You have two ways to obtain Ozempic/Wegovy (semaglutide) or Mounjaro (tirzepatide):

1. Compounded semaglutide or tirzepatide from a compounding pharmacy or…
2. A Prescription for the name brand drug Ozempic/Wegovy (active ingredient semaglutide) or Mounjaro (active ingredient tirzepatide).

The Benefits of the compounded semaglutide or tirzepatide are as follows:

• Medication shipped to you
• No hassle at the pharmacy
• No lines
• No insurance hassles
• No backordered medication

Drawbacks of compounded semaglutide or tirzepatide:

• Out of pocket cost
• May not be able to access semaglutide or tirzepatide from a compounding pharmacy in the future due to FDA regulations

The Benefits of a Ozempic/Wegovy or Mounjaro prescription:

• Insurance may cover some or all of the cost

Drawbacks of Ozempic/Wegovy or Mounjaro prescription:

Moujaro/tirzepatide: Whether you’re getting your medication directly from a compounding pharmacy or getting a prescription submitted to a traditional pharmacy, you will sign up here for the $600 monthly subscription of Mounjaro/tirzepatide. You will be charged $600 every 28 days for the first 6 months and after each charge, we will ship 4 prefilled syringes to you for your once per week injection or we will submit a prescription to the pharmacy of your choice that has the medication and dosage in stock.

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You probably didn’t know price transparency was being utilized for any healthcare services, much less cosmetic services! But it’s true. Consumers are demanding price transparency, ie knowing how much services are going to cost before they get said service. It seems like a novel idea but we know the cost of a service ahead of time in every other industry. Somehow, medicine was the exception, until now.

Initial objections to price transparency in the cosmetic space

When we started our journey along the path of price transparency, we started within the realm of cosmetic services. Cosmetics is easier in the sense that patients pay the cost out of pocket. There is no insurance middleman. Still, doctors said giving the consumer pricing info ahead of time was too difficult. What if the patient isn’t a candidate for that procedure? What if they need more than one syringe of filler. While these are examples of potential obstacles in rolling out price transparency initiatives, they’re about the lamest excuses ever.

Without knowing anything about cosmetic services, anyone with half a brain would understand how to overcome these objections. What if the patient isn’t a candidate for the procedure they checking pricing for?! Then you’ll educate the patient regarding the correct procedure, just as you would with any patient with unrealistic expectations, regardless of whether they knew cost ahead of time.

What if they need two syringes of filler?! Then list the price for one syringe of filler and, wait for it….list the price for TWO syringes of filler! As long as you’re providing accurate estimates, it’s worthwhile actionable information for the patient. They will understand if the estimated price they saw ahead of time doesn’t match the price given after the consultation – as long as the price difference is due to the doctor recommending a more appropriate procedure that is significantly different than the patient’s preconceived expectation. Conversely, if the pre-consultation procedure is the same as what the doctor recommends and the price is different, then that’s probably an example of a bait and switch. That’s not a problem with price transparency. That’s a problem with how your parents raised you!

Examples of how price transparency works across all healthcare sectors

If there were ever any doubts that you couldn’t provide useful pricing information for medically necessary outpatient services typically paid out of pocket because the consumer hadn’t met their deductible, then doubt no more! Enter, the Ohio Surgery Center and Georgia SurgiCare. Both providers/facilities provide pricing information in the form of a Price Estimator on their website.

The unique aspect of how they showcase their pricing is that the consumer gets instant, automated pricing information but only after the consumer provides their contact info. So the prospective patient gets what they want immediately, satisfying that need for instant gratification. And the provider gets the consumer’s contact info, a lead for follow up. Everyone wins.

These two facilities provide their pricing in two different ways. And that’s the point. Everyone can embrace price transparency in their own way and generate a lead in the process. That’s price transCAREncy! In the case of Ohio Surgery Center, the consumer can choose their insurance plan and then the procedure of interest. After the prospective patient enters their contact info, they receive an email with the allowables that the Ohio Surgery Center can charge for the doctor’s fee, the anesthesiologist’s fee and the OR fee based on that procedure and insurance plan. Pretty slick!

