Diabetic self-pay patient describes his experience

The Federalist is a web site that I’ve occasionally written for on health care matters, and it has featured from time to time other people describing their self-pay experiences. Today Scott Erlich, who is president of a consulting firm focused on consumer marketing of pharmaceutical and health care products, shared his experience as a diabetic with a high-deductible who found ways to save substantially as a self-pay patient.

How To Cut Your Health Expenses Without Waiting For Congress To Get Its Act Together

I was diagnosed with diabetes about a year ago. I also had what is basically a catastrophic insurance plan, meaning I would pay 100 percent out of pocket for everything (other than an annual physical) up to $3,000 in annual expenses. For me, $3,000 is three months of daycare for my son, three months of mortgage payments, and eight months of car payments, so I was in no hurry to pay that deductible. So I worked hard to see if there were any way I could get good treatment cheaper…

Of the long-lasting insulins on the market, I decided to try Tresiba… Tresiba has similar effectiveness as the other long-lasting insulins on the market, but stays in your system slightly longer, giving me a bit more flexibility in my dosing. Also, their insulin could last a bit longer than others, meaning it was less likely to go bad before I could use it…

Looking at retail prices, the sticker shock is pretty high. For example, the average price for five pens of Tresiba is $541. Five pens will last me about five months, but for people with much more severe cases of diabetes, could last as little as a month or so. Add in needles, glucose test strips, etc., and you could be looking at $700 or so per month retail in severe cases.

Toujeo, a competitor to Tresiba, is listed at just $275 for about an equivalent dosage. Tresiba is my preference for the reasons above, but are those advantages worth $250 per dose? No, but I still went with Tresiba. Why? Well, those coupons. While GoodRX offers some useful coupons, they work better on older drugs in a competitive space. For example, through them I cut my price in half on Effexor XR, to the point that it was cheaper to cash pay than to use my insurance…

But for newer drugs, the best way to save is on the websites of the drugs themselves, and, with that coupon, Tresiba became quite affordable. Since manufacturers know the incremental cost of the pill is small, and most people are resilient to switching drugs once they have started, they will provide savings that allow you to get newer drugs for a fraction of the price. As the Tresiba site states, “With the Tresiba® Instant Savings Card, you pay as little as $15 per prescription for up to 24 months and receive a FREE box of Novo Nordisk needles.”

Now, if you read the fine print, it likely won’t be quite that cheap, and the box of needles is of negligible value. But that still cut my price for five pens to around $100, bringing my annual expenses closer to $250 a year than $1,300. So because of the savings offered and researched, I was able to purchase something at a reasonable rate regardless of my insurance.

$25o a year, down from $1,300 – not bad! The key to Scott Erlich’s savings was researching alternatives to the insulin his doctor initially prescribed, and he cites GoodRx.com, www.drugs.com, www.sharecare.com and www.webmd.com as helpful sources of information to find out what his options were.

There are a few more things I’ve run across in recent days that I’m hoping to share soon!

Posted in Chronic Illness, Prescription Drugs | 6 Comments

Medical Cost Sharing, Inc. – buyer beware?

I posted the other day that there were two new* health care sharing ministries that had recently come to my attention. The first, Solidarity HealthShare, As I’ve mentioned before, I’m a big fan of the sharing ministry concept (and am a member of one, in fact), and am very happy to see Solidarity finally launch.

Regrettably, my take on the second new-ish entity is not quite so welcoming. At best, it looks like a well-intended operation run by people who are making some poor or questionable decisions. At worst – well, at worst it’s worse than that.

First, a basic review. Medical Cost Sharing, Inc. (MCS) of St. Joseph, Missouri, offers three separate levels of membership, with “personal responsibility” amounts (like a deductible) varying between $1,000 and $5,000. Up to $500,000 in medical needs can be shared annually at the Silver and Bronze levels (with a lifetime cap of $1 million, so after two really, really bad years a member would need to leave), while there is a $1 million annual limit with the Gold membership and no lifetime limit.

The monthly contribution per person for the Gold membership is $285, Silver is $240, while the Bronze level is $175 per person. There are also two additional levels, one for children age 2 months to 18 years and a second for young adults age 18 – 26.

So far, so good – MCS basically looks just like the other ministries, with the standard variations in membership levels that distinguish all of them from one another. But one of the crucial questions when it comes to sharing ministries is whether members are exempt from having to pay a tax/penalty for being uninsured under the Affordable Care Act (better known as Obamacare). And here the red flags begin.

As I’ve mentioned in the past, Obamacare stipulates that to be eligible for this exemption, ministries need to have been in operation since 1999. This is why Altrua, CMF Curo, Liberty, and Solidarity are all affiliated with other, older ministries, in order to ensure their members get this exemption, and it’s why I keep putting an asterisk after the word “new” when describing certain ministries.

MCS, on the other hand, has chosen a different path – they do not qualify for the exemption, and instead offer to pay the tax/penalty for members (up to a maximum amount). Here’s the language they use on their page headlined “No Penalties for MCS Members.”

The new law Affordable Care Act or Obamacare will access a 1% tax penalty for those who choose not to enroll in Obamacare. These funds will only be deducted from your tax REFUND.

