No One Cares About Your Health (or No One is Willing to Pay For It)!

Of course that is not true, but it seems like that sometimes, doesn’t it?  If you are working to promulgate a solution that promotes health in the context of our current healthcare system, there is no end to the challenges you will face.  Lets think a bit about the various actors, why they should care and why they do not.

I’ll start off with you. No one should care more about your health than you.  But as the behavioral economists remind us, we are not rational beings.  We are more likely to focus on tangible things in the moment rather than long-term uncertain benefits. So we persist in participating in unhealthy behaviors that provide short-term pleasure and lead to downstream sickness.  In addition, we’ve been addled into believing that once we are diagnosed, we are victims and that we can abdicate all responsibility for our care. (see 5-17-2010, Are Individual’s with Chronic Illness More Passive?).  This insidious combination makes it hard to hold ourselves accountable for our own health.  Most times, we’d rather blame the environment, or bad luck, and ask if we can take a convenient pill to make it better.

Next, how about your loved ones?  They are the best targets. In most cases our loved ones (the more current phrase is ‘social network’) can and do affect our health (See Nicholas Christakis’ book Connected and related articles).  It has, however, been challenging to get loved ones to open their wallet to pay for service offerings that improve your health.  In my experience, this is most often because of the same mentality that makes you a passive victim once you get sick.  We feel that society owes a victim.  We all feel like we’ve paid into various insurance programs – public and private – and that they should be the ones to pay for health-related services, particularly in the setting of chronic illness.  So your loved ones do care, but they have been trained not to open their wallet to support your care.  I can think of a dozen or so business plans I’ve seen over the years where the service to support a chronically ill individual was to be paid for by the “sandwich generation.” There is an appeal to this on the surface, but I haven’t seen one of those businesses scale yet.

What about those insurers then?  They probably care the least.  They see their role as spreading risk over large populations. So they work to recruit and keep healthy people on their rolls.  They work to be as efficient as possible at processing claims and mathematically predicting risk. They only got into the care management business because their customers (employers) demanded it of them.  They invariably vote for commodity or ‘check the box’ solutions.  Keeping cost down is held at a premium compared to improving health. Insurers are hard to engage in a visionary conversation about improving health, even though they’ll admit that in many cases the savings of improving health would accrue to them.

OK, so lets move upstream in the supply chain.  Employers hire insurers to help them with employee benefit health care plans.  Employers are motivated to keep you healthy if for no other reason than you will be a more productive worker if you are healthy.  They even care a bit that your dependents are healthy too, since you’ll be more productive if a sick parent or child doesn’t distract you.  And there is the original reason employers started paying for healthcare in the first place – because their benefits packages help them attract a more talented workforce.  The latter has largely been forgotten these past 2-3 years, as we’ve been adrift in a sea of employable people without jobs.  Supply and demand curves to motivate behavior and with such a large supply of workers, benefits are less important. That will change as the economy picks up.

So a high level analysis would conclude that employers are good targets for novel health-improvement interventions.  The challenge is that the direct customer is the human resources professional.  These poor, overworked souls are true generalists. They have to help you invest money in a retirement plan, guide you through how to handle a maternity leave, discipline a difficult employee and, oh yeah, choose your health plan.  Few of them have any training in health so it is natural that they develop trusted relationships with folks at health plans…so they get talked into purchasing check the box, commodity solutions.

Well, for goodness sake, what about your doctor? Your health professionals are there for you.  But they too have perverse incentives.  The most prevalent of these is that they are trained to and get paid well for taking care of sick individuals.  The system does not reward them financially at all for improving health.  They are also big believers in patient accountability and don’t usually buy that victim thing.  So they quickly articulate a treatment plan so they can go on to the next sick person who needs their help.  They expect you, the passive victim, to be proactive about learning everything you need to do to execute that plan and carry it out.  They are not on the same page as society is regarding who is accountable for keeping you healthy. They’d say it’s you, with their help from time to time.

Throughout this piece I have purposefully equated ‘caring’ with ‘spending’.   I suppose this too is controversial, but I think the linkage is fair.  What is the relevance to connected health?  Simply put, connected health interventions promote health over sickness management.  In today’s healthcare marketplace, they’ve been a hard sell.  Most folks I talk to readily agree that connected health as a care model makes sense.  But there is this mystery about ‘who pays?’.  I believe this phenomenon of ‘nobody cares enough about health to pay for it’ helps explain that conundrum.

So it feels a bit like merry-go-round to me, or if you take a more sardonic view, a game of Russian roulette.  So tell me: am I off base?  Who really does care?

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9 replies »

  1. Bobby G and I are right and the insurance employee is dead wrong ! Your contracts that include exceptions, exclusions, life time limits and permits insurance to break contracts at will. Are the True Death Panelists to the extent of Patient Care . You must be a novice insurer,who lives among those childish dreams that you can do no Harm. Only the Messager HUh!

    Apparently,Insurance employee has not the Comprehensive Grasps on real Outcomes of this product called Unhealthy Insurance Either by exclusion or economics ,You and Providers determine who Dies! Thus Death Panels!

    Insurances,only value is to multiply Profits and limit out of pocket expenses. Insurance companies arificially Hike fees to give the appearance of a contribution. However,Little be known how small their contributions.
    Although, it is well known of their record breaking Profits and their number of large bonus,
    The costs of doing Business is driven up by your Greed and Glunton want that lives High off the Hog. Driving Prices and cost beyond Reason.
    Stop Blaming your Members for your artificiallly spectualtive inflationary rates!!! Your the PiGs (insurer and Provider) that are Driving up costs of care.
    The legislature only has Insurance and providers that they listen too. After all your lobbiest are pampering their backsides to ensure you continue to screw everyone.

