I’ll say it again, ‘Health insurance is not the same as healthcare.’

It’s not just the uninsured — it’s also the cost of health care

It’s not just the uninsured — it’s also the cost of health care

We still have an uninsured problem in the U.S., but we have a far broader health care affordability problem that hits sick people especially hard.

Why it matters: It’s time to think more broadly about who’s having trouble paying for the health care they need. The combination of lack of insurance and affordability affects about a quarter of the non-elderly population at any one time, but almost half of people who are sick.

Now that the Affordable Care Act has expanded health coverage, the percentage of the non-elderly population that is uninsured is now just under 11%, the lowest level ever recorded. But as the chart shows:

  • Another 15.5% who have insurance either skipped or delayed care because of the cost or reported that they or someone in their family faced problems paying their bills in 2017.
  • That brings the total percentage of non-elderly people with insurance and affordability problems to 26.2%.

More striking: nearly half of all people in fair or poor health — 46.4% — are uninsured or have affordability problems despite having coverage.

  • That includes 13.5% who were uninsured and in fair or poor health — arguably the worst off in the entire system — and another 32.9% percent who have insurance but said they or a family member have had a problem affording care in the last year.

It’s not surprising that people who are sicker and need more care would have more problems paying for it. But arguably an insurance system should work best for people who need it the most.

All this says a lot about current health care politics.

  • It helps explain why so many people name health their top issue, despite the progress that has been made in covering the uninsured. And everyone who’s sick and can’t afford medical care has family members and friends who see what they are going through, creating a political multiplier effect.
  • It is also why health care is substantially an economic issue as well as an issue of access to care. When people have trouble paying medical bills, it’s a hard hit to their family budgets — causing many people to take a second job, roll up more debt, borrow money, and forego other important family needs.

For as long as I have been in the field, we have used two measures more than any others to gauge the performance of the health system: the number of Americans who are uninsured and the percentage of GDP we spend on health. Both measures remain valid today.

The bottom line: If we want a measure that captures how people perceive the system when the number of uninsured is down and overall health spending has moderated, we need better ways of counting up the much larger share of the population who are having problems affording care.

And whatever big policy idea candidates are selling, from single payer on the left to health care choices on the right, the candidate who connects that idea to the public’s worries about paying their medical bills is the one who will have found the secret sauce.

The tide is changing

As an advocate of free market principles in healthcare, I’ve pushed for clear transparent pricing for all sorts of services.  Naysayers argue that in the time of crisis a patient shouldn’t be asking “How much to treat my heart attack at that hospital?”  I agree.  However, a large amount of healthcare is not delivered during a crisis.  And as non-emergent prices drop, so will other prices.  A bag of saline shouldn’t change price just because it’s given in the ER versus the office setting.

The University of Michigan healthcare site now lists prices for many common office visits, advanced imaging studies, and procedures.  While these prices aren’t really that good, it is a good start.  Prices get better when the seller, in this case the hospital system, has to tell the buyer, in this case a patient wanting healthcare in U of M’s system, because this gives the buyer a chance to say “Are you nutso? I can get that CT scan of the abdomen without contrast for $250 from my DPC physician.  I’m not going to pay $1442.”  That’s how the free market works.

CT U of M

I’d be remiss if I didn’t point out that virtually all of U of M’s preventative visit prices for each age group would cover either all or most of the cost of a year’s worth of membership.  Our pediatric membership is only $348/year which includes the well child visit AND ALL OTHER VISITS FOR ALL OTHER REASONS TOO!   Additionally, U of M’s pricing doesn’t include labs which drives up the cost more.

Preventative Visit pricing at U of M

Seriously, you should check out their prices.  A lipid panel for $135?!  Even with the 40% uninsured discount that’s a rip off.   I can buy a lipid panel for less than $3 which is why I don’t charge for it but include it free with membership.

lipid panel at U of M

So the tide is changing.  U of M has put all other hospitals and major medical centers on notice.  They will be posting their prices too and then we get to compare.  Feel free to compare them to my prices too. 

New Trump administration rule will require hospitals post prices online | TheHill

Hospitals will be required to post online a list of their standard charges under a rule finalized Thursday by the Trump administration.
— Read on thehill.com/policy/healthcare/400279-new-trump-admin-rule-requires-hospitals-post-prices-online

This is a good start. Of course the charges are all made up anyway but this should force them to start lowering the prices the be in line with what they are willing to accept. Next I’d like to see hospitals post reimbursement rates from insurers so cash payers could compare self pay pricing with insurance based pricing and those needing non-emergent services could price (and value) compare different hospitals. It’s not always best to seek out the lowest cost, but knowing what the competition charges might bring about a lower price at the place that offers a better quality service.

