Problem 3: Rapacious Temerity of the Insurer
So far, we’ve seen the reduction of an individual’s life to discrete functions he/she wishes to control. From there to the physician, where discrete functional deficits are corrected, in exchange for society’s dollars and the individual’s autonomy. However, it is inside the insurers where de-individuation is completed. Once reduced to a claim number, all pretense of patient care may be dropped. These organizations are not evil, for that is the property of an individual. Nor are the people working at insurers particularly evil. Health insurers are simply focused on costs and shifting costs. There is no place, albeit no systems, for supporting patient autonomy, or provider autonomy, in most cases.
It’s easy to point to the insurers as the source of all that is wrong with healthcare. However, this is the height of hypocrisy. Our society, we the people, demanded this social insurance system, and any who condemn one or another stakeholder are ignorant, unless they admit their own complicity. And if we are party to the wrongs, we must bear up under the task of setting things right. And insurers have at their disposal a way to set things right.
Medical underwriting and adverse selection are topics beyond the purview of this short treatise. Regardless of the financing strategies that politicians manage to bungle, the most vital roles for insurers don’t change. Yes, if we have universal coverage we can create more accurate actuarial models. Yes, if we all embrace healthcare consumerism, we’ll pay more out-of-pocket expenses, but possibly control prices. However, the financing debate is moot without first drawing in stark relief the goals of patient autonomy and quality. If we can begin working on the solutions below, insurers can become more focused on coordinating the best care (You know. The care that increases the autonomy of the patient.), and less focused on simply shifting costs. How would this work?
As providers’ perspectives shift toward autonomy and effectiveness, quality will become more visible. The insurers cost-containment goals will be met by helping patients coordinate care among the best providers. For example, a patient is diagnosed with a serious kidney problem. Today, the generalist will refer the patient to a specialist based on professional/personal relationship or health plan networks. As for quality, it’s a crap shoot. But, if we are working with physicians who have made explicit their treatment protocol and outcomes metrics, the right docs are easy to find. The insurer has an opportunity to save money by making those connections happen. To get the patient to the right specialist it might cost $10,000 in transportation/lodging. Is it worth $10,000 to save a kidney? I’ll leave that for the actuaries. (If it were my kidney and my money, I’d know the answer.)
And, in the example above, specialist care will be limited to the acute episode. Once resolved, the specialist and generalist can agree or collaborate on the maintenance protocols, including the patients preferences. Soon, the patient may require only occasional support from an extender. Eventually, the individual is once again under self-care, having learned how to cope with any residual impact on life functions.
The insurer’s new role will be effective only if the individual performs their part (Solution Group 1), and the provider performs their part (Solution Group 2). Until then, the insurance companies have little opportunity to offer real solutions. The original medical relationships, patient and doctor, is where the solutions begin. We can stop beating up the insurers until we make advances, and improve the dialog, at the point of care.
Solutions to Problem 3:
- Harnessing the power of rules-based medicine, insurers must become the evangelists and coordinators of quality care.
- Insurers must foster a new kind of network, the crowd-sourced care network and build pathways from specialist to self-care.
- Insurers must abandon P4P until real outcomes (not process) metrics are being collected from defined (repeatable) treatments.