And in the case of Georgia SurgiCare, their website allows the consumer to check pricing on procedures from their multi-specialty clinic. They include procedures such as bariatric or general surgery services, as well as gynecological services. While the more medically necessary services are presented as bundled rates that include the MD, OR and anesthesia fees, their cosmetic services are shown as “simple” out of pocket fees.

No more excuses!

Price transparency, as demonstrated above, can be showcased in multiple ways. From insurance allowables specific to the consumer’s insurance plan to bundled or fee-for-service prices. It’s not a matter of “will it happen?” It’s happening! See how you can join the #PriceTransCAREncy revolution here!

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Price transparency isn’t just for cosmetic services anymore! first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

In the case of an insurance patient, they often just go with the doctor within their insurance network (not much choice). In contrast, the cosmetic patient can choose anyone they want. Simply by having a choice engenders a difference in expectations. Even still, I didn’t fully appreciate some of these differences in expectations until talking to one of my patients.

Things to keep in mind with the cosmetic patient vs the insurance patient

Of course every doctor should treat every patient, whether they’re using insurance or not, with respect. The primary goal is for the doctor to treat them to the best of their ability and safely. But after that minimum requirement, differences do emerge.

Think about when you go see a doctor for a medically necessary service. Your insurance requires you to pay a copay. Then potentially, your insurance covers a portion or all of the actual treatment. Regardless of whether you get another treatment, the copay doesn’t go “towards” that treatment. The treatment is covered or paid separately. That seems to be the running etiquette for an insurance-based visit and patients seem to recognize that.

Compare that to the typical cosmetic consult. You may have to pay for the consult (like a copay). But if you do receive treatment, your consultation fee goes towards that treatment (unlike a copay). I had a patient that recently went to another doctor for a cosmetic consult for a treatment I don’t offer. She was shocked to find out that the cosmetic consult fee was just the fee for the consult and would not be applied to any treatment. So this doctor was treating his cosmetic patient like an insurance patient where the copay didn’t go towards the treatment.

Copay vs Consult Fee

I don’t know why it’s ok for a copay to not go towards treatment but a cosmetic consult fee is expected to go towards treatment. But that’s what patients think is appropriate. So in the case above, the doctor that treats a cosmetic patient like an insurance patient in regards to the consult/copay is going to have an unhappy cosmetic patient. While obvious to me after the fact, I would not have appreciated this nuance prior to my patient telling me this story.

Our office doesn’t have this problem. Our consult fee goes towards treatment. However, it does make me worry I’m missing some other nuance in expectations from the cosmetic patient.

That being said, I definitely know one experience that both the insurance and cosmetic patient want, but don’t expect, but should! That’s pricing. How are we still in a society where you can know pricing on a car or house but not an X-ray or tummy tuck? The issue of price transparency for cosmetic services has been solved as you can see here.

The insurance industry on the other hand is ready with an excuse. Because of varying policies and negotiated rates, it’s too difficult to explain pricing ahead of time.  But difficulty isn’t an excuse for complacency. Whether it’s showcasing negotiated rates, reference pricing or bundled fees, the insurance patient should have, and eventually will have access to pricing prior to receiving treatment.

If you’re looking for pricing from a doctor near you, click here.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post The cosmetic patient vs the insurance patient first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Now that more patients are paying a portion of their healthcare costs of out pocket, eventually they’ll experience sticker shock in healthcare. To minimize sticker shock, the office staff must have that awkward conversation about “getting paid.” In this recent post from InstaMed, a healthcare payments network, they discuss four kinds of conversations healthcare staff can initiate to improve the payments relationship with patients. Let’s review the four kinds of conversations, and then one way to pre-empt the entire discussion.

