MR Microinsurance_2012_03_29.indd - International Labour ...

148 Health insurance
Box 6.6 Monitoring the service quality of health care
Zurich Bolivia and BancoSol have a TPP mechanism in place with a third-party
administrator (TPA), PROVID. PROVID receives a capitation payment (and
then pays contracted healthcare providers according to various methods of pay-
ment including fee-for-service). PROVID monitors utilization of health services
and maintains claims data. It also performs regular spot checks of service quality
in contracted health facilities by sending its staff to pose as potential patients to
test how they are received and treated.
Because BancoSol distributes the HMI product to its microfi nance clients,
comment boxes have been placed in BancoSol branches to allow insured clients
to comment on the HMI services. It is critical for the microfi nance institution to
make sure that clients are satisfi ed with the HMI scheme as it may aff ect
BancoSol’s reputation.
Source: Authors.
HMI schemes can evaluate the frequency and type of healthcare services being
delivered to individual patients, or by specifi c healthcare providers. Th e evaluator
(ideally a clinical professional from the HMI scheme) can meet healthcare providers
to discuss unusual cases and trends, and develop appropriate interventions.
Setting standards for quality
In all seven case studies, the contracts for healthcare providers establish standards
for various aspects of quality. For example, contracts often require that insured
patients be treated in the same way as non-insured patients in terms of access to
services and clinical standards of treatment. Th e behaviour of healthcare providers
towards HMI scheme members should be monitored for any evidence that
members receive inferior service. Th is can occur because of a perception that a
patient not paying cash out-of-pocket at the time the service is provided, or who
is receiving discounts or special rates, is socio-economically inferior. Some contracts
under TPP mechanisms stipulate adherence to treatment protocols or care
guidelines, and ensure availability of essential drugs.
In other contracts, such as that of UMSGF (see Box 6.7), healthcare providers
are prohibited from requesting additional fees beyond those laid down in the
plan of benefi ts, such as co-payments. Such provisions exist to discourage
fraudulent practices, which can be rampant in facilities where salaries are low or a
culture of corruption prevails.
For some HMI schemes, a performance-based contract may be a useful way
of promoting quality of care. GRET-SKY is testing a performance-based contract