Comment by mgkimsal | Hacker News Reader

Comment by mgkimsal | Hacker News Reader

> We believe the root cause is that the U.S. system is rife with misaligned incentives...

Involving "employers" is one of, if not the primary, root causes. I understand you're building a business, and ... you're playing in the same space as others. That may make sense financially, and allow you to take away from business from legacy insurers and save some companies 20% on existing costs.

But this doesn't seem like it's getting at the actual root problem, which is most people aren't actually involved in buying or paying for medical care (or... not until it's overwhelming).

I realize this is a national political issue, and not something a startup can actually address. The large companies, which could affect real change, have no incentive to legislate themselves out of business.

This (employer-provided health insurance) seems a perpetually intractable problem and seemingly unique to the US (based on my limited understanding of the problem space).

As a self-employed person, I'm basically an outlier and generally get little day to day benefit from any 'health insurance'. I paid $900/month (2 people) last year. 2nd covid shot caused a blackout, and I was ambulanced to an ER (I was actually only 'out' for less than a minute, but in less than 5 I was being driven away). 3 hrs in ER - nothing obviously wrong, so I was released. I got multiple bills over the next month for $4000. Insurance company graciously 'negotiated it down' so I only had to pay $2000, on top of the $11000 I already pay for this 'deal'.

I feel this. I pay $500 a month for insurance with a $6000 deductible.

I would have to have more than $12,000 in medical expenses every year before I would break even on this.

Hi - Mark here - I'm curious to know what you get for your $500 monthly premium. Do you get anything else of value, any incentive programs, knowledge support, coaching, etc. I am assuming you get free access to telehealth. I would like to know if you use any of these other things

I'm not the OP, but my insurance program (BCBSNC) offers some things. I get

* a 'wellness portal' (which... doesn't open anything when I click on it) - nope - goes to 'werally.com'

* a 'nurse support program' - which seems to be a bullet point list of things they say they help me with, but... no call to action, or phone number, or.. anything actionable.

* 'Behavioral Health Support' - which takes me to quartethealth.com, which says their service is free, but it's just the matching portion - services still cost something (and I've got... $7000 in deductibles to hit first, only for 'in-network' - out of network, it's... $35k)

* a 'blog' where I can 'explore articles and videos on fitness, nutrition and more to help keep you healthy.'

* 'nutritional counseling' - 'Simply make an appointment for nutritional counseling with a registered dietitian. If you see an in-network dietitian in an office setting, your copayment can be waived...' - except if you have a high-deductible plan, which is the only thing I can remotely afford.

"Telehealth" services are from 'Teledoc', and are 0% for me once I hit my deductible. Yay.

What I would value is being able to go visit a doctor more than once a year. If I'm physically ill (bad cough, aches, headaches, etc) I would like to be able to go see someone for some basic inspection without it costing hundreds of dollars or more. My wife broke a bone in her foot years ago - this was at least a couple of thousand dollars out of pocket on top of the (at the time)... $7k year in insurance premiums. But... it's my own fault because I 'chose' "high deductible". If I'd just have been willing years ago to commit to paying $12k/year for the two of us, perhaps we might have gotten away with 'out of pocket' for her foot of under $1k.

Essentially, between 'premiums', and 'deductibles' and 'copays', I have to be willing to commit to ... $15k-$20k up front before I see any 'benefit' from a health care encounter. I don't see how this is sustainable, but... I've been saying that for years, and... I'm hanging in there - I don't know how other people do it. 5 years ago a friend's insurance was $1900/month for him, wife and a kid. And.. yes, high deductible.

Sounds like each one of those "integrated" components are actually separate things and each has an expense to you. And theres noone at the plan to help you navigate or coordinate what you access or why you should. All up to you. Our approach is to make these types of things to be inside the benefit plan (e.g. no copays, no deductibles for telemedicine solutions), and support you with care guides and incentives. I hear your pain though - its why we are trying to do this. Better access, easy as well as affordable.

They do have free teleheath and I do appreciate that. If I don’t absolutely need to be seen in person, I use the telehealth option. No other features, tbh. It’s a bronze ACA plan in the NY State exchange.

