Health insurance companies as patient advocates

In the US , health insurance companies ( health plans) and HMOs are seen to be gatekeepers who ration medical care. They are seen as putting up barriers and hurdles in order to prevent patients from getting the care which their doctors prescribe and  which they need and want , simply because this care is expensive, and they do not want to foot the bills. Health insurance companies have a bad reputation in the US and doctors have to waste a lot of their time re-filling forms or arguing with health insurance clerks as to why their patients need a certain medical procedure !

Sadly, Indian health insurance companies don't seem to have learned anything from this experience . They usually interact with their customers only at two times: when it's time to collect the premium on the policy at the time of annual renewal; and when it's time for them to process a claim when the patient falls ill.

While they are always happy to collect the premium , when it's time to reimburse for hospitalization , they will often come up with a number of flimsy reasons as to why they are not liable to pay . Favourite excuses include: the condition was pre-existing; or that it's not covered in the policy. They wiggle out by asking customers to read the fine print on the policy – terms which were never properly explained to them at the time they signed up for the policy . This obviously creates a lot of angst , and patients , doctors and hospitals are extremely unhappy about health insurance companies and TPAs . There is often a battle going on between health care providers and the health insurance companies , which often spills over into the media. Both treat each other as adversaries. Health insurance companies believe that hospitals and doctors pad their bills, so they can collect more money from the insurance company. Hospitals believe that TPAs deliberately delay paying their legitimate dues by creating bureaucratic hurdles and needless paperwork.

The good news is that the health insurance market in India is still immature. There's still time for health insurance companies to reinvent themselves , so that they start acting as patient advocates , rather than being seen as villains . It's very easy for the doctor to blame the insurance company by telling the patient – Sorry, the insurance company is refusing to pay for your treatment ! Patients are easily swayed by their doctors  who carry a lot of clout. Insurance companies are painted as impersonal , uncaring , heartless bureaucratic corporations, who are just out to make a quick buck at the expense of the patient.

Sadly, the truth is that many hospitals  will take undue advantage of the fact that the patient is insured, by overcharging the patient; or by advising excessive tests and expensive treatments, which are not medically needed. The patient does not care, because it's the insurance company which is paying. In fact, some doctors will deliberately defraud the company, often in collusion with the patient. When the company starts  auditing these claims and clamping down to prevent these abuses, they are treated as heartless monsters, who do not care about the patient's well-being; and who are trying to interfere with the doctor's expert medical decisions, simply in order to try to save themselves some money. Most patients ( and doctors) still believe that new and expensive must be better, which is they want to use the latest technology. When insurance companies try to push back, to prevent wasteful expenditure because a lot of these new gadgets and gizmos and of unproven clinical value, doctors and patients get upset and angry, because they feel the patient is being deprived of the best possible medical care, even though he is insured and has paid for it !

Health insurance plans in the US are realizing their present models are broken and are reinventing themselves, so that they put their customers first. They are positioning themselves as being patient advocates, who are doing their best to keep their customers healthy , so that they do not fall ill ! They are investing in wellness programs; and information therapy, so that patients start seeing them as health guardians, rather than as mere financial intermediaries. This is a win-win situation, which makes a lot of business sense for the health insurance company as well.

What can health insurance companies in India do today ? The good news is that the market is still growing; and there is a lot of opportunity to experiment and try out new initiatives to learn what works best. They are not burdened by legacy issues ; and have the opportunity to use technology to reach out directly to their customers !

Thus, a health insurance company could set up a call center, which all their customers could call 24/7, anytime they had a health problem – whether this was a medical emergency, or just a simple cough or fever.  Today, family doctors are a dying breed and patients do not know whom to turn to when they are ill. This lacuna is a major opportunity for a clever health insurance company which needs to provide trusted Information Therapy. This is a valuable touch point, and becomes the first point of contact for the customer, who doesn't have to go running around looking for a doctor or hospital.

The call center uses medical triage software, to guide the customer in his time of need. Most callers may just need reassurance and home remedies; while others could be referred to the nearest hospital or specialist. The company could organise an ambulance or a hospital bed in an emergency; or help them to get an appointment with a specialist on a priority basis . Clever companies could also offer concierge services to their high end customers who are willing to pay for hand holding and extra attention. This way, customers would learn to call their health insurance company any time they have a problem; and the company could then hold their hand and help them to get better.

Insurance companies could help their patients to get a second opinion when they are confused. Even better, they are in the best position to guide patients to reliable, efficient , ethical and competent doctors . Insurance companies have very valuable data on the medical outcome performance of doctors – and they can use data analytics to refer their patients to doctors with the best track records .

By acting as their customer's first point of contact with the healthcare system, insurance companies can provide high quality services at multiple touch points. By sharing information with their customers , they can help their customers to remain healthy; and make better healthcare decisions . This is obviously good for their customers , and will create a lot of positive buzz for the company.

It's good for the company as well, because Information Therapy can help patients to avoid unnecessary surgery and overtreatment . This is a win-win situation, which makes business sense for the company.

Many companies are reluctant to explore this option today, because they say they do not want to become healthcare service providers. They claim that they are not in the disease management space . This is actually very short sighted. Every time a health insurance company rejects a claim because they feel it is not "medical necessary", they are second-guessing the patient's doctor. The trouble is that when they do this after the doctor has made a decision, this creates a lot of anger and resentment amongst doctors and patients, who feel the insurance company is being meddlesome or is interfering with the doctor's autonomy to make a decision in his patient's best interests.

Instead of this, if they were proactive; and provided their medical protocols and decision pathways upfront, patients would know exactly what to expect - and why ! This kind of transparency and accountability will help to create trust !

The good news is that thanks to technology, it's very easy and inexpensive for them to do this today. They could provide the information online; and this could be delivered through the patient's smartphone, when he wants it. If the customer needs more hand-holding, a patient advocate at the call center could provide additional support and help.

Insurance companies could also provide health related information ( to prevent lifestyle illnesses ) through ezines and smses, to help their customers to lead healthy, happy and productive lives. This can provide a very effective return on investment, because the longer their customer remains healthy, the more money they stand to make ! Even better, it allows them to touch their customer's lives in productive ways, so they are seen to be a caring company.

The sad news is that health insurance companies continue to fritter away opportunities to create good will amongst their customers. Even if they did not want to invest in Information Therapy, it would be very easy for them to call up their customer after he has been discharged from hospital, to ensure that he is healing well and if there is anything they can do to help. Such a simple courtesy call is likely to have a huge impact, because it shows that the insurance company cares for their customer's well being.  Even such a simple phone call could create so much positive buzz in the community about the company ! It's sad that health insurance executives are wasting these opportunities; and wasting their money on advertising, instead of investing it on taking better care of their customers by creating a Wow experience for them !