March 25, 2022

$1 Prescriptions: The Future of Health Insurance

$1 Prescriptions: The Future of Health Insurance

$0 deductibles and $1 prescriptions. It sounds almost too good to be true, but companies across the country have made these health plans a reality for their employees.  For the past two decades, the cost of insurance premiums and deductibles have...

$0 deductibles and $1 prescriptions. It sounds almost too good to be true, but companies across the country have made these health plans a reality for their employees. 

For the past two decades, the cost of insurance premiums and deductibles have skyrocketed, leaving Americans with medical debt, constant switching of coverage, and deductibles that are impossible to meet. 

Enter the 2022 Health Plan Hero companies. They are health insurance plan trailblazers who have diverged from the status quo. Hear from company leadership, employees, and benefit advisors who share how they have reshaped the benefit design of their insurance to save employers and employees money, while also improving healthcare coverage and care options. 


Terry Wilcox, Executive Director, Patients Rising

Dr. Robert Goldberg, “Dr. Bob,” Co-Founder and Vice President of the Center for Medicine in the Public Interest

Kate Pecora, Field Correspondent


Jaime Matthews, HR Director, Schaefer Autobody

David Johnson, Managing Partner, Alera Group

Lance Young, Director of Administration, Shine Solar

Adam Berkowitz, Benefits Advisor & Founder, Simpara

Gil Rodriquez, HR Administrator, Shine Solar

Matt Martin, HR Administrator, Matheny Motors

Anissa Rose, Employee, Matheny Motors

Bryce Heinbaugh, CEO, IEN Risk Management

Brittaney Medders, Employee, Johns Soules Food

Michelle Archer, Employee, Woodard Cleaning & Restoration 

Sheridan Keck, Spouse of a Employee of Matheny Motors


Health Plan Heroes

Most Medical Debts To Be Removed From Consumers Credit Reports

Most medical debt will not appear on your credit report if it's been paid off | CNN Business

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1 (6s):
They wanted to send me to Mayo Clinic to get the best healthcare that was out there for me and that meant the world to me.

Gil Rodriguez (15s):
They told us that the prescription was going to be a dollar and that's a dollar for a month. So if we wanted three months worth of prescriptions, that that would be three dollars. That made it so easy for me to afford, because now it became affordable insurance.

Terry Wilcox (30s):
Picture this, a health plan with a $0 deductible and one dollar prescriptions. Employers across the country are making this a reality for their employees and saving money in the process. How is this possible? Find out next. Welcome to the Patients Rising Podcast. I'm your host, Terry Wilcox, Executive Director of Patients Rising, a hundred-thousand members, strong organization of patients with chronic illness. I'm here with my cohost, whose signature black t-shirt, the one I love, was an inspiration for Robert Pattinson's Batman look. He's Dr. Bob Goldberg, co-founder of The Center for Medicine in the Public Interest.

Terry Wilcox (1m 14s):
Hi, Bob!

Dr. Bob Goldberg (1m 15s):
Pattinson doesn't hold a candle to my Batman look, that's all I can say. I tried to get that role, and for some reason, the studio didn't let me in. I did lend him my black t-shirt. I said, just wash it before you give it back to me, that's my only condition. Again, I am freed-up, Terry, to help pull back the curtain in Washington, DC and dive into the ongoing health policy debates happening in our nation's Capitol. Then we report back to you on how proposed legislation will impact your access to healthcare.

Terry Wilcox (1m 54s):
One of the ongoing conversations in DC, and everywhere, is around drug pricing and healthcare affordability. There's a major reason behind the lack of affordability, but it's not getting the spotlight it deserves. That reason is how your health insurance plan is designed. Benefit design of a health plan includes your monthly premium, your deductible, and the drugs and services that are, and are not, covered.

Dr. Bob Goldberg (2m 21s):
Well, Terry, you know premiums and deductibles seem to be going through the roof. At least that's how it feels. Ironically, the employer-sponsored healthcare plans used to be the gold standard for affordable health care. Now, even in the commercial markets, we're seeing not just rising premiums, but higher deductibles and out-of-pocket costs of stuff that is making it impossible for families to meet, even with the coverage.

