major health systems such as the washington hospital or heritage valley here in pittsburgh both of them are now offering transparent cash pricing to consumers and i think that's a very fair i think it's a very noble of them and our job is to make the of the people which a sponsor a is about education and i think that is key to everything that's key to enjoyable life that's key to health and wellness that's key to financial success i don't care what you look at it you have to know the information you have to have the facts in order to put out a good plan so what this reform that's going on well let me before i ask you that you brought this up this cash pay so if i walk in my physician's office and i have may be should it be left i don't know but it may be in fact what we're finding in many cases it is ok so how do i do that though i hand him my card and say well let me pay cash and if it's less you're going to it's all how you posture the consumer has all the authority in the world ok if you think about it you're a consumer you're buying a product or service and part of our education process is reminding the consumer you're in control just because they have a white coat does not mean they're your authority they're your servant they're here to help you so so yeah you have an insurance product i have an insurance policy and i am scheduled actually for an m r i because i had a small event when i was in ireland overseas recently and my doc wants to look into it ok and when i when she wrote me this script i could run it through the insurance get the p p o discount and be reimbursed you know whatever amount  or i postured is cash pay what because i want to learn how this works and i feel that i can help my agents in my my client by walking through it some self and this is where i found out that the washington hospital for example graciously will give you a seventy percent cash pay discount over their rack rate over their regular you know what they would normally bill and that two thousand two hundred fifty dollars benchmark price for an m r i i'm not guessing at this i have i have a prescription on my desk for this m r i and i'm the patient and i'm going to go to the washington hospital and render nine seventy five and that's all it's go cost me and then i'll be reimbursed by my insurance company because my insurance plan is a complete freedom of choice plan it's an indemnity product meaning it pays so much per procedure per day a cache and it doesn't care who it pays it to it can pay it to me the insured it could pay it to you the provider it could pay it to the hospital my insurance company doesn't care and that's the policy that's their policy you have ok and so it gives the consumer the ultimate choice it puts you squarely in the driver's seat and you get to negotiate the deal that is best for you in c and this is what managed care does not allow for all right now and going back to things like direct primary care my physician and many physicians now i spoke with dr kiersten lead i believe in allison park pennsylvania she's has a thriving practice that's practicing this rebecca plute paragon personal health care and canons burke my friend dr keith smith and oklahoma city runs it is part of a major player in a forty three thousand square foot surgery center called the surgery center of oklahoma or oklahoma surgery center they're all cash pay they don't take any insurance but if you go to their web site it's all transparent as well meaning you can you can see what a complete knee replacement cost including facility fee surgeon assisting surgeon radiology the whole thing and it's their prices are are lower than medicaid pricing which you know is the lowest reimbursement but that doesn't mean they're not getting quality health care is fantastic in fact in many cases let's say at the oklahoma surgery center many of the surgeons that are practicing there are the same surgeons that are practicing across the street at the very large very expensive big box corporate hospital and they like doing their work at the oklahoma surgery center better in many cases because it's swifter more efficient male i don't mind sharing what the pricing arrangement is i pay one hundred dollars a month every month as part of my risk management package to paragon personal health care what do i get in return for that i have a friend who is my physician who knows everything about me she probably knows more than i'd like her to know but you know if i have a symptom i can text rebecca say hey you know that rash is coming back ok will send me a picture of it and if i need to see you know but it's a great relationship and i just went there and she did the blood draw she has a place in her shop where they can draw blood for the lippitt panel to check for the cholesterol or the sugar and she uses the same labs that any other doctor she's using quest diagnostics and she pays she buys the lab and i just pay her but it's peanuts she's negotiated  direct pay prices so i'm not insuring any of this my office visits i have no co pay no deductible nothing my blood draws cost me very little money and it's all part of this subscription i remember you know i had a little nodule or you know like a skin tag or something growing on my right calf last year she just froze it took it off right there no cost part of you know so primary care or direct primary care is where i'm paying cash on a subscription basis concierge the concierge physician and let me tell you it's becoming more affordable and it is the best relationship i have ever had with a physician personal no middleman and let me tell you you know if you have one hundred physicians in a room and i was just in oklahoma city last year at the free market medical association convention mostly all docs all surgeons whatever and you can tell you can tell the direct primary care physicians in a room of one hundred doctors you know why they're the happy ones because they're not working for the corps they're not worked out or insurance there's that and  then insurance companies have techniques not to pay the primary care for the physicians the care providers they delay they they they say you messed up the billing code there's all kinds of things they do not to pay and you have to constantly fight to get your money absolutely it's very stressful and then i say hey we're only paying you this you know it's tough sometimes so so so then that impacts health care because now in order to keep the overhead under control you have been to see more people in less time bingo in this is the other thing people notice a difference in care people realize i mean how many people listening to my voice have an appointment they show up on time and yet they have to wait in the in the waiting room and then finally you know they're shuttled down the hall there you're weighed by you know a nurse's assistant or something and then you sit in the doctor's office and you wait some more and you're in there's ten stalls just like yours down the long hallway and you hear the doctor down the at and he's moving quickly you know here he comes and he comes in and it's you know his back is toward you and he's clicking mouses and entering codes on a laptop why because he's working for the for corporate america the bedside relationship in many cases is lost and a lot of these doctors are burning out i mean you know google the suicide rate among physicians and professionals it's i nteresting that what is occurring in the business because to get ahead these people or these these caregivers are under a lot more pressure to accomplish more they're managing more nickols more noses clicking more mouse as they're doing a lot of things besides caregiving and my my my private physician said this to me you know she went to what fifteen years of practice school and to pick a or for people but the corporate model had her caring for people twenty percent of the time and compliance eighty percent of the time her new model has completely reversed that where it's a lot more relaxed the patient provider relationship is at the top that's the neumar that's the number one thing you know tom we're about to come to a close of the show so is there any particular point you want to get across to the i would just say this that what we can do for clients if they're interested in learning more about what i do is i would say allow us to share with you education on how to access care primary care affordably simply efficiently and then how to manage your risk with a much more affordable health insurance plan should something major and there's a web site out there that you can actually go to breaks the cost down well they can visit my website which is west penn health dot com and then i can share with them other web sites that we've been discussing with their heritage valley or and wash there was something like a blue book oh yeah i forgot health care blue book that is something we're using to educate consumers on how things can be negotiated and what the real price of these products and services is so that's health care bill above the home that's correct google health care blue book just like the blue book for car you can now see what a cat scan really cost you can now see what a blood draw really costs that x ray really cost and now we have your information up on on the screen from time to time what is your phone number char office seven two four two two eight seven one eight seven highly recommend this guy