I frequently see insurance companies refer to their members as patients.
It always makes me disappointed and angry. Like, racing-heart, sweaty-palm frustrated. Why?
Because that terminology highlights the fundamental problem with the health insurance industry in our country today: It is a disease treatment system, not a system designed to achieve health. And calling us patients reinforces that paradigm.
Many of us working in the health care industry have been aware of this gap for a long time, but somehow we’re not uncomfortable enough with that reality to change it. Or, perhaps more accurately, the status quo works for the people who run the system.
As someone who has spent a career in health insurance, I’m here to argue that it’s time for a better way. We’re not going to see meaningful change in the increasing disease burden and rising cost of health care in this country until we look reality square in the face and intentionally make a fundamental shift.
We need to design health insurance around a care delivery system built for health and wellness, not just sickness and recovery. To do that, we have to start with a condition-first approach to health insurance. That probably sounds a bit like jargon, so let me explain. A good design delivers a specific intended outcome.
Consider this notable design concept from urban planner Fred Kent. If you plan cities for cars and traffic—you get a city designed around transportation infrastructure. But, if you plan cities for people, you get cities designed around very different kinds of human-centered spaces.
From its inception in the early 1940s, employer-sponsored health insurance has been designed for doctors, hospitals, and drugs. It should come as no surprise that “patients” get doctors, hospitals, and drugs. There is a one-dimensional association between the way care is subsidized and reimbursed and the health impact of that care. There’s little or no investment in condition-specific alternative treatments or care models that offer highly effective outcomes and lower costs.
Nothing changes if nothing changes. We have to change the basic design of how health insurance works. Period. End of story.
Health insurance design should be focused on the condition, treatment, and health. If health insurance was designed around improving and maintaining health, more effective providers would cost less, prices would be based on consumer value, and coverage would change as a person’s needs change. It would be human-centric; not patient-centric.
The first step is adopting a condition-first insurance design that can flex with our health journey. Designing insurance in this way instantly changes how consumers engage with their health. Their health plan becomes their wellness platform, their prevention platform, and, when necessary, their condition-management platform.
Condition-first is how consumers think about their health. They think: “I have a condition or a health need. I want to know what treatments can help me manage it and get me to my best health. And, if I need treatment, how can I most effectively source it, and what will it cost?” It’s an intuitive process like any other familiar consumer behavior.
The other critical element we need to bring to insurance design is cost certainty and coverage clarity. We know from decades of research and observation in shared decision-making that humans make better decisions when given a range of options. People should have that opportunity with their health care, too.
Consumers deserve to know that surgical interventions are not always the best option—and prices should reflect that. For example, for knee pain, that means putting more subsidy into physical therapy, chiropractic care, and pain injections, and less subsidy into immediate knee arthroscopy.
But if someone is truly a good candidate for a knee arthroscopy, their health plan should help them find the provider that has the best outcomes.
When a health plan delivers clear, upfront pricing that shows multiple proven treatment paths and the costs associated with each, people choose more effective, efficient treatments and spend less annually. Recent benchmark data proves this is true. When people buy better, we have an opportunity to break the cost curve and make health benefits more affordable for everyone.
We must create a future where consumers and employers have access to more personalized health plans to improve outcomes, reduce waste, and save money. When less invasive or less expensive treatments are chosen first, it means more money is available to reduce the consumers’ cost-sharing burden and makes health insurance a richer benefit that can actually lead to improved health. Additionally, this kind of flexible insurance design built on consumer health journeys provides the needed learning lab that fits the emerging reality of our ever-increasing bioengineered future.
Changing what we choose to subsidize means better coverage for things that will help us thrive as individuals. For example, putting more subsidies into chronic and emergent conditions where care avoidance can often be dangerous and lead to higher costs down the road is good for the individual and good for the health plan. More subsidies for maternity care, early cancer treatment, treatment of chronic conditions like diabetes, kidney disease, COPD, rheumatoid arthritis, and HIV are good for individuals and good for health plans.
Long term, I believe we can change the trajectory of disease in the populations we serve. But, we’ll never get there if we don’t stop financing health care by visits and services rendered. Sadly, nowhere in the Triple Aim does it say eradicate disease or help humans thrive—but it really should. If we aim at those things, we’ll have a much better system. As an industry, we owe it to our “members” to do the hard work and make it happen.
So, please, please, stop calling me a patient.