The Truth Sometimes Hurts about Healthcare Insurance Industries


Seeing the Elephant

Now here is a new concept – – CHANGE!

We really haven’t seen much in healthcare over the past 5 to 7 years.

I ends up that some of my readings for a course I am taking, published in 2009, are about some issues in healthcare administration that as of yet have not reached their peak.

The main issue here is the transition from Quality of Care analysis to Population Health analysis.  I favor the latter, worked in the former ten years ago.  2009 was the turning point for when changes were supposed to be made in order to drive the transition into population health care and analysis along the right routes.

Sorry to those who had such wishes that this change might happen.  It is far from even being on its most important uphill rise to success.

The Insurance companies and other businesses responsible for implementing these changes are–for lack of better words–too old fashioned and resistant to change.

True, the idea of changing things this quickly, this much, seem quite hard to fathom.  But the companies that should be embracing these changes, those that are to be closely associated with the Obamacare related changes, are too stubborn to take on these new responsibilities.

The idea of change has never been an active way of thinking in health insurance companies.

Sure, you want to think that new prevention program is a good example.  But I hate to say it is as great and effective as those anti-smoking hot line programs.  When I was monitoring the health of 60,000 for several years, of which a few percent were smokers, none of those several hundred to a thousand every used that hotline provided for by the program they were enrolled in.  15 total in fact could be documented as calling for help, or assistance on how to stop smoking.  With this in mind, how many members do you really think are going to participate fully in the regular health monitoring prevention programs develop? that place of the web where you can enter your goals and activities, or calculate you success with BMI changes and weight loss?

One such website that I enrolled in I never went back to again–it provided me with nothing new, other than to keep my workout logs on a computer instead of in my pocket sized notebook.

That was way to much time and work, and fat-developing desk time to manage, for a program designed to help someone lose weight.  Likewise, I don’t need their pictures of a healthy meal to know what a great salad looks like; I already know what to put into my salad.  There is no incentive to use these kinds of sites.  Those few incentives that in fact exist, are really more theoretical.  At one work place, I saw those who did participate in such company-based offering were already engaged, fully, and wanted to succeed even more by getting a 5 dollar Starbucks card or better yet, a 50 dollar accessory for whatever events they regularly engage in, such as running or swimming.

So the healthcare system and plans for change are as much unchanged today, as they were in 2009, or 2004/5.  I had the opportunity to see what plans were then in process with national healthcare, and can’t believe the Obamacare plan had some of its decisions already made in 2009, published as parts of the ongoing improvement programs I regularly engaged in and directed most of the research for in 2004/5.

That just demonstrates to me, and maybe others, how resistant to change we and the leaders in healthcare finances are.

These companies that fund our care are not leaders in their field.  They are providers of the most basic needs only.  They could easily implement a very effective population health care monitoring program to oversee their expenditures with.  But instead, they’d rather take the passive role and whenever active, complain, refuse or resist for the most part.

One such company even tried to hire me to monitor those patients who might opt out of care with their competitors, in exchange for seeking a new form of care through their agency.  Had I been hired, my goal was to detect or predict these high cost people frustrated with the program they are in, in need of better care elsewhere.  It was not the better care that this company thinking about hiring me was so much against.  It was the cost for providing them care.

This tells us that insurance companies want to recruit only the healthiest, least costly of members.  Not anyone who is handicapped or in desperate need of improved care.  Just the minimum number needed to meet their quotas, provide some services, and very easily demonstrate just how effective they are for keeping people healthy, not making sick people better.

What I state above is therefore true–the truth sometimes hurts about healthcare insurance industries.

My recommendation:  don’t ask for a pain reliever; it may not be on the flowchart somebody developed to improve your therapy, or pre-approved by your insurer, for recommendation by your PCP.

My readings that led me to write this essay:




One thought on “The Truth Sometimes Hurts about Healthcare Insurance Industries

  1. Reblogged this on Brian Altonen, MPH, MS and commented:


    It helps to document these things. Sometimes they are so recurring you tend to forget the earliest examples of prejudice and insecurity showing their faces in the job world.