Terry Wilcox (2m 50s):
To put it in context, in 2020, the average premium for a single person was $7,410. For a family, it was $21,342. It's unaffordable for individuals and it's unaffordable for the companies who provide these plans. Businesses are fed-up and thankfully there's a solution.

Dr. Bob Goldberg (3m 17s):
Yeah, today we're going to hear from a number of companies and how they ditched the traditional health plan design in favor of a new approach. What they've done is redesigned their healthcare plans to lower costs for patients, offer better care, and believe it or not, actually I do believe it, save on their own bottom line. Instead of spending hundreds-of-thousands of dollars on a plan that leaves patients to foot most of the bill, they can put those savings into other perks for their employees.

Terry Wilcox (3m 49s):
Exactly. HR Managers, health plan benefit design advisors and employees, are sharing their stories today. They represent the 2022 inaugural class of Health Plan Heroes. A new program we launched this year, that recognizes businesses that are reducing costs, while offering the high-quality care that their employees need. Before we get into the Health Plan Hero stories, there is some recent news we're going to dive into that helps set the stage for our conversation on health plans and healthcare affordability.

Dr. Bob Goldberg (4m 23s):
This is a huge deal for patients, Terry. Some of the largest credit reporting firms, including TransUnion and Equifax, have announced they will be wiping medical debt off of credit reports. It's about time! Whether it's my daughter, who had to pay for the delivery of my grandson, because he wasn't covered under her plan initially, or the out-of-pocket costs that I had when my daughter was really sick, these things stick on your record. It's not like you went out to Vegas to run-up an expense account or I went out and bought a Mercedes and defaulted on it. These are life-and-death decisions requiring life-and- death dollars and this is a real victory for consumers. I had tens-of-thousands of dollars that was in dispute with the hospital, and the insurance company, that I was lucky and I fought very hard to get it wiped-off my credit report.

Dr. Bob Goldberg (5m 16s):
Again, just to be clear, it's not like you can run-up a bill and default if you're not eligible, but if it's a huge medical expense, and you're paying it off like $5 a week, which sometimes happens, that should not hang over your head.

Terry Wilcox (5m 32s):
No, it definitely shouldn't. This great article, which we'll put in the show notes, that was in The Wall Street Journal. This is a great win for the consumers and it segues nicely into the main focus of our show today, which is the benefit design of health insurance. How we can make sure health plans are affordable and protect consumers from expenses related to medical emergencies and routine care. Before we get into all of that, I have to ask you a question, Bob.

Dr. Bob Goldberg (6m 0s):

Terry Wilcox (6m 0s):
It's a question that I have asked a lot of folks over the past few weeks and that we're going to hear today. What's your biggest pet-peeve with the healthcare industry, particularly when it comes to health insurance?

Dr. Bob Goldberg (6m 15s):
Well can I have more than one peeve?

Terry Wilcox (6m 18s):
You can.

Dr. Bob Goldberg (6m 18s):
My first pet-peeve is benefit design is stupid. In a lot of cases, it's not tied to individual needs and differences, and that is something that needs to be done. The second thing is something that you and I talked about a couple of days ago. When the health plans take the list price of the drug, make people pay a share of it, take the copay assistance and then go on with their business. Again, the use of those dollars should be directed to making those drugs maybe even zero out-of-pocket. So, those are my two pet-peeves and I'd be happy to provide people with more peeves in the next show.

Terry Wilcox (6m 54s):
At a later date?

Dr. Bob Goldberg (6m 54s):
At a later date, yes.

Terry Wilcox (6m 55s):
That's one of the things we will talk about today, because that is one of the big pet-peeves of taking the patient assist. The copay accumulator example is, we pocket the assistance, and then we still put the deductible back on the patient. A lot of the folks that we're going to talk to today, their benefit design is not that. They have taken the copay assistance, but they are charging the patient zero out-of-pocket, and they're making other negotiations, and other arrangements. Some are not sustainable when we look at it from the pharmaceutical industry perspective. That's one of the reasons why we've started Health Plan Heroes.

