“Your Insurance Policy Does Not Cover Ponies”

During my run, today I started thinking about the call I had with my healthcare insurance provider. It was not a pleasant experience.  The more I thought about the call, the more confused I became.

The payer, having no idea who was calling, asked me for my member number.  The term ‘member’, I think, is used to make us feel like we are being fawned over.  I thought about other organizations of which I was a member.  I was a member of the boy scouts. I belong to a gym; I am one of their members.  Being a member implies being a part of something bigger than myself.  It implies a sense of belonging, a sense of clubbiness, a sense of intimacy.

Sometimes it requires a payment—dues.  Having health insurance requires paying dues, but that is the only common thread of membership.  There is no clubbiness.  You become a member of an organization, you pay dues to that organization because you get something in return for those dues.  You get what you pay for.  Not only that, you get what you think you paid for.  There are no surprises.

At my gym, the attendant never tells me that my membership only entitles me to use the treadmill for thirty minutes.  I have never been told that page 37, paragraph 4, of my member agreement clearly states that I am not allowed to use the sauna.

The problem between me and my payer, and you and yours, comes down to a single point.  I want to accomplish one thing, and my payer wants to accomplish something totally different.  Even if my payer wanted to meet my needs, their customer experience strategy was not designed to meet them.

Their entire customer experience strategy is designed to do two, and only two things:

  • Maximize receivables
  • Minimize payables

Customer experience via their call center allows you to:

  • Buy a policy (a membership)
  • Make a payment
  • Add a family member
  • Update your personal information
  • File a claim
  • Try to dispute a claim—you can dispute it all you want, but this is a zero-sum game
  • Try to cancel your policy—the system is designed to make this very difficult

Online, your number of options are fewer.  Those options are designed to bring cash in, not to let it out.

I would not mind paying my dues if I knew that in doing so my payer would meet my expectations.  Like you, I have learned that the best a payer will do is meet a portion of our expectations. Your membership does not allow you to use the sauna.

There is no opportunity to use my membership to proactively manage my health and to drive my wellness.  In addition to maximizing receivables and minimizing payables, the entire payer business is designed to focus on what was—a treatment or a procedure.  It is all about cash flow.  Payers know nothing about the efficacy of your treatment or procedure.  They know nothing about your current health and the health you want to achieve.

Payers spend millions on big data.  They spend millions more analyzing that data.  Those millions tell them who and what to exclude.  They have a zillion data points about broad groups of people and zero data points about the current health of an individual.

People, members, want to be healthy and to stay healthy.  They want to be connected.

People want payers to know who they are and how they are.  It’s no more effective than a five-year-old wanting a pony.  Page 37, paragraph 4, of your insurance policy states, “your membership does not include ponies”.

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