Under the cover of medical insurance, the drug god is hard to pick up the beam

At the end of the movie "I am not a drug god", Cao police officer took over from prison and told him that there is no market for Gleinine in India because Glein has been included in medical insurance.

Art shines into reality. In 2013, Jiangsu Province included Gleinine and other anti-tumor drugs in the scope of payment for medical insurance funds, so that the annual medical expenses of patients with chronic myelogenous leukemia fell from more than 70,000 yuan to less than 20,000 yuan.

Look inside the doorway. In "I am not a drug god", Glebine, a life-saving drug for chronic myeloid leukemia, is expensive, patients cannot afford it, and extremes even commit suicide as a final solution. The story took place in 2002. At that time, the basic medical insurance for urban workers in China was established for nearly four years, and it has covered most urban families. After the film was released, the author fell into deep thought. In China, medical insurance coverage should never be just a breadth issue, and the depth of life is more difficult to solve.

In fact, the same problem also exists in the United States. Different from the “strong welfare” of the old European countries and the “big government” of the rich Southeast Asian countries, the US medical insurance system operates in a market-oriented manner, and a “wide and shallow” medical insurance network is rolled out in various states. Under the big net, it is hundreds of billions of dollars of leaking net medical bills. This article will first discuss the problem of insufficient coverage of medical insurance in the United States. At the end of the article, we will introduce some useful attempts by innovative companies to reduce the leakage of net bills.

The US medical insurance network is quite perfect

In 2010, the United States began to implement the "Affordable Care Act" (ACA), the so-called "Obama Medical Council", and former US President Barack Obama fulfilled his promise to the poor during the campaign. The ACA Personal Mandatory Provisions stipulate that all US citizens must purchase health insurance or they will be subject to a fine unless they are exempt from religious or financial difficulties. As a result, 30 million American citizens without medical insurance are also covered by medical insurance.

In fact, ACA is only a supplement to the US health care system. In the United States, most people work to participate in unit collective medical insurance. On this basis, the US medical insurance system has set Medicare, Medicaid and CHIP for the elderly, the poor and the disabled and children respectively over 65 years old.

The complex medical insurance system basically covers all the people in the United States, and there are few fish that are missing.

The burden of medical care for Americans is still quite heavy

However, a data from the US bankruptcy court broke this calm and beautiful. Every year, nearly 1.2 million families across the United States seek bankruptcy protection, of which bankruptcy due to medical expenses accounts for 62% of applications. It is worth noting that 60% of medical bankruptcy applicants have private health insurance and only 22% of applicants are not covered.

In the United States, insureds are required to pay thousands of dollars in insurance premiums each year. When medical expenses occur, they also need to pay for deductibles, co-payments, and fixed-rate fees. This is an important source of inadequate medical coverage.

Take a 50-year-old American man as an example. Assuming annual income of $46,100, he pays $10,585 in annual premiums, which is 22.9% of annual income. In the event of medical expenses, he also has to pay up to $6,250 for self-pay, so the medical burden rises to 36.5%. According to the ACA, 100%-400% of the federal poverty line can enjoy tax deductions and health insurance benefits.

According to the 2018 federal poverty line, this person is eligible. Even so, the medical burden of this low-income earner is still 18.6%. Statistically, there are some quantitative criteria for “insufficient coverage of medical insurance”. It is one of the criteria for an individual to pay a self-paying medical expense ratio of more than 10% of household income.

According to the National Health Expenditure Survey (NMES), between 1996 and 2003, the proportion of under-insurance coverage for individuals participating in collective health insurance increased from 14.2% to 18.2%. According to the Commonwealth Fund survey, the coverage rate of non-elderly insurance coverage in the United States in 2010 was 32%.

医保覆盖不足之下,药神实难扛起大梁

Image is organized by the arterial network according to NMES data

In terms of income level, the insurance coverage of the low-income group is the highest, about 33.3%; in terms of health status, the insurance coverage rate of the poor health is 32.3%.

Specifically, 39.1% of diabetic patients, 30.9% of hypertensive patients, and 29.2% of mentally ill patients did not receive adequate health insurance coverage. These diseases are the most common chronic diseases in Americans.

医保覆盖不足之下,药神实难扛起大梁

Image is organized by the arterial network according to NMES data

Studies have shown that the lack of insurance coverage to the insured is not only financial, but also health, and even life. In a randomized trial of Rand Health Insurance, inadequate insurance coverage resulted in a 21% increase in the risk of death for low-income people with severe illness. In addition, a 2007 national survey found that 29% of high deductible participants and 16% of low deductibles were delayed or abandoned due to cost.

