Insurance Company Executive
Operates in most states; Revenue of $68 billion; 60,000 employees; Headquartered in New York, NY; Offshore facilities in many countries.
Narrative
Insurance companies are often viewed as the enemy, only caring about making money and their stock price. This insurance company executive feels that people don’t realize how much healthcare actually costs, and that consumers need to be more actively involved like they are in other areas of their life. If consumers knew that 20% of the population uses 80% of the healthcare services, it might change their perspective. An insurance company will write a check every day for at least $1 million to cover pharmacy claims. Its goal is to provide patients with the healthcare they need while avoiding excessive tests and high-cost drugs when lower-cost alternatives are available.
The insurance company emphasizes innovative shared-risk payment models but is slow to adapt to changes like precision medicine. It works with multiple clearinghouses and is affiliated with a mail-order pharmacy. With a heavy focus on technology and data, it is increasingly partnering with EHR companies. It is considering buying physicians’ practices.
Quotes
“Our providers need help identifying gaps in care.”
“How do we know the providers are providing the right care?”
“We have to get a handle on care provided out of network.”
“We need clinical data to substantiate medical necessity based on industry guidelines to justify the cost of care.”
“Patients need to be more accountable for their outcomes.”
Short-Term Goals
- Education – help more providers and patients understand coverage.
- Patient population tools – use structured data to define and measure.
- Expand number of network providers for primary care.
- Price premiums competitively.
Long-Term Goals
- Pay for value (and only value).
- Shift risk to providers and patients.
- Reduce prior authorizations – faster time from providers to authorize.
- Increase profitability and market share.
- Use exchanged, structured clinical data to better understand the care patients are receiving (in and out of network).
Typical Problems Faced on the Job
- Need structured clinical data, but most practices push back against that and only want to provide claims.
- High staff turnover.
- Market consolidation (hospitals buying practices) is hurting the ability to favorably negotiate.
- Desire to measure quality, but doctors don’t think that insurance companies know how to do it.
- Patients who don’t understand their coverage or the care they received.
- Maintaining provider network participation and negotiating with hospitals.