Terry Wilcox (7m 35s):
We want to have substantive conversations with employers, the pharmaceutical industry, independent benefit designers, and really talk about where the issues are. Where the hiccups are, because it's not sustainable. I also posed this pet-peeve, healthcare question, to people who deal regularly with health insurance, including HR administrators, and independent benefit designers, who work with companies to make custom health plans. There's a common thread among their answers. Take a listen.

Jamie Matthews (8m 9s):
My biggest pet-peeve, in regards to the healthcare industry, has been the rising costs. The cost of healthcare continues to rise, but the coverage seems to stay the same or even lessen. For us to see such a significant increase in our premiums year, after year, after year, has been really frustrating. To have to pass that onto our employees is even that much harder.

David Johnson (8m 38s):
My biggest pet-peeve about the healthcare industry is how much it costs for families across the country. There are many statistics out there that show how much money the average American makes, how much money the average American has in savings, and yet when the average American has something that's catastrophic from a health perspective, happen to their lives, it costs them literally thousands of dollars. That's just too much money for the average person. Quite frankly, it's too much money for someone that is upper-class, that the cost of our healthcare system has grown to a point where it's just simply unacceptable to our country and it's unsustainable.

Terry Wilcox (9m 17s):
That was Jamie Matthews, the HR Director at Schaefer Auto Body in St. Louis and David Johnson, a benefit design advisor, who works with people like Jamie to create better health plans. Bob, it seems like a lot of it obviously comes down to cost. As I stated in the beginning, family premiums are through the roof. They've increased by 22% since 2015, and obviously, we're now in a state of inflation and other things. In 2020, that average premium was $7,410 and $21,342 for a family. It was unsustainable. It's unsustainable for workers. What it basically is, and maybe not everyone is going to agree with me on this, but when you look at an organization like National Federation for Independent Businesses, an FIB, when they do their survey every year for their membership, their number one issue they get back, without fail, is healthcare.

Terry Wilcox (10m 17s):
So small businesses, this is a major concern. The fact that their healthcare costs are rising, does keep them from doing other things. Giving raises, hiring more people, expanding, that isn't really thought about. Today we're going to be hearing from employers and employees and insurance benefit design advisors about how they have created new plans that cut costs and improve care. Some of these plans have $0 deductibles and prescriptions for just a dollar.

Dr. Bob Goldberg (10m 48s):
I'd love to see, and hear, one of those Health Care Heroes, Terry, because the solutions are not going to come from Washington. They're going to come from the people that we're honoring on the podcast today.

Terry Wilcox (11m 3s):
As I've said many times, healthcare is local.

Dr. Bob Goldberg (11m 7s):
Certainly is.

Terry Wilcox (11m 8s):
It's community-based. It's local. For Health Plan Hero Award winner, Shine Solar, a solar energy equipment supplier in Arkansas, it wasn't just the cost that had them fed-up. As I said earlier, it was the lack of transparency and not knowing exactly what their health plan paid for. Here's Shine Solar's Director of Administration, Lance Young, who describes the event that pushed their company to ditch the old way of health insurance.

Lance Young (11m 34s):
The pivot point was a direct conversation with my CEO and our benefits broker. I wasn't even in the room, but they were having a meeting and they were discussing these rising premiums. They were discussing the fact that we have no transparency. Terry, as a company, we had no idea what we're spending our money on. We get a bill every month for $50,000, or whatever it is, and there's no line items to the bill. It's like, this is just what you owe. I want to know what I'm spending our company's money on. Where specifically is this going. To who is it going to. I need more transparency. We get that in every other aspect of our business, but we did not get it with healthcare. The broker was having a conversation with my CEO and they're trying to get us to spend more money, on the company's behalf, to get more people enrolled so that we can get this new level of transparency.

