week 5 final 6211

Introduction

In the United States, the health department is among the departments given priority in terms of fund allocation. The citizens of a country must be productive; they must be healthy or access healthcare facilities whenever they are in need. Healthcare insurance, commonly known as healthcare coverage, is any program or institution that offers a range of medical costs. These programs could either be public or private companies. General insurance companies include Medicare which is responsible for pooling resources and spreading financial risks related to significant medical expenses to protect the entire population. Health insurance companies also cover for those who are disabled or under long-term nursing care in either nursing homes or at their residents. However, different insurance companies offer different levels of financial assistance, and the scope of coverage also varies from one company to the other. Affordable care act instituted in the year 2010 required that even those Americans without healthcare insurance are covered.

In most cases, those individuals without medical cover in most cases they are not able to pay for their bills. Through this act, the federal government can offer subsidized healthcare plans. In this case study, we will specifically discuss Humana, which is among the largest insurance companies in the United States. We will look at the mission, the general purpose, data needs, and an EER diagram for the company.

Mission

It is the mission of a healthcare insurance company to protect and enhance quality healthcare. Humana is a trusted insurance provider for innovative, comprehensive, fairly-traded, good-quality products and services for healthcare settings, practitioners, and other providers in the healthcare sector. Humana insurance company is also dedicated to enhancing the health of individuals and the well-being of its members, associates, and the entire community that they serve. It is also committed to making an inclusive organization of different people whose experience is based on a passion for patients and putting their customers first before anything else. Humana aims to ensure high standards in terms of the well-being of patients, career opportunities, and investor connections. In general, Humana's mission statement is to help employers handle healthcare costs, guide clients who make informed healthcare decisions, and benefit from the insurance cover (Tzeel, Lawnicki & Pemble, 2016).

General Purpose

Humana is a private insurance company that provides Medicare services. Plans have a general-purpose to co-establish societies where leadership, systems, and culture are geared towards improving and sustaining positive healthcare outcomes. The insurance company offers financial protection to people who experience catastrophic healthcare issues. In most cases, these devastating events are unpredictable, rare, and challenging to forecast and the cost of treating these diseases goes beyond what human beings can afford. Their general role is also to ensure their customers have broad access accompanied with a small fee usage. There is an annual fee paid, which in exchange, beneficiaries receive a free ticket to doctors’ visits or at a low cost (Tzeel, Lawnicki & Pemble, 2016). The company also negotiates with other health services by ensuring that health insurers leverage their power in the market to achieve price concessions. Humana being a private insurance company, promotes and provides clinicians and hospitals that are of excellent quality. Individuals are also encouraged to remain healthy by reducing premiums for joint members of health clubs.

Data Needs

The healthcare sector has now become an ever-evolving industry. There, insurance companies need to comprehend who their members are, what they need for their insurance covers, and what incentives they require to take action. Data analytics have made Humana clear that payers of insurance covers have different behavior, characters, and preferences. Therefore Humana and other healthcare insurance companies can use data analyzed to generate revenue. The company can also be able to target the right members by analyzing behavioral data, psychological and demographic profiles, which are then divided into buyer personas. Outstanding campaigns can also be established once Humana has identified the buyer persona; they can execute and design campaigns to acquire and retain members. Data can also be used to enhance onboarding and retention to boost loyalty and promote retention. They can also predict the value of the proposition to improve positions so as to know where the focus should be placed to ensure the most outstanding value is offered at a lower cost.

Standards

Although some healthcare insurance companies such as Humana are private, the federal government is responsible for setting standards that should be provided in the standards package. These insurance companies are obliged to accept every individual that applies for the standard package, and all policyholders must be charged equal premiums. Most Insurance companies in the United States are founded on social solidarity (Ryan et al., 2018). It means that together, they are in a position to pay for the entire cost of Healthcare. For example, every member of Humana's healthcare insurance company pays for maternity and other senior care. Although not all care is insured, such as physiotherapy and dental services, individuals must take additional insurance for such services.