Sticker shock in healthcare

The InstaMed post details these four kinds of conversations:

• -“What Payment Method Would You Like Us to Keep Saved on File?”
•  -“Your Credit Card Information Is Secure.”
•  -“We’ll Never Charge Your Card More Than What You Owe.”
• -“We Want to Make This Easy for You – You Have Options.”

Who could argue with these attempts to start the conversation? They’re polite but also direct.

Certainly patients think of doctors and doctor’s offices as places for offering care. But they forget the business side of the medical practice. Or simply don’t consider the very basic need of the doctor’s office to pay their employees or utility bills to keep the doors open. There’s a disconnect. And while that disconnect will never be fully repaired, patients eventually have to know they will owe money for the care they receive.

The InstaMed post refers to these conversations as ways staff “can initiate” the discussion. But these are techniques that shouldn’t initiate the conversation but rather continue the conversation. How should one initiate the conversation?

Make it clear on the doctor’s website that these services cost money and give the patient an estimate of those costs. There’s a fast-moving trend to push for price transparency on facility websites. But don’t just list a static menu of pricing. Get something in return, like a lead. By generating a lead in exchange for providing a cost estimate, the facility can then follow up with the consumer and help navigate them through the healthcare process from the start. Once they arrive, continue the conversation based on the four recommendations above.

Want more insights into payor relations, price transparency and lead generation? Attend the InstaMed User Conference! Use this discount code IMUC18-KEY99 to register today! Learn more and register here. #InstaMedUC18

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Preparing patients for sticker shock in healthcare first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

What will the CVS Aetna deal mean for primary care doctors

There are many unknowns with this new CVS Aetna deal. What will happen to Aetna competitors that use CVS as their pharmacy benefits manager? What will happen to CVS competitors that fill prescriptions for Aetna members?

Who knows! There are a million outcomes and ripple effects to this deal. We’ll have to wait to see what happens. But for the purposes of this post, let’s focus on the effect on primary care doctors.

The new combined company doesn’t own any physician practices, no hospitals or surgery centers. They aren’t bringing on doctors from the deal alone. Currently, CVS has Minute Clinics that heavily rely on nurse practitioners and in some locations, primary care doctors, that offer primary care services in their retail stores.

As Minute Clinics expand, Aetna will start to push their customers/members towards primary care in these retail based clinics. Of course, critics are welcome to suggest that consumer care will suffer with patients going to Minute Clinics rather than a primary care physician, but it will be less expensive for the consumer.

Obviously if consumers don’t receive some continuity of care, they’re theoretically more likely to end up in the ER. And that will ultimately cost Aetna more in paying out benefits. To avoid this outcome, there will be a shift in Minute Clinics becoming less like one-off clinics and more like a primary care doctor’s office.

For this reason, the CVS Aetna deal will begin to supplant the traditional primary care doctor’s office. And who knows, maybe they’ll also start to offer a concierge, direct primary care option. No one is safe anymore!

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post One aspect of the CVS Aetna deal – Primary Care Physicians first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

The knowledge gap in healthcare

The article above tells the story of a family taking their 3-year old to get an MRI for a new-onset illness. They did some cursory work to determine their out-of-pocket cost for this service. They thought they had a general idea of the cost beforehand. A few thousand dollars probably. Their bill ended up being $25,000. This was partly because they chose to go outside of their Obamacare-exchange insurance network.

Yes, this is expensive and yes, there are hidden fees at some facilities. That was the point of the article. But there is an underlying knowledge gap that led to the decisions on the part of the family, and even the facility, where the MRI was done. That was not the intent of the Vox article. Let me explain.

Extending bad insurance to more people isn’t the answer

First, Obamacare exchanges provide insurance for more of the population that what was available pre-ACA. The article correctly points out that it made insurance more affordable to the consumer. But did didn’t change the underlying cost of healthcare. But what is also missed by the consumer is that you can’t solve the healthcare crisis by extending bad insurance to more consumers. Not everyone takes these Obamacare exchange insurance plans because they reimburse so poorly. As in this example, Stanford Hospital didn’t accept the family’s plan because of low reimbursement from the insurance company. So the family was forced to pay the costs out of pocket. This leads to another example of a knowledge gap.

