FMMA Member Highlight

With a direct care practice, we're able to do several things that enhance the doctor patient relationship. I don't see as many patients as I used to. It's really hard to have a great relationship with your patients when you're seeing almost 30 individuals a day. In my practice today, I have much fewer patients, they have much longer visits. My initial consultation is 60 minutes, one-on-one, with me and we run like clockwork. With COVID, we've been doing a lot of virtual appointments but my patients always have the option, even before, for virtual visits, phone visits, I call my patients with their labs, I send them their labs in a timely way.

The point is that people need convenience and not everyone can take out a whole day to come and see their endocrinologist. Direct care gives me an opportunity to really know my patients, to engage with them, to have a relationship with them, be their cheerleader, be their support system, and answer questions that they have. There are so many things that we as physicians can do...but there are so many barriers to delivering that level of care for patients — especially for patients with chronic issues like diabetes. Direct care has enabled me to do that."

I had heard about concierge medicine for a while there were things I both liked and didn't like about it. Then I heard about Atlas MD, a group out of Wichita that have been doing direct care for a long time. I started learning about it, early in my practice. It just made so much sense to me. The non-transparency in pricing to both doctors and patients is harmful. I would have patients come and see me and they have insurance and their co-pay is $150 or $250. Or their insurance won't cover specialists visits at all...so the access to specialists was limited. I realized, they're paying these large sums of money to see me, with insurance — what if we just let go of the insurance and I could help them in other ways — such as with labs, better service, more treatment options?

​In a traditional practice, they're paying that much for a 10-minute visit. And that's not very good value. Not to mention the inconveniences of not being able to get through to your doctor, not being able to get an appointment in a timely manner, etc. The average endocrinologist has a 3-month wait-time to get in. So I thought, we can definitely provide much more value if we're not using this system."

I do have the chance to take on new patients but I do have to limit myself to only individuals with the specific issues I treat so that I can help them. I am so pro-physician-entrepreneur because it's a dying theme. So many practices are being bought by hospitals. In some ways, that might be beneficial. I do think you have to have vision and drive. If you want to be employed, that's great too because what I do isn't for everybody. But there is a space for this. I didn't think I was going to start my own practice. I just saw so many holes and gaps in the system and, also, holes and gaps in my life. So I didn't feel that there was an employed position that could fill those gaps.

The day I started publicizing that I'd be leaving my own clinic, everyone wanted to hire me. Cardiologists, family physicians, all these respected and established medical professionals here in San Antonio. And that told me two things. One, I've got something here and, two, there is still room for physician entrepreneurship. You don't just have to work for a hospital system. Of course that depends on your market, where you live, what kind of doctor you are, etc. But I do believe people should not be afraid to think outside of the box."

Through my personal experience as well as that of my patients, I've just been, to be honest, totally disgusted by the lack of transparency in medical care. It makes me feel like, what is this system that we're working in? What I mean by lack of transparency is that when you go to your doctor's office, you have no idea how much you're going to pay until they're done. You also didn't have the option to say yes or no to particular procedures. And then, worse, 3 months later, you get another bill...and then another...and another. People don't know that, hey, my specialist co-pays $60 but I actually spent $1,000 or I have $100 co-pay but I spent $2,000 on labs. I have patients who tell me they're spending $2,000 every 3-6 months on bloodwork. It's not that expensive! The only reason we're facing this is because nobody knows what it should cost.

There are people who are taking advantage of this fact. A lot of people are making a lot of money off of patients' and doctors' lack of education. I don't think that's ethical. Doctors-in-training are shielded from cost of care because the thought is that it's unethical to decide to type of care based on cost. However, that would be great if doctors were picking up the bill. And the fact is that not every patient can afford to spend $1,000 on an MRI. There are other options you can use instead as a doctor. Once I started learning more about this, it set me on fire. 

If you're in the direct care model, you start to have flexibility. You can negotiate prices for your patients, for example. That's how I got involved with FMMA —​ the pricing transparency and the improved quality of care you can provide patients when you're in a medical free market is life-changing for both physicians and patients."  

