Affordable cleft care and affordable cleft surgery is offered through our partnership with Texas Free Market Surgery (TFMS). Texas Free Market Surgery is revolutionizing healthcare through direct provider to employer contracting, transparent pricing, and outcomes-focused procedures. TFMS cleft bundles are priced 50-60% cheaper than PPO networks, often with Zero Out-of-Pocket to families. Find out if your employer sponsored plan is “self-funded”. See Cleft Surgery Bundles.
You may or may not have heard about bundled surgical services before, so we want to take a few moments to introduce you to the concept. Everyone is familiar with the crazy way that medical bills happen today. A patient meets with their surgeon in a clinic, decides on the procedure and details, then a “scheduler” gets everyone together at a specific time and facility to make it happen. It’s what happens after the procedure where all chaos ensues. Over the next 6-8 weeks, a litany of medical bills come in from various sources (many of which the patient does not even recognize). There is almost always one from the surgeon, one from the facility, and one from the anesthesiology group. There may also be bills from a lab, from a pathology group, and maybe even medical supplies, devices or equipment. Prior to and during the event, the patient feels like everything is just going to get taken care of. If you need a medication, you get a script and go to the pharmacy. If you need crutches, the facility just gives them to you when you are discharged. Seems so seamless. But the reality hits when the patient tries to audit the bills and verify accuracy. Additionally, there is no way for the patient to know if the charges are reasonable. On today’s bills, it is not at all uncommon for the facility or anesthesiologist to bill and collect 2-10 times what the surgeon does. Doesn’t make sense, does it? Surely the person in the room that has the most unique training and skill, and is expected to lead the entire process and ensure the safety of the patient all the way through (and actually, the only person that the patient has a moral and personal contract with to ensure a successful operation), would get a little better consideration, wouldn’t they?
Back to the bills. The patient keeps getting them, assuming all the while that their insurance company will just process them all and make it go away. It starts getting a little distressing when the late notices and threats for action by the billing entities start coming in. Again, the patient has no way of verifying that the Dr. Smith, the anesthesiologist that they met two minutes before their procedure, belongs to ABC Anesthesia. And for sure, there is no way to know if the $2000 bill is accurate or fair. Fortunately, an EOB (Explanation of Benefit) comes in from the insurance carrier which is going to make it all clear. Well, no. The EOB might be the most nonsensical document ever created. Trying to match up multiple EOBs that deal with parts and pieces of the medical event showing “actual charges”, “allowable charges”, “patient responsibility….deductible, co-pay, co-insurance”, and “discounts” is impossible for anyone who is not a complete expert in this business. And remember, it is the patient’s credit at risk here. Everything the patient signed on the day of surgery said that the patient, not the insurance company is ultimately responsible for payment. Finally, after three months and the patient can barely remember the details of the event, everything seems to start settling down. The patient will likely have to make a few calls and send in a few checks to clean up unpaid balances after the insurance company pays what they claim is their portion, again with no way of really knowing if they actually paid what they were truly obligated to pay!
Gaming the system….the patient is always liable and in the middle!
Because of the complexity and disorganization of this process, it is ripe for gaming by the various players in the process. Denial of benefit is probably the most common. This occurs when your doctor says you need something, you buy it and use it, and then later you find out that your insurance program does not cover it. To add insult to injury, it does not even count on your medical deductible. Most of the time, no one in the process can tell a patient prior to the billing process if the benefit is covered. Insurance companies will often “authorize” a benefit when their doctor’s office calls in to verify benefit, but later the insurance company comes back and says that it is actually not covered, leaving the patient on the hook.