Scalability

For Humana to be effective in the services they offer, they need to in apposition to meet the increased demands of their clients. The scalability can either be vertical or horizontal. For vertical scalability, Humana needs to add more power to the existing systems. On the other hand, horizontal scalability appears to be complex somehow but has a long-term benefit. Infrastructure and procedures need to be improved for better performance of the insurance company (Fracchia, 2021).

Adaptability

When customers visit an insurance company, the focus is on how they are treated from the reception to the point where they receive their services. The Healthcare sector is constantly changing, and healthcare insurance companies need to change in order to adapt to the current situations. The emergence of COVID-19 has destroyed Humana and other insurance companies, which have made them the policy of always being prepared in case of the emergence of an unpredicted pandemic. For healthcare insurance companies to adapt to systems, all that matters is the kind of leadership being deployed in the organization (Fracchia, 2021).

Performance

Humana works to protect individuals from extreme medical bills and ensure that they can access healthcare when they need it. Most members choose to engage in an employer-sponsored plan where they pay a premium, and in return, an insurance card is offered to them. Through this insurance card, they can access doctors, specialists, other healthcare providers, and hospitals that are part of insurance plans (Ryan et al., 2018).

Evolving

Globalization has been the cause of so many changes in almost every sector of the economy, including Healthcare. There has been an evolution and emergence of new diseases that were not there before, which means that the healthcare insurance company needs to take strategies and ensure that health insurance can cover these diseases. There is an emergence of so many companies dealing with healthcare insurance, implying that Humana needs to do something to gain a competitive advantage over the emerging companies (Christensen, Waldeck & Fogg, 2017).

EER Diagram for Healthcare Insurance Company

(Braunstein, 2018).

The above EER diagram shows the relationship between a member of an insurance company and the company itself. In the beginning, the healthcare insurance company needs to get details from the customer about their name, the identification number, their email, and even their address on where they reside. It also must include the starting date when the customer chooses to be part of the insurance company upto the duration for which they have paid their premiums or the end date, which can b renewed. After the insurance company gets this information from the client, the client must be made aware of the benefits expected, the sum they have insured and the kind of diseases which can be covered, as well as the policies governing the company or, in simple terms, the rules and regulations. Once the customer now visits the hospital for treatment, a medical history is recorded in terms of the disease they are suffering from, the diagnosis, the cure, and the tests that might have been carried out, including the claimed amount by the hospital from the insurance cover. In cases where the patient has been admitted or hospitalized, the bill i.d is recorded, the disease code, the bill amount, the date the patient was hospitalized and the name of the hospital, and lastly, the date that the patient was discharged. In other words, this diagram shows that the healthcare and insurance companies are networked, and they work hand in hand to ensure quality care is provided.

Conclusion

In conclusion, healthcare insurance companies are essential in the economy of a country together with its members. Without these insurance companies, healthcare costs could be prohibitive, and very few would afford it. Citizens should be encouraged to register themselves as members of a healthcare insurance company to ensure they do not have the burden of costly medical bills that primarily affect low-income societies. The government should ensure they have an affordable insurance program for those living in the rural areas to ensure quality healthcare is provided in community hospitals.

References

Braunstein, M. L. (2018). Payer Applications of FHIR. In Health Informatics on FHIR: How HL7's New API is Transforming Healthcare (pp. 113-124). Springer, Cham.

Christensen, C., Waldeck, A., & Fogg, R. (2017). How disruptive innovation can finally revolutionize Healthcare. A Plan for Incumbents and Start-Ups to Build a Future of Better Health and Lower Costs.

Fracchia, C. (2021). Secure and Scalable Collection of Biomedical Data for Machine Learning Applications. In Artificial Neural Networks (pp. 317-336). Humana, New York, NY.

Ryan, P. B., Madigan, D., Stang, P. E., Marc Overhage, J., Racoosin, J. A., & Hartzema, A. G. (2018). Empirical assessment of methods for risk identification in healthcare data: results from the experiments of the Observational Medical Outcomes Partnership. Statistics in medicine, 31(30), 4401-4415.

Tzeel, A., Lawnicki, V., & Pemble, K. R. (2016). The business case for payer support of a community-based health information exchange: a Humana pilot is evaluating its effectiveness in cost control for plan members seeking emergency department care. American health & drug benefits, 4(4), 207.