Healthcare Quality - a Janus view

1. Healthcare Quality - a Janus view Rajesh Patel BHF May 2009

2. 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.

3. Healthcare Quality

4. 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

5. What is “quality” in Healthcare?

6. Major attributes of Quality (noun) in Healthcare • Access • Transport • Benefits • Accountability • Affordability • Continuity of care • Efficacy • Effectiveness • Efficiency • Equity

7. 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

8. Quality (verb) Improvement & Medical Audit

9. NCQA: Diabetes quality improvementIt is an ongoing process!

10. Healthcare Quality: Implementation and Assessment • Structure/ standards • Process • Outputs including Outcomes

11. Healthcare Quality Assessment

12. 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

13. 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!

14. 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

15. 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!

16. Maternal Health 2005-2007 • Contraception • ppp • Above 30% • Inefficiency cost • Solutions: • Professionalism • Clinical governance • Financial incentives proposal… District Health Barometer 2007/08

17. According to Darwin: “future” human race

18. CAD DUR intervention to promote benefit 10% of adults

19. 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?

20. Diabetes: 2005, 2007 and CDENot Case-mix adjusted! 31x 11.5x 4x(US) CDE: n =13312; 7-10% of FFS Diabetics

21. 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

22. COPD:Too little, too late! ? *MAG conference 2002 Limited treatment options: What about Spiriva into the future?

23. HIV ? *MAG conference 2002

24. Preventative Care and the PMB • Screening is not justified when treatment is inaccessible • Prostate screening not included! • Marketing benefit • USPSTF

25. 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)

26. Janus peeped into the past!What is the view ahead?

27. 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…

28. 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

29. 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

30. 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

31. 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