  2. BobbyG, I often read that insurers don’t provide care, and therefore do not add anything to the value equation. You make the point perfectly as to exactly what value insurers add: they pool the money so we can get expensive treatments that as individuals we cannot afford.

    But let’s be clear: coverage is not care. Coverage is a contract to pay for specific things, and this contract invariably delineates exclusions. Insurers uphold the contract, to honor all the rest of the members’ contributions to the insurance pool.

    When people think the contract has been violated, there is recourse to interal and external appeals processes. If you just don’t like the contract, see if your state legislature will mandate the coverage you want. But be aware, the more you want covered, the more your coverage will cost. And we’re back to shooting the messenger.

  3. “Gary — This is difficult to grasp, I realize, but insurers cannot deny care.”

    Explain to me how denying PAYMENT for care materially differs from denying care — i.e., given that the care that really matters is typically multi-episode and predominantly of the acute variety.

    Kicking back a claim for a mundane “well patient” annual physical is one (trivial) thing. Denying a provider payment ongoing treatment for a usually expensive, life-critical set of px’s is entirely another matter — one regarding which the insurors are in the driver’s seat.

  4. Gary — This is difficult to grasp, I realize, but insurers cannot deny care. Only doctors can deny care because only doctors provide care. And why would doctors deny care? Because they want to get paid. Just imagine! Medical care costs money! The more you want covered, the higher your premium. It’s really that simple, whether it’s a for-profit or nonprofit.

    Please note: even the VA — a totally closed medical delivery system without the motives you attribute to for-profit insurers – is having difficulty with cost of care.

    It’s the costs, Gary. Those mean ol’ insurers are just the messengers of high medical costs. Go ahead and shoot them. That won’t kill the costs.

  5. Insurance is a business of Profitable Contracts and denying Care. Insurers are only interested in their Contracts. These contracts limit access with patients to seek Doctors and penalize patients to have tests.

    Insurance also plays two sides against the middle.Thats why members are getting screwed. They work out agreements with providers and pharma that leave you footing the bill .
    Insurance has always been the defacto “Death Panels” and Providers have become their Cheer Leaders of denial of services.

    The just do the math and your insurance commissioners roll over for them. No, they don’t care about your Health and /or Keeping you healthy. Instead they have made their members pay dearly for medically neccesary test and procedures. Often,so expensive that responsible people would forego the procedures because they would bankrupt them.

    Insurance and most providers only care are.

  6. I certainly agree, it often seems like the goverment doesn’t care about our health – at the end of the day it’s all about money!

  7. Passive people respond passively, and I’ve known quite a few active people who aggressively managed their chronic conditions. They were a doctor’s dream as far as compliance and a doctor’s nightmare as far as being an engaged, empowered patient. Your stereotype may reflect the preponderance of your experience, but it’s not everyone.

    It may surprise people that there are still nonprofit insurers, with all the emphasis on the big national outfits, but 61% of health insurers do not have shareholders. http://www.nonprofithealthcare.org/resources/BasicFactsAndFigures-NonprofitHealthPlans9.9.08.pdf

    But all the Bues and major insurers do have nurses and social workers who are case/care managers/coordinators who mine the claims for chronic users and try to work with them to remove barriers to staying with the treatment protocol.

    Some people genuinely don’t know how to identify these barriers in their daily life, whether that’s a system for taking the various meds at various times with or without food, or getting help for the squeamish on doing that finger-stick several times a day for testing. And doctor doesn’t have time to figure out if they’re missing appointments because they don’t have a ride and don’t know how to use the bus system.

    We do what we can to help them but as you’ve pointed out, some are passive and stay that way in spite of repeated attempts to help. But some do respond. Believe it or not, these are real people on the other end of the line who care whether or not our members can improve their quality of life by better managing their conditions. And we actually get thank you letters from both members and doctors whose patients we help. Unfortunately, we can’t publish those because of privacy laws.

    What makes your premiums go up is that everyone wants everything as long as somebody else pays – so to that extent you are right on the money, pun intended. The “greedy insurers” narrative plays better, even though premiums just reflect the cost and usage of care, coordinated or not.

  8. I really don’t quite understand the question and/or the premise of “who pays”, because we all already are paying, and quite a bit more than we should.
    It is not a victim mentality suggesting that after paying into various private/public programs, i.e. premiums to private insurers and taxes to public ones, it is now time for those programs to do what we hired them to do – pay for treating illness if and when it occurs.
    Now, if the question here is how do we get more money out of people once they, or family members, get sick, then I don’t have an answer, because I don’t think anyone should.
    If the question relates to how do we get folks (or institutions) to pay for the new wave of wellness programs (preventive or disease management), I would suggest that those should be included in what one pays through his/her lifetime to same private and public payers.
    I don’t think “care” has much to do with anything other than the age-old opportunity to monetize human feelings by inflicting guilt and fear.

  9. IMHO:

    Care givers ‘care’.

    Hospitals (companies), Insurance Companies, etc.. are Companies – they are amoral and dispassionate, they don’t care.

    Payment is not related to caring. Payment is related to profit.

    Generally speaking, insurance is for catastrophic events… most policies don’t do a lot for chronic care because of this model.