Presentation (CTI)

Problem Statement: The process of selecting high-cost surgical materials (specifically for maxillofacial, BMF, procedures) within the healthcare system is characterized by a significant asymmetry of information and objectives between primary stakeholders. Healthcare providers prioritize technical autonomy and brand preference, while health insurance operators (payers) focus on economic sustainability and cost containment. This divergence often leads to inefficient resource allocation, increased costs, and conflicts, highlighting the need for a value-based approach.
Description: This paper describes the implementation of a pilot project involving organizational and care-delivery changes aimed at restructuring the flow of requests for BMF procedures within a mid-sized health insurance operator. The project, conducted in Bahia, Brazil (August-December 2024), utilized patient journey mapping as a central framework to redesign the care pathway, adopting a model based on validated clinical protocols and enhanced clinical governance. Key interventions focused on efficiency, safety, and humanization of care: 1. Joint elaboration and implementation of specific clinical protocols for BMF procedures; 2. Restructuring the accreditation process, focusing on credentialing a network of referenced and qualified providers; 3. Implementation of an automated system to block requests from non-qualified providers, followed by the assisted redirection of patients to the qualified network; 4. Creation of a new, humanized welcoming service (patient navigation) to guide beneficiaries.
Lessons Learned: The results of the pilot study were expressive, demonstrating both economic gains and improvements in care quality. Of the 66 requests analyzed under the new governance model, 71% of the procedures initially demanded were deemed unnecessary based on protocol adherence, generating an estimated saving of R$ 14.8 million for the payer. Furthermore, litigation was significantly reduced, with the number of related lawsuits/injunctions dropping from 28 to just 1. Beneficiary satisfaction (measured by Net Promoter Score - NPS) reached an average of 4.2 out of 5, indicating high approval of the new standardized flow.The findings suggest that transitioning from an autonomy-based model to a protocol-driven, value-based healthcare model is highly effective in optimizing resource allocation in supplementary health. Implementing robust clinical governance mechanisms can drastically reduce unnecessary procedures and litigation while maintaining high levels of patient satisfaction. This model provides a blueprint for other payers seeking to balance economic efficiency with evidence-based quality care.
Stakeholder Perspective: Payer (Health Insurance Operator)