using performance information in national health insurance, korea

USING PERFORMANCE INFORMATION IN

NATIONAL HEALTH INSURANCE, KOREA

Kyohyun KIM MD, MPH

HIRA Research Institute

OECD Meeting on Sustainability of Health Systems

Paris, France, 4-5 February 2016

People Providers

Single Payer (NHIS, collecting & pooling)

• Patients can access specialists and hospitals without referrals (no registration with GP, no gate keeping)

MoH designing health system

Purchasing (HIRA, claim review)

Notify Payment amount

Co-insurance rate

Health Insurance Policy Deliberative Committee

Benefit package, insurance rate, relative fees for service

• All providers are automatically contracted • 95.8 % of facilities (hospital, clinics, etc) are owned by private sector

• Payment system • FFS 93% • DRG 3% • per diem 4%

• MoH : Ministry of Health and Welfare • NHIS : National Health Insurance Service • HIRA : Health Insurance and Assessment Service • FFE : Fee for Service, DRG : Diagnosis Related Group

• OVERVIEW

• BACKGROUND OF NHI’S MEASURING AND USING PERFORMANCE INFORMATION

• HIRA’S ROLE AND MEASURING AND USING OF PERFORMANCE INFORMATION

PERFORMANCE ASSESSMENT

SYSTEM

People Providers

Single Payer (NHIS, collecting & pooling)

Informed with performance information Healthcare resources

Purchasing (HIRA, claim review and QA)

MFDS (pharma, device)

Licensing Examination

Institute

Measuring performance information (since 2000)

NECA(HTA) (services)

Notify Payment adjustment

Structural requirements

• KCDC : Korea Centers for disease control and prevention • MFDS : Ministry of Food and Drug Safety • NECA : National Evidence-based Healthcare Collaborating Agency • KOIHA : Korea Institute for Healthcare Accreditation

Public Reporting

Quality Assessment Coordinating Committee

Lump sum payment scheme

Professional associations Developing the clinical guideline

KOIHA Accreditation for

facility

Reporting performance information

KCDC (health status,

health behaviors)

Health Insurance Policy Deliberative Committee Differential fee scheme

(Acute care, Long term care, tertiary care,, emergency care)

MoH designing system

Supplementary

• OVERALL SNAPSHOT

• MEASURING PERFORMANCE INFORMATION

OVERARCHING RULE, INDICATORS MANAGEMENT, EVOLUTION (2000-2015)

MEASURING

PERFORMANCE INFORMATION

50

210

86

346

Office (clinic, 28,883) Hospital Acute care hospital (1,804) Long-term

care hospital (1,337)

Mental care hosp. (170)

Special care

Financed by Public(56%) and Private(44%) (Public : NHI (90.7%), Medical Aids(9.3%))

Primary care

Financing

Basic Allocating System

(No. of facility)

(Payment system)

Measuring Performance Information

(No. of indicators)

FFS

Using Performance information

Feedback to providers

Structure Process

Outcome

0 55 0

All indicators

Inpatient care Outpatient

care Inpatient

care

FFS FFS DRG

FFS(main)/ DRG

FFS Per diem (main) FFS

FFS Per diem

Office or outpatient care Items: 11 (HTN, DM, etc)

Acute care Item: 22 (IHD, stroke, cancer,etc)

Non-acute care Item: 3 (LTC, ESRD, etc)

Structure Process

Outcome

24 134 55

Structure Process

Outcome

26 21 31

Total 55 Total 213 Total 78

Public reporting

Structure

Process

Outcome

Total

36

121

27

184

53% of all indicators

Structure

Process

Outcome

Total

14

67

15

96


Structure

Process

Outcome

Total

1

22

0

23


Structure

Process

Outcome

Total

14

66

15

95


Structure

Process

Outcome

Total

Pay for performance (some indicators are used twice) Lump sum payment

scheme(a) Total (a+b) Differential fee scheme (b)

62 % of all indicators 23 % of all indicators 16 % of all indicators

Items : 36

Structure Process

Outcome

50 210 86

Total 346

All indicators

• Above figure describes all indicators of HIRA’s Quality Assessment Program only. • Differential fee scheme integrating some of above indicators and indicators from other sources

SECTOR AREA Item Indicators 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Acute care

(mainly for hospital)

Ischemic Heart dz (integrated) 3 48

(AMI, 2013) (1) (16)

(CABG, 2013) (1) (14)

Acute stroke 1 25

Prophylactic antibiotics for surgery 1 12

Volume of surgical/procedural care 1 1

Colon caner 1 21

Breast cancer 1 20

Lung cancer 1 22

Gastric cancer 1 19

Hepatic cancer 1 2

Pneumonia 1 15

Intensive care unit care 1 13

Overall mortality & readmission rate 2 2

DRGs for 7 surgical cares 7 13

Non- acute care

Long term care hospital 1 35

Mental care hospital (Medical Aids) 1 25

Hemodialysis 1 18

Outpatient care

Hypertension 1 12

Diabetes 1 10

Asthma 1 7

COPD 1 6

Use of pharmaceutics 6 15

Use of antibiotics for AOM (<15 year old) 1 5

Discontinued (Cesarean delivery rate, 2013) (1) (3)