Is Your Child’s Liver Dying?

On the day after Halloween while your kids and mine are still suffering from a HFCS induced hangover, I’m going to be a buzzkill.  My kids will not be surprised.

Fatty liver disease fastest-growing reason for transplants in young U.S. adults

The shear amount of candy they collected in the neighborhood is insane. I suppose if I had gone to Krogers and bought this amount of candy, it would have been a small fortune.  But what are the long term effects of chronic sugar ingestion common in the Standard American Diet (which is very S.A.D.) let alone yesterday’s society induced binge begging holiday?

Fatty liver disease is a disorder where the liver simply fails to function normally due to being bombarded by a steady diet of carbohydrates.  One of the liver’s main roles is to create glucose, or blood sugar, out of almost nothing. It’s literally called gluconeogenesis (glucose-new-creation).  To describe how important this is, imagine if your lungs created all the oxygen your body needed to survive. Exploration of the ocean and of space would be so much easier.  That’s what your liver does with glucose. 

The liver produces so much glucose that you have no physiologic need to eat any glucose, or any carbohydrate, to survive.  In fact, for fructose, which is half the chemical structure of high fructose corn syrup, there is no essential metabolic reaction that requires fructose. You literally could never eat glucose or fructose and live a long, happy life.  In contrast, you may not survive six months without enough protein or twelve months without enough fat in your diet.

So what happens when we chronically eat too many carbohydrates?  Our liver continues to produce glucose but cannot deliver it anywhere.  It then, in an over-simplified explanation, tries to store it as fat (called a triglyceride) inside the liver. It starts to take up so much space it even becomes visible within the liver on ultrasounds and cat scans. 

With all this extra fat getting in the way do you think the liver functions normally?  No, of course not. The liver starts to become more and more irritated and eventually, cell by cell, it starts to die off. Fatty liver disease can progress to liver failure or cirrhosis. In the end stages the only viable treatment is a liver transplant. 

What can you do to save your child’s liver before it fails from all that Halloween candy and school snacks? Get out of the way and let it do its job.  Seriously, the single best thing you can do is cut out the excessive carbohydrates from their diet. Cut out all the liquid sweetened drinks.  Cut out all the Little Debbie snacks and treats. Cut back on other common carbohydrates like bread, pasta, potatoes, rice, beans, and corn.  Get the kids off the couch and on their bikes for a little exercise. What burns excess glucose better than active muscles?  Not much. 

And then comes the hardest part of prevention and treatment: Stop being a bad example.  Step up and change your diet to a low carb, high fat, whole food plan. If you don’t know how to do that. I’ll teach you. I had to learn myself and Trinity has spent the last 10 years building the area’s largest nutritional and wellness program which has already helped thousands of patients lose weight, reverse their metabolic disease, and preserve their organs.  VitalSigns Wellness is located in Hardin Valley at 2531 Willow Pointe Way. Their phone number is 865-249-7566. 

Call today to find out more. Trinity’s Direct Primary Care program helps members have better access to their doctors for more accountability and understanding about their health.  Our monthly memberships offer unlimited phone and email contact with office visits having no per visit fee. If you need to be seen five times in a month to get your blood sugar under control, we’ll do that at no extra cost.  Dr. Jackie Hone manages our Maryville office. She can be reached at 865-980-8551. I manage the Hardin Valley office and can be reached at 865-244-1800. Give us a call today to sign up.

Obamacare premiums expected to climb 38% nationwide

Axios.com reported this interesting infographic on the predicted average increases of Obamacare premiums when open enrollment starts November 1st.  It is expected to be a sharp increase again.  Tennessee is slated to be a 20% or higher increase as a statewide average. Knox County has fared worse than most Tennessee regions in the last couple years.  Many patients choose lower tiered plans to shave cost off their premiums only to find that their deductibles are so high they provide no practical help with day to day health needs. Even the gold plan requires  nearly $1200 out of pocket before it starts to cover routine primary care needs. 

