Health insurance is at the center of one of the most enduring and prominent social controversies in recent history. With costs rising year after year at an unprecedented rate, and the roster of uninsured continuing to grow as well, the health insurance quandary is at the forefront of the social and political dialog.
For those who are attempting to understand the nature of this controversy it is hard to know where to even begin to look. The health insurance debate spans so many aspects of society; from providers to customers, from hospitals to malpractice attorneys, and from the function of private markets to the role of government in healthcare. However, if one seeks to educate themselves on the many facets of the issue, then understanding health insurance companies is a logical starting point.
It has been over three-hundred years since the concept of health insurance had its genesis. The original health insurance business model was one where the focus was solely on disability. Only injuries that could leave the patient disabled were covered; everything else was paid for by the patient. Amazingly that basic arrangement remained in effect for the next two-hundred years. It wasn’t until the 20th century that the disability model of insurance was replaced with the more familiar, contemporary health insurance; hence, the modern health insurance companies were born.
The essential philosophy on which health insurance companies operate is that they enter into a contractual relationship with their customers. The customers pay insurance premiums, and in return the health insurance companies cover the costs of predetermined medical conditions such as most routine, preventive, and emergency medical conditions. In many cases some or all of the cost of prescription drugs is covered as well.
The obvious reason for people to purchase insurance is that despite the high costs of insurance, the high cost of medical care can be much greater if they are unfortunate enough to become sick or injured. And that scenario does hold true in reality, and health insurance companies frequently pay more in coverage than they collect in premiums for some individuals. To understand how they can do that and still remain profitable then you must understand the basic assumptions under which health insurance companies operate.
The first thing health insurance companies do when reviewing an application for coverage is review the individual’s medical history. The company knows that high risk individuals are likely to incur large medical expenses, and those individuals are generally rejected or offered coverage at an increased premium rate.
Of those who have medical histories that fall within normal parameters, they are offered coverage and become customers. The health insurance companies know that, with the help of some statistical calculation, they can determine the percentage of their insured clients who will become ill during the year, and they charge a sufficient premium that will not only cover those costs but allow for profitable operations as well.
Another way that health insurance companies control expenses and maintain profits is to make the customers pay for a portion of their service at the time it is rendered. That payment is in the form of a co–payment, which is the out-of-pocket expense for which the customer is responsible.
The purpose of the co-payment is multifunctional. Not only does it directly offset some of the expenses, it prevents people from abusing their coverage by seeking unnecessary treatment. If out-of-pocket expenses were very low, or non existent, people would be likely to go to the doctor or pharmacy for the slightest issue or problem; issues that in many cases do not require medical attention.
At the same time, health insurance companies know that if co-payment expenses are too high, people will put off seeking attention, and that could ultimately lead to even more serious problems for the customer and more expenses for the health insurance companies.
Ultimately, health insurance companies seek a balance in all things they do. They seek to find the right balance of price in co-payments and premiums, and they seek the ideal balance of patients who will require predictable needs and consistent premium payments.
They use enticements like exercise or smoking cessation incentives that may cost them a little now, but could save them much in the long run. It is a business model that has evolved over the centuries and continues to evolve to this day, but the basic principles on which health insurance companies operate remain relatively constant.