The concept of quality of products
goes back to the end of the 13th century, when, according to the American Society for Quality (ASQ), “craftsmen across Medieval Europe were organized into unions called guilds.” These
guilds developed strict rules governing
the quality of products and services.
Since the Industrial Revolution of the
early 1800s, theories and strategies
around quality have been developed and
implemented. By the 1970s, as a
response to competition from foreign
countries such as Japan, many American
companies adopted the Total Quality
Management (TQM) approach, which
focuses on an organization’s processes.
“Over the centuries, quality became a
primary driver of manufacturing standards in the United States,” says Dr.
Wendy A. Richards, national medical
director for Aetna Small and Middle
Market Business. “The quality concept
has now clearly moved beyond manufacturing and into various other sectors of
the economy, such as health care.”
Smart Business spoke with Dr.
Richards about the role health insurance
companies play in ensuring the quality of
health care.
What is the definition of quality when it
comes to health care?
The Institute of Medicine (IOM) defines
quality as ‘the degree to which health
services for individuals and populations
increase the likelihood of desired health
outcomes and are consistent with current professional knowledge.’ So one
would consider high-quality health care
services to be those that are in keeping
with current standards of care and that
help an individual achieve his or her
health goals.
What can health insurance organizations do
to ensure quality of care?
Health insurance organizations partner
with various constituents, such as government and professional organizations,
providers and members, to help ensure
quality of care. For example, an insurance company will use current evidence-based medicine in the form of clinical
guidelines developed by groups such as
the American Diabetes Association
(ADA) or the Center for Disease Control
and Prevention (CDC) as the foundation
of its programs, products and coverage
policies. Additionally, the health insurance organization establishes criteria for
credentialing and admitting providers
into its networks, and its provider contracts often include requirements to participate in various quality assessment
and quality improvement processes.
Members also have the opportunity to
contact their health insurance company
with concerns over the quality of care or
service they have received, and the
organization will evaluate these situations through an established process.
Finally, some health insurance companies have evolved their transparency initiatives to provide members and employers with information on not only cost of
care but the efficiency and quality of care
rendered by providers and facilities in
their networks.
How is quality measured?
To illustrate how quality is measured,
consider the following scenario. A health
insurance organization wants to reduce
the mortality rate for people that have
had a heart attack and evidence-based
medicine suggests that these individuals
should take a medication called a beta-blocker because it will increase the likelihood of the reducing the mortality rate
(according to the American Academy of
Family Physicians). This health insurance
organization will measure the extent to
which its members are being prescribed,
and taking, this medication after experiencing a heart attack. The organization
will evaluate the results of this measurement and determine whether actions are
needed to improve the quality of care
being provided to its members.
Will quality of care continue to be important
in the future?
As society’s expectations of health care
delivery, financing and outcomes continue to increase, measuring and working to
improve quality of care will be a vital
component in shaping our country’s
future state. Given that almost 60 percent
of health insurance coverage is provided
by employer-based plans (according to
the Center on Budget and Policy
Priorities), these plans have a great
responsibility and a large stake in
improving the health of Americans and
the care they receive. But ensuring quality is really everyone’s ‘job.’ Providers,
members, employers and health insurance companies need to continue to
work collaboratively to accomplish the
goal of a healthier America.
DR. WENDY A. RICHARDS is national medical director for Aetna Small and Middle Market Business. Reach her at (312) 928-3307
or [email protected].
