The biggest misconceptions about payers

We asked the Managed Healthcare Executive editorial advisory board: What are the biggest misconceptions consumers have about health insurers? Here’s what they said.




The reality is that against the changing winds of the Affordable Care Act, payers had to pivot their business models from a third-party to a first-party customer relationship.  They also had to forge, structure, and operationalize a multitude of partnership arrangements with a broad assortment of provider organizations sharing risk in hundreds of ways.

- Dennis Schmuland, MD, chief health strategy officer, Microsoft Corporation




The reality is that higher costs of healthcare in this country are driven by a number of well-documented factors including hospital costs; provider and drug price increases; new technologies; waste; an aging population; and unhealthy lifestyles among a large portion of our society. In contrast, administrative costs represent less than 2% of healthcare costs in the U.S., and private insurance industry profits are at or well below profits of most other facets of the healthcare industry, and administrative costs are actually less than that of public entities such as Medicare. Additionally, private insurers employ a wealth of strategies to reduce healthcare costs through programs like utilization management, fraud detection, disease management, wellness programs, and investments in information technology.

- David Calabrese, vice president and chief pharmacy officer, Optum Rx




In the United States, people want the best of everything, want it to meet their individual needs and do not want to pay for it. This is also true for healthcare. Since we do not have a social mandate in the United States for universal coverage, we need a lot of ways to pay for the delivery of healthcare. We need health insurers, health plans, PBMs, etc., to handle the payment of healthcare claims for individuals. This is why we need health insurers in the United States.

- Perry Cohen, chief executive officer, The Pharmacy Group




The reality is that insurers only decide whether they will pay for care; providers decide whether they will provide it.

- Don Hall, principal of DeltaSigma LLC




We actually represent the smallest percentage of healthcare costs. In addition, while we are very focused on making sure the right care happens in the right setting at the right time, many consumers see us as blockers. We are changing those perceptions, and it is gratifying to work in a company where every day we focus on improving the health and wellness of our customers. The reality is we are dedicating incredible amounts of time and resources to break down those barriers so we can deliver on our mission-to helping people improve their health, well-being and sense of security."

- Mark Boxer, executive vice present and chief information officer, Cigna 




That assumption describes health insurance from the last century, not today. True, paying claims is a small piece of what we do, but our primary role is keeping people well. That means not only thinking innovatively and collaborating with other leaders in healthcare, but also putting people at the center of everything we do-something we call Human Centered Innovation. In fact, we take our role as innovators so seriously that we say we’re not a healthcare company that happens to be innovative; we’re an innovation company that happens to be in healthcare.

- Daniel J. Hilferty, president and chief executive officer, Independence Blue Cross.




This perception is likely well-earned when we consider the focus on utilization review and gatekeeper models of the past. Today, we lead with the Triple Aim in mind, particularly health and focusing on evidence-based practices to ensure individuals are getting the most valuable care and avoiding unnecessary care.

- Kevin Ronneberg, MD, vice president and associate medical director of health initiatives, HealthPartners