ACA storms, it is still difficult to understand the depth of medical insurance coverage

The ACA mentioned at the beginning of the article helps Americans effectively solve the problem of non-insurance and under-insurance, but objectively increases the insurance coverage. On the one hand, the supervisory authority allows the ACA to request co-payments and deductibles for insured persons who receive Medicaid. On the other hand, the underwriting ratio of the ACA Medicare program itself is low. For example, the bronze program covers 60% of the average medical cost, the silver plan covers 70%, and the gold plan with the largest underwriting coverage covers only 80% of the average medical expenses.

ACA is regarded as the most protected health care reform bill in history. Due to the increased financial pressure of the federal and state governments, it has been opposed by many parties from the beginning.

In June 2012, the Federal Supreme Court ruled on Republican lawsuits against the ACA for unconstitutional cases. While supporting most of the ACA content, it is unconstitutional to assume that the federal government is threatening Medicaid grants and requiring states to expand coverage of Medicaid.

In 2017, after Trump took office, he advocated the abolition of "Obama Medical Administration." In May of the same year, the US House of Representatives passed a new bill to replace the "Obama Medical Council", the 2017 American Health Care Act (AHCA). Fortunately, in the Senate vote, the ACA alternative bill was not passed. "Obama medical administration" has been implemented to this day.

The US media has done a statistic. If AHAA replaces ACA, by 2026, the number of uninsured people in the United States will increase by 23 million.

医保覆盖不足之下,药神实难扛起大梁

Image from KFF official website

How to place hundreds of billions of leaked net bills? These attempts are worthy of attention

The arterial network made a rough statistic. In 2018, for example, there are about 130 million in-service workers in the United States, and the average salary is $43,460. Assuming that after the population structure is weighted, the medical expenses that require personal burden are 10%. More than 560 billion. This number is still rough, but the volume is large enough to attract people's attention. In fact, some companies in the United States are already trying to compress this bill.

Advocatia Solution: Link more people to insurance coverage

Recently, two startups won the finals in the “Health: US 2018 Program” jointly organized by Caesars Medical and Village Capital, one of which is Chicago-based Advocatia.

Arterial Network learned that the “Health: US 2018 Program” is a specialized venture capital program designed to train early companies that address key issues in population ageing. Advocatia provides hospitals with tools to help them save uninsured and underinsured patients, such as making patients aware of the financial assistance policies they provide.

Advocatia co-founder Laura Robbins believes that more than 28 million people do not receive adequate insurance, of which 11.7 million are eligible to participate in health care plans, but they are not aware. The latter is the target group of Advocatia.

Advocatia's solution consists of three modules: Benefit Triage, Benefit Text and InsurNav. Benefit Triage is a SaaS financial advisory platform that can be used to help identify financial assistance for patient care options, optimize workflow and increase reimbursement efficiency of services provided; Benefit Text is a decision engine that uses SMS text and uninsured or covered by health care Insufficient people communicate instantly, so they actively screen available items; InsurNav is embedded in the hospital website to give doctors and patients a better understanding of the resources around them.

TCARE: Evidence-based solutions for home caregivers

TCARE is another company that entered the “Health: US 2018 Program” finals with Advocatia. Headquartered in Madison, Wisconsin, TCARE provides intelligent management to tens of millions of Family Caregivers across the United States. TCARE's solution divides home care into two parts, identifying problems and providing resources, and optimizing this unpaid medical practice in six steps.

医保覆盖不足之下,药神实难扛起大梁

Image from TCARE official website

Among them, the most important step is the third step, after the home care staff completes the assessment, TCARE determines the best treatment target, community support strategy and professional medical staff priority service list through special algorithms, so that professional medical personnel can better locate medical treatment. Demand and integrate resources.

MDSave: Expedia Healthcare Release

MDSave is headquartered in Nashville and was founded in 2011 by Paul Ketchel, a technical system administrator for the former Capitol professional lobbyist (Lobbyist) and former Tennessee Senator Bill Frist.

In 2013, MDSave's website was officially launched, functioning similarly to Expedia's healthcare version, allowing patients to compare medical procedures and assure medical providers almost immediate payments.

医保覆盖不足之下,药神实难扛起大梁

Image from MDSave official website

What patients need to do is enter their location, find the treatment they need, and choose the treatment that best suits them based on price, proximity, and doctor's score. For ease of use, all costs are tied together, so patients do not receive a large number of bills that include unexpected expenses.

In international trade, independent monetary policy, fixed exchange rate system and free flow of capital cannot happen at the same time. It is called “impossible triangle” or “three yuan paradox”. In the provision of medical services, the “impossible triangle” also exists, that is, improving the quality of medical services, increasing the accessibility of medical services, and reducing the price of medical services cannot be balanced.

Medical insurance has increased the accessibility of medical services from a financial perspective, but it has produced "wide and shallow" problems. In the future, only technological innovation can break the medical “impossible triangle”. In the previous three cases, we saw that innovators tried to use Internet technology and artificial intelligence algorithms to compress the cost of medical insurance. Although the results are not significant, they have opened up new ideas for the supply of medical services for low-income people outside the policy.

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