  1. Example A – if you made $60,000.00 this year and you owe $900.00 your penalty would be ZERO dollars.
    • Remember your tax penalty is only if you’re receiving a refund.
  2. Example B – using the same criteria from above but your receiving a refund of $900.00 your penalty would be 2% (2% of $60,000.00) or $1200.00.
    • C.S would confirm this on your tax return and reimburse you $1200.00
    • There are income limits on how much M.C.S. will reimburse
    • Ages 18 to 26 maximum annual salary of $40,000.00 per person
    • Ages 27 to 65 maximum annual salary of $85,000.00 per person
  3. Example C – if you were 50 years old and made $95,000.00 M.C.S. would reimburse a maximum of $1700.00 your responsibility would be $200.00 or 2% of $10,000.00
  4. Example D – if you made $95,000.00 that $10,000.00 above the maximum limit that we reimburse leaving you with $200.00 not being paid by M.C.S.
    MCS Medical Cost Sharing strives to be the leader in our industry, providing the most comprehensive, and complete healthcare Solutions affordable to you today. M.C.S. says No Penalties!

According to the laws passed by congress (A.C.A Obamacare) all Christian Medical Cost Sharing organizations formed prior to Dec 31, 1999 that have been in continuous service are exempt from all penalties from Obamacare. We here at MCS Medical Cost Sharing Inc. were not in business prior to Dec of 1999. Does this mean you are responsible for any penalties “NO Penalties ” All penalties are paid by M.C.S, However what sets us apart from any other medical cost sharing organization is are added benefit program at no additional cost to you. Benefits like are Return of Contribution (ROC) are Contribution Cap (CC) and are Vanishing Personal Responsibility (VPR) Please click here to compare us and a complete list of our added benefits.

The page is correct in that the penalty can only be collected if you have a refund, something I’ve pointed out in the past. But the headline is misleading. Example A, for instance, suggests that if you don’t have a refund due then there is no penalty. This isn’t quite correct – because those penalties do not simply disappear because you aren’t owed a refund, they remain on the IRS’ books (which is what really counts) for future years, and while you may not have a refund this year to have the penalty taken from, you might next year. Or ten years from now.

Second, the language repeatedly states that members don’t have to pay penalties – which is false, as examples 2-4 demonstrate. Each of them states that there is a maximum amount they will reimburse, and penalty amounts that exceed those levels are in fact the responsibility of members. So “No Penalties” is really “Reduced Penalties,” not quite the same thing.

It’s probably worth noting that the only way this can be done is by increasing the monthly membership contributions in order to fund this pledge.

And it also occurs to me this may not even be legal – there are strict limits on what charitable funds can be used for, and I’m not sure reimbursing tax penalties for members qualifies (would love to hear from anybody knowledgeable on this subject).

If it were just this one thing, I probably wouldn’t be quite so alarmed. But a few additional items are raising red flags with me:

  • MCS has a web site aimed at the Kansas City area in particular. Nothing wrong with that, but the site uses the term “Christian medical insurance.” In the headline. That’s basically an invitation to the state department of insurance to come in and shut them down, since as every other sharing ministry goes to extensive pains to explain, repeatedly, sharing ministries are not insurance. It is, to the best of my understanding, illegal to market something as insurance that is not, in fact, insurance. They also have a web site using the term: http://christianhealthinsurance.weebly.com/ Being ignorant of this basic distinction between sharing ministries and insurance, or worse fraudulently marketing something as insurance that is emphatically not insurance, is deeply troubling.
  • MCS on the same site touts a nurse hotline. Here’s how they phrase it:

24 Hour Nurse Hotline: Would it help if you could talk to a nurse any day, any hour? Call our hotline here: 24/7 Nurse Hotline – free and confidential: Call (816) 271-4000 or (800) 455-2476.

The problem is, those phone numbers belong to a medical organization, Mosaic Life Care, that is also headquartered in St. Joseph but that has no affiliation with MCS. A spokesperson for Mosaic Life Care described the nurse hotline to me as a free community service not affiliated with or connected to any other organization, and they seemed more than a little annoyed that MCS was claiming and promoting it as their own.

  • One of the two founders of MCS, Craig A. Reynolds of St. Joseph, Missouri, is a former insurance agent licensed in both Kansas and Missouri (and therefore ought to understand that marketing MCS as “Christian insurance” is a big no-no). Perhaps more relevant, he lost both licenses based on his problematic business practices (here is the Kansas revocation, and here is Missouri).
  • Despite receiving an IRS ruling in 2014 recognizing them as a 501(c)3 organization, I could not find their 990 form that every nonprofit is supposed to file.

Finally (and I should really say firstly, since it was this communication that sent me investigating this operation), I heard from a very dissatisfied former member:

You should know “Medical Cost Sharing” which is a .com is apparently TOTALLY FRAUDULENT! We are now out $3990.00. No medical bill paid. We called the local news outlet in St. Joseph, Missouri have told us the address listed for them is a defunct bar. All this since we filled a claim after 7 months of paying them.

I followed up with this person asking for more information, and this is what she replied:

We joined them in January. The premium membership. $570. Per month.  My Husband began having knee problems in the spring we went to the dr they filed and nothing!  The dr office nor the MRI folks heard from them. Neither did we. Now they because of a “comprised” payment card and them not returning my 6 or so calls we are “dropped by them and they refuse to deal with us over claims made during the time we “supposedly had coverage. They hung up on us when we finally did get someone to answer the phone by calling repeatedly in the same hour.  My husband contacted St Joseph news and they looked up the address and said it is a closed bar. That there hasn’t been a business at that address for years. We called the nurses number on the card from medical cost sharing and the nurses that answered the phone said they had never heard of them. That they were not affiliated with Medical Cost Sharing.

I did place a call to MCS, and spoke with one of the co-founders and the chief operating officer, Jim McGinnis. He seemed like a nice enough guy, and he assured me they are not operating out of a closed bar (and the address on the web site is for an office building, at least as near as I can dig up). He claimed MCS has actually been in operation since 2009, which is possible of course, but the LinkedIn profile of Reynolds indicates he’s been CEO since 2012, and in terms of internet searches there’s not much to indicate they began operation any time before 2014. Jim also said they’d be getting the tax filings taken care of at some point in the near future.

