Quality indicators and their role in contractual relations between health care providers and health insurance

companies

Janka JančovičováHealth Care Surveillance Authority,Bratislava

 

Quality of provided health care

• From the view of WHO

• the highest possible level of expertise

• effective usage of resources

• minimal risk for patient

• high level of patient satisfaction

• patness of health care provision

 

„Quality“ of provided health care

• Quality is a category, describing in quantitative and qualitative terms the level of provided health care or provided services

• quality thus consists of two parts - the quantitative, measurable, and the qualitative, based on the system of values,

• Quality is a relative, not an absolute category

(Dr. Marx, JCR/JCI, WHO, Bratislava 2005)

 

Quality indicators

• internal – monitoring and evaluation of results of provided health care

(unveiling the problems, proposing solutions, permanently increasing of quality)

• external – assessment of the quality of health care providers, comparison with other providers

 

Legislative framework of quality indicators

§7, Law No. 581/2004 Z. z. issued by the government directive for the

purpose of assessment of selected areas of health care provision

• accessibility of health care• effective usage of resources• effectiveness and adequacy• perception of provided health care by the

patient• results of provided health care

 

Legislative framework of quality indicators

§7, Law No. 581/2004 Z. z. Obligations of health insurance company• to publish criterions of conclusion of contracts

related to 1.material and technical equipment and human

resources of the providers2.quality indicators• to create a list of providers according to criterions

fulfillment • to conclude contracts with providers on the grounds

of their position in the list

 

Criterions for conclusion of contracts on health care provision and coverage

VšZP, a.s.

SZP, a.s.

Apollo, a.s.

Dôvera, a.s.

Sideria, a.s.

Union, a.s.

EZP, a.s.

30% 40%

45% 30% 15% 45% 45% 45% 40%

45% 30% 15% 45% 45% 45% 40%

10% 10% 30% 10% 10% 10% 20%

90% 90% 65% 90% 90% 90% 80%

Source: Health insurance companies

quality indicators

minimal level of all criterions

Health insurance companiescriterions

health care accessibility

material and technical equipment

human resources

 

Number of contracts between health insurance companies and health

care providers - 31.12.2006

VšZPSZPApolloDôveraSideriaUnion

VšZP SZP Apollo Dôvera Sideria Union10299 10539 9025 10344 9589 1129

Total :50 925

 

Percentage assessment of levels of quality indicators

VšZP, a.s. SZP, a.s. Apollo, a.s. Dôvera, a.s. Sideria, a.s.

0,14-10,00% / 8 1,22 -17,89%/ 5 3,00-7,00%/ 5 5,93-15,13%/ 5 4,89-15,50%/ 5

0,80-7,62%/ 23 0,86-16,13%/ 18 1,00-8,00%/ 15 1,75-58,87%/ 13 0,81-16,19%/ 16

56,80 -100%/30 82,11-100%/27 24,00-100%/27 41,13-100%/30 83,81-100%/30

10 -50% /10 2-76%/13

Source: Health insurance companies

non-measurable data

Percentage range of assessment /number of indicatorsLevel of indicator assessment

high

low

standard

 

Role of quality indicators assessment in contractual relations

• in relation to legislative framework in force

• in relation to actual demand of health insurance companies

• In relation to actual demand of health care providers

 

Role of quality indicators assessment in contractual relations

• selection of appropriate quality indicators???

• methodology of quality indicators collection and assessment ???

• validity of data???

• competition or motivation???

 

Problem areas of assessment of external quality indicators

from the view of health insurance companies• Universal set of quality indicators

(not influenced by specifics of insurance base) • Methodology of collection and assessment

(error of little numbers)• Setting of clear criterions of conclusion of

contracts considering quality indicator level • (effectivity and quality )

 

Problem areas of assessment of external quality indicators

from the view of health care providers• Validity of data in relation to increasing

administrative burden of health care providers

• Assessment of „non-measurable“ part of selected forms of health care

• Feedback by assessment of results in relation to increasing level of quality of provided health care

 

Quality indicators in contractual relations – future vision

• Assessment of quality of provided health care aimed at:

Creation of differential treatment system by conclusion of contractual relation between health insurance companies and health care providers according to appropriately selected and targeted criterions of quality and effectivity of provided health care.