7.14.2018

Totally off topic: Healthcare. Not a discussion about the Affordable Care Act !!!


I know many of my readers worked for the government or big corporations before retiring or may still work within those entities. I don't want this to devolve into a political discussion about the ACA. I just want to start a discussion about how freelancers access healthcare and what my strategy is for my healthcare. It's part of being a photographer and it's even more important as one hits middle age (and older).

I've always carried health insurance, rarely had to use it. I researched physicians in Austin about 30 years ago, asked my dentist and friends of mine who were doctors in various specialties, and went out and actively interviewed general practitioners. Most people just throw a dart at the dart board of whoever is offered in their employer paid health plan but I wanted an actual partner in my healthcare and I wanted someone who would go beyond the seven minute evaluation and the quick exit after writing a prescription. I wanted the kind of doctor my grandfather was; a caring and dedicated professional who would follow you through life, understand your history and think before diagnosing.

I found a great general practitioner and over the years I'd go in for a yearly physical, get ear infections treated and get my immunizations done. He never blindly prescribed, we talked through modalities of treatment and he offered options and let me know his preferences.

About two years ago my doctor decided he'd had enough of jumping through hoops and reducing fees for the big insurance companies and he decided to re-start his practice as a "concierge medicine" practice. Clients pay a yearly fee (mine is $1,600) and in return they get a thorough yearly physical exam with lab tests and all the office visits one might need over the course of the year.

I was also happy to get a direct cellphone number (not a medical exchange number) so I could get in touch right away if I needed to. Since insurance is not involved (although I still carry an ACA approved policy with a high deductible) there's no paper work when I go to see my doctor. There are no bills, no copays, no road blocks.

I had a rash on my forearm that popped up a day or two ago and after swim practice yesterday I called my doctor's office to request an appointment. It was 9:15 in the morning. The scheduler at my doctor's office let me know they had appointments available that day. Did I want to see my doctor at 10:15 a.m. ? They could make that happen.

I arrived on time and was ushered straight into an exam room where my doctor's nurse took my temperature, blood pressure and asked me a few pertinent questions. She was out of the room for 30 seconds when there was a knock on the door and my doctor entered. He examined the rash and prescribed something. He burned off an actinic keratosis on the other arm with liquid nitrogen. Then he asked me how life was treating me. We talked about my dad's recent cardiac event and my anxiety over the impending house sale. In all he sat and chatted with me as a friend and advisor for nearly 45 minutes. I left with the assurance that the rash was not some deadly cancer (me: ever the hypochondriac), feeling better about my recent changes in lifestyle (father's administrator and supervisor of his care) and happy to see that my long term "white coat syndrome" has largely resolved and that I can actually have a normal blood pressure of 115/65 while talking about my health.

Jointly my wife and I pay nearly $20,000 a year for health insurance although both of us are very healthy and rarely need more than glancing course correction. That represents nearly 15% of our income. Some of my associates suggest that I not pay for the concierge medicine and only pay for health insurance but I can say that once you've experienced appointments on demand, real continuity of care and the unhurried attention of a professional you trust it would be very difficult to give it up.

I remembered back, as I was writing this, to December 24th which was the day my mother was rushed to the emergency room. Being able to get my personal physician on the phone on Christmas Eve to talk me through the enormity of issues confronting my mother, and, by extension, me as her medical P.O.A. was something I just can't put a price on.

At 62 years old I am cognizant of the inevitable decline all of us will eventually experience. No one gets out of this alive. But there are good ways to get care and frustrating ways to get care. For me the investment in a dedicated professional seems to be a bargain.

If you are a freelancer under 65 years of age what is your strategy? Have you looked into Concierge Medicine providers? What has your experience been?

In a way my physician has become more of a freelancer, like me. He's just working on a fixed retainer. I get the whole idea. I like it. I'm waiting to see what changes in whole insurance world. I'd love to be able to buy a catastrophic policy and have that in reserve instead of having to duplicate some expenditures to get my care the way I want it.

You could buy a lot of cameras for $20,000 a year.......

20 comments:

  1. Wearing my health policy hat, I am opposed to Concierge Medicine. It allows the relatively rich to escape the hassles of our broken health care system, and thus mutes the pressure for meaningful reform. Like public schools in places like Louisiana (my home), where the rich and upper middle class put their kids in private schools and abandon support for the (mostly terrible) public schools.