The yearly out of pocket maximum is about $7000 so it’s essentially only for catastrophic situations. I just wish there were a cheaper option. At this point, I’d take a plan with a much higher deductible/ out of pocket limit if the premiums could be half of what they are.

Now I am curious why you buy health insurance. Are you insuring against the risk of a high cost claim, like a heart attack or premature baby, cancer or transplant? Is it just something you think you should have (but from your comments, dont really use the healthcare system very often)?

I’m sorry to hear about the bad reaction you had to the vaccine and then the terrible experience you had with the care system. You are correct, individuals do need to have better understanding and connection to the cost of care, and the cost dialog is convoluted and lacking transparency for a long list of reasons. We are operating within the system but are looking to change it. What we can change is how you, as an individual, receive value from your insurance company. The most obvious way is to be protected against the super high cost of some catastrophic circumstance, like a massive heart attack or surgery. But another way to receive value is through incentives and rewards that support you in your pursuit of wellness, whatever that means to you, as well as making it easy for you to get access to things that are of interest to you that individuals or smaller employers do not typically get access to because there are no economies of scale to encourage these vendors to offer their products and services to the retail public. I understand and appreciate your pain as a self-employed or small group.

> We are operating within the system but are looking to change it. What we can change is how you, as an individual, receive value from your insurance company

But only if this is something an employer pays for.

I understand it's a big problem, and you'd like to make changes to the system. I wish you good luck in your efforts :)

We are embedding several programs into the benefit plan and still charging a lower price. We think its the best solution to the employer demanding positive ROI on the disease management and telehealth based solutions

> We think its the best solution to the employer demanding positive ROI on the disease management and telehealth based solutions

Just rereading this one line - again, I'm pretty sure your motives are noble, and perhaps you can move the needle a bit. But... why should employers be demanding positive ROI on something that isn't their core business? "Employers" as a whole, having to learn about various 'insurance' options and dedicated people to help guard their investments in Human Resources - something about this troubles me greatly. It's... as if... unless I'm somehow 'good enough' to warrant the protection/benefit of a 'good employer'... I'm less than worthy of good health, or access to necessary care. And... once that employer has no more use for my services (or someone else can provide them cheaper)... I'm essentially on the scrap heap (someplace we'll all be, metaphorically, at some point, sometimes through no fault of our own).

Again, I wish you the best of luck, but "employer provided health insurance" is just something that really is past its sell-by date, even if you can squeeze out some savings for employers and provide some good for the select few special/lucky enough to be employed by a company so forward-thinking as to engage your services.

You nailed it on the head.

Employer based insurance is at the core a monstrosity. I hope these founders make a dent in cost but ultimately i dont see how any ROI will translate to lower industry costs, especially since outcomes-based billing is just another more confusing way to ration care and squeeze independent doctors to work for larger systems that can do the accounting.

And squeeze the little guys, and everyone else ends up paying ASC or Hospital pricing.

The only real solution is to actively get rid of employer based insurance and to break down barriers to independence practice.

I dont see how this startup does either, unfortunately.

Hi Mark here - Just to be clear we are not using ROI, but rather clinical impact. The expectation being that the expense of encouraging better care through facilitating coordination, clinical teaming, and incentives addresses issues of access, transparency, and engagement/compliance. We are looking to change the healthcare experience from being confusing, disjointed, costly, and wasteful.

As for employer-based insurance, it is the market that more than 50% of all people get their insurance from currently [1]. Is it the best way to make sure people get access to care? No, its just a convenient way to pool risk, and there are significant tax and regulatory support structures in place to prop it up. No private enterprise is going to change this and it is unreasonable to expect that outside of massive political and regulatory changes. And when that revolution happens, our technology and infrastructure will be able to continue delivering the same positive benefits to the disaggregated community because quite frankly we are agnostic to whether 50,000 people are insured by us through 250 employers or as individuals - we are still treating the issues being faced by the people in the community.

[1] KFF Data https://bit.ly/3IFQkoB

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