Your Company Health Plan Sucks and Costs Too Much

I bet you feel you pay far too much for healthcare insurance through your company’s plan. You spend a lot and don’t get much except a high deductible, long waits for appointments, short visits with your primary care physician, and frequent referrals for tests, imaging, and specialists. And then, the specialist has no available appointments for weeks, if not months, does more tests and imaging, and maybe sends you to another specialist. Your problem persists while your high deductible means out-of-pocket expenses. You feel frustrated and unsatisfied. But that is the system, and it is hard to get around it.

Or is it? Help is possible for both you and your employer. Companies can change how they pay for healthcare coverage so they and you get a much better deal — happier, healthier staff with employees and companies spending less. It’s as simple as paying for you to get outstanding primary care with a direct primary care or concierge physician.

You will get what you need in care quality and satisfaction, and your employer will have reduced total care costs and a healthier and more engaged employee. Good for both parties.

What does company insurance cost today?

The Kaiser Family Foundation reported a new high of nearly $23,000 per year per family for employer-provided health coverage in 2022. This is more than double the cost in 2004 and 43% higher than a decade ago. The employee portion is also rising steadily to over 30% of the total.

Bringing down the costs and improving quality

Can these intolerable levels be brought down and, at the same time, improve care outcomes? The answer is a definite “Yes,” but not using the techniques politicians and policymakers recommend. Conservatives would say it is a matter of needing more competition between insurers. Progressives recommend universal health insurance (“Medicare for All.”)

These approaches begin with the insurance itself rather than the actual care. But the problem is with care delivery; this is where the money is spent. It starts with primary care. Little recognized by politicians or policy gurus is that primary care is broken. This aspect of our dysfunctional healthcare delivery system results in the rapid escalation of costs, especially the 75–85% of the dollars spent on managing complex chronic illnesses.

Whatever is done regarding insurance coverage, it is clear that individuals today are getting less than adequate care, and America’s per capita costs far exceed other developed countries. The real and relatively simple fix lies in a dynamic primary care system. But primary care physicians (PCPs) are trapped in a non-sustainable business model, forcing them to see too many patients daily, usually 24 or more, meaning only 10–12 minutes of “face time” per patient visit. That is not enough time for a complicated problem, for patients on multiple prescription medications, or with impairments of hearing, mobility, and maybe cognition, nor for aiding a patient with substantial anxiety. PCPs are also reeling under the constraints of government and insurer rules, regulations, and responsibilities that further take time away from the patient.

Not having enough time with each patient results in PCPs referring far too many patients to specialists when they could have dealt with the problem, including managing most chronic illnesses with more time. They prescribe drugs when lifestyle changes would suffice because working with a patient on lifestyle issues takes time. PCPs often order many tests when more time with the history and examination could give the answer. There is no time for developing a close, trusting relationship so critical to effective care. And there is no time to address anxiety which accompanies at least 40% of doctor visits. Visits to the ER are frequent, and many hospitalizations could be avoided.

The result is higher and higher expenditures yet diminished quality of care. More than 50% of PCPs show signs of burnout, and patients are less than satisfied. PCPs are retiring early or seeking other career options, and medical students no longer choose primary care as a career. Yet somehow, America tolerates this highly dysfunctional system of medical, not health, care.

Direct primary care to the rescue

There is another way. It is being done very successfully by individual primary care practitioners. It is not being mandated from above down but rather developing from the grassroots up. It is called direct primary care or DPC. Other terms used are membership, retainer-based practices, or concierge practices.

Although each of these has some differences, the essence is as follows: the primary care physician reduces the number of patients under care from the current 2,500 to 3,000 to a more manageable 400 to 800 and usually accepts no insurance. The patient pays a fixed amount directly by month, quarter, or year. The PCP commits to same-day or next-day visits, appointments for as long as necessary, 24/7 cell phone, text, and email access, and an extensive annual evaluation focusing on wellness maintenance and disease prevention.

Direct primary care costs are not reimbursed by insurance. You must pay out of pocket, but your health improves, satisfaction rises, and doctor frustration falls.

Many DPC physicians purchase generic drugs wholesale and pass them on at little or no markup. They may also arrange for markedly reduced-cost laboratory testing and radiology procedures. These can help substantially if you have a high deductible policy.

With the added time available for each patient, most issues, including the management of chronic illnesses, can be resolved by the PCP without the need for a referral to a specialist. But when one is needed, the PCP has the time to call the specialist directly, explain the issue and request a prompt appointment. More time with your primary care doctor results in fewer tests and prescriptions and more attention to lifestyle modifications. The costs of primary care do become your responsibility but the total costs of care decline markedly. With DPC or concierge primary care, the result is better health, the development of a trusting relationship, fewer specialist and ER visits, and fewer hospitalizations. A win-win for everybody.

Here is what your employer can do for you

It is essential to understand that employers are generally self-insured. They use an “insurance company” to manage the costs. The “insurer” calculates the approximate costs for your company for the year ahead based on the previous year’s activity plus an inflation allotment. This almost always results in an increase in the premiums for the upcoming year. The employer decides how much to pass along to the employee to pay, and the employer also sets the yearly deductible with the assistance of the “insurer.” In the following year, the company’s costs will decline. Should the company’s staff have better health and hence use fewer medical resources, the company will see a reduction in premiums in the following year; this rarely, if ever, happens today. But it could.

Employers can embrace this approach by reimbursing the cost of DPC. Paying for DPC may seem like an added expense to your employer. Still, the result is improved employee health, reduced absenteeism, and sick leave while bolstering employee satisfaction and decreasing the total care costs for both employer and employee.

Here is how to make it happen

DPC’s time has come. It is time for employers to embrace it, but it won’t happen unless they are “nudged” into action. Here is my advice to you. Go to your employer and advocate for direct primary care/concierge care paid for by the company. Let them know why it is to their definite benefit. And get your co-workers to do the same. It is definitely to your advantage to advocate.