Regarding the nurse hotline, the web site currently notes the following:

We recently had to discontinue the use of the 800 number to reach a nurse 24/7.   A phone number for this service was printed on some of our older membership cards.   We are planning to upgrade this service  to better serve our members in the very near future.  We apologize for any inconvenience this may have caused.

I don’t recall seeing this notice the last time I was on the page (yesterday), but I could have just missed it, or it could have been added since I contacted them a few days ago.

It’s entirely possible I’m misunderstanding some key facts here, and a few modest or irrelevant mistakes by the MCS leadership team and the tale of one dissatisfied former member are obscuring an otherwise fine and valuable organization. But as self-pay patients look for options that fit best fit their needs, the cautionary principle caveat emptor (let the buyer beware) is always a good rule, and it shouldn’t be ignored by anyone looking at MCS as an option.

**UPDATE 9/28/2016**

Thought I would do a brief update on Medical Cost Sharing, Inc. In the few days since I first posted this report, they have substantially revised several sections of the web site, particularly those that I singled out for attention. For example, the deeply problematic language regarding paying the tax/penalty for being uninsured has all disappeared, and it now reads:

According to the laws passed by congress (A.C.A Obamacare) all Christian Medical Cost Sharing organizations formed prior to Dec 31, 1999 that have been in continuous service are exempt from all penalties from Obamacare. We here at MCS Medical Cost Sharing Inc. were not in business prior to Dec of 1999, but we have set aside 2.5% of all sharing contributions into a separate account that will ONLY be used if there are MCS Members that need the funds. As of 2016, NO MCS MEMBERS has had to pay a single penny out of their pocket in ACA Fines. We are here for you!

That’s quite a bit different than what was there before, of course. Hard to tell what it means, as no guidelines are provided – are there still limits on how much any person can be reimbursed, and if so are they lower or higher than previously stated?

The plans have been changed as well. For starters, they are now much more expensive – a single person joining at the Gold level now pays $362 per month, compared to $285 last week. And all plans now have a $200,000 annual limit for sharing medical bills, down from $1 million for Gold and $500,000 for Silver and Bronze. They’ve also added a basic plan and dropped the two plans for children and young adults. These seem to be very major changes to the MCS plans, bigger than I would expect (some tweaking and adjustments are to be expected, of course, particularly for a new entity).

The Kansas City-specific site has been changed as well, with references to “Christian health insurance” having disappeared, replaced with the following statement:

Please note that we are a Christian Healthcare Sharing Ministry. We are NOT insurance or an insurance company and should not be misconstrued as such

The web site http://christianhealthinsurance.weebly.com also appears to have been scrubbed of the problematic term.

In addition, the community nurse hotline MCS was directing members to and touting as their own despite no affiliation with the hotline provider has disappeared, replaced with a reference to a telemedicine program that members enjoy.

There is one feature of MCS that I didn’t pay much attention to last week but upon further review raises further red flags with me – the “return of contribution” pledge. Here’s how it’s described:

The ROC is one of Medical Cost Sharing’s most unique features. This concept is unheard of in the health care industry. What it means is this: after ten years of continuous membership minus any hospitalization or outpatient services, 100% of all remaining contribution will be refunded back to you. What does that mean to you? Lets take a look at a few different examples.

  1. Let’s say your monthly contribution is $362.00 per month. Over 10 years you paid in $43,440.00. Now let’s suppose the only funds used were when you had minor knee surgery and the total cost for that surgery was $8,000.00. Your refund would be $35,440.00!
  2. Let’s say you made the same contribution as above. However, this time you needed heart surgery and the total cost of the procedure was $250,000.00. Your refund would now be zero but your claim would be PAID IN FULL.
  3. Next, let’s look at a different scenario. Suppose your monthly contribution is $565.00 per month. Over 10 years you pay in $67,800.00 (This would be for yourself and your spouse). Now let’s assume that you and your spouse had no healthcare claims over that 10 year period. Your refund would be $67,800.00! What a smart way to save for college or retirement and be covered at the same time, and what a reward for healthy living?

This doesn’t make a lot of sense to me, to be honest. I mean, I get the concept, I’m just not sure why a sharing ministry would make such a promise and how this doesn’t end in disappointment.

MCS is assuming, probably correctly, that only a small number of individuals will stick around for ten years and put in significantly more than they receive. But even if only one or two percent of its membership manage to do this, the cost will be very significant. For example, if MCS had 10,000 members and in a given year 100 of them hit the 10-year mark, and on average they had submitted claims equal to half of what they contributed, then using the numbers above ($342/month x 120 months) MCS is going to need to pay out more than $2.1 million.

The only way to do this, of course, is to be setting aside some portion of the funds sent in right now, or to plan to raise the membership cost in ten years to cover this expense. And it’s really, really important that they get the numbers right – if they’ve calculated it will be one percent of members get half their contribution back and it turns out to be two percent get three-quarters back on average, it’s a serious problem. Either way, this program adds to the cost of membership.

Another concern with this is that it makes pledges for ten years into the future when, as anyone familiar with how sharing ministries operate can tell you, these are private, voluntary entities that make no promise for even next month, let alone a decade down the road. At any time the members can decide to stop contributing and go elsewhere, potentially reducing the number of people willing to stick around and pay for this pledge. In some ways it’s similar to the problems many traditional pension funds are facing – too many people drawing and not enough contributing to make the math work.

Oh, and it’s worth mentioning that in example #2, the claim for a $250,000 heart surgery (actually, not a claim – that’s an insurance term – it should probably read shared amount) is incorrect, or at least seriously misleading – all the plans at MCS now have a $200,000 annual limit, so the member’s medical bill of $250,000 would still leave them with $50,000 to pay.

