Healthcare Quality - a Janus view

Rajesh PatelBHF

May 2009

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.

Healthcare Quality

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

What is “quality” in Healthcare?

Major attributes of Quality (noun) in Healthcare

• Access– Transport– Benefits

• Accountability• Affordability

• Continuity of care• Efficacy• Effectiveness• Efficiency • Equity

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

Quality (verb) Improvement &

Medical Audit

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)

Healthcare Quality: Implementation and Assessment

• Structure/ standards• Process• Outputs including Outcomes

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

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

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!

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

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!

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

According to Darwin: “future” human race

CAD

7

100

75 76

JH, 100 JH, 100

Prevalence Cholestrol Asprin Statin

10% of adults

DUR intervention to promote benefit

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?

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

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

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

?

HIV

64

58

56

2000 2001 2002 2007

Proxy Compliance %*

*MAG conference 2002

?

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

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)

Janus peeped into the past!What is the view ahead?

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…

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

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

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

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 lj.botha@iafrica.com