Yosuf Veriava School of Rural Health and School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand. Chairperson of Council Council For medical Schemes. REGULATING CLINICAL QUALITY
LOCAL CONTEXT: PRIVATE HEALTH CARE EXPENDITURE • Bulk of benefits paid to the following disciplines: • Private hospitals (40.5%) • Specialists (23.6%) • Medicine (13.9%) • In 2012, these three components accounted for 78% of the health care benefits paid from the risk pool • Where must we focus?
Our focus must not only be on lowering health care costs, but also on achieving high value for patients, with value defined as the health outcomes achieved per rand spent. Porter ME Value = Quality/Cost
PRESENTATION • Concept of Quality • Evaluation of quality. • The need to regulate quality. • Responsibility to ensure quality health care • The present initiatives in evaluating quality. • The way forward.
The operational definition of quality of care is a reflection of values and goals current in medical care system and in larger society of which it is part
QUALITY DIMENSIONS CLINICAL/SCIENTIFIC ETHICAL Appropriate process of care in diagnosis and management Infrastructural Outcomes Recovery Restoration of function Survival Patient Experience
QUALITY MEASURES/PERFORMANCE INDICATORS • Process measures • Outcomes • Infrastructure
AIM OF USING PERFORMANCE INDICATORS • Inform policy making or strategy • Improve quality of care at health care facility • Monitor performance of health care funders • Identify poor performance to protect public safety • Provide consumer information to facilitate choice of health care provider Jonathan Mant
OUTCOME MEASURES • Advantages: • Measures something that is important in its own right. • Reflect all aspects of the process of care and not simply those that are measurable • The data to construct simple rates are available from routine information systems • Causes of variations • Differences in type of patient • Differences in measurement • Chance • Differences in quality of care Jonathan Mant
OUTCOME MEASURES • When to use outcome measures • When variation in quality of care might lead to significant variation in outcome • Whether the outcome indicator is likely to have the statistical power to detect differences in quality • Whether there are any practical alternatives to using outcome indicators in any given area. Jonathan Mant
QUALITY STANDARD FOR PATIENT EXPERIENCE • Quality statement • Patients are supported by health care professionals to understand relevant treatment options, including benefits, risks and potential consequences • Quality measure • Structure: Evidence of local arrangements to ensure that health care professionals support patients in this regard • Outcome: Evidence from patient experience surveys and feedback in this regard. NICE guidelines
PROCESS MEASURES • Advantages of process measures • More sensitive than outcome measures to differences in quality of care. • Easy to interpret eg use of aspirin in AMI is a direct measure of quality, where as hospital specific mortality for AMI is an indirect measure. • Process measures are valid indicators if correlated with positive clinical outcomes and endorsed by nationally credible consensus guidelines Jonathan Mant
OBSTACLES TO REPORTING PERFORMANCE STANDARDS • Managed care services may be rendered by more than one managed care company • Regulatory requirements do not include guidance in the type of data to be captured, the format or means of collecting such data • Clinical information not being provided routinely by service providers • Systems cater only to capture claim information • Clinical information received via application are scanned or kept in hard copy.
MANAGED CARE ORGANIZATIONS • Most MCO are able to demonstrate the following: • Evidence based medicine used in compiling protocols • Cost effectiveness and affordability studies • Cost vs benefit ratios • Savings
LEGISLATIVE REQUIREMENT ACCREDITATION OF MANAGED CARE ACTIVITIES • Managed care organisations are accredited in compliance with Section 67(1)(m) of the Medical Schemes Act and Chapter 5 of Regulations • Comprehensive standards developed over time with roleplayers involved to ensure consistency • Section 7 (c) of the Act outlines one of the functions of the Council to “...make recommendations to the Minister on criteria for the measurement of quality and outcomes of the relevant health services provided for by medical schemes…” Furthermore Section 7 (e) mandates “...collection and dissemination of information about performance of private health care...” • The above provisions drive the health and quality outcomes framework currently being developed by CMS
EVALUATING QUALITY - RESPONSIBILITY • Managed Care organizations • Medical schemes/ Trustees • Outsourced administrators for medical schemes
PRESENT INITIATIVES • Health Quality Assessment (HQA) • Some Schemes • CMS
HQA PROCESS INDICATORS • Primary care including screening • Chronic disease management • Management of pregnant mothers and their newborns.
HQA • Primary care: • Pneumococcal vaccine industry average 0.49% • Chronic disease management • The coverage with respect to the process indicators for diabetes mellitus were on the average all below 50%. (HbA1C 48.37%) • The process indicators for hypertension • Creatinine 39.82% • Cholesterol 22 % • ECG 22%
INDUSTRY TECHNICAL ADVISORY PANEL (ITAP) • Commenced in 2012 to determine and explore the value of managed care services provided by accredited entities to beneficiaries of medical schemes, through the development of data specifications to enable the office to collect appropriate data to enable satisfactory reporting of the value of managed care.
ITAP - AIMS • ITAP is a Technical Advisory Panel: • Of industry experts • Advising on specific technical issues and projects agreed with CMS • Helping with the collection of data • And development of methodologies • With the object of increasing understanding and publishing objective, industry wide results
WAY FORWARD • Accreditation and Research and Monitoring Units at CMS will drive the process • Prepare the industry to collect relevant data • Define outcomes, process indicators, quality, and the value component by CDL / disease management program (DTP’s later) • Design minimum data specifications for each CDL / disease management program
WAY FORWARD • Focus on Chronic Disease List conditions with clear link to the disease programs • Selection of CDL conditions linked to the top 10 prevalent chronic conditions • First step is to focus on process indicators • Collection of data/process indictors have to be feasible and practical. • Selection of process indicators/outcomes evidence based. • Transparency and inclusive of stake holders.
ACKNOWLEDGEMENTS • Accreditation and Research and Monitoring Units at CMS • Ms Tania Booth • Dr Anton Devilliers • Mr DanieKolwer