    There were two recent encounters I had in interviews that stank of Ageism–that behavior that tells you they are going to accept or reject you for a position due to personal prejudice rather than anything to do with pro-corporate success.

    A national PBM was recently searching for experts in pharma marketing research strategies. Obviously, having a very lengthy and rich background in researching the demographics and health economics of the nation should be in your favor. However, this is not the case when they team initiating this program hasn’t an inkling of an idea of what the pharma industry is like at the small group age-gender-culture level. When one cannot read a map to success, one is unlikely to every blaze the trail to make it to the end of such adventures. Such is the case with this major pharma company. Out of tune with the population, expect little advancements or innovations to come with this pharma PBM (not the #1 PBM in this country, so don’t worry you others who might recognize my name, you’re bad, just not “ageists” or age-prejudiced as much when it comes to producing success.)

    Another example of this came in a work place. To improve and redefine the “team”, three changes were made. Three of of the three changes involved the few remaining males in the research group. The order in which these changes happened resulted in removal of those with the richest, most successful problem solving background–the oldest and most experienced was removed first, with his counterpart untrained in the same processes for analyses, allowed to hold her position. The second loss involved the most important IT/HI member of the team–the individual who designed the investigative processes and pathways. He left due to personality conflicts ultimately; the same that caused the first male manager be told to leave.

    An interesting piece of the third of three males told to step down however is interesting. Being on the big mailing list, the plans to undergo change reach you, which others are seemingly unaware of.

    So imagine for a moment suspecting you are being ousted from the team, for whatever reason, and as a result of your departure you know there is no other person there trained in your skillset. Obviously, you are going to wonder, who made this decision, because obviously it is counter to producing any productivity in the near future.

    That mailing that goes around is kind of like a bunch of kids forming a new team at school, excluding some from the list, but still sending the correspondence to those other members, perhaps to make them think they’ll be a part of this change. The only thing is, when the brainstorming begins, and the duties of each defined, you are not attached to any of those steps that are defined. Obviously, you are being excluded from the team’s planning process.

    A brief review of those on the list reveals that all of those who are included are the ones that need to learn what to do. They are the ones who never produced a history of their work, failed to keep any records of the research processes they developed, failed to produce effective tools for generating useful study results the first, second and third times through, each time there was a failure of making the project succeed.

    So who is best to blame for these fiascos? Favoring the younger, inexperienced and eliminating the only ones who knew how to engage in a detailed statistical study in the first place?

    The managers ultimately are the decision makes here. Uneducated, or poorly experienced managers are also incapable of seeing a light at the end of a tunnel leading to the final, highly successful project.

    Businesses habitually hire experienced managers who lack the knowledge base needed for performed the work related tasks. A manager or higher who cannot see why a particular manner of keeping data is problematic, shouldn’t be in charge of a program that requires correct data development, data management in the first place.

    In this case, the reverse sexism that surfaced as well alongside ageism could be read in the emails–that “okay girls, here is what we’re gonna do–let’s divvy up these skills and see if we can figure it all out . . . ”

    It takes more than just a team of people trying to break the code to produce intelligent results. Garbage in=Garbage out in the medical IT world. That is the only equation we have to be able to be sure to recognize and avoid. In this case, many clients (companies) and patients are the victims of these poor management steps. Poor managers are the reasons that projects ultimately fail, managers who are not well experienced in the field and are certainly not great team leaders.

    “Human Resources” has let this issue slide for this company, perhaps way too much. Talent Searchers are now back to square one with these projects. Square One means that it’ll be another year or two or three before the new team catches up with the old.

    Three years in any HIT field is equal to a generation. That means that 3 years from now, they will have someone with the right experience and skills to implement innovation and change. Meanwhile, their competitors will become 1, 2 or 3 years ahead of them.

    Sometimes, the best members of a team just never get the acceptance they are due, and the team never advances. This chaos is actually going on all through the HIT professions right now. No managers/VP/COs/Presidents are willing to hire new recruits, new skills, or pay for the experts.

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