Trinity Direct Primary Care stands ready to provide exceptional primary care services for you and your family regardless of insurance coverage or deductibles.  We offer month to month memberships that cover all visits, all phone calls, and emails with your physician and most in house labs such as strep tests and flu tests as well as many labs used to manage common medication concerns such as diabetes and hypertension.  One out of pocket payment for a walk in clinic or urgent treatment center often exceeds 2-3 months of membership costs. One 15 minute visit for the same price as 3 months of access in Direct Primary Care. Which seems like a better deal to you?  

Employers lower healthcare spending with Onsite Clinics and Direct Primary Care membership

blood pressure cuffTrinity Medical Associates offers two  excellent options for employers seeking to lower their healthcare spending while maintaining a high level of employee care and accountability.

The first choice is a Trinity Onsite Clinic.  We can setup, staff, and operate a full service primary care office within your facility.  With a Trinity provider onsite during the work day employees have ready access to a trusted healthcare profession from their community.  Follow up visits, wellness and nutrition counseling, and preventative health visits can all be obtained with minimal work interruption.  Trinity has become the second largest independent primary care group in the area and are able to provide a great depth of resources which are at the disposal of the onsite clinician.  Lab draws, point of care testing, referrals to specialists, and all typical primary care office services can be arranged through the onsite clinic.  Visits are most often processed on a fee-for-service basis through the employers health benefits plan.  Trinity operates several onsite clinics in the region and has the experience to establish new locations quickly and competently.

Dr.McColl-9768-683x1024The second choice is to provide employees a membership in Trinity Direct Primary Care.  Trinity established their Direct Primary Care (DPC) program in January 2016 and now operates the largest DPC practice in the region with offices in Hardin Valley and Maryville.  DPC focuses on providing members a comprehensive primary care experience through a low cost monthly membership fee.  Members have the freedom to directly contact their DPC physician via phone or email throughout the business day and schedule office visits that are longer in duration and more in depth.  With no per visit fees and most common labs included in the cost of membership, most patients have no extra charges apart from the membership fee.  Labs and services not covered by membership are offered at 60-90% off retail pricing.  Members also have access to discounted rates for advanced imaging such as CTs and MRI which are less expensive than rates provided through insurance plans.  Employers can choose to cost share with employees by having them be responsible for non-membership charges or choose to  reimburse employees for these charges.  This provides employers with a stable, predictable monthly healthcare spending plan.  DPC is especially appealing to employer with self-funded insurance plans.  Trinity DPC has contracted with several area employers who are providing full service primary care to their employees.

If you have questions about which program might be best for your company please contact Leah Parker, Trinity’s Practice Administrator, at 539-0270 or Dr. Mark McColl, managing partner of Trinity Direct Primary Care, at 244-1800.

Here’s a helpful reference article describing some of the differences of Onsite Clinics and Direct Primary Care programs.

What is the difference between an Onsite Clinic and Direct Primary Care? by Tom Valenti

Article: Health Care Is So Expensive Because You Don’t Pay For It Yourself

Health Care Is So Expensive Because You Don’t Pay For It Yourself

I could write a good review of this as it is an excellent read on healthcare economics.  This truly complex topic can be simplified by using a few easy analogies and these four quotes.  I’d highly recommend you read it for yourself though.


Health care is essential to life. But it is far less essential than food or housing, which do not require third-party payment.

What is unique about health care is not fee-for-service, but third-party payment. Only in health care is someone else picking up the tab for our spending.

The problem is third-party payment.


No one will ever reform the U.S. health care system without bringing the consumer along and, indeed, placing consumer choice and accountability at the very center of the reform initiative.


Article: The Truth About Healthcare That Nobody Will Discuss


Article: The Other Republican Health Plan

The Other Republican Health Plan

Democrats have spent most of this week accusing Republicans of trying to create a dystopia where Americans are denied basic health-care treatments. So note that the Food and Drug Administration, under new political management, took initial steps this week to lower the cost of prescription medicine for patients. You might not have noticed amid the latest Trump Twitter meltdown.

Earlier this week FDA published a list of drugs that don’t face competition from generic alternatives even though their intellectual property protections have expired. FDA said it will expedite the approval process for such applications “until there are three approved generics for a given drug product.” The agency says it will take more steps and has announced a July meeting for public feedback.

