Clinical Quality Role of Insurer in Safeguarding Patient Care

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The traditional relationship between medical insurers and healthcare providers is evolving and driven by a number of factors including global customer demands, the need for more reliable information about the quality of healthcare provision across the world. The role of the medical insurer in assessing and monitoring the quality of care has not always been clear. What is increasingly obvious is that the provider-payer dynamic has to change for good. This relationship should not be seen as an audit of the provider by the insurer, but instead a collaboration to improve outcomes and reduce cost and therefore genuinely transforms the healthcare industry.

How to Assess Quality

There are a number of national and international accrediting bodies that have a major role in promoting recognized standards of care. Joint Commission International (JCI) and the Australian Council on Healthcare Standards International (ACHSI) have seen their reach stretch to the far corners of the world in recent years.


These organizations serve as a good compliment to domestic-based companies, such as the National Accreditation Board for Hospitals and Health Care Providers (NABH) in India and the Malaysian Society for Quality in Health (MSQH). The issue for the medical insurer is that the number, depth and reach of accredited healthcare facilities are not enough to meet customer demands for high quality.

There are many shortcuts or quasi measures of quality that could be used to address this intriguing gap: from local licensing bodies to registering authorities and medical associations. However, none of these really meet the demand for information that customers are quite rightly asking for from their healthcare insurer.


The most obvious way to meet this demand is for the insurer to take responsibility for its customers and gather the information themselves. They are in a prime position to do this because they sit neatly between the healthcare user and provider, have access to abundant claims information and, in the end, pay for healthcare services.


It is by no means an easy process and insurers need to have a good idea about:

  • What international standards are relevant to their organization;
  • Resource implications and scale required;
  • Customer demands;
  • Intentions to continuously monitor quality and performance.
The issue for the medical insurer is that the number, depth and reach, of accredited healthcare facilities is not enough to meet the demands for high quality from customers.


The latter is a really key issue and one that accreditation organizations also struggle with. We have all studied hard for an exam at the last minute and passed; whether we maintain that knowledge or would pass the same exam three years later is a completely different question.

One of the most important conundrums is to resolve how an insurer can have “eyes on the ground” on a daily basis. It is here that the customer has a role to play. Any evaluation system (see fig.1) will need to marry a detailed clinical assessment with real-time feedback from patients.


The final role belongs to the hospital. Transparency is at the core of this role. Clinical data provides the ultimate evidence of performance, sidestepping any questions on validation and reliability.

image-2


Patient-Centered Care

Patient feedback and clinical outcome measurement all contribute to an opinion of a hospital’s performance. Increasingly, commissioners of care can look to alternatives such as patient experience or patient-reported outcome measures (PROMs). Use of PROMs is increasing, but remains restricted by geography.


For example, use of PROMs is fairly developed in the United Kingdom for certain conditions and used to support clinicians to provide better, more patient-centered care. PROMs focus on quality of life and functional status from the patient’s perspective and may offer an alternative opportunity for commissioners to benchmark quality or even — although less proven — measure clinical outcome.


Comprehensive Contracting

As the role of the insurer in monitoring changes, so will the traditional relationships between insurer and healthcare provider. Contracts historically based on principles of access to service and costs will have to include clear use of quality and clinical governance language.


There will be examples where this has existed before like the mandated inclusion of baseline standards and expectations. At the center of this contract is a need for greater transparency and more symbiotic, or partnership, relationships.


The line of provider and payer is too simplistic to continue to exist. Healthcare provider and insurer should be interested in only one thing: better health outcomes for the patient.

Role of Bundled Payments and Care Pathways

The aforementioned contracts provide the platform for commissioning safe, effective, evidence-based healthcare. While the pros and cons of bundled payments have been discussed in many recent articles, there is a good argument for their role in improving quality and incentivising healthcare providers to think about treatment as a holistic process measured by outcome.


There are a multitude of recognized clinical care pathways available and the arguments for not adhering to these are weak. Insurers have a quite legitimate role in working with providers to ensure that the care received by their customers is consistent with internationally recognized standards.


This is not about doing what is right as a payer, but rather what is right to deliver the best clinical outcome for the individual customer. Marrying these care protocols with payment for better outcome is a key component of the contractual relationship.

Centers of Excellence

Payers should foster incentive mechanisms for providers to build centers of excellence. A COE is a holistic provision model that promotes efficient and quality healthcare delivery with a focus on a specialty, or subspecialty, and a multidisciplinary approach to diagnostic and treatment, such as in breast cancer, cardiac arrhythmias, or spine surgery where a group of physicians, surgeons, nurses and other healthcare professionals work together to provide highly specialized services.

A COE routinely applies internationally recognized clinical practices and measure outcomes to evaluate improvement and learn from practice. In addition, it manages the entire cycle of care including inpatient, outpatient and rehabilitation services.

Safeguarding Patient Care

The primary objective of a person accessing healthcare, at its most basic level, is for an improved state of health. When the trust for accessing care is put in the hands of a medical insurer, that role becomes commissioning the best care available for that individual.


This way, the medical insurer is delivering on a duty of care to protect their customers. Therefore, insurers have a crucial role in monitoring quality, challenging inappropriate and unsafe practice and in guiding their customers through complex and often alien healthcare systems.

About the Authors

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Jose Quesada, M.D., M.B.A., is the medical director for Bupa Global Market Unit. He is responsible for designing strategies to support a worldwide provider’s network for customers in more than 190 countries.


Previously, he was director of clinical operations for Bupa Latin America. Prior to joining Bupa, Dr. Quesada was director of finance and operations at University of Miami Health System where he managed the relationship with international insurance companies and TPAs to provide access to thousands of international patients.

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Alf Theodorou is the head of Healthcare Quality for Bupa Global Market Unit. He is responsible for understanding the quality of the healthcare providers and healthcare systems within which customers seek medical care.


He has responsibility for designing strategies to support the categorization of providers based on quality. Previously, Alf worked in roles in medical and health information within Bupa and at the London Oncology Clinic, one of the United Kingdom’s leading outpatient chemotherapy centers.