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Global Health Council June 16, 2011

The Health Insurance Organization of Egypt Utilization and Case Management Thomas Schwark, Abt Associates, Inc. Mohsen George , Chief Medical Officer, HIO, Egypt. Global Health Council June 16, 2011. Health Insurance Organization (HIO).

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Global Health Council June 16, 2011

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  1. The Health Insurance Organizationof EgyptUtilization and Case ManagementThomas Schwark, Abt Associates, Inc.Mohsen George, Chief Medical Officer, HIO, Egypt Global Health Council June 16, 2011

  2. Health Insurance Organization (HIO) • The social health insurance system (HIO) in Egypt has been in existence since 1964 • HIO was the outcome of many legislations started in the early decades of the 20th century

  3. Total Number of Beneficiaries (in thousands) 56% 8.3% 0.5%

  4. Number of beneficiaries (in millions) Census: June 2010

  5. Percentage of beneficiaries according to LAWS Census: June 2010

  6. HIO provides services to beneficiaries all over Egypt from Alexandria to Aswan HIO Owns: • 37 hospitals • 600 clinics • 78 work related injury centers • 34 general medical committees • Thousands of school clinics  Outsourcing:(640 hospitals – 1141out-patient clinics)

  7. Main problems facing current HIO • Near one half of population has no health insurance coverage • Different laws & systems dealing with beneficiaries “The more laws the less justice”, Marcus Tullius Cicero • Unrealistic rates of premium that have been fixed and unchanged since 1964 (financial sustainability is at risk) • HIO is the payer and service provider

  8. Health insurance reform in Egypt Aiming at: • Universal coverage • Sustainable financing resources • High level quality health care • Unifying the laws • Payer/provider split

  9. HIO will be EXCLUSIVELY a payer HIO will no longer operate hospitals or clinics HIO will contract with health care facilities to provide care to HIO beneficiaries HIO must ensure compliance with contract requirements and accreditation standards relating to quality and safety In the near future …

  10. Being the payer, HIO must ensure that the care for which it pays for is: Medically Necessary Appropriate (means that the treatment proposed is the one most likely to be effective for the patient’s condition) of High Quality Provided Efficiently Safe In the near future …

  11. To ensure those dimensions of care, HIO must have: A Medical Management Process Medical Auditing Utilization andCase Management In the near future …

  12. Utilization management: Definition Technique used by the payer of health care to manage costs (primarily a financial tool) through analysis of the medical necessity and appropriateness of care, including appropriateness of: Admission Treatment and investigations Length of stay Discharge (criteria – needs)

  13. Utilization management: Approaches • Prospective Approach(pre-certification – pre-authorization) • Concurrent Approach(assignment andtracking of length of stay – information gathering – hospital rounding – discharge planning) • Retrospective Approach(claims review – pattern review)

  14. Case management: Meet the patient’s health needs efficiently Concurrent Review, during hospital stay Is a collaborative and communicative process of the assessment, planning, and facilitation of the services byassessing: Any delays in treatment, investigations, or consultation Length of stay (LOS) Discharge needs Discharge criteria

  15. Special case management Comprehensive contact with patient and family during and after hospitalization To optimize care for HIO members with complex or chronic medical needs Intent is to reduce frequency of hospitalization or emergency room visits

  16. Primarily a financial tool Supports quality care Unnecessary admissions or procedures places patients at risk Helps identify complications and adverse outcomes Why utilization andcase management?

  17. Why utilization and case management? Reduces financial risk of inappropriate use of services (excessive LOS – delayed investigations – delayed consultation) Most important to the risk-bearing entity (HIO or hospitals) Critical to the hospitalif they receive “Package Price” Critical to HIOfor those cases when they pay “Fee for Service”

  18. Utilization and case management training Classroom sessions Introductory course on Utilization Management (UM) and Case Management (CM) (1 day) Theoretical and hands-on medical records training (3 days) Practical training in hospitals Demonstration by expert – participants are observers (3 days) Participants conduct the process – expert observing them (3 days) Final written exam Certification Utilization and case managers (57 of 61)

  19. Outcome of UM/CM in Gharbia governorate: 36% decline in spending on medications Egyptian Pounds Established protocols & guidelines for the top diagnoses & procedures. Concurrent review.

  20. Outcome of UM/CM in Gharbia governorate:24% decline in payments to hospitals contracted by HIO Egyptian Pounds Precertification Preauthorization Case Management Office Structured retrospective utilization review of claims & medical records .

  21. Conclusion • UM/CM program is a critical and necessary system for the HIO • When fully implemented and rolled out to HIO and contracted facilities, financial and quality implications will result in reduced costs and unnecessary LOS and re-admission

  22. Thank you www.HealthSystems2020.org

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