When members are living with a serious health condition such as cancer or a chronic condition such as heart disease or COPD, the cost for their care can add up quickly, leaving many with large bills for medical care and prescription medications.
The Kaiser Family Foundation
67% of people in the U.S. are very worried or somewhat worried about unexpected medical
. And many people are having difficulty paying high medical bills. The credit bureau TransUnion found that 68% of patients failed to fully pay off medical bill balances in 2016, up from 53% in 2015, and 49% in 2014. That percentage is projected to climb to 95% by 2020.
To help manage the risk of high medical bills and debt,
can deploy several strategies focused on educating themselves on how to get the most out of their medical cost sharing program and utilize support services that help them pay for care and ensure that the medical bills they receive are accurate.
Low Unshareable Amounts
Members pay lower monthly share contributions for a
program than they do for a traditional Affordable Care Act health insurance plan. A member can elect an individual Unshareable Amount as low as $500 (the maximum is $5,000 in the Access version of medical cost sharing) per individual, can use any provider, and in most circumstances have no maximum cap on shareable costs. In contrast, insured Affordable Care Act plans have maximum in-network maximums in 2019 of $7,900 for an individual and $15,800 for a family, and these amounts will increase in 2020. Out-of-network maximums can be double or even more, depending on the plan selected. Monthly contributions for a
program are 30 to 90% lower than with a traditional insured Affordable Care Act plan.
Avoidance and Prevention
According to the Centers for Disease Control and Prevention, 86% of annual health care expenditures are for treatment of chronic disease. Chronic disease is responsible for 81% of all hospital admissions; 91% of filled prescriptions; and 76% of doctor visits. A significant portion of these expenditures can be prevented, delayed or alleviated by eliminating three risk factors: poor diet, inactivity and smoking. This could result in the elimination of 80% of heart attacks and strokes; 80% of type 2 diabetes; and 40% of cancers.
focuses on attracting health-focused individuals and emphasizes the importance of avoidance and prevention.
offers state-of-the -art avoidance tools such as the artificial intelligence-based functional assessment, the personal medical vault, and the QR Life Code. The program provides the Mayo-clinic developed Twelve Habits of Highly Healthy People educational program and a wide variety of educational programs and discussion groups.
In addition, four of the five programs (the self-directed program is the exception) offer all Affordable Care Act-required preventive care benefits. Members are highly encouraged to use their preventive care services.
Necessity of understanding how the program works
An important step in helping members to better manage their healthcare costs is to make sure they have a strong understanding of how their program works.
tries to ensure that prospective members understand the program before joining and discourages individuals from joining if they are not health-focused, not prepared to actively manage their health care, or who do not understand the program. Explanatory welcome calls are scheduled for all new members, and a single point of access through the concierge is provided so that members know who and where to call if they have questions, concerns, or need help in understanding and using the program.
Benefits and services that lower the risk of high unexpected medical bills
There are several ways
helps manage and mitigate the impact of the cost of care for members who face high medical costs.
Help members of the partially self-directed program pay for care with voluntary HSA accounts and all members pay for care by establishing voluntary health matching accounts.
Offering these types of accounts gives members a way to budget for and fund expensive healthcare costs incurred before meeting their individual unshareable amount (or for other items not included in medical cost sharing, e.g. dental work).
Provide access to second opinion services:
To ensure members are not only getting the most accurate diagnosis but also the most appropriate treatment plan for their condition,
offers members access to second medical opinion services for those who face a
new diagnosis, a possible surgery, a change in medication, or a chronic illness, even including one currently excluded from sharing because it's a pre-existing condition.
Members have access to more than 300 nationally recognized, board-certified medical specialists that cover more than 120 sub-specialties. These world-renowned physicians are available for consult via video conferencing or telephone from virtually anywhere in the world within about 3 days, providing program members the peace of mind that they want and deserve.
The program's experience with the second opinion program is that 1/3 of planned surgeries are cancelled; that treatment plans are improved 73% of the time; and that the average savings/consultation are $3,000.
Help with medication costs:
When members are prescribed high-cost medications, the Concierge and Sedera Member Services help the member reduce costs through programs such as World Meds and Pharmacy Checker. They also help the member find the most appropriate and cost-effective setting for administration of the drug: for example when a member needs an infusion or an injection it can be up to five times less expensive to administer the infusion or injection at a physician’s office instead of a hospital outpatient clinic.
Lower the risk of inappropriate care and duplicate testing:
The program offers member access to services of a Sedera Member Advisor who can provide them with information on treatment options as well as gathering and reviewing all medical records to lower the risk of unnecessary or duplicative care, lab tests and imaging.
Connect members with a Sedera billing advocate:
According to some estimates, between 30% and 80% of medical bills in the U.S. contain at least one error, and in nearly a third of those cases, the error represents a significant amount of money. A billing advocate can not only review bills for accuracy and dispute incorrect charges with hospitals and providers but can also help negotiate a cost reduction when members face high medical bills.