Readers can draw their own conclusions about what all of this means and whether they wish to consider MCS as an alternative to conventional health insurance, but given the sudden changes to its offerings and marketing I thought an update would be helpful.

Posted in Health Sharing Ministries | 42 Comments

A new Catholic sharing ministry

Readers of this blog will know that I am a big fan of health care sharing ministries as an alternative to conventional health insurance.

If you aren’t familiar with sharing ministries, the concept is fairly straightforward. They are voluntary associations of people, typically Christian in nature, who agree to share one another’s medical bills. Members pay a set amount each month, and those funds are used to pay medical bills of members (typically referred to as “needs”). There are a few variations on the theme – at Samaritan Ministries, for example, members send the funds directly to their fellow members, while at others the money may be sent to the ministry’s central office for distribution – but the general concept is the same.

The ministries typically have what they call a “personal responsibility” amount, which is similar to a deductible in that members are expected to take care of that portion of medical bills before turning to the ministry. And a number of ministries also offer services such as nurse hotlines and bill negotiation.

Despite looking somewhat like health insurance, they are not insurers. The biggest distinction, at least from a legal standpoint, is that there are no guarantees that any particular member’s medical bills will be paid. As I like to say, they are faith-based in two critical ways – first, they are based on Christian faith and the Biblical injunction to “bear one another’s burdens,” and second, members truly are placing their faith in the goodwill and generosity of their fellow members to cover their medical bills.

This sounds dicey to some, and if you’re of the cynical variety you may not think this sounds like a very good deal.  Such ministries have existed and generally done well at fulfilling their mission for decades, and at this point hundreds of thousands of Americans (myself included) have opted for this alternative to conventional health insurance. But for a variety of reasons it isn’t for everyone, and if it’s too much of a leap of faith for some people, then there are other options that are probably a better fit.

In the past I’ve written about the five health care sharing ministries I was familiar with: Samaritan, Christian Healthcare Ministries, Christian Care Ministry, Altrua Healthshare, and Liberty HealthShare.

Two new* sharing ministries have come to my attention recently, Solidary HealthShare and Medical Cost Sharing, Inc., so I thought I’d provide a little information on them in two separate posts.

Solidarity HealthShare was created specifically for practicing Catholics. While to the best of my knowledge all of the ministries welcome Catholics, by and large they are rooted in Protestant traditions and understandings (Altrua began as a ministry focused on Mormons). This isn’t a theology blog so I’ll just note that in the past I have heard of some Catholics expressing reservations about certain language often used by the ministries that was, at least to them, problematic.

Here is how Solidarity HealthShare describes their mission:

Pope John XXIII addressed in his encyclical Mater et Magistra the vast field for personal charity which would absolutely include health cost sharing. He wrote: “Tragic situations and urgent problems of an intimate and personal nature are continually arising which the State with all its machinery is unable to remedy or assist. There will always remain, therefore, a vast field for the exercise of human sympathy and the Christian charity of individuals. We would observe, finally, that the efforts of individuals, or of groups of private citizens, are definitely more effective in promoting spiritual values than is the activity of public authority.” (Mater et Magistra, 120)

Solidarity HealthShare seeks to restore and rebuild an authentic Catholic health care system that will, in every way, respect and promote the Church’s teachings and traditions with regard to love, responsibility and the sanctity of all human life while endeavoring to share the eligible medical expenses of our members.

The requirements for membership in the ministry are fairly consistent with those of other ministries, for example no drug or alcohol abuse. Regular church attendance is also expected . Not surprisingly for a Catholic entity, there are also prohibitions on contraceptive use (Protestants tend not to have objections to married couples using contraception) and an expectation that members “[r]eceive the Sacraments regularly” and “[c]onsult with our priests over matters of moral conscience.”

Solidarity HealthShare offers three different membership levels. The “annual unshared amount” (personal responsibility amount) is the same for all three levels, $500 for an individual, $1,000 for a couple, and $1,500 for a family. The most generous level, Solidarity Whole, will share 100 percent of medical expenses up to $1 million per incident after the annual unshared amount has been met.

The other two programs, Solidarity Extend and Solidarity First, will both share expenses up to $125,000 per incident. The difference is that 100 percent of medical bills are shareable in Solidarity Extend, while only 70 percent are shared in Solidarity First.

It may surprise those who aren’t familiar with the distribution of medical expenses, but the differences in monthly membership costs aren’t all that significant despite the significantly more generous amount that can be shared at the Solidarity Whole level.

For example, a couple between the ages of 30 and 65 signing up for Solidarity Whole, with a $1 million cap on shareable expenses, would pay $299 a month. Solidarity Extend, with a $125,000 cap, would cost the same couple $277, and Solidarity First would cost $248. This repeats a pattern familiar to members of other ministries who opt for some form of add-on coverage – at Christian Healthcare Ministries, for example, membership in the Brother’s Keeper program typically costs around $25 every three months for each person in a family.

These costs are generally much less than individuals, couples, and families would pay for conventional health coverage. And, just like the other ministries I have written about in the past, members of Solidarity HealthShare are exempt from having to pay the tax/fine for being uninsured, even though technically it isn’t insurance.

One interesting feature of Solidarity HealthShare is something called HealthTrac, which is aimed at members with pre-existing conditions. Here’s how it’s described on their site:

HealthTrac is for Sharing Members of Solidarity HealthShare who qualify for our medical cost sharing program but have certain pre-existing health conditions that can be improved through lifestyle changes. HealthTrac is in place for Sharing Members to improve their health while reducing the risk of developing or exacerbating serious diseases.

