Healthcare is evolving at a rapid pace and from every angle, from primary care to payment and financing solutions, scheduling software to charting, drugs to technology and wearables, and it’s all only the beginning. It’s easy for professionals deep in the healthcare trenches to argue that they are innovating the “first ever’s” and major breakthroughs, enamored with their findings alone in their offices across the USA, all still in startup mode and hard to find each other. Innovation is a seedling, not plastered across the New York Times until a major debt financing, a micro-acquisition, or venture capital or private equity puts them on the map.
I learned that I, too, was guilty of a narrow-view understanding of my competition when I formerly considered what Health Possible did from 2017 – 2020 a “first ever,” only to find at least three more similar or identical companies in the United States who opened 1+ years later and claimed, in writing on their websites, that they were the “first ever” or “only one” in the execution of identical operations – just in bits and pieces. Back then, our nonprofit was a combination of voluntarily-subsidized-wellness and an online provider/appointment store for user resources (stores now known as an online healthcare “marketplace”). Anyway, I immediately removed “first ever” claims from any of our brand’s language, because of course it could not be true, nor did I want us appearing (1) unaware of competition and (2) advertising a young-minded distortion from reality.
Note, online Marketplaces are just online retail stores of healthcare service providers – like diverse experts on a shelf.
However, what we startups can all be truthfully proud of together is that Health Possible (2017) and Upper (2021), like other startups, are simply pioneers. We are living through an explosion of healthcare, entrepreneurship versus higher education, then add venture capital to water that garden, and you get great companies rising up like Transformers to re-invent an industry. It’s an inspirational movement and feeling to meet similar Founders.
Now how can we all work together? Well, as a Founder who drove a 501(c)(3) nonprofit through three major evolutions, not to mention during my simultaneous launch and management of a membership-based IV Infusion medical practice (PLLC), all the way to the extent of incidentally farming a new company (Upper) from the limb of an old company (Health Possible), I seem to have taught myself the interstellar universe of how (1) Cost Sharing Communities, (2) Direct Primary Care, and (3) online Marketplaces work so synonymously (and how they don’t). There is a very specific, deep, and natural relationship between these three major sectors who all share one huge concrete foundation: Cash.
Cash as opposed to what, you ask? Insurance. Cash rates or otherwise known as self-pay rates are the middle cost, a lesser rate, as opposed to the incredibly inflated insurance premiums, deductibles, and provider visit rates that insurance plans come with. The insurance rate in America is typically the most expensive cost of healthcare you can find in 2021. America also spends more money on healthcare than the rest of world, with some of the worst outcomes comparatively. We are beyond broken, maybe even on life support at this point… pun not intended.
Claire Parker, an Author at The Washington Post, also wrote, “The United States has the worst health-care system overall among 11 high-income countries, even though it spends the highest proportion of its gross domestic product on health care, according to research by the Commonwealth Fund.” – U.S. health-care system ranks last among 11 high-income countries, researchers say, August 5, 2021
SCALE OF HEALTHCARE RATES
- $$$: Insurance Rates (HIGHEST)
- $$: Self-Pay or Cash Rates (MEDIUM)
- $: Fair Market Value (FMV) or as I call it, “What’s Actually Negotiable” (LOWEST) – Yes, your cash and self-pay rate healthcare bills and costs are negotiable (if you go through insurance, it’s not.)
Roots of Direct Primary Care
Dr. Garrison Bliss, a pioneer of Direct Primary Care in America, recorded the following excerpt in his article The Origins of Direct Primary Care: Transformation, Simple Ideas, and Trojan Horses, “Two of my partners from my original practice eventually left to set up MD2, the first monthly fee practice in the US. At $1,000 per member per month, MD2 was also the first ridiculously priced primary care practice, so it attracted comments in the press about concierge care and boutique primary care.
When I looked at financing an optimized primary care system, I was attracted to the monthly fee concept. Primary care is a fixed-cost business, so a monthly fee could replace the fee-for-service insurance model, with its foolish incentives and toxic costs.
I calculated the lowest monthly fee that could support a 600-800 patient panel at $30-50 per patient per month (depending upon age). It worked both as a care model and business model, so Mitch Karton and I launched the new Seattle Medical Associates in 1997, filling our practices in just over a year.”
DPC is being referred to as the original value-based care specific to primary care, meanwhile value-based care is a newer 2000’s concept being injected into the insurance world as insurance companies scramble to bury their “fee-for-service” model – the excess ordering of patient labs, bloodwork, drugs, and other services leveraged by Doctors to skyrocket the insurance claim and their profits. Can we even blame them? Paying back higher education loans to become a Doctor is no joke… Who is to blame here? Overall, even the insurance industry knows that fixed rates and cash operations is what’s best for people, and they need to get in on it quick while so many of us cash-focused entrepreneurs try to leave them in the dust for what they’ve done to our wallets. Know anyone who’s monthly household premium is more than their mortgage? Right or wrong, I do.
