How Does Medical Insurance Affect Patient Care?
Written by Pelle Gustafson CMO and Jon Ahlberg Senior CMO, Patientförsäkringen LÖF
Medical insurance is often seen as outside the patient pathway, but insurers can have real influence over how patients are treated and cared for.
Medical insurance companies can drive healthcare costs upwards and are less motivated to become involved in improving care if hospitals are paid per “executed task” regardless of necessity. Although this kind of remuneration is common in the medical community, it is increasingly being questioned and replaced by other reimbursement models where payment is based on objective or subjective results.
These new models are proving hugely beneficial for patient care. As well as lowering net costs, by reducing poor outcomes and adverse events, medical insurance companies have a new incentive to influence the level of quality and safety. By offering rewards that are based on an agreed level of quality or service, they can help healthcare providers place more emphasis on outcomes. Both providers of care and insurers benefit from this close cooperation and the main winners are the patients.
Financially Motivate Caregivers
Perhaps the most significant result of these developments is that insurance companies can financially motivate caregivers to comply with certain levels of education, staffing, training programs and safety procedures. Across the world there are countless examples where minimum levels of staffing and competence must be kept intact or the insurance policy is simply not valid, or is more expensive or limited for the caregiver. The insurer can also agree to decrease premiums with increased levels of competence, training and safety programs. In a US hospital, for instance, medical employees who have been involved in adverse events were identified by the insurer as “poor communicators and poor documenters” and were trained to improve in these areas.
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Risk & Compliance
But beyond the immediate financial benefits there is also a great deal that healthcare professionals can learn from the methods, practices and culture of insurers. Two very central themes in the running of an insurance company are “risk” and “compliance”. Handling and controlling risks is something that insurers are clearly good at and those in healthcare are learning from this system of identifying, describing and minimizing risks.
Gathering & Analyzing Information
This is not simply a case of learning by osmosis. Insurers are also taking active steps to collect and distribute information of risk-prone procedures and treatments to care-providers to improve safety and quality. Various early-warning systems for certain medical procedures or implants are being set up with insurers playing a major role in their design and implementation. Insurers are also contributing through the sponsorship of research in the fields of patient safety and quality improvement.
This process of reinvesting earnings into safety programs is an increasingly common solution in the insurance sector, especially if the organisation is a mutual. In Sweden for instance, our mutual national patient insurance company Patientförsäkringen LÖF (P-LOF) has run four projects in cooperation with 24 separate professional organizations and care-givers in areas of safe delivery care, infections after joint prosthesis surgery, abdominal surgery and medication practice in primary care. In each case the professional medical organizations are fully responsible for the medical contents of the projects while P-LOF takes the financial and administrative responsibility. The projects begin with self-assessments made by clinical departments that are followed by peer reviews, agreements on action programs and finally a follow up also performed by the peers.
Although insurer-led, these programs instigated the type of self-assessment that is needed to uncover latent risks that may be known about but not acted upon. Questions around procedures and guidelines, measurements of staff compliance and suggested areas of improvement were all asked by the insurer and answered comprehensively by care providers.
Facilitating Safe Delivery
In our safe delivery program for instance, all 46 Swedish delivery departments (and their teams of obstetricians, midwives, pediatricians and neonatologists) participated. Among the results from this project are a new definition and terminology regarding CTG-interpretation, interactive web-based training programs on interpretation of CTG-curves and neonatal resuscitation. Virtually all departments have updated or produced new local guidelines as a result and most reported an increased awareness of the importance of compliance. Preliminary data show that the number of birth-related adverse events resulting in hypoxia has decreased as a result of this insurer-provider collaboration, though these early findings have to still be interpreted with the utmost care.
Similar joint projects aimed at eliminating prosthesis-related infections and promoting safer abdominal surgery are now also underway. This type of structured, collaborative model is proving effective because it is multi-professional, voluntary, self-rated, non-normative and focused on the system and the processes. The healthcare organizations have, without exception, risen to the challenge.
Although these improvements to patient safety must ultimately be implemented by healthcare providers, insurance companies are increasingly taking a role in encouraging, incentivizing and facilitating change. Insurers must be accountable for patient care and use their resources and knowledge to create safer health environments for the future.
Research from Patientförsäkringen's projects will be presented at the Patient Safety Congress, 21-22 May in Birmingham, UK.