The other more insidious way for the players to game the system is to be out-of-network. A number of institutionally affiliated physicians (ER doctors, Anesthesiologist, Intensivists, Neonatologists, Radiologists), who have a contract with an institution to cover the service day-in and day-out, don’t like the extremely low rates that the insurance carriers try to force on them, so they just refuse to write a contract with the insurance carrier. Most of these physicians are encountered by patients when the patient presents to an institution because of an urgent/emergent medical issue or at the instruction of their own physician or surgeon. Patients really don’t choose these doctors. The institution chose them and they are ready at all times. The problem comes when a patient gets a procedure at an institution and encounters one of these doctors (sometimes, never meeting the doctor). When the EOB comes in the mail later, it says that it is not covered because the provider is Out-of-Network. Often insurance companies will eventually pay these bills on behalf of the patient, but it requires a very astute patient to understand the game and ensure that happens. Remember that the patient is ultimately liable for payment of all bills and it is their credit at risk! Many times Out-of-Network plays are a little more sinister and associated with efforts to profiteer. This is especially prevalent among facilities that attempt an out-of-network strategy, often billing patients 10-100 times usual and customary charges.
So in the end we have a ridiculously confusing and inefficient system that makes no sense to anyone. We have medical providers, facilities (hospitals, ASCs, etc.), pharma and device manufacturers, and insurance companies all looking out for themselves, and no one is looking out for the financial health of the employer (footing the great majority of the bill) or the patient, the true customers of healthcare. What is the solution?
Bundling of Surgical Services….one of the solutions
One way to clean this mess up is to offer patients, employers, and insurance companies a single bill for all charges associated with the delivery of a service, a “bundle”. Bundling of services has several very important benefits. First and foremost, it allows the customer to know exactly (barring any unforeseen or unlikely adverse events) how much the complete service is prior to actually obtaining the service. We are all familiar with this process. We don’t just take our car into the shop and say, “Fix it, and charge me what you want later.” We say, “Diagnose the problem, give me an estimate and then I will decide how to proceed.” It is natural to want to know what your financial exposure is before the service, as opposed to after, like it is in medicine today. Complete bundling (versus, partial bundling) occurs when everything the patient needs for the entire process is included in the bundled price. Bundled prices are particularly powerful when they are posted publically for other competitors to see, enticing competition on price (see Value Based Care section to read about importance of quality as well). Bundling gets rid of the EOB and all the bills that come in the mailbox to the patient later, gets rid of the patient in the middle with all the risk, and most importantly, gets rid of the administrative quagmire that adds so much cost to the system. The bundling entity (like Texas Free Market Surgery) takes care of paying all the players. And guess what? They know a whole lot more about what is high quality service and what is a fair price. Depending on how administratively complex employers and payers make it for the bundling entity to get paid, a bundled surgical price is often 30-40% cheaper than the same service and same providers at a traditional Ambulatory Surgical Center when the billing goes through the traditional PPO network billing process. And it can be as much as 80-90% cheaper than a hospital!
How is this possible? By cutting out the middlemen, eradicating administrative complexity, and eliminating any potential for gaming, the bundling entity can reduce the cost of care, make it transparent with upfront pricing, ensure high quality, and still make a profit. Now that is the free market at work.
Cleft Care Bundles
Texas Free Market Surgery has partnered with Dr. Kelley and the Craniofacial Team of Texas to develop a complete offering of cleft bundles to cover the entire 18 year care continuum of a patient with congenital cleft lip and palate (isolated, non-syndromic CLCP). This an example of the initial work performed for patients with cleft lip and palate:
Initial analysis of PPO network claims data suggests that an employer (who foots the majority of the bill) can save more than 50% of what they currently spend for the same outcome of care. What are the benefits to the patients? First and foremost, the patient gets a streamlined care process. No longer is a patient required to come into the office for something that can be taken care of over the phone, just so the doctor can get paid. With upfront transparent pricing, the patient will never have to deal with egregious out-of-network bills and denials of service by their insurance provider. The savings are so incredible that most employers will relieve their employees (the patient) of their entire out-of-pocket responsibility for surgical bundles (deductible, co-pay, co-insurance)!
Interested in our care bundles? Contact the Craniofacial Team of Texas or Texas Free Market Surgery to inquire about our cleft bundles. We hope to offer more care bundles in the near future.