Medisense would be a state-level, quasi-governmental agency designed to fix our broken health insurance system. Learn more about the benefits for members, providers, and the system as a whole and how it works.
All providers are in-network. Coverage follows you across jobs. Vouchers plus price transparency keep payment simple and enables shopping for the most cost-effective care. No fighting for coverage with a profit-motivated insurance company. Income-based premiums ensure affordability to all. Incentives for preventative care promote long-term health
Medisense is a quasi-public agency offering a simplified, opt-in public insurance plan that prioritizes transparency, affordability, security, and simplicty. Prices for care are required to be completely transparent so you know the cost of your care ahead of time. Affordability is achieved through income-based premiums, a simple voucher-based payment system, and competitive forces among healthcare providers. Security is achieved by eliminating coverage denials, surprise bills, and out of network doctors. This is paired with the ability to keep your coverage across jobs. Simplicity is achieved by eliminating all the fine print with our current system and equiping you with the tools to easily find the most cost-effective option. Lastly, this program is opt-in so you are not forced to give up your current insurance coverage, though all employers will be required to offer this as an option for those who wish to opt-in.
In short, likely yes. Medisense ensures affordability through three prongs. First, Medisense sets income-based premiums, so that coverage is affordable for all. In particular, Medisense will ensure people can afford to continue their coverage through periods of job loss or low income. Second, Medisense avoids costly negotiations over reimbursement rates and procedure approval. Moreover, it promotes healthy competition among providers. Both of these serve to drive down the cost of care, and hence premiums. Third, Medisense is a quasi-public agency, meaning that it does not exist to make a profit. Instead it focuses on its mission of bringing transparency, affordability, security, and simplicty to healthcare.
Yes! In fact, Medisense completely eliminates restrictive networks so that you are free to visit any healthcare provider, creating more freedom than most plans today.
Medisense does not deny coverage for members. Instead, Medisense checks for overspending and fraud through provider audits, but covers all care for members that a provider has determined to be medically necessary. As is typical, this does not apply to purely elective procedures (e.g. LASIK or braces, in most cases).
When you receive care, the cost of your care is offset by a voucher tied to the local average price. At the beginning of every year, Medisense calculates the average price for every procedure in your area (e.g. $100 for routine bloodwork). Then, depending on the member's tiered plan, Medisense offers a voucher worth a certain fraction of this average cost. For example, if you have chosen a plan with vouchers equal to 100% of local average costs, then you receive a $100 voucher for routine bloodwork, in line with the average price in your area. These vouchers are eligible for any care that a provider has determined to be medically necessary for you (through a referral and script). Medisense pays the provider for care directly, and you pay Medisense for your portion (cost of care minus voucher amount). If the cost of care is less than the voucher amount, then you are credited a share of the savings into a flexible spending account. This simple voucher-based system empowers you to shop for the most cost-effective care, while still ensuring that you are covered for all medically necessary care
Medisense prioritizes simplicity, so its plans are straightforward. You can choose to pay a higher or lower premium for a plan that offers vouchers with a higher or lower value. For example, if you choose a plan with a lower premium, you may receive a voucher that covers 80% of the average cost of each procedure, while a plan with a higher premium may offer a voucher that covers 100% or 120% of the average cost.
When patients receive care that costs less than their voucher amount, they receive a portion of the savings. These savings go into flexible spending account where patients can use the funds for a wide class of health-promoting products and services (e.g. massage therapy or an Apple Watch).
Medisense will require all employers to offer Medisense as an option to their employees and to subsidize premiums to the same extent as they do the other insurances they offer. This means that you can choose to opt-in to Medisense regardless of your employer and can keep your coverage across jobs. Additionally, Medisense does not individually negotiate rates with employers, which levels the playing field for small businesses and entrepreneurs.
Medisense breaks the link between employment and health insurance, allowing you to remain covered for as long as you choose. This means that Medisense has the incentive to promote long-term health by incentivizing preventative care and healthy behaviors. This can even take the form of rewards credited to flexible spending accounts for healthy behaviors. Over time, this contributes to driving down the cost of care for everyone and making our society healthier.
Let's consider an example. You sign up for Medisense and provide information about yourself, such as your income. Medisense checks your eligibility for subsidies on your premium. You choose an income-based premium level that provides you with a voucher worth a certain fraction of local average cost of procedures (LACP). For example, suppose you choose a plan with a voucher worth 100% of LACP. If the average cost of routine bloodwork in your area is $100, then you receive a $100 voucher for routine bloodwork. Members can choose to pay a higher premium for a voucher with a higher value. Once registered, suppose your primary care doctor refers you to a cardiologist. You open the app and are presented with cardiologists in your area, their prices, and reviews and other quality indicators. This easy-to-navigate interface allows you to shop for the provider that best fits your needs. Once you arrive for your appointment, Medisense pays for the cost of care and charges you for your portion (cost of care minus voucher amount). That's it! There is no coverage denial or out-of-network concerns, no hidden fees or surprise bills.
Prices can be freely set by providers, subject to competitive forces, but must be reported annually to Medisense for each order. Medisense automatically pays for procedures with no coverage denial and no rate negotiations, reducing administrative costs.
Medisense legally mandates that all providers disclose prices for each procedure and service at the beginning of the year. Prices will be set by the provider and Medisense will offer patients tool to compare prices among providers. Patients will be able to instantly know the price of a given procedure along with their expected cost, allowing them to shop for the most cost-effective care. In a small number of cases where there is insufficient competition (e.g. a highly specialized procedure or a remote hospital), Medisense may be empowered to directly adjust the price of care to remain affordable. However, this may vary state-to-state and is unlikely to affect the vast majority of providers.