I can't say I have a firm plan for where I want to be in five years but I do want to be a voice for this city to use technology and telemedicine. That's part of what I researched during my fellowship and I utilized it a lot. I have spoken to officials here in the city about telemedicine as a way to access healthcare. The majority of people are dealing with chronic, metabolic diseases, especially in lower socioeconomic neighborhoods. Something we could do is have a hub where we provide telemedicine services, even if there's no setup for high-speed internet yet.

I want to help people recognize what the cost of poor health is. A patient with diabetes spends 2.5 more on healthcare than someone who doesn't face this issue. It is hard because some people feel that investing upfront in my services or in new therapies are higher. But the cost savings down the road is so much greater than the upfront cost. Health is something long-term...and I want to keep reminding people about that."

One of the biggest cost savers comes from healthcare operating under a free and open market.

I really want people to be happy with what they have. I want people to have a joyful experience during the process of getting coverage for themselves and their employees and dependents. I want them to have peace of mind. Sadly, this is not the experience that many Americans have when dealing with their healthcare. I joined the FMMA to represent brokers that are keeping Americans from falling into financial ruin through connecting them directly to sellers of health care where insurance is just not enough.

Many people struggle to find affordable health insurance that meets their needs and their budget. It’s not hard to find affordable insurance, but is it what you need? Even after they find insurance, most people have trouble understanding their options. A lot of customers end up making uninformed decisions.

I help people understand the complexities and constant changes in health insurance, Medicare, and related programs through my experience in the health insurance industry for over 13 years. I have been a licensed and trained insurance agent with experience working with individuals, families, and small businesses, and I’ve been doing it since 2007!

I’m involved in the Texas Tri-County Chamber of Commerce, Texas Tri-County Chamber of Commerce Toastmasters International, Federal Employee Service Association (FESA), America’s Health Insurance Providers (AHIP), and many networking groups across the city.  I love to meet people!

Allison de Paoli, CEO & Founder of Altiqe Consulting

We help employers get predictability. The happy side effects of what I do is that employees have access to higher quality care and lower out of pocket costs. I focus much more on connecting employees and employers to healthcare than I do selling health insurance."

Yes. We structure plans to help employers control their costs and help employees get access to care. One of the more ironic things about health insurance is the more access that people have to care, the less access you have to problems down the line. If I have diabetes and I go to see the doctor as I should, and I’m taking my medications as I should, and I get my teeth cleaned, and I get my eyes checked, I’m not a very expensive health plan. But if I do not go to the doctor and I do not take my medication then, one day, I can show up in the Emergency Room and will cost $40,000.​"

For a well-managed health plan, typically that means self-insured, it should not be an issue at all. If you are not on a well-managed health plan, I have no idea. I have seen -10%, -20%, +11%, +38%, +40% it’s been all across the board. It depends, but for a well-managed health plan, it should be a non-factor. If you have somebody that had a severe case of COVID-19, that’s going to be a shock claim for you but most employees have a typical amount of shock claims every year. If someone just had to stay home, that’s not a very big health claim. If you have someone that had to stay in the hospital for a couple of days, it can be a huge expense. It all comes back to how well-managed your health plan is.
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For months you’ve now had no elective surgeries. I know surgeons that are not just working Monday through Friday, but Saturday and Sunday to catch up on the backlogs. That’s all going to hit your plan now because most of the elective surgeries must be done.​"

Providers have all built a business plan that is profitable for them that is generally reasonably priced. You have an organization of people doing free market which shows that it’s possible, it’s a matter of connecting consumers to the members of the FMMA. Sometimes it is easier said than done, but there is high-quality, affordable care all over San Antonio, but you have to hunt to find it.​"

Employers offer employee benefits. More employers are starting to understand that the health plan they created is not helpful to the average employee. If your average workforce is making $12-15/hour and your deductible is $3,500 what you’ve given them is not useful to them. They will not seek care because they're afraid of what it will cost and they can’t afford it. They’re already living paycheck to paycheck, so it’s useless.