HealthTrac is designed to help individuals with diagnoses such as diabetes, hypertension, cancer, heart disease, high cholesterol and obesity, as well as tobacco users who are willing to work towards a healthier life. Each HealthTrac participant is assigned a Health Coach to develop a personal plan for achieving goals related to their condition or diagnosis. Regular communication with the coach and tracking of progress is part of the program.

It’s an additional $80 per month to join the program, but I can see where it would be a real value for people struggling with specific conditions.

There is one additional thing that should be pointed out about Solidarity – it is part of a longtime sharing ministry operated by Gospel Light Mennonite Church of Canton, Ohio. No surprise there, since restrictions included in the Affordable Care Act limited the ability to avoid paying a penalty for being uninsured to members of ministries that existed prior to 1999. By partnering with one such pre-existing ministry, Solidarity HealthShare is able to provide this important benefit to its members.

What is a little unusual is that Gospel Light Mennonite Church is also the partner of Liberty Healthshare, and the two ministries seem to have roughly identical programs, including the monthly membership contributions and the HealthTrac option. The web site layouts are pretty similar as well. There’s nothing wrong with this in my view – having separate entities that rely on the same infrastructure is a pretty common business model – but it does raise the question of what the difference is in the two ministries beyond membership requirements (I’ve got a question in to the founder of Solidarity HealthShare on this, and will share his response when I get it).

Solidarity HealthShare is the second ministry aimed at Catholics. CMF Curo, which is part of Samaritan Ministries, has been operating for about two years now. So if you’re Catholic and are looking for a health care sharing ministry that more closely reflects your faith than the generally Protestant-oriented ones, you now have two choices to compare and see which best suits you.

The second sharing ministry that I’ve become aware of recently is Medical Cost Sharing, Inc., based in St. Joseph, Missouri, which I hope to write up in another post in the next few days. If you or anyone you know have joined this ministry, I’d love to hear about the experience so I can include it in my writeup (ditto for any members of Solidary HealthShare, or any of the other ministries for that matter). I can be reached at selfpaypatient@gmail.com


* “New” is something of a term of art here, given that some entities have partnered with older sharing ministries in order to provide members the benefit of being exempt from penalties for being uninsured under the Affordable Care Act.

Posted in Health Sharing Ministries | 16 Comments

‘The Wedge’ – a new tool for finding cash-only doctors

As I have mentioned in the past, the number-one question I get is “Where can I find a cash-only or cash-friendly doctor?” In the past I’ve pointed readers to two sites that provide directories of practices that are aimed at self-pay patients, one from the Association of American Physicians and Surgeons and the other from SimpleCare. I’m not sure either has been updated recently, however.

A friend who also works to promote independence from third-party payers contacted me recently to let me know about a site she has launched, called “The Wedge of Health Freedom.”

“The Wedge of Health Freedom will put patients and doctors back together — and set them free.

Obamacare, more than 132,000 pages of Medicare regulations and onerous contractual requirements from corporate health plans have intruded in the confidential patient-doctor relationship — and caused health care costs to skyrocket.

But around the country, pockets of doctors and patients are breaking free. The Wedge of Health Freedom will point the way to this exciting escape route. With high deductible insurance policies and health sharing organizations on the rise under Obamacare, patients want doctor’s offices that are affordable, patient-centered, and confidential—and doctors want to start them. Doctors using “Wedge Principles” work for patients—not the government or a health plan.

Today, these pockets of health freedom — affordable third-party-free practices and surgical centers — are not visible to most Americans. The Wedge of Health Freedom will draw the public’s attention to these practices, make them a visible attractive choice for patients nationwide, defend their legal right to practice freely and grow The Wedge so large that health freedom can never be taken away:

The Wedge Principles

  • Transparent, Affordable Pricing
  • Freedom to Choose
  • True Patient Privacy
  • No Government Reporting
  • No Outside Interference
  • Cash-Based Pricing
  • Protected Patient-Doctor Relationship
  • All Patients Welcome

Wedge practices follow these eight principles.

All patients, insured or uninsured, are welcome. Payment is by cash, check or charge. Imagine a practice where your doctor, dentist or other health care practitioner really knows you. Imagine an practice that doesn’t demand your insurance card and ID before the staff even say hello. Wedge Practices and their doctors are the way back to the future! A future where patients and doctors are free, prices are affordable and care is confidential – just between you and the doctor.”

That may be a bit more political and policy commentary than some self-pay patients prefer, but everyone who has to pay directly for some or all of their health care could benefit from the map of practices that cater to self-pay patients.

The map is by no means exhaustive, but it is being continuously added to and maintained, and I’d guess there are currently close to hundred practices listed, a number that will hopefully continue to grow – I’d estimate there are anywhere from five to ten thousand practices in the country that are cash only or at least equipped to deal with patients paying directly for their care. To give you some idea of the scope of the site, it lists five in the Southern California area, four in Maine, and six in Missouri.

Finding a doctor willing to offer fair, simple, and transparent prices for health care is crucial for those of us who pay directly for our health care. With this new site, self-pay patients have another valuable tool to help us do just that.

Posted in Cash-Only Doctors | 9 Comments

Sanctuary Functional Medicine, an insurance-free practice in Tennessee

Self-pay patients in the area south of Nashville, Tennessee have what looks to be at least one terrific option when they need a doctor’s office prepared to cater to their needs. Sanctuary Functional Medicine, founded by Dr. Eric Potter, has an office in Spring Hill, which appears to be about half an hour south of Nashville (depending on traffic, of course). Another office will be opening next week in Franklin, also south of Nashville.