In short, yes. Providers must adhere to the prices they reported and accept patients with Medisense, but they have the freedom and autonomy to set prices to fit the needs of their patients. Medisense simplifies the reimbursement system by eliminating network designations and automatically approving coverage deemed medically necessary by the provider. This eliminates tremendous administrative costs for providers, but requires that all providers accept Medisense patients. In order to disincentivize wasteful spending or fraud, Medisense reserves the right to audit providers who are flagged to be spending excessively, though this is unlikely to affect most providers. Overall, providers are likely to prefer the simplicity and predictability of Medisense over the status quo.
Medisense significantly reduces administrative complexities in several ways. Besides the one-time effort of disclosing prices as mentioned above, Medisense does not individually negotiate prices for any procedure. This eliminates the need to manage these negotiations and also provides medical providers with the freedom to set prices that best fit their needs the needs of their patients. Additionally, patients come in knowing the cost of care, and medically necessary procedures are automatically covered, which eliminates the need to contest denied coverage. Finally, providers are paid directly and in full by Medisense, with payments arriving immediately. This eliminates the need for providers to establish payment collecting mechanisms from Medisense patients.
Medisense eliminates the need for providers to collect on unpaid bills by directly and automatically paying providers for full cost of care received. Individual patient responsibility for the cost of the care will be collected directly by Medisense.
Medisense does not directly approve or deny coverage for procedures deemed medically necessary by the provider. This means that coverage and payment is automatic. However, to ensure that providers are not overtreating patients or that patients are not seeking unnecessary care, Medisense reserves the right to audit providers. The basis of the audits is whether the care is medically justifiable, and providers will be flagged for unusually high spending. Sensible spending from providers is unlikely to be audited, but unusually high spending may be flagged. Medically unjustifiable and wasteful spending will need to be reimbursed to Medisense, and providers will be prohibited from recouping the costs of these audits from patients. Medisense understands the need for experimentation in medicine and will not penalize providers for reasonable deviations in the standard of care. Additionally, providers will have the option to appeal the decisions of these audits. Overall, this system discourages wasteful spending without micromanaging the doctor-patient relationship.
With greatly reduced adminstrative burden, providers can expect lower overhead costs. Streamlined payments enable more predictable compensation and reduced revenue losses from unpaid bills. Additionally, smaller clinics may find it easier to operate without the complexities of traditional insurance billing.
No, Medisense is a public option. Providers can still choose to work with private insurers, though over time more and more patients may choose coverage through Medisense.
Medisense reduces administrative costs through price transparency, no network designations, and automatic coverage of procedures. Members are incentivized to shop for the most cost-effective care, unlocking competitive forces among providers to further drive down costs. At the same time, Medisense provides security to patients through income-based premiums, vouchers for care, and continuity of coverage across jobs. This last piece levels the playing field for small businesses and entrepreneurs and promotes long-term health. Most importantly, Medisense fits into state budgets, generates winners, while providing meaningful reform.
Medisense legally mandates that all providers disclose prices for each procedure and service at the beginning of the year. Besides the one-time effort of disclosing prices as mentioned above, Medisense does not individually negotiate prices for any procedure. This eliminates the need for administrative staff to manage these negotiations and also provides medical providers with the freedom to set prices that best fit the needs of their patients. This market-based approach to pricing paired with tools that allow patients to shop around allows for competition among providers, which can drive down costs. In areas with few providers, Medisense can have a greater role in setting prices to ensure that patients are not overcharged.
Medisense drives down costs by first reducing administrative costs associated with network designations, individual coverage negotiations, and collecting unpaid bills. Second, patients are empowered to shop around for the most cost-effective care, which promotes competition among providers. Third, Medisense is a quasi-public agency, meaning that it does not exist to make a profit. Fourth, by allowing members to keep their coverage across jobs, Medisense is incentivized to focus on improving long-term health. This means that Medisense can promote preventative care and healthy behaviors, which drives down the cost of care for everyone.
Substantial psychological burden is lifted by providing simple, transparent, and secure coverage. Hours spent on the phone with insurance companies are replaced with minutes spent on the Medisense app. Workers are now able to leave their job without losing coverage, which allows them to take risks and find better roles. This improves the dynamism of the economy. Small-businesses are now better able to attract employees because of the more level playing field in finding health insurance coverage.
One of the things that makes Medisense different from other universal healthcare proposals, is that it is politically feasible at the state-level. It does this by being cost-effective and generating a lot of winners. As a public option, Medisense is able to be somewhat cost-neutral. Funding for income-based subsidies can be re-routed from existing government programs such as Medicaid, CHIP, and other state-level funding. Additionally, Medisense preserves private insurance, which makes it more politically palatable to those who are unsure about the promised benefits. As Medisense proves its worth, it is likely that more and more people will choose to opt-in to the program. Providers also benefit from the program, as it reduces administrative costs and regulations and allows them to focus on providing care. Thus, Medisense is not just a proposal for patients, but also for providers. Additionally, Medisense helps small businesses and entrepreneurs by leveling the playing field and allowing them to offer competitive health insurance options. Medisense makes meaningful reform of many major issues in healthcare, but it does so in a way that is realistic of political realities on the ground.
In order to make sure Medisense has a strong start it needs a foundation of stable membership. Therefore, Medisense will be the exclusive health insurance option for all state employees as well as public school employees and students. Medisense will also be required to be offered as an option for all employers in the state. This will allow Medisense to build a strong membership base at the beginning. Premiums pay for coverage for the most members, and subsidies for low-income individuals will come from existing government programs such as Medicaid, CHIP, and other state-level funding.