Written by Bernie Saks MD

The Intelligent HSA

To read more please click on the About The Intelligent HSA tab above, or copy and paste the link below


I brought up your idea at the Board of Directors Meeting of the IMS today, we spent nearly four hours talking about many different models of healthcare payment reform.  Your plan as well as many others has many merits, there were as with the others questions and concerns.  I thought I would relay some of those to you, as they may help you fine tune your proposal.

December 15th, 2008

Larry: thanks for the wonderful feedback you received from your Board of Directors Meeting from the IMS. All of the points are good but very easily addressable. I will take them in order and then make a little summary. 

  1. The feeling of all in the room, including two attorneys , was that the coach would have some if not a large amount of legal responsibility for the medical advice under the current culpability laws, especially if they contradict the doc.

1- The medical coach would have legal liability.  We live in the United States where everybody  has the inalienable right to sue (and many [over]exercise that right!). If we are concerned about litigation for anything and don't act out of that fear our country grinds to a halt. Should McDonald's not sell coffee because if it spills on a commuter while driving they can sue? Should a medical researcher not publish a paper about trial outcome because an adverse outcome presents liability?

Remember, the "coach” is an informational arm in the plan, neither a mandate nor compulsory. The individual has the right to choose, but hopefully in a less biased and more informed state. 

  1. Incentive to the coach for giving the "cheapest" advice, or that is to say, advice that would result in the lowest utilization would inheritantly(sic) cause a severe bias. They must be paid for quality advice, not cost effective advice.

2- It is not the incentive of the coach to give the "cheapest" medical advice. Quality is not the antithesis of cost-effectiveness. Ask any doctor in your conference room about that. The statistics show that although the USA spends the most on health care we are not buying the most quality. We waste huge amounts of money because we try to provide care quickly (fast-food mentality) and often pander to the patients. Once the patients realize that it is their own money to spend or conserve, cost-consciousness will be patient driven!

  1. How much time will it take to get the coach involved, will you need two appointments or more to have the coach and doctor play point counter point, or just put a phone in every room, or maybe the coach has to go with them. Maybe a coach is assigned to each doc, as the only way to give individual advice is to know all the information about the patient, including medical, social, family issues etc.

3-Time constraints are up to the patient.  I have an HSA presently and HSA's and HDHP's are no different from typical indemnity health insurance except that deductibles are higher and the HSA dollars are in my account as opposed to the insurance companies’ account. I do not act any differently than anybody else with health insurance. Currently, I am not asked to consult with anybody. As a physician, however, I know when suggestions are "CYA" or "feel good" mentality that typically has little positive influence. I know when tests are "shotgun" ordered because we are in a hurry or don't want to take the time to think out a differential diagnosis; I know when we are not ordering the differential diagnositc possibilities from most likely to least likely and when we are not waiting for the results of the test most likely to provide the answer before moving on to the next test. Those that wish to get the coach involved and take their time will have the potential to save money. Those that don't wish to get the coach involved don't need to. They will go through their HSA quicker and get to their HDHP sooner.

  1. Would the coach do only high dollar expense reviews, or everything form EKG, CBCs, and antibiotic choice for pneumonia, to Hip replacements 

4- The coach could review high and/or low dollar expense items or no items.  As I stated in the preceding paragraph, the coach is not a mandate but is voluntary. Those who take advantage of it have the potential of saving and conserving their OWN money, not the insurance companies’ money. That is the beauty of this plan; it is consumer driven but not mandated!

  1. How do you figure in Emergency room services 

5- Emergency room services are treated the same as with regular insurance plans, just like it is now for my current HSA/HDHP.  We are talking about "The Intelligent HSA" being used in the setting of UNIVERSAL coverage (please refer to the paper written to Dean Tom Campbell). Everybody has coverage; people do not need to use the ER as a dumping ground.  Ask any physician how many ER cases are truly emergent. Once people are insured universally they will realize not using the ER for non-emergent problems saves money. The financial reward for good cost-conscious medical decision making behavior is IMMEDIATE and DIRECT for the patient. The patient is not mandated to see their primary care physician instead of the ER physician. However,  if they see their neighbors and friends saving money by utilizing the ER appropriately, they may become more motivated consumers. TRUE emergencies are emergencies and are treated no differently with this plan. 

  1. Who breaks the tie when a doc makes a strong recommendation, and the coach says no. Is that a reason to break the doc-patient relationship, as the relationship is now tainted? How do you get the dispute resolved?

6- There is no tie breaker. The coach and his advice is not a mandate. Remember that paradigm shift that we are trying to make is to get the patient educated and involved in cost conscious medical decision making. When you control utilization externally it is called RATIONING and the patient will bristle against it. When utilization is controlled internally it is called CONSERVING. By rewarding the patient immediately and directly for good decision making they are not made to feel as if it is rationing but healthy conservationism because the patients are involved-- that is the paradigm shift that this Intelligent HSA plan makes! In any instance the patient can still choose which medical path he wishes to take. However, I know  as a physician, if the patient show up in your office with the conservationism mindset you are not being put in the position to have to talk them out of some process or procedure that is probably low yield to begin with. You are working more cooperatively with the patient. It may be easy to track physician outcome versus dollar spent than other practice parameters!

  1. Maybe the coach could just be involved if the patient needs advice, but could do what they feel is needed if they "trust" their physician

7-The coach can be involved only when the patient wants. That is the beauty of the system.

Larry: No system is perfect. There is the potential for waste in “The Intelligent HSA” as there is in any system. Third party fraud will be diminished as the patient will not be dissociated form the payment process as is currently seen. Remember, however, those patients who use the system wisely are rewarded. The shift in logic that we must make is to get the patient involved in cost conscious decision making! When patients are involved and utilizating appropriately  we will be conserving services rather than rationing them.

It is human nature to take better care of things that you own. When it is the insurance companies’ money paying for services, you are more inclined to spend it. When it is your own money paying for services, you will think harder and longer  before you spend it. Your incentive to consume medical services more appropriately is greater when you are rewarded immediately and directly for that decision. You are more likely to consume more at a buffet than when eating al a carte and more likely to order more when being treated by the "rich uncle".

Health care reform can be successful only when the patient is empowered. Reward is a powerful motivator (especially financial reward). In the current indemnity model, if 10% of the people are cost-conscious and healthy consumers they will see no dividend; in fact others will see them as getting less for their money. In the universal "Intelligent HSA" model, if 10% of the people are cost-conscious and healthy consumers, they will see their reward immediately. Others will see that too and the reform trend will grow. However, in no instance will those that wish to be unhealthy or dollar wasteful be mandated to do anything differently. That is what freedom loving people enjoy!

I hope this addresses your concerns. I would love to field any other questions and be involved in the discussion.

Bernie Saks, MD