    At the individual level, Concierge Medicine can make a lot of sense, combined with a real catastrophic coverage plan. As you have discovered, a big deductible does not save nearly as much money as you might expect. That is because you are insuring against a low frequency, high severity event such as a bad car wreck or cancer, or an expensive chronic illness. You are not insuring to pay for routine doctor visits or low level lab tests. That is why you should be suspicious of low cost catastrophic coverage. The Trump administration is authorizing the sale of limited coverage plans to lower the perceived cost of insurance. The problem is that if you have one of those bad events, you blow through that low coverage cap and go bankrupt on the unreimbursed costs. As a successful business persons with with saving, that is a real risk. (Elizabth Warren made her academic reputation studying health care cost driven bankruptcies.)

    While I have not researched Austin in particular, Texas is an expensive place to get health care, and I expect Austin is on the high end for Texas. That also increases your insurance costs.

    Without getting into a long discussion about health policy in the US, we have a system that delivers relatively poor care at very high cost, and we pay for it in ways that hit small business very hard. Talk to a photographer in business in Canada for comparison. In practical terms, there is not much you can do. I assume you already have a high deductible policy and a health saving account. Don't be tempted to go to lower coverage limits - you are gambling with your financial future. In a couple of years you can go to Medicare, which will be cheaper, but not remotely close to free at your income level.

    I did health policy for 30 years and finally quit because we have not made any meaningful progress on the cost/quality problem during that period. I shifted to climate change to have a new wall to beat my head on.

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  2. Edward, Your response was beyond what I'd hoped for. I understand your points and agree with them all. Just to be clear our health insurance policies are ACA Silver level and don't have life time caps, just high deductibles. Thanks for bringing experience and clarity to the discussion.

    As to healthcare in the U.S., I'll step outside my usual reticence to get into political policy and say that I wish we had a great single payer system like my friends in Canada. The wealthy will always take care of themselves but the Canadian system seems to not only provide great care but also with an eye to preserving everyone's basic dignity.

    One more aside: I'm sure that when I "age in" to Medicare my income will have taken a commensurate drop like rock...

    That' the next column: The importance of saving and investing outside your core business....

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  3. Having been in the Canadian system and now US system, I can say there are major problems with both. The US insurance system with a for profit model on the acceptable death level seems wrong. However equally the Canadian system were you may not see a doctor. Be kept out in a hallway, as your "room". Equally has issues. So there is no easy fix. Canada also does have a 2 tier system not talked about. The rich do have their own doctors whom they pay and mobile pay as you need medical vans exist.
    But the US insurance system by far is the most expensive, factoring in all taxes.

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  4. I doubt that your income will drop like a rock coincident with the onset of Medicare. You’re too agile, too fit, and too open minded. There’s a drive to create combined with a willingness to adapt within you. No arbitrary date will snuff that out.

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  5. I have worked as an independent contractor in the high tech world for 29 years. For the last 17 years we have had to buy insurance on the open market (my wife carried it thru her work before that). I pay 24,000 for a family policy with a $5K per person deductible. We are all without any major medical problems and I am 56 years old with a wife(52) and 2 kid 17 & 20).

    It is $20 to visit my doctor. Although I would have to visit him a lot to add up to the $1600 you pay for premium service, if I could receive the sort of attention you mention, I would do it in a second. This would represent an extra 6.7% extra.

    For the last 17 years I have watched my premiums raise typically from 15-20% every year. A few cases it was only single digits, but never less than 6.7%. So in one manner you are paying less than one years increase for premium service. Sounds like a deal to me. You won't not go to the doctor for something that could be serious because of either the cost or having to wait several days just to be seen.

    A little off topic but to illustrate a point why those who pay there entire medical expenses on their own want something done about costs, I have seen my monthly premiums go from $500 to $2000 in 17 years and have increased the deductible during that time to keep costs down (if you can call that down). Also before the ACA, if someone got seriously ill the premiums could skyrocket and we could have even been kicked off our insurance. Most people have never had to deal with this sort of impending doom looming over their heads for most of their life. Hard to understand completely if you haven't been there.

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  6. I am in Canada and I wish the US had something similar to the Canadian system of provision. Why? Because as things are now we (in Canada) tend to compare our system to the US one and say, great, we are so much better off (arguably true). BUT we are comparing to a substandard system (surely, given the great wealth and talent present in the US, the health care system there should be producing better outcomes?). It might spur the Canadian system to improve if we started comparing our selves to Denmark instead of the US!

    Dave.

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  7. My wife and I have been retired for ten years, live in Canada and have daughters and grand kids in both Canada and the US. We carry no health insurance of any sort. Two years ago my wife wife went for a routine mammogram and was called the next day for a "follow-up". We met with our GP who has known us for many years and sees us regularly. He advised that he would be our case manager, and recommended that we proceed on the assumption of a cancer diagnosis while other tests were conducted. He recommended a surgeon who was best for this type of operation. We interviewed the surgeon (while other tests were underway), and my wife was provisionally scheduled for surgery. We got back confirmation that yes, it was cancer, and the operation took place. The total elapsed time from the first routine mammogram, to leaving hospital with the surgery complete was 9 days (which included a long weekend).

