healthcare quality - a janus view rajesh patel bhf may 2009
TRANSCRIPT
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Healthcare Quality - a Janus view
Rajesh PatelBHF
May 2009
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Janus
• In Roman mythology, Janus (or Ianus) was the god of gates, doors, doorways, beginnings and endings
• Janus was usually depicted with two heads looking in opposite directions. According to a legend, he had received from the God Saturn, in reward for the hospitality received, the gift to see both future and
the past.
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Healthcare Quality
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Objectives
• What is quality?• Janus view of quality using HQA 2008
report results• Message
– System excellence, weaknesses and cost drivers
– Some suggestions on risk management– Value of HQA report and participation
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What is “quality” in Healthcare?
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Major attributes of Quality (noun) in Healthcare
• Access– Transport– Benefits
• Accountability• Affordability
• Continuity of care• Efficacy• Effectiveness• Efficiency • Equity
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Quality Assurance
• Definition – Anything done to measure and improve quality of
care.
• 3 dimensions– To define– To measure– To improve
• Tools– Accreditation– Provider profiling– etc
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Quality (verb) Improvement &
Medical Audit
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NCQA: Diabetes quality improvementIt is an ongoing process!
30
40
50
60
70
80
90
100
1999 2000 2001 2002 2003 2004
Nephropathy testing
HbA1c test/year
Cholesterol test/year
Eye exam/year
LDL Control (<130)
LDL Control (<100)
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Healthcare Quality: Implementation and Assessment
• Structure/ standards• Process• Outputs including Outcomes
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Healthcare Quality Assessment
Indicator type Practice Hospital Medical Scheme
Structure Guideline/ minimum practice equipment
Licensing /accreditation
Benefits / provider network
Process Treatment application
Infection control and sanitation procedures
Member access to benefit
Outputs including outcomes
Reduced hospitalisation or death rates
Infection rates Admission rates, Health status of population served
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Structure: Practice Guidelines
• 52-55% adherance to guidelines1,2
Use of CPGs by 28 Canadian healthcare facilities 3 % of respondents
Use CPGs regularly (well-established CPG process/program) 12.7 Use CPGs occasionally (on an ad hoc basis) 23.3 Beginning to explore of develop CPGs 22.8 Never use CPGs 40.7 No response 0.4
1. NCQA2. Disease Management Network3. http://www.law.utoronto.ca/healthlaw/basket/docs/BP2_financialincentives.pdf
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Structure: PMB
• Equity & Access– 26 CDL
• Iniquitous, therefore unconstitutional
• Technically, not part of PMB!
– DTP• Menopause• Life threatening
vitamin and mineral deficiency
– Always late Pathologist
• Effectiveness– Interferon for MS
• Efficiency– At cost, no limitation
• Affordability– Without specification
• Accountability
Too many inconsistencies! Good intentions lost through implementation!
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Health quality improvement for “Industry Medical Aid Scheme”
• As seen through the eye of trustee, CEO or health risk manager
• HQA report– 2007 claim data– Claims paid from risk and savings benefits
• Unpaid claims not included
– Normalised– 2 schemes resubmitted data
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Medical School Humour
• Physician– Knows a lot, does little
• Surgeon – Knows a little, does a lot
• Pathologist– Knows a lot, does a lot, always too late!
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Maternal Health 2005-2007
69.465.0
10.6 15.4 20.0
60.475.0
50.0
Uni
nten
ded
preg
Publ
ic Se
ctor
SA M
etro
C/S
Caes
ar ra
te(%
)
Hos
p pl
an
Com
preh
. Pla
n
2005 2006 2007 • Contraception– ppp
• Above 30%• Inefficiency cost• Solutions:
• Professionalism• Clinical governance• Financial incentives
proposal…
District Health Barometer 2007/08
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According to Darwin: “future” human race
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CAD
7
100
75 76
JH, 100 JH, 100
Prevalence Cholestrol Asprin Statin
10% of adults
DUR intervention to promote benefit
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Diabetes: 2005 and 2007Is there place for disease management?
•What happened to cholesterol coverage?•2005/2007 difference•Podiatry and LL amputation observation?•Intervention: In-house or CDE?
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Diabetes: 2005, 2007 and CDENot Case-mix adjusted!
1.5
13
1.150.41 0.1
Adm
issi
ons
LL a
mpu
tatio
n
31x
11.5x4x(US)
CDE: n =13312; 7-10% of FFS Diabetics
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Asthma It’s about reversibility!
10
26.85
17.7215.12
Admissions Asthma related re-admission (% )
Flu Vaccine Coverage(%)
LFT coverage (%)
• SA– 4th highest asthma
related death rate in the world
• 1999: MSO– Peak flow for self Mx:
17%– World Asthma meeting 2001
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COPD:Too little, too late!
50
70
11.5
Admission (all)
Admission (compreh)
Flu vaccine
Limited treatment options:What about Spiriva into the future?
*MAG conference 2002
?
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HIV
64
58
56
2000 2001 2002 2007
Proxy Compliance %*
*MAG conference 2002
?
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Preventative Care and the PMB
Indicator Result (%)
Chlamydia screening70-75% of infected women are asymptomatic. Less in men.
0
Hepatitis B virus screening in Pregnancy4.5-30% prevalence of hep (B&C) virus in pregnancy
1
Bone densitometry >65y• 40% women and 25% men have osteoporosis related fracture in US.•Prevalence in elderly: 30% F; 12% M
0.22
Flu vaccine >65y 8.22
Pneumococcal vaccine >65y 0.17
Screening is not justified when treatment is inaccessible
Prostate screening not included!-Marketing benefit
USPSTF
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Summary
• Under-utilisation and underfunding of essential services that is available in current benefits
• Avoidable expenditure is being incurred
(big demand for costly latest and greatest)
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Janus peeped into the past!What is the view ahead?
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Looking forward
• Structure– Benefit design:
• What are the objectives?– PMB: “prevent dumping on the state”
» Hospital, not “healthcare”, access achieved!
• Use the needs analysis approach• Affordability level?
– Accreditation• Third party: effectiveness of Managed Care can be
improved• Service provision…
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Looking forward
• Process– “expensive” PMB to cost more (investment)
before it will cost less
– Member access to PMB benefits• Lack of awareness of entitlement by members • PMB claims identification and assessing issues
– BHF commenced engagement with schemes/administrators
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Looking forward
• Opportunities to intervene and make a difference, together with providers of service and other stakeholders– Providers are hungry for this type of feedback!
• They too have an interest in our members well being
• Provider remuneration (PBR)– ?incentives/rewards and ethical considerations
• Performance based reimbursement using withhold/reward
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Looking forward
• If you don’t measure, you don’t manage!– Need for active and proactive management
• Minimum reporting standards for schemes– Demographic monitoring– Public health / health status indicators (BHF 2007)– Clinical quality indicators - HQA– Utilisation indicators and report– Finance & Economic indicators– Third party processes report
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HQA
• Section 21 Company• Established by the industry for the industry• Includes Associates• Initiative supported by BHF, CMS and
Consumer Union• Ongoing development for improvement• CEO: Louis Botha [email protected]
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