The Payer Business Strategy? On Tuesday’s You Get Broccoli

It’s a humid Sunday in Philadelphia. The air is thick enough to cut with a feather. The people in Phoenix like to tell us; at least it’s a dry heat. My reply; so is a convection oven.

Sunday’s are a day of rest. Sundays in June, your day of rest comes with an extra serving of humidity—hold the sprinkles. On Sundays in June, your serving of humidity makes you miserable. And when you are miserable, you want to be less miserable. And when you want to be less miserable, sometimes you think of eating something cool. In the Philadelphia area on a humid June Sunday when you are miserable and when you want to eat something cool you think of eating an Italian water ice—those of you in the Midwest may need to use Goggle to figure out what a water ice is.

When you order a water ice, you can order toppings for it. Sprinkles and Gummy Bears and jellybeans.

You cannot get a water ice with a topping of sweet potatoes or broccoli. And the reason you can’t is because people don’t want them. Sweet potatoes and broccoli ice are not why they got in a hot car on a hot, humid, June Sunday. That is how the water ice business model plays out.

And then there are the payers. And their business model.

Let’s take a brief look at their business model. Suppose it is a hot humid Sunday in Philadelphia. You had planned on going out for a watermelon water ice. But before you did that, you needed to file an insurance claim with your payer. You have to file a claim because the last time you went to get a water ice on a hot, humid Sunday, your water ice caused some of the jellybeans and Gummy Bears to freeze together. And when you swallowed them they blocked your airway and you had to go to the ED.

An emergency room physician removed the blockage, but she could not save your water ice; it had melted. The hospital sent you a bill for their services. You called your payer and explained what happened. But your health insurance policy did not cover a jellybean/Gummy Bear blockage.

Each of us has called our payer trying to find out what we are paying for, and why they aren’t paying. (You’ve got to admit, calling themselves payers is about as ironic as things can get.)

The phone conversation with the payer goes something like this. Although we are not able to pay your claim, even though we would really like to pay it, there are many other reasons for you not to cancel your insurance. With your insurance policy, you get all sorts of extra benefits. We call them toppings. For example, if you sprain your ankle on a Tuesday, and if you need an Ace Bandage, we do not charge extra if you want to get a different colored Ace Bandage—it’s a member benefit. We recommend a pink bandage for girls and a blue one for boys. Another topping we offer is a ten percent discount for people who are injured while traveling to outer space.

People who pay for health insurance do so every month. Payers like to call those people who send them money members; like what country clubs call the people who send them money every month. And just like country club members, health insurance members get a little membership card to put in their wallet as a testament of their membership privileges.

If payers were to survey their members asking why those members purchased insurance, those surveyed would reply, “Because when we file a claim we want you to pay it.”

Members don’t want toppings, no matter how good those toppings may be. The payer business model could be very simple. People send us money. And when they need money, we send it to them. But if that doesn’t work, maybe on Tuesdays, your payer can give you a water ice with a broccoli topping.

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