Stop Adding. Start Subtracting
David Epstein has been talking about a bias most of us never name. When something is broken, people reach for more. More parts. More rules. More layers. Researchers call it subtractive neglect. We overlook the fix that removes something.
Healthcare is that experiment at national scale. A visit gets a prior auth. A prior auth gets an appeal. An appeal gets a portal. A portal gets a middleman. Nobody asks whether the claim should have been there at all.
I am not shocked. The system was built to add. Direct care is the subtractive move. Flat monthly fee. No claim. No network. No permission slip before you see your doctor. Keep a policy for the wreck. Primary care is not a wreck. We take care of patients for a flat monthly fee. The number on the door is the number you pay.
You do not need another layer on the Lego tower. You need the one brick taken out.
Source clip: www.instagram.com/reel/DcJna25mwIl/
One Hundred Fifty Dollars Keeps the HSA Open
Congress did not invent Direct Primary Care. It finally stopped punishing people for buying it with an HSA.
Under the new rules, a qualifying DPC membership stays compatible with HSA contributions if the fee stays at or under one hundred fifty dollars a month for one person, or three hundred for more than one. Go over that line and you can still pay the fee from the account. You just cannot keep feeding the account while you are enrolled. Most adult DPC memberships already sit between fifty and one hundred fifty. The ceiling is not a price. It is a permission slip.
Source: www.irs.gov/pub/irs-drop/n-26-05.pdf
I am not shocked. For years the tax code treated a flat primary-care fee like "other coverage," as if texting your doctor was a policy. Patients chose between the membership and the savings account. That was a paperwork tax on common sense.
I am not anti-insurance. Keep a policy for the wreck. I am anti a rule that made the cheap, monthly door the expensive one. We take care of patients for a flat monthly fee. No claim. No network. The number on the door is the number you pay, and now the HSA can help pay it.
One hundred fifty is a line. Stay under it and the savings account keeps working.
Forty-Six Minutes on Shrugging Off Insurance
Josh Umbehr sat down with Center for Modern Health’s Healthcare Builders podcast for about forty-six minutes on a line we keep repeating: shrug off insurance for most care, keep it for the wreck, and let Direct Primary Care rebuild the doctor–patient relationship.
That is not a stunt. It is the model. Flat monthly fee. No claim. No network. A doctor who answers. Catastrophic coverage for the day you need the hospital. Primary care should not ride the premium.
If you want the long version in his voice, the episode is up.
Same Brain MRI, Thirty-Six Times the Price
Same scan. Same CPT code. A brain MRI without contrast.
At Henry County Memorial in New Castle, Indiana, the posted cash price is four hundred six dollars. At Sky Ridge Medical Center in Lone Tree, Colorado, it is fourteen thousand six hundred eighty-one. Thirty-six times more. MedicalPriceCheck pulled those figures from two hundred seventy-four hospitals across forty-six states. Five years after the federal posting rule, the gap did not shrink. It just got public.
Source: medicalpricecheck.com/research/mri-cost/
I am not shocked. A posted price without a shopper is still a sticker.
The median cash brain MRI sits around twenty-two hundred. Freestanding imaging shops run lower still. The transparency rule showed the problem. It did not fix it. The winners are the patients who know to ask for the cash price before they walk through the door.
I am not anti-insurance. Keep a policy for the wreck. I am anti a ZIP code that multiplies the invoice by thirty-six. We take care of patients for a flat monthly fee. No claim. No network. The number on the door is the number you pay.
Thirty-six is a price. It just depends which door you open.
One Hundred Fifty Hospitals Kept Their Name on the Door
Becker’s Hospital Review counted more than one hundred fifty independent rural hospitals across eight states that have joined clinically integrated networks in about three years. Shared data. Shared quality measures. Shared negotiating leverage with payers. Local boards still own the place. The buildings did not get absorbed. The letterhead did not change.
Missouri just added the newest chapter. Twenty-three independent hospitals launched the Show-Me High Value Network. Together they serve more than 1.8 million people. Craig Thompson, who chairs it, said the point out loud: gain scale with peers while preserving the local focus that defines the care. Optional shared purchasing. Optional shared services. Nobody had to sell the hospital to get a seat at the table.
I am not shocked. Rural hospitals have been staring at the same fork in the road for a decade. Go it alone and watch margins thin. Sell to a system and watch the name on the door become a logo. The network is the third door. Affiliation without absorption. Independence through a handshake, not a closing.
That is not a hospital story only. Direct primary care doctors live a smaller version of the same choice. Stay independent. Show price, access, and care in numbers a patient can read. Keep your name on the door. Join a peer group when you need scale for labs, contracts, or purchasing — without turning into a brand that forgot who answers the phone.
I am not anti-systems. Some towns need the big hospital. I am anti the idea that independence means isolation, and that survival means selling. We take care of patients for a flat monthly fee. No claim. No network tax. The number on the door is the number you pay. The name on the door is still the doctor’s.
One hundred fifty is not a merger count. It is how many hospitals decided not to sell.
Source: www.beckershospitalreview.com/finance/the-rural-hospital-network-boom-150-hospitals-8-states/