A major shift in the way the UAE's largest health insurer reimburses hospitals will dramatically improve the quality of care, a senior company official says. Daman, the national health insurance company, announced on Saturday that it would adopt a new repayment system for hospitals and clinics - one based on results rather than simply prices.
Dr Jad Aoun, the chief medical officer at Daman, said the aim was to make sure the treatments the company were paying for were of a high quality. Patients would end up with more and better information about hospitals, too, he added. "We need to be more focused on the outcomes, which is what the patient ultimately wants and what we are paying for," he said in an interview. "Bad quality leads to increased cost."
The aim was for hospitals either to provide better care or to stop providing services they cannot offer at a high standard. "When we used to tie-up with the provider it was a discussion of utilisation and pricing lists, then negotiations about prices," he said. "The issue of quality was never on the table." Beginning in January, Daman will require extra medical data on patient outcomes for each provider's 10 most common procedures.
Dr Aoun said much of the other data was already included on the electronic claim form. The data will include basic information on the patient, such as age and sex, and also details on the success of the treatment. Determination of success will be influenced by factors such as length of hospital stay, information on infections and unplanned admissions to the intensive-care unit within seven days. "We previously concentrated on broad inspections of providers to ensure everybody in the network met basic international standards," he said.
"Now we would like to focus on the outcomes of the treatment performed in these hospitals. "After assessing the data we may go back and restudy the price paid for the procedure to see if it reflects the quality of the outcome." Hospital officials contacted by The National said they did not want to comment on the programme until they had more details. They were first told about it by a letter issued two weeks ago.
Daman has more than 1,400 contracts with health practitioners across the UAE. Some individual contracts cover a large number of premises, and more than 90 per cent of the health facilities in Abu Dhabi are included in the insurer's networks. Worldwide, it has more than 450,000 providers. Currently, each facility in the network sends Daman an electronic claim detailing each procedure carried out on their cardholders. The company then pays the hospital based on a pre-agreed price list.
Facilities that fail to send the data required as part of the new arrangements could be penalised with reduced payments, Dr Aoun said. On the flip side, those that outperformed the prescribed standards might be rewarded. He added that the information Daman collected would eventually be made public so patients could make more informed choices about where they sought treatment. Dr Aoun referred to a study in the UK that showed most patients base decisions about where to get treatment on recommendations from friends, family or their doctors. Only five per cent relied on published facts.
"We may find out that there is a hospital which performs lots of a particular treatment but actually has very bad outcomes," he said. Hospitals will be the first to come under the new scheme; smaller clinics and private practices will come next. Daman will meet providers over the next few months to discuss the details of the plans before they are implemented. Some of Daman's more expensive policies cover treatment abroad at certain hospitals and clinics, but the new results-based system will not apply outside the UAE, Dr Aoun said.
The funding model is similar to those in other countries. Australia, for example, measures hospitals' performance and rewards them accordingly. Its system takes into account the types of patients hospitals see, so that like-with-like comparisons can be made. Daman is also promising to ensure that benchmarks are fair for all providers. "The Government expects us to achieve certain quality standards comparable to the best health systems throughout the world," Dr Aoun said. "To achieve an increase in quality, it is necessary to monitor quality."