​My best clients, my favorite clients say, “We’re not wild about the cost, and we are a business and whatever we can do to reduce it we’ll do, however, we need to get something useful into the hands of the employees.” It takes all the stops off, because you can ask, “alright, have you considered Direct Primary Care or Direct Patient Care? Have you considered this kind of surgeon? Here’s cash pay only, but they cost a third of what it costs normally and their quality metrics are just as high and probably higher than this provider over here.” Helping an employer to understand this doesn’t happen in their office but they can set their parameters of the level of quality they want their employees to have access to and what kind of reimbursement level they want to pay for that care. It’s not an overnight conversation, it’s not a five-minute conversation, it’s a conversation that happens over time.​"

Family Service Association is one of the oldest organizations in San Antonio. They are 119 years old! Their mission is to strengthen families from cradle to grave. They own The Neighborhood Place. They keep kids in school and make sure parents are okay. They do community engagement, and more. South Texas Blood & Tissue Center is trying to get blood donations. Now that elective surgeries have started back up, San Antonio is in DIRE need. Donating blood is safe and easy. They are setting up at AT&T Center, and on social media, you can schedule your appointment so everyone is safe and protected.”

Allison is also the media chair of the San Antonio Health Underwriters. “We help insurance agents be better.”
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It just seems that the delta is getting wider and wider and I know banking employers that want to do the right thing for their employees but they don’t know how. Well, I know how. So I can help with that. 
Every employer is different, they don’t all need the same strategies and the same tools but they do need a bit of an individual kind of structure and those are easy to create, quite frankly.
Employers still need help in figuring things out and knowing what to do. I spend a lot of time talking to people.

I read all the time; non-fiction.  I actually read a fiction book called Untamed by Glennon Doyle and I highly recommend it.

Seth Denson

“There is only one way to reduce health insurance premiums, you reduce the number of claims you’re consuming, or the price at which you’re consuming those claims.”~

It’s also important to keep in mind, there are only two types of insurance, self-funded and fully insured; there is no “in between”.

“Healthcare trend will be up next year.  In turn, health insurance trend will be significantly up two years from now, and so those are the things that you want to start thinking about as you start thinking long-term.” ​​

“Roughly 90% of all APIs, (these are what are called active pharmaceutical ingredients), that go into the drugs that you and I take each and every day, are manufactured in the People’s Republic of China.  That should strike fear into anyone in the United States.  If China wanted to get really serious about having an overall impact economically or socially in the United States, they could do so without ever firing a shot.  They just shut us off from our drugs.” ​

 “As a result of Coronavirus, insurance companies who, by and large, along with Medicare have set RV units, have restructured the way by which doctors can be compensated for their work.

“Insurance networks provide no intrinsic value to the healthcare system.  They create an opaque curtain by which the healthcare system and the health insurance system can be in collusion….What I loved seeing as a result of the situation that we were in is, for a brief moment, nobody was worried about insurance networks, the Javits Center in New York became a makeshift hospital. No one knows today whether or not that was in-network with Blue Cross, United, Cigna, Aetna, insert-name-of-insurance-company-here, and quite frankly, nobody cared.  And, that’s the way it needs to be.

In short, while they shouldn’t conflict with each other, healthcare needs to be healthcare, and insurance needs to be insurance, and neither one should interfere with an understanding of the care received or the price paid.

Future predictions for the short term; lower health insurance trend. Long term, however, higher health insurance trend..  Secondary long-term health insurance trend will be higher than the first.  As health insurance trends tend to follow healthcare trends, whatever healthcare does today, the health insurance industry will quickly follow.

 “70% of all drugs delivered in the United States are done so through a mechanism of one of three pharmacy benefit managers.  They were supposed to be the Sam’s Club and Costcos of the pharmacy industry.  Instead, they have become more like the loan shark on the back end where you never know what you’re getting and what you’re paying for. The pharmacy benefit manager is the cash cow for the health insurance industry."

70 percent of all prescription drugs are filled by one of three prescription benefit managers.