Total (2015) 36 346

Measuring 36 items

346 indicators

Public reporting 23 item

184 indicators

Lump sum payment scheme 7 items

23 indicators

Differential fee scheme 11 items

95 indicators

• OVERVIEW

• PUBLIC REPORTING

• TWO PARALLEL P4P SCHEMES : INTRODUCTION

LUMP SUM PAYMENT SCHEME

DIFFERENTIAL FEE SCHEME

USING

PERFORMANCE INFORMATION

For supporting patient informed choice

Name of

facilities

Performance

grade

Location of

facilities

ITEMs

For supporting patient informed choice

Name of

facilities

Values of

individual

indicators

※ Amounts of incentives for Lump Sum Payment Scheme (for 7 items, 2014-2015)


No. of

Indicators

Eligibility for

bonuses

Stroke

(2012~) Structure 1

Process 10

•Top 20% of composite scores

• Improvement of composite

scores (+10 points)

Hypertension (2013~)

Process 2 (continuity of

prescription)

Prescription

of medicine (2014~, 3 items)

Eligibility for

penalties

• A composite score of 55

points

Diabetes (2013~)

Process 2 (continuity of

prescription)

ITEMS

(Targets)


Incentive size

± 1 %

(of insurance

payment)

Prophylactic antibiotics for

surgeries (2013~)

Process 6 •A composite score of 97 points

• Improvement of composite

scores (+30 points)

• A composite score of 40

points

± 5 %

(of insurance

payment)

•Absolute target of two indicators

(80% for both) No penalty

Proportional to patient volume

(about 4 % of office

visit fee)

•Absolute target of two indicators

(80% and 90% for each) No penalty



visit fee)

Process 3 (1 indicator per 1 item)

(overuse)

•Top 11% by indicators

•Improvement of ranking

•Two consecutive bottom

11% by indicators and

absolute value



visit fee)

C-Section (2009~2013)

Outcome 2 •Top 22% of composite scores

• Improver

• A composite score of

previous year’s bottom 22% ± 2 %

(of insurance payment)

AMI (2009~2013)

Process 5

Outcome 1

•Top 22% of composite scores

• Improver

• A composite score of

previous year’s bottom 22% ± 2 %

(of insurance payment)

DIFFERENTIAL FEE SCHEME

• PROGRESS OF MEASURING AND USING PERFORMANCE INFORMATION PROGRAM

• OUTCOMES OF THE PROGRAM : PERFORMANCE IMPROVEMENT

• EVERLASTING CHALLENGES : MAINTAINING PARTNERSHIP WITH PROVIDERS

• ACHIEVEMENTS AND PLAN FOR 2016

• CHALLENGES (BEYOND EXPANSION)

ACHIEVEMENTS AND CHALLENGES

Introductory Stage

(~Mid 2000s)

Expanding Stage

(mid 2000s~2015)

Indicators Structure, Process

Increasing the number of

indicators

Adding outcome, safety,

efficiency

Data

source Claims data (mainly)

Resource data

Adding provider reported data

Patient-reported data (in pilot phase)

P4P

Consolidating Stage

(to be achieved)

Selecting significant

indicators

EHR linked data (in pilot phase)

Public

reporting

Feedback to providers

Disclosing high performers

(only)

Disclosing all performers

(only for some of indicators)

Disclosing all indicators

while addressing

unintended consequences

Lump sum payment scheme

By relative target mainly

(ranking)

Adding differential fee

scheme

By relative target (ranking)

Improving predictability

Consolidating two schemes

aspect

stage

Reflecting feasibility, acceptability by providers, and social needs

Source : Comprehensive Quality Report of NHI, 2012 (HIRA, 2013, Korean) Comprehensive Quality Report of NHI, 2014 (HIRA, 2015, English)

Proportion of 3rd or higher generation

ceph-antibiotics use

Use of prophylactic antibiotics within 1 hour before skin

incision

Proportion of aminoglycosides

use

Use of antibiotics more

than 1

Use of antibiotics at

discharge

Days of antibiotics use

(average)

[email protected]

[email protected]

Acknowledgement

Sunmin Kim, MD, PhD, Commissioner for Healthcare Assessment Coordinating Committee, HIRA

Choonseon Park, RN, PhD, Head of Quality Research Team, HIRA

Jeesook Choi, PhD, Associate research fellow, Benefit Policy Research Team, HIRA

Soo-Hee Hwang, PhD, Associate research fellow, Quality Research Team, HIRA

using performance information in national health insurance, korea

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