Talking to An Insurance Company

A couple of days ago I talked to a nurse on behalf of a long-term care (LTC) insurance company. They wanted to do an evaluation of a resident who is in our assisted living home to make sure they qualify for coverage.

We also do this for residents who are running low on money to help them qualify for the Arizona Medicaid program. If they qualify, the Government will pay for their assisted living care.

I understand that the insurance companies don’t want to pay for people who aren’t sick. The trouble is the whole incentive structure feels wrong.

When we have these interviews, we hope that the resident has ‘a really bad day’. Sometimes a resident, especially those with dementia, have ‘a really good day’. They can suddenly seem a lot better than they are.

What does a really good day mean? It means the insurance company or Government denies coverage. Which can be devastating for a family.

The incentives are all lined up to make people sicker. The system often punishes people for improving your health.

They punish providers as well. If I improve the health of people on Medicaid, the Government believes the person requires less care. Consequently they pay me less.

Insurance companies and government programs such as Medicare do offer some incentive programs for hospitals. Maybe eventually they will expand to assisted living.

The trouble is that many of the incentives focus on completing an act, rather than achieving a result.

Here are some examples of rewarding ‘healthy behaviors’:

• Someone who attends a smoking cessation class receives a $25 prepaid debit card.

• Members can earn a $50 gift card if they see their primary care doctor for an annual wellness screening.

• Policyholders receive a $50 e-gift card after they complete a personal health assessment on their insurer’s secure portal.

• Anyone who receives a flu shot during flu season gets a $10 cash reward.

• Members who complete a biometric screening receive a $25 prepaid card.

• Policyholders can earn up to $100 annually by hitting their daily step goals after syncing a step tracker with their insurance company's mobile app.

• Eligible individuals who lower their blood pressure receive discounts on wellness-related resources. These can include meal plans, gym memberships, and weight management programs.

They reward taking a class, rather than stopping smoking. Or a gift card for doing a health assessment, not for improving your markers of health. Or taking a flu shot instead of making it though the season without contracting the flu.

The only incentive that focuses on results is the last one - for lowering blood pressure.

There’s a great saying I learned in the military.

“Never tell people how to do something. Tell them what to do and they will surprise you with their ingenuity”.

If we could incentive ‘ingenuity’ by focusing on results like lower blood sugar, lower blood pressure, lower weight or VO2 max, I bet we would see some real innovations in healthcare.