“You may ask, if they’re very thin and there’s no margin, why are hospital systems buying physician practices as quickly as they can and why would a recent financial report show that their average return on investment is eight to one? Because that’s the sales force. The doctor has become the sales force, which is why it has never become more important for you to engage with the doctor.”

​“The American citizen is not a good consumer when it comes to healthcare.  We must help them along and give them the tools to be that.  The second thing is everybody is self-funded.”  “You need to get engaged with your insurance company whether you’re fully insured or self-funded; start understanding the pool structure.  Ask questions! Get them answered!  You don’t like the answers?  Go find somebody else!  That’s the American way.  Start being a consumer and acting like it.  That’s the only thing that’s going to solve this problem.  Don’t be subservient to the industry.  Take control of it.”

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Dr. Ray Altamirano, San Antonio Business Journal 2020 Man of the Year, standing next to his lion portrait

We have a home 24/7 for those who have tested COVID positive and they can come here to get treated.

I reached out to people who were in this group of creative and eager social entrepreneurs like, 'hey, let’s find another way to get tests out there.' What we did is not a matter of competition, the goal is to test as many people as possible. When you look at the objective of testing it’s to help the current system in place, which is Metro Health locally. 

​Metro Health is hiring more contact tracers. If you get more contract tracers you can nip this thing and it’s usually the asymptomatic tracers that are spreading it. That’s what we’re trying to capture by testing more people.

I help those who test positive.

Part of what separates what we’re doing is that we include a telemedicine visit for those who test positive and for those who test negative but are symptomatic they can go to their doctor, or Casa Salud.

These last few weeks with this demographic, there are so many courtesy visits that I’m doing without them paying because they can’t. I think [about] doing the right thing for people.

It’s hard to predict who is going to get super sick.

At first, they thought it was only the elderly, but if you start looking at diabetes and obesity, San Antonio is the diabetes capital of the United States. Maybe you don’t have it but Gramma could get it.
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The more you can test, the more you contact trace.

​I’m from the south side. I’m very proud to be Mexican. I’m proud to cater this demographic that doesn’t exclude anybody but serves more blue collar workers that are just working contributing to this country.

They need access. And good access--not just any access. I decided I was not going to wait for a government agency to do it. It has to come from us.

I said, ‘the only way I’m ever coming back to primary care is on my own terms' because I don’t want to be working in the system contributing to these money games with diminished care.

I wanted to be back in the community through primary care and I knew the only way that would work is to be outside of the world of insurance, so that’s why in March of last year I formed my clinic, Casa Salud Family Medical Clinic.

There’s definitely more liberty to treat how I see fit. There’s luxury that I have working outside of the world of the networks of insurance. For me, I like staying fee-for-service mostly to fit my demographics. However, I have the luxury of having my ER job and I see my clinic as more of a service for people who don’t have insurance and I’m able to have some staff.

It’s a matter of creating a free market and what I’ve learned about insurance and about labs that take insurance, about imaging centers, etc., is the prices they fill out are completely arbitrary. There are numbers much less than that they’re willing to work with if you’re paying with cash, So that’s definitely what I love about my clinic and how I feel that freedom.

The most important thing that I’m doing outside of treating patients is training mid-levels. They learn conscious medicine, putting prices on what they need to do because that’s what people are most worried about.

​Patients are more concerned about what it costs than why they’re sick.

When they see there won't be any back billing that will put them in bankruptcy for a procedure or for anything because I was able to negotiate upfront a price and approach the problem with a price tag to it, it is more effective.

I really like the service in my community. I think what I’m doing serves as a blueprint for anyone who wants to do that for their own community. If they want to train under me that’d be great. I tell everyone that there is a way to make money and you don’t have to be a specialist. 
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You can be a primary care doctor and still earn a good living through this model and be completely free and have the liberty to practice as you choose and you’re working for your patients not the payer,

​so that’s exactly why I do what I do with my clinic.

Pictured above: Member of the San Antonio Free Market Medical Association Dr. Ray Altamirano of Casa Salud Family Medicine Clinic holding his artwork from his collection that can be found on Facebook page ‘Amar es Vivir.’