Potter and the practice’s other doctor, Theron Hutton, offer what they call “functional medicine,” which their web site describes this way:

Functional medicine is a modern approach to healthcare that seeks to address the underlying causes of disease, rather than just treating acute symptoms. Practitioners of functional medicine take a more patient-centric approach to your care by viewing you as a whole person—with an integrated body—as opposed to just an isolated set of symptoms.

One of the benefits of this approach, and one that is fairly typical of most cash-only practices, is that they are able to spend a lot of time with their patients:

As a functional medicine practice, we spend at least 90 minutes with each of our patients on their initial visits. The average visit after that is 30-60 minutes. We take the time to ask thorough questions and to listen in order to gain an in-depth understanding of the root causes of your body’s dysfunction.

They also try to incorporate approaches to health care beyond standard Western medicine:

Unfortunately, many of today’s patients are often forced to choose between traditional Western medicine and alternative, holistic approaches to healthcare when evaluating their care. We believe both have value and can play in important role in treating a patient. In addition to prescribing medicine, we may also prescribe a new nutrition program or fitness regime. In some cases, a botanical supplement, or counseling, can serve as an effective, much safer alternative to taking a pharmaceutical drug. Each patient is unique and deserves to have the best science-based care from both Western medicine and holistic care.

Dr. Potter’s story of why he founded Sanctuary is one that will sound familiar:

After spending several years trying to care for patients in multiple conventional medical settings, Dr. Eric Potter realized the clock was ticking faster and faster: either see more patients in a day (spending less time with each one) or get off the hamster wheel and provide real care. Once he discovered the Direct Pay Care business model, the pieces fell into place that enabled him to found and open Sanctuary Medical Care and Consulting in 2014.

And his explanation for why he doesn’t accept insurance will not surprise anyone either:

Paying at the time of service means that you are not paying for bureaucracy, nor for administration, but for your health. It means that you and your physician decide your care, rather than third parties whose interest may not coincide with your own best interest. Moreover, your physician can spend more time caring for you, rather than filling out paperwork.

One of the under-appreciated benefits of the services offered by Sanctuary is that it has its own pharmacy, and bill patients at cost for the medicines it sells. I spoke with Dr. Potter yesterday and he said they keep about 40 commonly prescribed medicines in stock, typically at savings up to 80 percent. He specifically noted that a prednisone prescription that normally runs $20 at a pharmacy is available to his patients for around $5 (I neglected to ask what the dose/quantity was). Sanctuary can also order in specific medicines for patients that it doesn’t routinely stock, offering more savings. Lab tests performed in-house are free, while patients only pay the practice’s cost of labs that are sent out.

Sanctuary is a direct primary care practice, meaning a relatively modest monthly fee covers all routine visits and treatments, which typically can be scheduled for the same or the next day and typically last from 30 minutes to an hour as needed. In addition, the practice will also see patients who aren’t members on a walk-in basis, similar to cash-only practices that haven’t gone the direct primary care route.

If there’s one criticism of the practice, it’s that the web site doesn’t include prices, instead inviting patients to call and request pricing information. Dr. Potter did share with me that most patients pay between $70 and $120 a month, with the younger patients paying towards the lower end and older patients paying at the higher end. Compared to what self-pay patients and even many with “comprehensive” insurance pay these days for a doctor’s appointment, these fees seem pretty reasonable for anyone who will be visiting the doctor more than a few times a year.

The practice is located at 3011 Harrah Drive, Suite T, in Spring Hill, and those looking for more information should either call (615) 614-2500 or e-mail spaske@sanctuarymedicalcare.com.

Posted in Cash-Only Doctors, Direct Care Practice | 2 Comments

Cash-Only Pharmacy Offers Savings on Medicines

I’m pleased to introduce another member of the Self-Pay Patient team, Yana Krinker! Yana is a DC-area resident who works at the U.S. Patent & Trademark Office, and who has an interest in self-pay healthcare and health economics. She will be writing occasional articles for the site, hopefully allowing us to get out more frequent content. Please welcome her to the site!

Many self-pay patients looking to save on prescriptions drugs are familiar with chain store discount programs (Costco and Walmart have popular ones) and drug price comparison websites such as GoodRx, but another excellent resource that hardly ever gets mentioned is the cash-only pharmacy. As I explain below, self-pay patients may want to check prices at Medsavers Pharmacy or another cash-only pharmacy before filling their next prescription.

Medsavers Pharmacy is a family owned and operated pharmacy in Austin, Texas founded in 2005 on the principle: “we don’t deal with insurance companies.” By refusing to work with third party payers, co-owners Pharmacist Chris Johnson and his wife Bryna, are not required to stock a certain amount of brand-name drugs, thereby lowering overhead costs, and insurance companies can’t influence the prices Medsavers charges for medications.

For customers this translates to drug prices which are often significantly less than cash prices offered by other pharmacies. It also means that all shoppers, regardless of insurance status, are charged the same prices on prescription drugs. Medsavers pharmacy has a retail location in Austin, and for those of us who don’t live in central Texas, Medsavers will ship any non-controlled prescription for $5 (within the states where the pharmacy or supplier is licensed). Continue reading

Posted in Prescription Drugs | Tagged , , | 7 Comments

More Cash-Friendly Medical Practices

I continue to get people asking me “where can I find a doctor or other medical provider that treats self-pay patients fairly,” by which they mean will offer them an honest, straightforward price to patients. Fortunately I also continue to get e-mails and calls from doctors and other providers telling me about their practice, or self-pay patients letting me know about those that they have found. Here’s a couple of recent ones:

Alliance Internal Medicine & Aesthetics

Located in Fernandina Beach, Florida (which looks to be about 30+ miles north of Jacksonville), the husband and wife team of Drs. Sam and Catherine Featherston* offer a primary care practice that also provides cosmetic treatments. Both are trained internists, and it looks like they just opened, at least judging by the special they are currently running offering 25 percent off of all medical treatments for the month of September (one of the great things about cash-friendly practices is they tend to offer deals and specials that can be real bargains).