For some drugs on the roster, no company has submitted a generic application. One reason is that the cost of developing a generic product can run into the millions of dollars, and many can’t fetch the profit to recoup the expense. Yet competition is essential for lowering prices: Consumers pay 94% of the branded price on average when one generic firm enters the market, but that drops to 52% with two competitors and to 44% with three, according to an FDA analysis.


The savings ripple across the health-care system, and last year generics saved $253 billion, according to a June report from the Association for Accessible Medicines. Case in point are alternatives for chronic troubles like the cholesterol-reducing statin, Lipitor, which cost $3.29 a unit before its patent expired. The generic version last year cost $0.11.

One barrier to innovation is that some manufacturers are abusing FDA safety and risk mitigation regulations to protect monopoly positions. A generic competitor has to prove equivalence to the branded product to win FDA approval, and that requires extensive testing with anywhere from 1,500 to 5,000 tablets of the original treatment. But companies are invoking FDA safe-use and distribution restrictions to avoid handing over the capsules.

In 2014, Alex Brill of Matrix Global Advisors analyzed reported cases of this misuse. Delayed competition for 40 products cost $5.4 billion annually in lost savings, Mr. Brill found. About $1.8 billion of the cost is picked up by the federal government through Medicaid and other programs. This issue will no doubt capture attention at the agency’s public meeting next month, and Congress could help by codifying changes as part of an agency reauthorization. Bills to rein in this behavior have been introduced.

A larger challenge for FDA is developing an approval process for “complex generics,” like the allergy shot EpiPen, that require a device or present some other complication. The good news is that no scholar has devoted as much attention to the issue as new FDA Commissioner Scott Gottlieb, who has testified to Congress that the generic approval process was written when most products were molecule pills that were straightforward to recreate. Regarding EpiPen, FDA regulations helped keep a generic alternative off the market by requiring an identical device to deliver a shot of adrenaline.

This week’s announcement is the beginning of a process, and other unresolved issues include that most generics are not approved on the first round, and revisions create substantial work for companies and FDA staff. The agency also has a backlog of applications and has struggled to hire enough staff to keep up with applications.

None of this will ever attract the media attention of “Pharma bro” Martin Shkreli, who jacked up the price of a treatment that faced no competition, or the periodic mugging of some drug company CEO in front of Congress. But Dr. Gottlieb has dedicated much of his career to explaining the benefits that competition can bring to medicine, and now he’s bringing that experience to one of the most resistant bureaucracies in Washington.


Appeared in the July 1, 2017, print edition.

Knoxville: where insurance goes to die


Recently, various new outlets reported on the spiraling failure of the Affordable Care Act otherwise known as Obamacare.  One of the key indicators of failure is the availability of health insurance in a market.  Several major markets across the country lack more than one insurer from which individuals may choose.   When there is only one insurer in the market, like any other monopoly, prices rise.  This makes it more affordable for individuals buying policies.  In turn, the insurance company ends up dealing with more risky individuals which makes paying out on claims more costly.  Pinal County in Arizona was the first marketplace that experienced all their health insurance companies leaving the marketplace.  At the last minute, a deal was struck and those citizens were given an option.  Knoxville may not be so lucky.

Humana recently announced that it was not going to be offering health insurance on the individual market next year.  Blue Cross Blue Shield dropped out at the last minute in 2016 and stopped offering coverage the three major metro areas of Tennessee.  Over 130,000 Tennesseans lost their BCBS insurance as a result.  Humana’s decision is reported to affect 40,000 Knoxvillians.

As a physician this is heartbreaking to watch.  And yet, I’m very hopeful.  If this is going to be the epicenter of the modern national tragedy, I’m thankful that I’m here working and able to help.  Knoxville has a chance to show the rest of the country how healthcare can still be exceptional even when government sponsored health insurance fails.

I hope the story that comes from the failure of big business and big government to run healthcare is that high quality, affordable healthcare will always exist apart from their intervention.  Patients can get healthcare regardless of health insurance.  They always have and hopefully always will.  Direct Primary Care is charting a new path for patients to have their primary care needs met at a fraction of the cost.  Places like Good Shepherd Health and the Surgery Center of Oklahoma are offering affordable options for medications and surgery regardless of insurance.  We can make a better way for our neighbors and our community.

If you are interested in how Trinity’s Direct Primary Care program can meet your healthcare needs, then please give us a call or email me at mbmccoll@trinitymedical.net.  We can schedule a Meet and Greet appointment or a Medical Consult so that you can find out first hand how a DPC membership works.