Private health insurers or payers play a pivotal role in shaping modern, sustainable health systems in most countries. Through the benefits they design, the providers they contract with and the customer and physician incentives they create, health insurers can exert some level of influence over how care is delivered and experienced.

Last year, in a multipart series of blogs, we examined the mission statements, public disclosures and sustainability reports of 14 UK and Irish private health insurers, and we benchmarked the private health insurance industry against an ambitious and widely known reference: the Quintuple Aim,^1,2 a framework aimed at measuring and transforming health systems.

In this blog, we bring together the lessons learned and challenges we see in the health ecosystems, and explain why it is important for health insurers to measure outcomes to achieve a sustainable healthcare delivery model.

Population health: From participation metrics to driving health equity

Population health features prominently in health insurers’ narratives and mission statements. Many aim to improve the health and well-being of the communities they serve by addressing broader social, economic and environmental factors that impact health. Central to this is health equity: reducing disparities through effective, targeted intervention and improved access to healthcare. However, even though health insurers have presented population health as a strategic differentiator, implementing measurable outcomes has proven to be more challenging.

Good progress has been achieved in certain areas, particularly disease prevention and access to healthcare services, but there is still significant room for improvement in tracking both narrow outcome metrics for specific interventions and demonstrating that insurers are improving population health more broadly.

For those organisations that report some forms of metrics, they typically highlight participation rates, engagement statistics and wellness programme reach. These measures are necessary, but they are not sufficient to demonstrate the addition of value to customers, either individually or in aggregate. Although insurers may be investing in prevention, the absence of outcome-based measurement makes it difficult to assess effectiveness or value. The most significant gap in metrics we found was in addressing health disparities; metrics related to equity are particularly scarce and often limited to programme reach rather than demonstrable impact.

To manage population health strategies and evaluate their success, health insurers should have robust process and outcome metrics to track and measure the impact of disease prevention, health education, access to healthcare services and health inequalities. In our blog, How health insurers are measuring their impacts on population health, we discuss best practices and key metrics used in global health economies.

Patient experience: From customer service metrics to care delivery gains

Health insurers frequently report on “customer experience,” often through Net Promoter Scores, satisfaction surveys and service metrics. These measures provide insight into service interactions and operational performance of insurers—claims processing, helplines or digital platforms—but they rarely capture the lived experience of being a patient within the funded care pathway. Patient experience in healthcare is multidimensional, encompassing access, timeliness, communication, involvement in decisions and confidence that care provides good outcomes. A substantial evidence-based systematic review³ links positive patient experience with better clinical outcomes. Yet patient-level insight is largely absent from public reporting and is under-represented in health insurers’ corporate purpose statements. Some insurers are running limited programmes to collect hospital- or clinician-focused patient-reported outcome measures (PROMs). Although these are useful, they are not a complete answer, as they focus on short-term, episodic interventions, such as the experience of an inpatient hospital stay, rather than on medium- to long-term health outcomes that matter to patients, such as reduced incidence of chronic disease or improved functional status.

As health insurers increasingly expand vertically into care delivery and integrated services, through networks, pathways and owned services, measuring patient outcomes matters. There is a clear opportunity to demonstrate value by designing patient-centred pathways and measuring whether they improve both experience and outcomes.

To meaningfully assess patient experience over time, a health insurer should measure both process and outcomes to systematically capture patient views on access and care quality and use this evidence to differentiate providers and actively steer customers towards those delivering better experiences. We discuss how the patient experience is measured in our blog, How good are health insurers measuring patient experience?

Healthcare cost containment: From financial performance metrics to quality healthcare performance

Healthcare cost containment is a major challenge for health insurers, particularly in the face of persistent medical inflation and rising affordability pressures. Achieving quality healthcare performance requires more than just managing loss ratios.

We examined public reports that suggest most health insurers continue to manage costs largely through aggregate financial metrics, for example, loss ratios, claims volumes and inflation commentary, without systematically linking these figures to outcomes. As a result, healthcare cost control is framed as a defensive and reactive management action rather than a strategic lever for improving overall system performance and getting value from healthcare interventions at the patient and population level.

A value-focused approach to managing healthcare costs would require a target operating model that integrates both cost and outcomes explicitly, for example, monitoring and managing unit costs alongside quality, identifying unwarranted variation, reducing waste and inappropriate care and aligning incentives with outcomes. In other words, it means treating healthcare cost containment as a means to improve and demonstrate value whilst ensuring financial sustainability.

In our blog, How good are health insurers at measuring cost containment?, we discuss the importance of integrating both the process and outcome metrics by linking the effectiveness of healthcare cost containment with the value of propositions in terms of improving health and clinical outcomes for health insurers’ customers.

Concluding thoughts: UK and Irish health insurers must aim to boost health equity and patient outcomes