Many people look at health insurers simply as the company that pays the bills when a member is injured or ill.
But a health insurer can play a much larger role, supporting clinicians to provide a higher quality of care and encouraging providers to work together to avoid duplication of services and to encourage wellness, says Marty Hauser, the president of SummaCare, Inc.
“By integrating clinicians into the health insurance industry, members can receive even better quality of care and fewer unnecessary tests and hospital readmissions, which will lead to lower costs and healthier members,” says Hauser.
Smart Business spoke with Hauser about the role of health insurers in improving the quality of care.
What is the role of health insurers in improving quality of care?
Health insurance organizations can partner with providers to help ensure a high quality of care for members. For example, an insurance company can use clinical information from claims data it receives to help determine which types of programs to offer and which products and coverage policies to make available to its members based on their clinical needs.
Additionally, the insurer can establish criteria for credentialing providers into its networks, including specific requirements that those providers will promote a high standard of care by doing such things as participating in quality improvement processes.
Some insurers may also provide information to members through a quality-of-care rating, in which it rates the efficiency and the quality of care offered by facilities and individual providers that operate within its network.
Finally, insurers are bringing together leaders in the medical field and those working on the front lines to help identify the best practices for the most effective care. By standardizing work practices across providers and bundling payment systems, health insurers can help ensure that members receive the most comprehensive care possible with the best medical practices.
Insurers may also set up access to electronic health records, registries to track how members with chronic illnesses are cared for, reminder systems for renewing prescriptions and making appointments and simplify the way members contact clinicians, resulting in better communication and, therefore, better care.
