My organization is one of the key stakeholders in health insurance; others are enrollees, health maintenance organizations (HMOs), and health care providers. Over time, it has been discovered that corruption has eaten deep within each of the aforementioned stakeholders. Examples include, but are not limited to, impersonation and abuse of drugs by enrollees, falsification of procedures by healthcare providers in order to extort or defraud the HMOs, withholding of capitation or funds for enrollees care by the HMOs, etc. These are many more, and here is where my organization comes in to mediate and resolve these complaints through thorough investigations.
Permit me to quickly summarize the checks put in place by relevant stakeholders. When a patient is admitted to a hospital and the HMO is contacted for an authorization code to be issued, the requesting HMO must convincingly provide clinical details to justify the admission and also the phone number of the enrollees so they can be reached for confirmation of their health status. Occasionally, representatives are sent to the hospital for an on-site investigation. The HMOs are not left out of the blame, as they unjustly hold on to monies that should be released to hospitals as reimbursement for services delivered.
All these above and many more necessitate the input of my organization, and this is where I come in. My job summary involves interfacing with relevant stakeholders to ensure patients have access to quality healthcare at an affordable rate. We, as an organization, are bound by operational guidelines that dictate how the chains of treatment should flow. Unfortunately, the organization has just reviewed its price tariff in 2021 after about seven years and also the operational guidelines after about a decade. You will agree with me that such steps were long overdue, as prices have been largely influenced by inflation. Imagine a drug skyrocketing to more than 300% of its previous cost, and healthcare providers are expected to comply with tariffs that cannot even meet the cost of production or purchase.
Should the black-and-white operational guidelines be followed without compromise, or should human influences and understanding be applied when the system is unfavorable? This is where a robot has limitations. The organization is working on bringing to par the technology that would embrace health insurance. However, just as we know that machines cannot reason but would only oblige that which has been programmed, would such robots be able to compromise in the face of a failing healthcare system? I doubt that!
Robots can malfunction as they may experience wear and tear or have compromises in their programming. Can such deficiencies be tolerated in the face of life-threatening situations? The robots would without doubt make life easier for all stakeholders, but when issues that require human compromise or emotions arise, it would most probably be difficult to accommodate, especially for the enrollees.
Luckily for me, I'm a medic, and I would remain relevant to humanity, as we are often deemed demigods when lives are involved. Fortunately for me, I have also acquired skills like writing and am passionate about farming. I'm sure I would cope if the practice of medicine were compromised.
Thank you for reading. I would love to have your comments and contributions.