Healthcare Quality - a Janus view
Rajesh Patel BHF 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
Analysis
Guidelines/ Standards
Monitoring
Implementation
NCQA: Diabetes quality improvement It is an ongoing process!
100
Nephropathy testing
90 80 70 60 50 40
LDL Control (<100) HbA1c test/year
Cholesterol test/year
Eye exam/year
LDL Control (<130)
30 1999 2000 2001 2002 2003 2004
Healthcare Quality: Implementation and Assessment
• Structure/ standards • Process • Outputs including Outcomes
Healthcare Quality Assessment
Indicator type Structure Practice Guideline/ minimum practice equipment Treatment application Hospital Licensing /accreditation Medical Scheme Benefits / provider network
Process
Infection control Member access and sanitation to benefit procedures Infection rates Admission rates, Health status of population served
Outputs including outcomes
Reduced hospitalisation or death rates
Structure: Practice Guidelines • 52-55% adherance to guidelines1,2
Use of CPGs by 28 Canadian healthcare facilities 3 Use CPGs regularly (well-established CPG process/program) Use CPGs occasionally (on an ad hoc basis) Beginning to explore of develop CPGs Never use CPGs No response % of respondents 12.7 23.3 22.8 40.7 0.4
1. NCQA 2. Disease Management Network 3. 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!
• Effectiveness
– Interferon for MS
• Efficiency
– At cost, no limitation
• Affordability
– Without specification
– DTP
• Menopause • Life threatening vitamin and mineral deficiency – Always late Pathologist
• 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
2005 2006 69.4 65.0 60.4 2007 75.0 50.0
• Contraception
– ppp
• Above 30%
• Inefficiency cost • Solutions:
10.6
Unintended preg
15.4
20.0
Caesar rate(%)
Public Sector
SA Metro C/S
Hosp plan
Compreh. Plan
• Professionalism • Clinical governance • Financial incentives proposal…
District Health Barometer 2007/08
According to Darwin: “future” human race
CAD
100 JH, 100 JH, 100
DUR intervention to promote benefit 76 75
10% of adults 7
Prevalence
Cholestrol
Asprin
Statin
Diabetes: 2005 and 2007 Is 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 CDE Not Case-mix adjusted!
13
31x 11.5x 4x(US)
0.41
Admissions
1.5 1.15
LL amputation
0.1
CDE: n =13312; 7-10% of FFS Diabetics
Asthma It’s about reversibility!
26.85
• SA
17.72
15.12
10
– 4th highest asthma related death rate in the world
• 1999: MSO
Admissions Asthma related readmission (% ) Flu Vaccine Coverage(%) LFT coverage (%)
– Peak flow for self Mx: 17%
– World Asthma meeting 2001
COPD:Too little, too late!
70
50
11.5
Admission (all)
Admission (compreh)
Flu vaccine
?
*MAG conference 2002
Limited treatment options: What about Spiriva into the future?
HIV
Proxy Compliance %*
64
58
56
?
2000 2001 2002 2007
*MAG conference 2002
Preventative Care and the PMB
Indicator Chlamydia screening
70-75% of infected women are asymptomatic. Less in men.
Result (%) 0
Hepatitis B virus screening in Pregnancy
4.5-30% 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
Screening is not justified when treatment is inaccessible Prostate screening not included! -Marketing benefit USPSTF
Flu vaccine >65y
Pneumococcal vaccine >65y
8.22
0.17
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 • • • •