Introduction

Usually in this space we discuss health care and health insurance and today is no different. We have all read the articles about integrating coverage into the medical record and thusly automating the entirety of the health insurance industry. Here is an article with details about that. Acquiring the bell, however, is far different from tying it on the cat. Today, then, let’s discuss how we can actually deploy a new type of coverage (we aren’t using the term “insurance” that is what the big legacy bizdiots do), acquire consumers and deliver coverage.

The Concept

We, Sentia, as the coverage company, provide the Electronic Medical Records system (EMR) to practices and hospitals. We integrate coverage right into the EMR. That means that as a patient encounter is documented, we can pay for procedures performed in real time.

A New kind of EMR or The Secret Sauce

All current EMRs use the Epic process. They force practitioners to write their notes in English so that they then have to be translated by medical coders to the codes insurance companies pay. Sentia does things differently. We use discrete values plucked out of a database to document care. That means that not only is there no medical coding, but we can relate symptoms to lab results to diagnoses to treatments to outcomes. That gives us the ability to research a set of symptoms and give the practitioner a list of possible diagnoses based on historical values along with outcomes. Imagine Dr. House just sitting down and typing the symptoms into the EMR and getting 5-6 differential diagnoses with a list of tests run and outcomes. The show would be really short, but patient care would be greatly improved.

Further, Sentia’s EMR is universal, meaning you can document any kind of care with it. There are 130+ specialties in medicine, meaning that every other vendor on the planet, according to Epic’s legacy playbook, writes 130+ different programs, one for each specialty. This is madness and just a bad practice all around. We use the UMLS, a nomenclature suitable to document any patient encounter, any time anywhere, fixing their shortsighted mistake.

The Costs and Savings

An Epic installation can cost over a billion dollars. Sometimes Epic installation just fail and the hospital is left to fend for themselves with paper. Sentia’s EMR requires no installation, is universal and charges $10 per login/practitioner per month.

Integrating coverage into the EMR also automates everything the big inefficient, legacy insurance companies do. Because we are discrete value based and because we integrate coverage, we eliminate medical coding, verification, adjudication, pre-authorization, denials, delays, insurance networks, rate negotiations, sales/brokers/agents, money for a third-party EMR, skyscrapers in every major city, hundreds of thousands of employees, all the monkey business and reduces cost by about half.

It also eliminates both Epic AND BUCAH.

The Delivery Methods

We said all that so we can say this: Here is the deployment plan to completely fix healthcare and all its problems. There are three separate deployment processes, each with their strengths and weaknesses.

Sentia Health Insurance

Sentia offers our own health insurance. We charge $10 per month for the data management service plus the cost of the risk and stop loss. It is really that simple. The risk is calculated by taking the incidence of the procedure, or the number of times it was performed per population group, multiplying by the cost, dividing by the population to give us a cost per patient in the population, then dividing by twelve to give us a monthly risk per patient. That means that a $5000 open appendectomy occurring 228 times per 100,000 costs the patient $0.95 in risk. A $15,000 laparoscopic appendectomy would incur $2.85 in risk. We do that for each 10 year tranche and that gives us the risk number. We estimate about $350 per month for all risk across all age groups. Add in the $10 per month for our fee and you have $360 per month for full coverage with no deductibles, co-payments or co-insurance.

Captive and Third Party Administrator

A captive is basically just an insurance company that your employer owns. These are a vehicle to cut the cost of health insurance. An employee goes to the doctor and the practitioner submits claims the same way they would to any other insurance company. The employer does their own adjudication, determining if the care is covered, and pays the negotiated amount.

A Third Party Administrator (TPA), does the exact same thing except they use existing legacy insurance company networks, adjudication, and negotiated rates. The TPA aggregates the cost of the care and submits a bill for the care to the employer for payment.

Sentia does all this automatically. As the captive or TPA, we either pay for care provided or submit the aggregated bill to the employer. The difference is that we charge $10 per employee per month (PEPM) where a TPA would charge 5-10 times that.