The prices look excellent too. A basic visit dealing with two chronic conditions or one new condition is $45, which probably equates to either a Level 2 or Level 3 visit (10 minutes and 15 minutes, respectively) which Healthcare Bluebooks show as an $82 and $137 fee, respectively for that area.

Walk-in visits are also $45, and phone or video consultations are the same price.

The “About Us” section of their web site provides a brief explanation of how the Featherstones have set up their practice, and it fits quite nicely into the self-pay world:

At Alliance Internal Medicine & Aesthetics, we believe that: health care does not have to be expensive; you shouldn’t have to wait for weeks or months to see your doctor; you shouldn’t have to sit for hours in a waiting room; you should be able to see your doctor and not an assistant; and you deserve to have a doctor who keeps in mind that most people are living on a budget and who will consider costs when prescribing medications, ordering tests, etc. We feel that governmental departments and managed health organizations have created a system where health care costs are now prohibitive and medical decision making is largely out of the hands of patients and physicians. We have decided to opt out of those systems in order to not be bound to their price plans and other bureaucratic restraints. This allows us to keep our costs down and we enjoy passing along those savings to you.

Self-pay patients in the north Jacksonville and Nassau County areas of northwest Florida can contact Alliance Internal Medicine & Aesthetics through their online contact form or call them at 904-206-9354. The office is located at 1001 Atlantic Avenue in Fernandina Beach.

Gold Direct Care

I haven’t reported on a lot of doctors in the Northeast that have embraced self-pay patients, so I’m happy to be able to write up Gold Direct Care, a direct primary care practice located in Marblehead, Massachusetts, about fifteen miles northeast of Boston. The practice was started by Dr. Jeffrey Gold, apparently a native of the area, in February of this year. He explains on his web site why he opted for the direct primary care model:

When I made the decision to become a Family Practice Doctor, I had a vision of what I thought my practice would be like…it would be in a community similar to where I grew up; I would have personal relationships with all of my patients; I would be accessible to my patients when they need me; I would be able to spend as much time as I want with my patients; and the list goes on and on.

Over the course of the past couple of years, due to many factors, it became very clear to me that my vision for how I wanted to practice medicine was not coming to fruition; at least not in the dysfunction of the current healthcare system. I started to read about a movement in the world of primary care medicine called Direct Primary Care (DPC)…The more I read and the more research I did, it became obvious to me that the vision that I had for how I wanted to practice medicine- as well as the vision that I had for how my patients deserve to have me practice medicine- could be achieved by opening my own DPC practice. I truly believe that Direct Primary Care is a large part of the solution to the healthcare crisis in this country…

I am the first doctor in the state of Massachusetts to open such a practice, and I know it is the right thing to do for me, but most importantly for my patients.

As do most DPC’s, Dr. Gold offers free visits, same- or next-day appointments, and unlimited communications (phone, video, e-mail, etc.) for a monthly fee. The fees are adjusted for age, starting at $30 a month for those 21 and under, $50 for those 22-30, $75 for the 31 – 44 age group, and $90 for those between 45 and 65. He also offers membership to those age 65 and older, charging $125 a month. He also has posted on his site the discounted lab prices he can offer patients, such as an electrolyte panel for $5 that Healthcare Bluebook says has a “fair” price of $18 (meaning that’s what insurers typically pay) and a Vitamin B-12 test for $45 ($39 according to Healthcare Bluebook, so a little higher but not much).

His web site also notes he offers discount prescription drugs, details of which aren’t available but can offer huge savings. I recall being on a panel earlier this year in Vermont discussing self-pay health care and Dr. Josh Umbehr of Atlas M.D. in Wichita, Kansas, mentioned during his presentation that he was able to basically give away most generic medicines to his patients without having to charge them (it’s built into the monthly fee, obviously) because it was so cheap for him to get as doctor. I can’t recall the exact numbers he gave, but it was for Imitrex, a migraine medicine that I recognized because my wife used to take it. The name brand costs close to $400 for 9 doses and the generic version costs about $15 for nine doses according to GoodRx.com, Dr. Umbehr said he was able to buy a large bottle with 1000 doses for about $10. It literally would have cost him more to bill his patients $0.01 for each dose than to just give them away. If Dr. Gold is able to offer even remotely comparable savings on prescription drugs, the monthly fee could be the bargain of the year in the state of Massachusetts.

So, self-pay patients in the Boston area, or “fully insured” patients who aren’t terribly satisfied with third-party payer, take a look at Dr. Gold’s practice. He can be found at 123 Pleasant Street in Marblehead, or reached by phone at 781-842-3961 and e-mail at nfo@golddirectcare.com.

*Somehow I managed to get the names wrong in the initial post, my apologies! It is Drs. Sam and Catherine Featherston, not sure why that was so difficult for me the first time around.

Posted in Cash-Only Doctors | 23 Comments

Reporter Looking for People With Unexpected Medical Bills

I’ve been contacted by a reporter looking for anybody who would like to share their story regarding unexpected medical bills, primarily those of insured individuals who wind up getting an “out of network” provider and the resulting inflated bill. If you’d like me to put you in touch with her, please send me an e-mail at selfpaypatient [at] gmail [dot] com.

Posted in Media | 6 Comments

More Self-Pay Practices – June 2015

I’ve had several doctor’s offices and other medical providers who cater to self-pay patients reach out to me in recent weeks, wanting me to pass along their information. Finding a cash-only or at least cash-friendly doctor is probably the biggest challenge for those of us operating outside the third-party payer system, so I’m always happy to pass along information when I get it (even though I may not be terribly timely). Here are a couple that have contacted me recently, I’ll have more in the coming days and weeks (hopefully).

