Nursing and health insurance

Nurses can have a major impact on health insurance costs for patients, a recent nursing conference in Cayman heard.

Generali Worldwide country manager Annikki Brown told delegates at the International Nursing Conference last month that because health insurance is a financial product owned by the person accessing health care, and not a health care product, many nurses and health care providers have been educated about the relationship between nurses and health insurance.

“The quality of what an insurance company can provide patients with depends on how health care providers such as nurses and insurance companies work together. In essence, both parties become reliant on open and consistent dialogue to meet the expectations of clients,” Ms Brown said.

Discussing the role nurses plays in the health insurance system, Ms Brown encouraged nurses to be mindful on the job and become more engaged in how they access and affect the health insurance of their patients.

“Depending on where the nurse does his or her job, their exposure to health insurance is different. For example, it is likely the nurse at a private facility who fills out the insurance claims forms as part of her job will understand the claim system where a nurse in a surgical practice is likely to be more familiar with pre-authorisation systems,” she said.

She said the Cayman Islands has moved away from a system of socialised health care into today’s system which has certain socialised elements, but has incorporated private health insurance to cover health care costs.

“Health insurance is a financial product and not a human rights instrument,” Ms Brown said. “Insurance is a tool used to manage risk. Risk is loosely defined as an uncertainty of the outcome of a loss and, therefore, something that is inevitable or a known event is not a risk in strict terms.

“It is for this reason, exclusions of pre-existing conditions, which are known certainties, are built into many health insurance plans. When an individual is underwritten, or assessed for risk, at the commencement of their insurance cover with an insurance company, their state of health is reviewed for risk and known costs.”

Ms Brown also explained the concept of pooling risk. Insurance assists the individual in meeting unexpected losses by pooling the premiums of many groups or individuals in a common pot out of which claims are paid when any of the subscribing individuals access health care. In this way, the losses of the few are met by the contributions of the many.

“The key difference with health insurance compared to any other form of insurance is that you cannot indemnify the loss of one’s health. Indemnity is the name given to the process where you put someone in the position they would have been in before they suffered the loss.

“With health insurance, if someone loses an arm, how do you indemnify that loss? How would you know the financial value his arm has to him? Health insurance does, however, cover the medical costs for that person’s medical bills as per their policy maximum pay-out amounts,” she said.

She added: “Oftentimes the general public expresses the belief that insurance companies collect a lot of money in premiums, however, there is little discussion about the high payouts for medical care particularly in the USA which costs insurance companies a lot of money.

“The Cayman Islands as a whole does not boast a well population. We have high incidences of premature births, accidents, and ongoing health issues as recently identified by the Minister of Health.”

Ms Brown gave the nurses a list of things to consider in the way their work affects health insurance. She stressed the need for nurses to be informed so they can help patients particularly with the coding of the services the patient received and to help them with the authorisation process.

She encouraged the nurses to exercise integrity in providing care and honesty in their note-taking and to ensure they are accurate, compassionate and reliable in all that they do. “It is these attributes that their patients rely on and in turn so does the health insurance provider,” she said.