Lance Young (12m 28s):
It came across to him as a complete pay-to-play type scenario. The pivotal point in the conversation was, they were wanting to suspend about another $300,000 a year, to get this enrollment up. My CEO just slyly asked the broker, "Dude, what's your cut of that?" The guy, without batting an eye, said about 48%, and I immediately realized what he had said and he had that astonished look on his face. My CEO was like, there's no way I'm doing this, because the broker had openly admitted how much they were going to make off this money of ours. That was it. That was the breaking point. My CEO came out of that meeting, came into my office, and was like we're going to do things different.

Lance Young (13m 9s):
We're not doing this. That was when we started the search for a healthcare consultant to show us a different way of doing things.

Dr. Bob Goldberg (13m 18s):
I'm still in shock. Who could do that and sleep with themselves?

Terry Wilcox (13m 24s):
That's why when we're talking about the whole picture of benefit design right now, and health plans, people like to say, Oh, these independent benefit designers, they're kind of going off the grid. They're doing some untraditional types of arrangements, et cetera.

Dr. Bob Goldberg (13m 37s):
That's good.

Terry Wilcox (13m 37s):
I'm like, well, that's actually a good thing. They may need to be tweaked some. There may be some conversations that need to be had around how healthcare is changing. I'm all for that, but I've got to tell you, from what we hear at Patients Rising Concierge and other patients who talk to us, who have what they call off-the-shelf traditional health plans by United Healthcare, Aetna, et cetera. They're functionally uninsured. Their deductibles are too high. Their employers are paying through-the-roof and they don't even have healthy employees.

Dr. Bob Goldberg (14m 15s):
Right. You know that guy who's getting 48% thinks he's making his money, because he's delivering them a health plan, that on the surface looks cheap, because instead of getting a 90% premium increase, you'll be getting a 20 percent premium increase. Part of the brokers take, so to speak, is for making sure that some of the rebates, that are generated from the drugs, goes back to reducing the premiums for their customers, so to speak. You can take the money that the broker makes, and you could take the rebates, and that pot of money, along with some smart, simple, homebrew benefit design, can really make a difference and reduce the out-of-pocket cost and improve care.

Dr. Bob Goldberg (15m 1s):
I want to say one thing, Terry, that you said. This is local. The revolution is not going to happen in Washington. It's going to be talking to employers who are close to their workers and saying, I want to do it a better way.

Terry Wilcox (15m 19s):
Absolutely. If you're a regional employer, you can make regional deals with hospitals, with independent specialty pharmacies. There's all sorts of ways that you can create your health plan that's not only beneficial to the bottom-line of the employer, but it is beneficial to the bottom-line of the employees, which is what you want. This was a situation that was facing many of the companies that are featured today. To help them create a better health plan, they worked with other folks we're going to be hearing from. Independent benefit advisors, not the health plan brokers that we heard about with the 48%. After Lance and the team at Shine Solar, hit their breaking point with insurance, they turned to their benefits advisor, Adam Berkowitz.

Terry Wilcox (16m 2s):
Here's how Adam describes the new kinds of plans that they can create for companies like Shine Solar.

Adam Berkowitz (16m 8s):
We were building plans that provide the protections that most folks never thought was possible. By that I mean, expecting moms don't have to worry about paying or affording a deductible, because they don't have one. They don't have to worry about finding the top providers and top hospitals, because our plan is by default have included them. You know that's where you go, so we've built plans around quality. We've built plans around accessibility so that there is no barrier to great health care, and unfortunately the largest barrier that exists today is the financial barrier. Whether it's a co-pay, a deductible, or co-insurance, the majority of our plans don't have them anymore.

Adam Berkowitz (16m 49s):
That was a wake-up moment for us, because we realized that that was really the one roadblock to getting employers to start saving money, was the path to spending less, was actually improving benefits. Improving healthcare for their employees. We really create these environments where everyone is winning and everyone is thriving. We've solved such a hardship for so many people, which is, Gosh, I'm spending all this money just to have the insurance, but I don't even know if I can afford to get sick, or afford to have a child, because I can't afford my deductible. Those are the things that we started fixing early on, and quality-of-care, it's a much harder thing and harder not to tackle.