Direct Universal Care (DUC)

Using Sentia’s EMR and risk model, a practice or hospital can offer its own direct coverage. This works exactly the same as Direct Primary Care (DPC) except it is for all care. Sentia Still charges the same $10 per month, and the hospital contracts with Primary Care Practices (PCP) to keep costs down. These PCPs have admitting privileges at the hospital in any case, so this isn’t a big stretch. The patient pays the hospital a subscription fee to be a part of the system and gets his or her care covered for about the same $360 per month on average. Younger people will pay a little less, older people will pay a little more. That’s how averages work.

Additional Benefits

84% of all spending in the US is on behavior-based, avoidable, chronic disease. That was over $4 trillion in 2024. Part and parcel in our EMR is a health and wellness package. We offer discounts on health coverage in exchange for demonstrated healthy living. You demonstrate healthy living by having good, or improving lab results. We prescribe patient education based on lab results and a healthy result earns the discount of 15%. An improving result, demonstrating compliance with the education, also earns the discount. Worsening labe results earn a cumulative lack of discount. Accumulation means the coverage goes up by 15% year over year until it is more expensive than traditional legacy insurance.

This shifts the cost of unhealthy behavior to the people behaving unhealthily. Helping the US get to the OECD mortality for behavior-based, avoidable, chronic disease saves another $1.34 trillion.

Caveats

It is going to be difficult to displace the Epics, Cerners and Athenas of the world even though we proved they are simply doing it wrong and for an eye-wateringly huge price. While Sentia could build integrations into these old, legacy inefficient and just badly designed and executed systems, our mantra is to solve the entire problem. Integrations would require medical coding, but we could capture those and pay them in real time as above. It isn’t something we want to do, and it would require custom code for every installation and we don’t want that either, but it can be done. Of course a better path forward would be to use a system that was designed and executed to solve the general problem and do it in a repeatable and sustainable way that would quite literally save millions of lives and increase profits and decrease work loads at the same time.

Conclusions

We have shown three viable plans to move toward lower cost healthcare in the United States. These plans cut more than half from the cost of health coverage and eliminate the big payers and the legacy EMR vendors in one fell swoop.

We have built a comprehensive health information system to keep the patient healthy and on the right track with the ability to incentivize healthy living. This system includes the automation of the health insurance industry completely, eliminating more than half the costs by Sentia as the coverage company, employer based captive or TPA or by direct payments to doctors and practices.

Here are additional points detailing the costs incurred by the legacy insurance companies that you pay currently, in addition to wasting about half your premium, according to Grand View Research and current as of 2023 and that Sentia would eliminate completely:

Medical Records:

The average practitioner spends $35,925 annually on electronic medical records
The average patient spends $106 annually on electronic medical records
The average patient encounter or visit cost for electronic medical records alone is $32

Medical Coding:

The average practitioner spends $20,286 annually on medical coding
The average patient spends $60 annually on medical coding
The average patient encounter or visit cost for medical coding alone is $18

Compliance and Efficacy Reporting:

The average practitioner spends $17,165 annually on compliance and efficacy reporting
The average patient spends $51 annually on compliance and efficacy reporting
The average patient encounter or visit cost for compliance and efficacy reporting alone is $15

Totals:

The average practitioner spends $73,376 annually on completely avoidable costs
The average patient spends $217 annually on completely avoidable costs
The average patient encounter or visit cost for completely avoidable costs alone is $66

Yes, you read that correctly $66 per visit. There must be a better way. There is a better way and Sentia has it. Remember also that these costs are over and above the 50%+ your insurance company wastes or shoves into their pockets.

We have designed and are building an ERP style practice/hospital management system that will pinpoint and eliminate cash leaks and inefficiencies in enterprise medical facilities. Implementing this system should be fairly simple and will completely revolutionize the way healthcare is delivered and paid for, saving countless lives. We have shown a way to use this system to make the best healthcare system in the world also the most efficacious and the most affordable.

If you liked what you read contact us here, on our site, SentiaHealth.com, our parent company SentiaSystems.com, or send us an email to info@sentiasystems.com or info@sentiahealth.com.

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