About Cost Sharing Communities
Cost Sharing Communities were created Before Christ (B.C.) and in modern language have evolved into non-insurance, membership-based pools of money that all their members pay into, and then can get back in greater sums from the total pool when they need it for their healthcare. Otherwise known as: members get money back when the organization’s guidelines qualifies the “Need” (illness, injury, etc.) as “shareable” (or per their ethics – legitimate). Pay something in, get something back. They collectively save everyone’s money together, through membership, to help each other.
Cost Shares are provider network free because members are self-pay or receiving the cash rates anywhere they go in the world – that’s whats cheaper and how they save consumers money. Upper was legally formed in April of 2021 to acquire Health Possible‘s back-end software and provider network for over $37,000, transforming Health Possible into a sustainable membership organization and Cost Sharing Community, just focused on wellness. This move provided Upper with the founding asset required to become an online Marketplace – a plethora of providers and appointments for sale online that the nonprofit was using as its custom resource over four years, but any organization or individual person can now shop from this. For five years, Health Possible was unknowingly a mesh of these two major industries: Cost Sharing and newly tech-industry innovated Marketplaces (service stores). A mesh-concept that simply needed to divide into two parts to find great focus and scalability in each. Now, how does a Cost Share help its members with affordable medical care? You got it, Direct Primary Care offices.
The Cost Sharing Community customer is not you as an individual – its actually DPC centers, a cash pay affordable medical office, with low cost memberships, volume customers, looking to attach themselves to similarly operating health plans for their own members additional or catastrophic financial needs, and a place that can continuously keep people well. But wait, it gets better, DPC memberships are a fixed monthly rate in exchange for DISCOUNTS (what’s actually negotiable): Monthly wellness or sick visits, discounts on lab work, blood work, and even pharmaceutical drugs and prescriptions. All by itself, DPC offices are saving Cost Shares on payroll – the time that Cost Share employees take to negotiate its members bills for them.
Cost Sharing Communities discount their own memberships the rate of, or close to, a member’s Direct Primary Care membership, which saves everyone money, and any additional or outside expert needs can be bought at cash rates through online Marketplaces. This alliance makes for a seamless cash ecosystem.
Cost Sharing or Healthcare Sharing Ministries became legally qualified as medical coverage in the Affordable Care Act (ACA) in 2018, much of which was for business and consumer tax purposes. Prior to 2019, there was an individual mandate that basically stated that if someone does not have Minimum Essential Coverage (MEC), such as standard health insurance, they would be financially penalized at the end of the year – an effort to force consumers to purchase big player health insurance plans. In 2018, 104 cost sharing communities were federally inducted as MEC to the ACA, allowing their members to not be penalized and thus setting requirements for these cost shares to meet. Thankfully in 2019, the individual mandate went away, sparing those who were members of smaller and non-federally-qualifying cost sharing communities.
Let’s see if you can pinpoint the law that I still scratch my head over here. In order for members to be exempt from the tax penalties outlined in the Affordable Care Act, ministries must meet the following qualifications:
- Must be a 501(c)(3) Nonprofit Corporation
- Members must share common ethical or religious beliefs
- Must not discriminate membership based on state of residence or employment
- Members cannot lose membership due to development of a medical condition
- Members have (or a predecessor must have) existed and been in practice continually since December 31, 1999 (a grandfather clause)
- Must be subject to an annual audit by an independent CPA, which must be publicly available upon request.
The five ministries that meet these qualifications, which makes them eligible for large employer purchasing and medical-tax-deductible benefits offerings (and competitive and scalable) are: Christian Healthcare Ministries, Liberty HealthShare, Medi-Share, Samaritan Ministries, and OneShare. There is an organization called MCS Medical Cost Sharing, which was founded after 1999 and does not meet the qualifications, but offers to pay the tax penalties incurred by members… so they can compete.
So, why 1999? If you ask me, the government is making an effort to stop new cost shares from opening, because why bother opening if you can’t sell and scale with employers? Well, it doesn’t seem to be working when you come across non-qualifying players like Sedera, Zion, Altrua, and someday Health Possible. Newer cost shares will find innovative ways to scale and just mitigate the risks of any individual mandates or penalties coming back on its members later. Thankfully, it is part of the United States Constitution that American citizens are born with the right to share in each others expenses.
What’s to come of all of this?
Empowerment, change, and simply putting consumers back in charge of their own health – to not be left to the devices of big insurance, big pharma, higher education, and the blackhole that was American healthcare.
This is the springboard, and as one Founder, I welcome you to the interstellar universe of cash pay healthcare. There already is and will continue to be a focus on community, human prescription, technology as drugs designed for self-control, personalized pharmaceuticals that are prescribed and/or change according to your individual genome, and the continued growth of internet universities.
By Sara R. Auld
Founder of Upper & Health Possible