Adam Berkowitz (17m 31s):
We're getting there, and bringing the provider community into the conversation and working directly with hospitals and doctors is certainly transformative in this space, because I think for a long time they were an afterthought.

Dr. Bob Goldberg (17m 46s):
You know, it occurs to me, and this is something that I've been working on for years, and we're working on, sometimes what you have to do is, if the model is broken, don't fix the model, build a new model. What I see happening is, because of the fact that marketplaces and connections are digital, and they're easier to connect, you can create micro-channels and customize the patient experience, or the consumer experience, in any number of ways. You can depart from the cookie-cutter approach and I think that we're really on the cusp, hopefully, of a revolution in the way that healthcare is delivered.

Terry Wilcox (18m 31s):
Shine Solar's new plan incorporated many of the things Adam just talked about, including a $0 deductible for most services done through local hospital systems. It also includes more than 500 name- brand drugs at no cost to patients. On top of that, it incorporated a personal touch to healthcare through the role of a patient navigator. Gil Rodriguez, is an employee of Shine Solar, who is battling end-stage renal disease. For him, having someone advocate for his healthcare and insurance coverage was an absolute game changer. Here's Gil.

Gil Rodriguez (19m 3s):
I went to one of my appointments and they said that I had to go ahead and pay upfront what I owed. I want to say it was like a thousand dollars. I said, "Did you go through Ashley to go ahead and have this approved?" They said, "Well, Ashley is not here right now." I was like, "Can you give her a call?", and that's one of the things that I'm not used to. For their billing department to take me into their office, have me on the phone with Ashley, and they said, "No, no, you're very, very wrong. Gil does not pay anything upfront. You bill me."

Gil Rodriguez (19m 42s):
I felt like crying, because no one's ever done that before. She had my back, and since that day, Ashley has been a tremendous help. I rely on her. I really rely on her to go ahead and be that support person. I think it's one of the things that you don't ever see with insurance companies and I think this one is very special, because she's an advocate for us.

Terry Wilcox (20m 6s):
On top of all of that, that we just heard, prescriptions on that plan were a dollar!

Gil Rodriguez (20m 11s):
When we first enrolled in the system, and they told us that the prescription was going to be a dollar, and that is a dollar for a month. If we wanted three months worth of prescription, that that would be three dollars. That made it so easy for me to go ahead and afford, because now it became affordable insurance.

Dr. Bob Goldberg (20m 33s):
That's the way it should be. I mean, that's incredible, but it's something that should be ordinary, if you know what I mean.

Terry Wilcox (20m 42s):
It does, and especially since we've subjected ourselves to such high premiums, high deductibles and high out-of-pocket costs, but making a big change in health care requires buy-in from your employees too. Here's Matt Martin. He's the HR Director at Matheny Motors in West Virginia. Another one of the Health Plan Hero awardees. For him, he said that employees were also ready to make a leap to a new health plan.

Matt Martin (21m 5s):
I was really shocked. I thought we would get a lot of concerns, pushback, and it was the exact opposite. I think our employees were on the same edge we were on just knowing there had to be a better way. When we went through our tour of our many locations, through five different states, we saw lightbulbs click on and ultimately they were like, yes, that's exactly what we were looking for. It helped that we were able to provide a decrease in our costs that first year and have continued that for our employees. We've added some additional perks to the plan to be able to say, "We want to give back." We want to help employees have the best quality healthcare that they can have.

Terry Wilcox (21m 48s):
Obviously, this is a big cost savings to the company, but it's also an important investment to the health of employees. Our field correspondent, Kate Pecora spoke with Anessa Rose, an employee of Matheny Motors. Anessa lives with a rare disease, and especially in the rare disease space, care can come at a high cost. She shared how the new plan helps her get the care she needed at one of the best healthcare facilities in the country. Take a listen.