Don’t go out of network for standard procedures

While the family was forced to pay out of pocket because they went out of network, going out of network wasn’t necessary in the first place! The family thought that they should get the MRI at a hospital that specializes in that particular disease process. What they didn’t understand is that an MRI is an MRI is an MRI. No matter where you get it. An MRI is a commodity which means it’s essentially the same test no matter where it is performed. So best to get it in-network and avoid the costly out-of-network rate.

Sometimes, even the facility doesn’t know what they’re talking about

The next example of a knowledge gap was on the part of the facility. When the family called around asking about pricing, my guess is they “simply” asked about the cost of an MRI or more specifically, the cost of an MRI for a 3-year old. The distinction is critical and I would argue the facility didn’t appreciate this distinction when providing an estimate beforehand. You see, an MRI requires the patient to stay perfectly still for the better part of an hour. While some adults may be able to do this, clearly a 3-year old child can not. So part of the $25,000 bill from Stanford was for an anesthesiologist and placing the child under general anesthesia for the MRI. Placing a child under general anesthesia for an MRI may sound unusual but it is necessary for a study (MRI) of this nature.

Yes, the cost of healthcare is critically important. While checking pricing on healthcare services is easier than ever, it can’t completely fill the knowledge gap. Parents will continue to think they’re doing the right thing by getting insurance, even if, unbeknownst to them, few facilities will accept it due to poor reimbursement. Consumers will still think they have to go to the most well known institution for a test that can be done anywhere (and probably for less). And ultimately, the consumer’s knowledge gap is no match for knowledge gap exhibited by the facility for their own services!

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post The knowledge gap in healthcare is wider than I realized first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

What’s the difference between the free market rate and the negotiated rate

The negotiated rate is the amount the insurance company “negotiates” on your behalf as a consumer. They negotiate the amount they will pay the doctor or the hospital or X-ray facility for example. How they arrive at these negotiated rates? We may never know!

But here’s the interesting thing. Even if you’re paying for a service out of pocket to an in-network doctor or facility, you would still pay the negotiated rate. Again, the insurance company negotiates this rate for you even if they themselves don’t end up paying for it. We’ve come to expect that the negotiated rate is the best rate, but it’s not. And that’s what brings us to the concept of the free market rate.

The Free Market Rate

The free market rate is what some doctors and facilities (like this one and this one) charge for services. The facility has left the insurance company out of this discussion. They come up with a charge that covers their expenses for whatever services they’re providing, plus a reasonable profit margin. Yes, that’s right, it’s still ok to make a profit without sticking it to the consumer. But at the end of the day, the free market rate will be less expensive than the negotiated rate. Why? Because the insurance company’s bureaucracy has been left out of the decision-making process.

The facility doesn’t submit your claim to the insurance company for payment when you pay the free market rate. The idea is that if you have a high deductible, you’re paying for the service out of pocket no matter what. Might as well pay the most affordable rate – the free market rate. While the facility or doctor doesn’t submit this for insurance, you can still send your receipt to the insurance company so that it counts towards your deductible.

Now, you may be thinking, let’s just submit it to insurance to see if they cover it. Don’t do that! If you try to submit something to the insurance company and they don’t cover it because you haven’t met your deductible, then you’re stuck with the negotiated rate. You can’t go back and ask for the free market, or cash-pay, rate because the facility has already gone through the process of submitting your claim to the insurance company.

Now that you’re armed with this knowledge, your next step is to check pricing from a facility near you, which you can do by clicking here.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Free market rate vs the negotiated rate first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

FMMA: Join the Healthcare Revolution

According to the FMMA website,

“The Free Market Medical Association’s goal is to Unite and strengthen the benefits of free market healthcare.

