The Payer Shares Responsibility for Care Quality
The payer's decisions on purchasing, approval, and payment schedules affect continuity and the provider's ability to maintain the required team, reaching the patient just as surely as clinical decisions do.
This post is a translation of the original Arabic article.
We began working on relationships with insurers at Cura in 2017. We had a service, doctors, and users. Establishing a route through which insurance could cover that service was another undertaking with its own requirements.
In Rimthan, I explained how financial regulation and healthcare regulation met in that relationship. We needed arrangements that allowed the parties to contract, pay, and deliver care. Change accelerated during the pandemic. We worked with the Council of Health Insurance to help enable that route and reached agreements with insurers.
That experience belongs to an earlier stage of the market. What stays with me is how readiness for a service is distributed across several parties. The doctor can deliver a consultation, the platform can run it, and the payer needs a clear way to purchase it.
The payer therefore shares responsibility for care quality. Its decisions determine the services purchased, their price, approval conditions, and how claims are reviewed and paid. These choices affect continuity and the provider's ability to maintain the required team.
Take a hypothetical home-care service. The provider is responsible for qualified staff, the visit, and the care plan. It needs a contract that purchases capacity suited to the need, clear claims rules, and a payment schedule it can plan around. A breakdown anywhere in that relationship can reach the patient's home.
The Saudi Model of Care describes the intended separation of funding, regulation, and delivery. This creates an opportunity to measure each party's responsibilities more precisely.
Providers should answer for quality and access. Purchasers should answer for how well the capacity they bought matches the need, how quickly they decide, whether payments arrive as agreed, and how clearly they explain rejections. When a problem arises, we need to identify who can address its cause.
A referral waiting for an appointment needs a different response from one waiting for approval. A contract that bought too little capacity needs a different review from a clinic struggling to use its available capacity.
I want patients to have a team following any interruption in their care while these issues are resolved. Clear responsibilities should help them obtain treatment and help us identify who answers for the decisions affecting it.