Anessa Rose (22m 20s):
I was diagnosed with a disease called mastocytosis that had different levels. The worst level was terminal. Of course I had that on my mind. I had been referred to Cleveland Clinic, and they were going to hopefully tell me what part of the disease that I had. When the new company came in, JP Farley, the nurse navigators that they use talked to me after their presentation of what they were all about and what levels. They had a couple of different plans that you could pick. I stayed over and told them about what I was going through.

Anessa Rose (23m 3s):
They actually told me that they had an Edison Health Care program specifically designed for special needs like this. Like for cancer, or heart disease, and I would probably qualify for this. They wanted to send me to Mayo Clinic to get the best healthcare that was out there for me and that meant the world to me.

Kate Pecora (23m 25s):
When you did go to Mayo Clinic, were they able to find a solution that wasn't available to you at Cleveland?

Anessa Rose (23m 32s):
Yeah, I kept my appointment with Cleveland Clinic only because I was already in a month after my diagnosis. I wanted to keep that, because I thought I would find out quicker. I actually didn't find out anything other than what I already knew. They had already set me up with the Mayo for a second opinion and that was towards the end of the month. I actually traveled and they paid for my airfare. They paid for my food, as well as my companion, which I took my mother, and they put us up in a hotel. All of this was cost-free for me. That also meant a lot, because as a parent of two kids, I don't have a whole lot of extra money just to throw around for stuff like that.

Anessa Rose (24m 24s):
I was there a week and I learned that I wasn't going to die. I learned what part of the disease that I had, how I could keep it under control with certain medications, and through all of that, their health care was phenomenal.

Kate Pecora (24m 46s):
So you obviously had success at the Mayo Clinic. Do you still go there?

Anessa Rose (24m 52s):
I do not. They actually, "they" meaning the nurse navigator, referred me to a mastocytosis doctor in Ohio that was closer to me. I go there every six months.

Kate Pecora (25m 2s):
So the hard part is over, right?

Anessa Rose (25m 4s):
Yes. Thank God. It's a disease that I can control with medications and proper care.

Kate Pecora (25m 8s):
Talk to me about those medications. I imagine this is, like you said, a rare disease, and I would imagine every rare disease comes with a lot of expenses, right? The medications that you're on, were they particularly expensive for you?

Anessa Rose (25m 27s):
Yeah, so the medication that I take for this disease is anti-histamines. As you know, you can purchase some of these anti-histamines over the counter, but my case, I have to take sometimes quadruple what a normal person would take just for normal allergies. With that being said, it would have cost a significant amount of money. Just to keep a monthly supply would be four times the amount as a normal person would spend over-the-counter. When I found out the insurance wasn't going to pay for the over-the-counter medication specifically, I contacted the nurse navigator and told her what was going on.

Anessa Rose (26m 13s):
She actually contacted them and told them that this was over-the-counter, but the amount of medication that I had to take, she was able to get an override on the medication.

Dr. Bob Goldberg (26m 26s):
Thank you, Kate. So Terry, we've talked about the benefits for patients and employers, and it saves everyone money across the board and provides better care, but how is this done, and can we replicate it across lots of other companies?

Terry Wilcox (26m 42s):
To break down that question, here's Bryce Heinbaugh. He's the CEO of IEN Risk Management, where he helps companies create these personalized health plans.

Bryce Heinbaugh (26m 51s):
When we do take on a new client engagement, what we try to do is better benefits at a lower cost. Many times, what we mean by better benefits, it's bringing all of these additional values and resources to their health plan. Like a nurse navigator - A patient advocate to walk them through, guide, shepherd, and protect them when they have a major health event. It's free diabetic supplies or durable medical equipment. It's the low-cost prescription copays, however possible, and it's working with local independent providers, like a community pharmacy and an independent primary care physician. There aren't those misaligned incentives so much.

Terry Wilcox (27m 30s):
Well we know a thing or two, Bob, about misaligned incentives.