We facilitate and assist:

• Patients finding free market doctors.
• Free market physicians growing their practice.
• Facilities being able to run their businesses like a business.
• Business owners who want to provide quality affordable healthcare for their employees.

Our mission is to unite all of the “Islands of Excellence” in healthcare and accelerate the speed and growth of the free market healthcare revolution.”

Price Transparency and Lead Generation

Price transparency is one of the pillars of the FMMA, which is the topic on which Dr. Kaplan will be speaking. His talk, entitled, “Think like a Plastic Surgeon: Combine Price Transparency with Lead Generation!” will take the audience through a journey.

He’ll start with a discussion of the new healthcare consumer. This new consumer is less beholden to their healthcare plan. They’re paying more out of pocket and therefore want the most affordable option. Surprisingly, their in-network negotiated rate isn’t always the least expensive. With a more inquisitive consumer, they search out the best option, taking quality and cost into account. They figure, “if I have to pay out of pocket because my deductible hasn’t been met, then I need to find the best price for my budget.”

With this understanding, Dr. Kaplan will point out that the cosmetic surgery patient has thought like this for years! Aside from checking reviews and other quality measures, they’re curious about price since they’re paying out of pocket.

Similarly, the cosmetic plastic surgeon has been navigating this type of consumer-driven marketplace for years as well. For that reason, plastic surgeons dealing with cosmetic, cash-pay patients can offer guidance to doctors offering medically necessary services that are typically paid out of pocket because a deductible hasn’t been met within a high-deductible health plan.

To capture and retain these cash-pay patients, Dr. Kaplan has developed a platform to allow consumers to check pricing automatically on the doctor’s website but only after the consumer provides their contact info. This way, everyone wins. The consumer gets pricing information they’re so desperately looking for and the healthcare provider generates a lead for patient follow up.

To check pricing from a doctor in your area, use the BuildMyBod Health platform here.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post BuildMyBod Founder Speaking at FMMA Annual Meeting first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

What are pre-existing conditions?

With the advent of the Affordable Care Act (Obamacare), insurance companies could not deny coverage for pre-existing conditions. For example, if you had cancer or cystic fibrosis and lost your insurance, the next insurance company might not cover you. Health insurance companies want your premiums but would rather not pay out a benefit. So if you have a pre-existing condition, they would prefer not accept you as a customer because of the risk of a high payout.

The Affordable Care Act stopped that from happening. While it didn’t get rid of pre-existing conditions, the Act simply made it a requirement that insurance companies cover anyone with a pre-existing condition. Those patients unfortunately cost more. So rather than charging only the patient astronomical insurance premiums, that cost is spread out to the rest of us.

Everyone is welcome to their opinion in regards to whether that is fair or not. That’s not the purpose of this post. The point is to separate fact from fiction regarding pre-existing conditions. In recent discussions, the suggestion is that a child born with a birth defect is now labeled as having a pre-existing condition and can’t get coverage. That led to the suggestion that a child with a pre-existing condition would not get treatment in the hospital at the time of their birth because they couldn’t get insurance.

Even kids with pre-existing conditions get coverage

If you think I’m misreading the conversation, I beg to differ. Proponents of Obamacare claim that until the Act’s passage, newborn babies would not get treatment because of their pre-existing condition. So does that mean before Obamacare, a hospital could discharge an ill newborn baby because they didn’t have insurance?! Of course not.

Even before Obamacare, there was Medicaid, a state insurance plan. Medicaid has a unique characteristic that differs from all other insurance plans. It covers illness retroactively. That means you can get sick and even if you don’t have insurance and qualify, the hospital will assist you in getting coverage. In other words, Medicaid will agree to pick up the tab even if you got sick before you had insurance! No other insurance does that.

And that’s why kids born with congenital abnormalities, even if they have a pre-existing condition, can still get insurance. With or without Obamacare.

Click here for the original blog post written by Dr. Jonathan Kaplan for BuildMyBod.

The post Let’s be clear about pre-existing conditions first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.