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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

Healthcare Quality - a Janus view

Rajesh Patel

BHF

May 2009


Janus
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.



Objectives
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



Major attributes of quality noun in healthcare
Major attributes of Quality (noun) in Healthcare

  • Access

    • Transport

    • Benefits

  • Accountability

  • Affordability

  • Continuity of care

  • Efficacy

  • Effectiveness

  • Efficiency

  • Equity


Quality assurance
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



Ncqa diabetes quality improvement it is an ongoing process
NCQA: Diabetes quality improvementIt is an ongoing process!


Healthcare quality implementation and assessment
Healthcare Quality: Implementation and Assessment

  • Structure/ standards

  • Process

  • Outputs including Outcomes



Structure practice guidelines
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
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
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
Medical School Humour Scheme”

  • 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
Maternal Health 2005-2007 Scheme”

  • Contraception

    • ppp

  • Above 30%

    • Inefficiency cost

    • Solutions:

      • Professionalism

      • Clinical governance

      • Financial incentives proposal…

District Health Barometer 2007/08


According to darwin future human race
According to Darwin: Scheme” “future” human race


CAD Scheme”

DUR intervention to promote benefit

10% of adults


Diabetes 2005 and 2007 is there place for disease management
Diabetes: 2005 and 2007 Scheme”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
Diabetes: 2005, 2007 and CDE Scheme”Not Case-mix adjusted!

31x

11.5x

4x(US)

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


Asthma it s about reversibility
Asthma Scheme”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
COPD:Too little, too late! Scheme”

?

*MAG conference 2002

Limited treatment options:

What about Spiriva into the future?


HIV Scheme”

?

*MAG conference 2002


Preventative care and the pmb
Preventative Care and the PMB Scheme”

  • Screening is not justified when treatment is inaccessible

  • Prostate screening not included!

    • Marketing benefit

  • USPSTF


Summary
Summary Scheme”

  • 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
Janus peeped into the past! Scheme”What is the view ahead?


Looking forward
Looking forward Scheme”

  • 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 forward1
Looking forward Scheme”

  • 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 forward2
Looking forward Scheme”

  • 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 forward3
Looking forward Scheme”

  • 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 Scheme”

  • 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 [email protected]


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