Dr. Bob Goldberg (27m 33s):
Oh gosh, geez.....

Terry Wilcox (27m 35s):
Now this approach to health insurance has created solutions to the major problems in health care, but there is still the question of what to do about specialty drugs, which can often come at a hefty price tag, especially for small businesses. I asked benefit advisor, David Johnson, about this and the answer isn't so simple.

David Johnson (27m 58s):
I think that the answer to the question of, "Is there another lane, and why is it that the reality of today, with specialty drugs, is what it is?" The answer to that question, unfortunately, is above my pay grade. I think that the answer involves the larger PBMs. It involves the federal government. It involves the distribution system. It involves the manufacturers. I think it involves a lot of people coming to the table with an understanding of, "This is what our reality is today, and our reality is unfair to the American public." Even though they're benefiting financially, nobody's asking them to do anything at a loss, or no one is asking them to not make a profit, but on the backs of the Americans the way it is today, it is very hard to swallow.

Terry Wilcox (28m 49s):
So, Bob, this question was really interesting. I was putting to him the innovation piece that we talk about, because it's one thing to look at some of the medications that are used by a mass number of people, and then looking at those in the rare disease space. I kept posing that question to him. When you're looking at smaller biotech companies, how can you justify trying to just use their patient assistance programs? If everybody uses small biotechs, or even large biotechs, if everyone goes to use just the patient assistance program, and there's no pay-in, where are we going to go with innovation? His answer was, that's kind of above my pay grade. You and I talk about this a lot.

Terry Wilcox (29m 31s):
About looking at the big picture and we should be focused on how we're going to pay for great innovation and not so focused on how we're going to pay for hearing aids. I don't mean that in a negative light at all.

Dr. Bob Goldberg (29m 54s):
Yeah, so it's easier to get the care you need after you're sick, and pay less, than to get the care that you need to keep you healthy. That costs more. So if I'm a diabetic, and I'm not on the right medication, those insulin strips, they're cheap. Therapy, transportation, all that, there's limited out-of-pocket, but we don't make money and that's a good thing. We have the money in the system, Terry, you, and I know it. We have the money in the system so that everybody can get $0 coverage for the medicines that make them healthier and keep them from a disease degenerating.

Terry Wilcox (30m 31s):
There's all kinds of conversations, which we won't dive-down too many rabbit holes of risk-pools and kinds of things. You look at your W2 statement and you pay $7 a paycheck, or whatever, to go into Medicare. It's almost like what could these small businesses, employers, and others, be doing to sort of offset what may be coming down the pike when we're looking at gene therapies, and others, that may just be a one-time drug. How can you saddle a small business with a $1 million medication and their employee may leave in a year?

Dr. Bob Goldberg (31m 13s):
You can't.

Terry Wilcox (31m 13s):
You can't make a deal with that. I think there's large innovation-thinking that needs to go on around how we're going to pay for some of these things. That is valuable time spent for the healthcare of our citizens. I don't think we can understate the impact this is having on employees, especially those with rare and chronic conditions. Here's some of the highlights from patients on how these kinds of health plans have shaped their healthcare journey. Here's Sheridan, who's husband works at Matheny Motors. Because she worked with a nurse navigator during her breast cancer diagnosis, and treatment journey, her deductible was waived completely. She shared that experience with Kate.

Sheridan (31m 53s):
I basically told them what I needed and they helped me either figure-out where I needed to go, or if I already knew where I was going, because I had already chosen my surgeon, because it was my mother's surgeon a few years ago. I basically didn't have to do anything. When there were problems in figuring- out what was owed, and what to expect at my appointments, they took care of it. Basically all I had to do was show up, which was nice, because I had enough on my mind. To not have to worry about the logistics of it all again, I just sort of had to show-up and deal with what I had to deal with and not worry about the unpleasantries of insurance.

Kate Pecora (32m 35s):
So, as I understand it, you actually had your deductible waived. Can you talk to me about what made that possible?

