People think healthcare’s least understood concept is the relationship between payers and members (customers and patients). I believe the opposite to be true. People clearly understand the relationship, and it is that understanding that has such a negative impact on almost everything related to a person’s health.
The member/payer relationship not only discourages access, engagement, population health, accountable care, and wellness, it seems to do so in a particularly purposeful way. In fact, to members, it seems like payers are either guilty of designing it to be that way, or they are guilty of neglecting the member/payer relationship.
To give us a starting point for exploring this topic, I searched Google for the following: “t-shirt” and “I love Humana.”
I could have searched on any number of payers and received similar results. My search returned zero hits. (You get the same number of hits if you search for the phrase, “French military victories”.) If Google were more advanced, I think the number of hits for my search would have been negative. I also searched the phrase, “Why do people hate their insurance company?” That search returned 1,750,000 hits, and my laptop started laughing at me.
The relationship between members and their payers is a topic that is only mentioned behind closed doors. I wish I could state that both parties are culpable, but that is not the case.
Everyone who has ever called his or her payer to dispute a claim thinks the term ‘payer’ is an oxymoron. Their payment strategy for dispute resolution seems to be based on the premise that if they can get you to call them seven times, they know you will not bother to call and eighth time.
Wreck your car; your insurance company gives you a new one. Have a heart attack while driving, one company gives you a new car, the other company, your payer, tells you what is not covered—page seventy-two, section eleven, sub-paragraph six.
To be fair, payers do offer a number of other free benefits to offset the fact that they may deny some portion of or your entire claim. Someone in your HR department probably skimmed through those free benefits on January 2 when they were explaining your new and improved and more expensive health insurance. Very few of you or anyone else could probably list, or as ever made use of those benefits.
Stating that your firm wants its members to have a good experience, and delivering that good experience, is vastly different. Most payers only interact with twenty percent of their members on a regular basis. They either pay the members’ claims, or they do not pay their members’ claims. The one thing they do not know about those claims is whether the services their members claimed made them better.
I learned today that I have a torn meniscus and a stress fracture of my tibia. My orthopedist wants me to be on crutches for a month. Just for fun, I Googled the cost to repair the tear and to fix the stress fracture. The estimated cost to repair the tear is $5,000 and the cost to repair the stress fracture is around $16,000. Knees are expensive.
Crutches cost $40. I called my payer—let’s call them Hartford-Anthem-TIAA-Esurance (HATE), to find out if it will pay for repairing my meniscus tear and my stress fracture. The person with whom I spoke said HATE covers those procedures.
That was the good news.
Then I asked if HATE would cover the cost of crutches. Crutches, I was told, are not covered. Up until that moment I had considered buying an “I Love HATE t-shirt.” I asked to speak with a supervisor. No supervisors were available to speak with me—were they out buying their own crutches? I asked.
An hour later I received an email from HATE. In their email was my Case Number, #38756. I replied to HATE’s email and told them that their Case Number was #00001. I received a new email from HATE telling me that my Case Number was #93852. I replied and told them that their new Case Number was #00002. I don’t know how long HATE’s patient engagement with me will continue, but I am prepared to play their game for as long as it takes.
HATE will pay about $20,000 for the two surgeries, but they will not pay $40 for crutches.
Payers spend tens of millions of dollars on data and they spend equal amounts on advertising. Their data, were they to look at it, would tell them that the outcomes from two surgeries and from using crutches are identical. Their data may tell them that someone with of my age and weight, who exercises six days a week, may have a higher probability of having a stress fracture and torn meniscus than, say someone who wears skinny jeans and who drinks lattes. The one thing their millions of dollars of data will not tell them is that you or I will injure our knee.
Payers spend almost nothing on my wellness or yours. They do not know how to lower their costs, engage members, improve member experience, and promote their wellness.