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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

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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


NCQA: Diabetes quality improvementIt is an ongoing process!


Healthcare Quality: Implementation and Assessment

  • Structure/ standards

  • Process

  • Outputs including Outcomes


Healthcare Quality Assessment


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

  • NCQA

  • Disease Management Network

  • 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

  • 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

DUR intervention to promote benefit

10% of adults


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!

31x

11.5x

4x(US)

CDE: n =13312; 7-10% of FFS Diabetics


Asthma It’s about reversibility!

  • 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!

?

*MAG conference 2002

Limited treatment options:

What about Spiriva into the future?


HIV

?

*MAG conference 2002


Preventative Care and the PMB

  • 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


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