Associated Urologists of Orange County

Primary care physicians who cater to self-pay patients are generally easier to find, so I’m always pleased to see specialists as well. Associated Urologists of Orange County is one such practice, located in Santa Ana, California. They do accept insurance, but their web site says “We welcome all patients, including Self Pay patients.” They offer a price list for self-pay patients, and according to the page they offer cash prices comparable to what PPO insurance companies pay. I checked out a few of the procedures they had listed and this appears to be the case. A vasectomy, for example, is listed for $800, while according to Healthcare Bluebook in the Orange County area a typical insurer would pay $850. A pelvic ultrasound at AUOC lists for $125, close to the $116 price that Healthcare Bluebook shows.

An initial visit for new patients is $150 while follow-up visits are $75 for self-pay patients, which compares favorably to what I’d guess would be the closest “standardized” visit type, a Level II visit to see a doctor ($161 and $95, respectively).

Associated Urologists of Orange County is located at 1801 N Broadway in Santa Ana, and can be reached at (714) 639 -1915 or by an online form available at http://ocurology.com/contact-us/.

Note: 8/26/2016

Dr. Horiagon has had his license to practice medicine revoked as of March 10, 2016. See Colorado Division of Professions and Occupations, Department of Regulatory Agencies.

Dr. Tom Horiagon

Self-pay patients in the Denver area ought to know about Dr. Tom Horiagon of Littleton, Colorado. He lays out his vision and practice on the home page of his practice:

…Ambulatory care is now an out-of-pocket expense due to high deductibles, narrow networks, and long wait times to be seen in network. Moreover, as hospitals have purchased physician practices, the fees for ambulatory care have skyrocketed in Denver. Hospital master charge lists are not transparent for the most part and indefensible price variations emerge in the absence of constant scrutiny. These price variations can be as much as tenfold for identical services in the Denver metropolitan market.

To make medical care realistically priced, administrative costs, labor costs, and rent need to be as cheap as possible. A 2 room practice like I have can repair wounds, treat simple eye injuries, treat a huge variety of musculoskeletal injuries, and manage the majority of chronic medical conditions with episodic or scheduled visits. Everything is priced by the amount of time I personally spend treating someone ($50/15 minutes). EKG’s, complete pulmonary tests, sleep apnea evaluations, simple urinalysis are all available at the office. High-quality imaging services are available in the same building and the price for patients who pay cash is a small fraction of the cost applied when insurance is used. A network of other providers who have superior quality and cash prices for patients who do not wish to use insurance is used preferentially for referrals.

$50 for a 15 minute visit with a doctor of his experience and expertise (his bio shows board certifications in internal medicine and pulmonary disease, and he received his medical degree in 1981, giving him 30+ years of experience) is a bargain. Again looking at Healthcare Bluebook, an established patient visit to a doctor for 15 minutes runs about $140 dollars in the Denver area. And judging from the introduction on his homepage, it’s clear that Dr. Horiagon is fully on board with the self-pay idea!

Dr. Horiagon’s office is at 26 W. Dry Creek Circle, Suite 640 in Littleton and he can be reached at 720-306-8280 or chestmedicine@gmail.com.



Posted in Cash-Only Doctors | 6 Comments

Insured but not letting the doctor know?

I’ve been incredibly negligent in posting here the past several months, hopefully getting down to one job will allow me to post here more frequently (and yes, I’ve said things like that before).

Today I wanted to address something I’ve gotten several e-mails on over the past few weeks. Early last year I put up a post titled “Insured patients can save money by pretending to be uninsured.” The gist of the article was that the negotiated rates paid by insurers to doctors are sometimes more than the cash price the same doctor might charge someone who is uninsured. In those circumstances, for people who are going to be paying the full bill because it’s under their deductible, it’s better to hide the fact that you have insurance and just pay the cash price.

The question I’ve gotten a couple of times recently has to do with the legality of doing this, and what might happen if the doctor finds out you are insured. The answer to the first one is easy – it’s completely legal to not use the insurance you have, or at least I’ve never heard of an insurance policy requiring that their policyholders use them for all treatment.

The second one can be a little tricky. A couple of people have told me that they’ve tried to get the cash price after they have given their insurance information, only to be told they have to charge them the negotiated rate. Unfortunately, this is true, even though the patient will be paying the full price, whatever that may be. Once you tell a doctor’s office you are insured, they are contractually obligated to charge you the rate they agreed to with the insurer.

Someone else described the following scenario: they’ve been getting the cash price by not telling the doctor they are insured, what happens if they find out they’re insured? Will the doctor go back and have to re-price all the past bills? Two thoughts.

One, it depends on what exactly the doctor finds out the patient is insured. If they only find out that now, as of this particular visit the patient is insured, they’re likely going to assume it’s new coverage and not ask about whether past visits could have been covered under the insurance policy as well, so this shouldn’t be a problem.

If, on the other hand, the doctor discovers the policy was in effect during previous treatments, there might be a problem, and I just don’t know what might happen. Some doctors might opt for a “water under the bridge” attitude and not worry about it (there’s not much financial incentive for them to pursue the higher charge, as the marginal increase in revenue is likely to be gobbled up with the bureaucratic hassle of going back and dealing with it), while others may insist on going back. It probably depends on the doctor and how devoted they are to the third-party payment system (if they were offering good cash prices to begin with, the answer is probably “not very”).

I’d be interested in hearing any experiences anybody has had that relate, shoot me your thoughts at selfpaypatient [at] gmail [dot] com.

Posted in Cash-Only Doctors, High-deductible health insurance | 51 Comments