Creating healthcare pathways and specialist networks will allow insurers to drive value for customers far beyond just writing the cheque for care, argues Aviva’s associate medical director Dr Subashini M.
The firm updated its Healthier Solutions and Solutions PMI cover earlier this year with a new guided hospital option Expert Select, enhanced cancer cover and a mental health pathway.
She says these developments mark a significant change in the insurer’s role.
“We see guiding and networks as levers allowing us to be better custodians of our customers’ premiums,” she says.
This is in keeping with the Financial Conduct Authority’s (FCA) customer’s best interests rule and ultimately the value of the product.
“From our point of view that value depends on whether the customer has returned to health or what is the health gain, then asking how we define that value and evidence it. We are moving from a transactional to a relational way of working.”
Get it right first time
One of the big issues is around standards of care. Among other things this means asking the private sector to offer the same assurances if not better than the NHS.
Dr Subashini M cites two examples – the first regarding spinal injections for back pain where there are concerns about the need for repeat injections. She references the Getting it right first time research on spinal treatments.
“While the best evidence suggests that repeated injections shouldn’t be happening at all – for the NHS the repeat rate was 4.3% but for the independent sector it was 11%,” she says.
“There is all this activity but who is benefiting? Who will hold individuals to account or ask the question – has it made anybody better?”
“We want to make sure people are making the best choices and doctors offer treatments that have evidence behind them.”
Another study, which looked at cancer drugs approved by the European Medicines Agency between 2009 and 2013, found that 57% of drugs approved had no supporting evidence for better survival rates or quality of life when they entered the market.
Even after six years only 15% of those medications showed any improvement for patients. It also means some patients could be taking drugs with no gain, but with significant side effects.
“As an insurer, I want to ask, what have I funded?” she says.
“It is this sort of issue we want to look at from a strategic point of view. It’s a knotty problem. It’s not nefarious, but we don’t want treatments being done because they are easy to do or because it’s assumed the status quo is okay.”
Person-centric approach
The person centric approach informs the three components to guiding.
This design covers issues such as whether the customer can get an appointment and even car parking, so that is the non-clinical element.
The clinical element means securing safe, effective personal care. You can, generally, assume safety, she says. Ensuring effectiveness can be challenging as the examples for spinal injections and cancer drugs indicate.
The personal element in clinical terms means ensuring that the healthcare provider views things from a customer’s point of view and the customer is treated with dignity.
The commercial aspect – in terms of securing value – is about effective but also efficient care which helps increase the sustainability of the premiums.
Of course, guiding can run a little contrary to some customers instincts to want the widest choice possible, almost expecting a directory so the case needs to be made for why a more limited choice can be better.
A curated approach to knee pain does not just consider the orthopaedic surgeon. You might need an x-ray, MRI or CT scan, and you want a centre that is good at all this.
It can encourage specialisation as well which is also beneficial.
“Guidance is about enabling informed choices based on the condition you have. It also signals that we don’t want hospitals doing everything.”
A generalist approach may be fine with a hernia operation but not for cardiac or neurosurgery where a narrower choice of centres of excellence matters, though it might require the customer to drive past their local hospital.
Provider benchmarks and warranties
Expert Select is underpinned by the Quality Care Commission and Health Improvement Scotland ratings.
But the network approach will also involve Aviva increasingly measuring outcomes and costs. Providers, she says, should be happy to benchmark but also to sign service level agreements.
For a hip and knee network they will want to know how many operations a surgeon did, the complication rates and the patient outcomes. Are patients still in pain and how much pain relief has there been?
With cataracts, the question set includes whether someone is seeing better or seeing glare. It is not just about “measuring but also incentivising”.
There are already other benefits from specialisation borne out during the pandemic – cataract clinics do not see surgery held up by having to wait their turn along with other operations.
And they were also easier to protect against Covid than general hospitals.
Aviva will also demand a two-year warranty – so the provider is responsible and accountable for new problems which arise rather than them sometimes falling on the NHS, meaning there is a shared risk with the provider.
In mental health, in developing the pathway approach, they observed that private customers were getting in-patient care, not because they had a more severe condition but because they reached the limit for out-patient care.
She says: “We ended up rewriting the rulebook. Our mental health pathway now has no excess and no outpatient limit across the book, so you get the care that you clinically require to get you better.
“Care should not be dictated by the financial constructs. It should help customers get the best out their premiums.
“It is about thinking about the right measures. Outcomes based payment rather than payment by activity.”