Sheridan (32m 42s):
To be perfectly honest, I don't know. It was offered to me. I didn't know it was something that was possible. I just assumed, because of standard healthcare, you have a deductible and you have percentage copays. I never knew that was something that was even an option for me. Again, it was offered and taken care of. Any correspondence, regarding to deductible ways, was articulated to whoever I was having my service done. They took care of all that for me. Again, all I really had to do was show up.

Dr. Bob Goldberg (33m 21s):
Kate also spoke with Brittany Metters of John Soules Foods in Tyler, Texas. After testing positive in a genetic test for breast cancer, Brittany relied upon her nurse navigator, Rachel, to guide her through the insurance process. She received a double mastectomy and reconstructive surgery at no cost to Brittany.

Brittany Metters (33m 34s):
She's the one that kind of walked me through the insurance part, because I had been dealing with it for a year on my own. Trying to pay for it out-of-pocket, trying to build a case to get surgery. So when I went in to renew my plan, I had asked for the lower deductible. Rachel being Rachel, attentive and paying attention, she's like, Brittany, unless you're really sick.....What's going on? I lost it. You don't want to tell your insurance provider, Look, at any moment this is what's going on - this is what I've been through. She just helped me and was like, this is not how it's supposed to be, and we're here to help you. Let me get on the phone, and essentially because of her, is the reason that I got my surgery and I got it paid for.

Brittany Metters (34m 19s):
Because of her, I got to stop paying out-of-pocket for preventative maintenance, because I didn't meet a certain age-requirement, or I didn't have a certain diagnosis, so she's huge in all this.

Terry Wilcox (34m 31s):
And last up, here's Michelle, an employee at Woodard Cleaning and Restoration in St. Louis. Probably one of the most "thought-of" reasons behind high hospital bills is childbirth. Michelle was about to give birth to her first, when her company switched health plans. The unexpected change had her concerned about the cost of giving birth and keeping the provider she was already with, but those fears were quickly put to rest. Here's Michelle on how the plan accommodated her and protected her from high costs.

Michelle (35m 1s):
I kind of have two stories that kind of merge together. Kind of the history - When we were originally on our high deductible plan, when I was pregnant with my first child, I had to pay, I want to say probably $80 to $100 for every doctor appointment I went to, or ultrasound. Then we changed that in April and I was due with my first child in May. When I found out that that was changing, my current provider was no longer the provider that would provide me $0. I really had to choose between, do I stay with the provider that I've been with for the last eight months, that I'm comfortable with, that I've been able to tour the hospital, or as a pandemic is hitting our country, do I try to find a new doctor?

Michelle (35m 54s):
Probably can't see them in person, can't tour the hospital, so I was really stuck between what did I feel the most comfortable with emotionally, and going to have a child for the first time, versus how much money did I want to pay. That was a really hard choice and thankfully I reached out to my plan and they were able to negotiate a deal with the current provider that I had. Now that I'm pregnant with my second child, we have switched providers, so now I'm more in-line with the plan. We didn't have to do any negotiation or anything like that. So far, I am twenty-three weeks pregnant, and I think I've only gotten a bill for $13. That includes probably five or six doctor visits, two ultrasounds and I have a $13 bill.

Terry Wilcox (36m 40s):
If you want to learn more about the future of health insurance, head to the show notes.

Dr. Bob Goldberg (36m 51s):
If you go there, you'll also find a link to the Health Plan Hero website. It features the six companies who have been recognized for delivering high quality care at a lower cost for all their employees.

Terry Wilcox (37m 3s):
Thank you for joining us for this special episode of the Patients Rising Podcast. Let us know what you think of the show by leaving us a rating and a review. We'd really appreciate it.

Dr. Bob Goldberg (37m 16s):
Please don't forget to subscribe to the podcast on your favorite podcast app, that way you'll get alerted when we release a new episode.

Terry Wilcox (37m 17s):
We'll be right back here again next Friday with the latest healthcare news that impacts you. Until then, for Dr. Bob and everyone at Patients Rising, I'm Terry Wilcox - Stay healthy!