    After the surgery had healed we met with chemical and radiation oncologists. It appeared that chemotherapy was probably not going to help, but we were told that it was available if we wanted it and would cost nothing (including a test that involved a lab in California at a cost of $3000US, but not to us). After consultation, we opted for the radiation therapy alone (every week day for six weeks).

    That was the first time we had seen the medical establishment in top gear, and we were very impressed. We saw many physicians, nurses, and technicians. All appointments were held without delay, and were on time. The hospitals were clean and well equipped. Everyone was very friendly – I remember the surgeon coming round from her desk to give my wife a reassuring hug during one visit! I am now delighted to say that my wife has an excellent prognosis, and is in good health. We did have to pay a 'deduction' for the suppression drug that is needed but that was $6.11 (no typo!).

    Based on our daughters' experience in California and Ontario respectively, who each had babies in this period, everyone in the family agrees that you can get excellent health care in both countries, but the cost is vastly different even if you have insurance, and life wrecking in the US if you don't.
    Peter Wright.

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  8. Thanks for your discussion on this topic Kirk -

    This is a key piece of an overall plan which can help our transition into our senior years a bit easier.

    Most folks have only bit and pieces of a vision and plan for their family's future. They are not sure what will happen when they or their parents encounter health setbacks. This is a lot scarier if little has happened on the discussion side.

    I hope your prompt will cause more to sit back and think about how this all comes together.

    Thanks - Chris

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  9. I’m independent and have to arrange for my own coverage as well as the income to pay the premiums. I’m two years older than you are and have concierge medicine, similar in fee to yours. I rarely meet the deductible for my health insurance, and my annual premium is very high.
    I’m soon to enroll in Medicare with the supplemental coverage. That should be interesting. I’ll maintain my concierge medical situation although my Doctor is talking about retiring.
    All of that said, I’m fortunate to be healthy as I have little to no confidence in our healthcare system.

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  10. The medical system that we use has recently updated their electronic medical records system so that no matter who we see in the system we now have an improved continuity of care. Information from all our visits to various specialists are routed back to our primary care physician for her review. We have online access to all of our records including lab test, medical notes, prescription history, etc. My wife and I now use medicare and have a supplemental policy (Plan F) through USAA that has proven to be worth every penny we pay each month. The fly in the ointment for us these days and the future is dental expense and long term health care insurance. We ended dental insurance after doing the numbers and decided that self insurance was better for us - but throw in a few dental implants/crowns and bridges and the cost is painful. LTL is an ongoing concern as we get older and insurance companies are dropping coverage or dramatically increasing monthly premiums. For us the medical system has generally worked well for us up to this point but with the potential need of assisted living, etc. I can only hope that we have planned properly for those days.

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  11. My wife and I pay $26,736 per year for our health insurance in California. I am 62 and my wife is 64.
    She will be graduating to Medicare at the end of this year and will be paying $154 per month.
    We are on Kaiser health insurance and have been very happy with it for these many years.
    When I had employees, I paid for their health insurance but as they were generally young and single the premium for each of them was in the neighborhood of $200/mo. It was appreciated far in excess of what I paid for it and resulted in me keeping super people for very long time.

    I am making more money now than at any time in my career but I need to because as business people we live on net income, not gross.
    Studio rent and health insurance are the two biggest business expenses for me and I anticipate a huge boost to my bottom line when I close my studio in 2020 and when I finally get off the expense of full priced health insurance.

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  12. Dear Kirk

    $20,000 per year is terrifying! Why? Because I live in the UK with our much derided system of 'socialist medicine' (70th birthday this year) where we pay via general taxation and ALL of my health care is free at the point of delivery (except for a small prescription fee). A rough calculation based on tax rates and government budgets suggests that when I was earning around $80,000 my contribution to the health care system was around $5,000.

    I'm not a freelancer but I am temporarily unemployed and am receiving exactly the same care as I did when I paid income tax.

    No, I won't get 45 minutes of personal attention with my overworked GP but when my 87 year old mum broke her hip she had a new one within 48 hours, a week in hospital and two weeks in an excellent convalescent home at a total additional cost of zero.

    I don't want to be overtly political but my point is that I simply don't need to worry about this - I'll pay when I'm earning (cheerfully) and be grateful for the service when I'm not.


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  13. My parents are retired and living in Canada - I have dual citizenship but have lived in the US most of my life - my dad's experience with cancer care (as well as heart attacks) is similar to what Peter Wright described in the comments above - excellent care that doesn't bankrupt you. Does the Canadian system have flaws? Sure. But dollar for dollar, it beats the daylights out of the inefficient for-profit system in the U.S.

