Quality health care Featured

8:00pm EDT August 26, 2008

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 Shanahan-RichardsW@aetna.com.