Health insurance is health care financing.
It's not health care. It pays for health care. If anything, an insurance company is nothing more than a financial corporation that cares about reducing its risk - it's own gambling risk.
Every month you make a payment to an insurance company, betting that you will get sick and need that money to help pay for your medical costs. And every month, the insurance company accepts that payment, betting that you WILL NOT get sick and won't have to pay you.
Gamblers are all about probability and math. I remember my grandfather doing a bunch of calculations to determine if one dog was a better "bet" than the other based on track record. So for health insurance, actuaries use past data to determine the probability of this or that, or what is a risky "bet" for a health issue. Then the administrators take these facts and create rules around coverage, determining what will and will not be covered. And the rules change - depending on how the risks calculate each year (factored with costs and profit) to be more or less or just off the table.
I haven't even reached claims processing yet, and already you can see why health insurance can be expensive. Just to create a plan, there is a large amount of staff and work involved. Now add the paperwork for claims - which is ridiculous (I've worked on systems to automate that process and there is a lot to it) - and a profit margin. Welcome to our current health insurance mess!
How does this relate to Agile? Or UX? or CX?
There is a company, Collective Health, and they are cutting out the middleman health insurance companies, and allowing companies to pick and choose what will be covered for employees. It's a self-funded plan - rather than an employer going off to an insurance company to have them manage it, the company could work with Collective Health to manage it online. So much simpler!
“While insurance is supposed to be a risk-sharing business, health insurance has increasingly become a middleman business devised to generate profit for the health insurers above all else. As a result, there is a fundamental disconnect between the incentives of traditional health insurance companies and people’s and organizations’ health insurance needs,” says Diab.
This new approach will eliminate a lot of the rule books that guide insurance and make claims almost impossible to understand - especially when an insurance company changes its mind about how much risk it wants to assume to make a specific profit margin.
The current health insurance system is like a waterfall system, but the similarity isn't in the paperwork or requirements, although that is a factor. It's about the silos and lack of transparency. Health insurance companies just aren't transparent.
“Patients are often left to advocate for themselves and trying to get a clear answer from your health insurance company about what’s driving costs is impossible,” says Dr. Batniji.
With that said, creating a Web site for companies to select and manage their own plans for employees is revolutionary. The company and employees will better understand what is covered and there is less rule changing to cover profits/reduce "risk."
And if there is a software product to manage it, the managing is based on rules that someone programmed. That means any question can be answered pretty easily.
To boot, you can get answers to your questions easily and simply on your computer or device. How great is that?
Agile methodologies haven't only benefited software creation, but is starting to influence how people think about business in general - less paperwork, fewer silos, more streamlined direct communication, and greater transparency. It is shaking up a lot of middleman industries, influencing them to be more transparent and easier to understand, making them obsolete. Health insurance seems to be one of the next targets.