    Ken

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  14. Alex Bush points to what we don’t understand in the US. The cost per person, varying with income via taxation, of what we seem hellbent on disdaining as “socialized medicine”. No politician that I’m aware of has made a strong point of the idea that it can be less expensive and a rational choice. Of course, we also have to recognize the credibility of reports of inadequate capacity, overcrowding, and lengthy wait times in some circumstances. Multiply that by our government’s almost infinite capacity to screw things up and there may be an equally compelling counterargument.

    By the way, in planning for spending the windfall in cost relief accompanying Medicare be sure to include truly adequate prescription drug coverage. My prescription drug costs run more than $145,000 per year, now covered by my wife’s employer-provided insurance which followed her into retirement. If said employer ditches its retirees, which it has come close to doing in the past, I’ll be dead in two years. Or we sell the house, spend our frugal savings, and she celebrates her 80th birthday living in a refriferator box under a bridge.

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  15. I had CLL diagnosed about 25 years ago and have had a lot of chemotherapy. Currently the chemo that I have is for the rest of my life unless something better comes along. I read that the cost is around $150000 pa and for many the whole cost is not covered by insurance, however, like Alex, I am in UK and so pay nothing.
    As I understand it the US government pays out about the same per head of population as the UK does but for a much smaller percentage of the population. I guess doctors or insurance companies etc take a bigger slice in the US.

    Richard Parkin

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  16. I've had friends and family who have had to become creative. A friend is taking 2 classes per semester at ACC so he can get student insurance (well past his 30's). It's good insurance though. Another friend, ironically an atheist, joined a religious organization that provides insurance. That insurance is interesting in that it demands good health habits. Smoker? You have one year to quit, overweight .... you have to commit to losing weight.

    I pay insurance for our company. The yearly visit from our insurance rep (who we adore btw) is one we dread. Will we be able to afford it for one more year?

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  17. In most European countries, we are absolutely unable to understand the ridiculous US health system. My late, pensioner mother with regular long term medication, paid nothing for treatment or medicine in the UK. When she developed serious problems and could no longer live alone, she joined my family in Finland. As a new patient to the Finnish health system, she was checked, scanned and inspected in minute detail, at very little expense. Medicines are subsidised and all in all we are talking of some hundreds of Euros.

    Five years ago I was struck by something nasty. Since it was a mystery, I probably went through most hospital departments. As new symptoms appeared, a young specialist doctor solved the puzzle, because he was familiar with the obscure problem. Cost, 35 Euros per hospital visit — which did build up as I was attending the hospital ever couple of weeks. An operation that cost a couple of hundred. Medication by the bucket load, subsidised and partly free once a patient reaches 600+ Euros in a calendar year.

    I am fortunate, in that I also have private medical insurance, so if I am in a hurry, I can go private and avoid all queues. But if I were in the US, I would probably be dead in a ditch.

    I enjoy your blog, especially the swimming posts… even though I find swimming a tedious activity ;-) but I am impressed by your expenditure of energy and translate it to my own methods of physical training.

    Go well,
    Leslie.

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  18. Congratulations on overcoming white collar. My blood pressure is pretty normal, taken at home, and a little low shortly after arrival at the office (that brisk twenty minute walk from the tram stop is good for me). At my last trip to the docs? I went tachycardic!

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  19. With usual apologies for the auto correct errors.

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  20. Good Morning
    It's good because I'm up and moving around. Beside being a photojournalist for 30 years I've worked in the health care for 20, and now I've retired out, although I still see patients at the largest hospital in our area (12,000 employees) 4 days a month. I also support the use of CBD and CBN oil from hemp for health issues. Very misunderstood products, the scare of the 1950's. It's called follow the money and you'll see why.
    Anyway our health care in the USA is a wreck. The EU, Canada and other countries have far better care than we ever thought of for less cost or nothing.
    Here's a question, why do the politicians get better health care than us? They only work 4 years and get free health care for ever. Are they better than us? They must be.
    Here's an example, a patient was in the hospital for 3 days cost $60,000 insurance didn't pay all of that so he was responsible for the rest. Another one, 2 weeks in a burn unit for a car accident 2.5 million dollars, guess who they went after when the insurance stopped paying?? The hospitals have the right to sell your house, car, or attach your bank accounts to satisfy your account. They can go after your family as well, and do. You don't know what might happen, cancer, stroke, heart attack, no matter how healthy you are or how well you eat, work out, things happen, out of the clear blue for no reason. Shit happens. So ya, our health care system is a joke. Once again follow the money.
    Don't get me started, my BP goes up to high.

    Enjoy
    Roger

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