Measuring the value of managed care interventions - PowerPoint Presentation

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Measuring the value of managed care interventions

Report Back from Working Group

Danie Kolver

Background

The Council and National Department of Health requested the office to undertake a project(s) to explore in depth the following issues:

What is the role of managed care organisations in the medical schemes industry?

To what extent do managed care organisations contribute to the healthcare environment?Do managed care organisations manage costs and improve quality? What is the value of managed care in the medical schemes industry?

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Managed care accreditation standards currently measure compliance with…

Clinical oversight

Clinical effectiveness and quality management.

Documented protocols in place, are evidence based, contain details of limitations on rights or entitlements of beneficiaries, including restrictions on coverage of disease states, protocol requirements and formulary inclusions and exclusions;Furthermore, protocols incorporate procedures to evaluate clinical necessity, appropriateness, efficiency and affordability of services provided, to intervene where necessary and to inform beneficiaries, providers of care acting on their behalf, and medical schemes of the outcomes of such procedures and Protocols provide for clinical pathways and appropriate exceptions where a protocol or specific treatment is or has been ineffective, or causes or would cause harm to a beneficiary, without penalty to such beneficiary.Demonstrating value added services

Current reporting on the value or impact of managed care has been found to be

lacking

Financial indicators rather health outcomes available

Clinical information not collected and or reported onData collected should enable us to assess value of managed care provided  Need for Managed Care Assessment

Regulators Function

Develop

and introduce measures to assist medical schemes to

capture appropriate indicators/outcomes to measure and evaluate the value of managed care interventionsEnsure that the interests of beneficiaries are not only protected but are best served. Standards and data specifications must be developed:Process indicators; andClinical outcomes indicators Regulators Function

Project Scope

To

collect quantitative and qualitative data from managed care

organisationsTo understand quantitative value of managed care interventionsTo understand the cost effectiveness thereofProject Scope

History

Consultative process

Identified possible pilot projects

HIVBreast CancerData request resulted in no real usable data other than vague process indicators at best (Pockets of good data)Identified 3 Task teamsCDLRegistries of High Cost InterventionsUtilisation management reviewHistory

Project

After

initial analyses decided to focus where resources and data allows progress

CDL process progressed Task teams 2 and 3 on hold Project History

Collect data at benefit option level (SR)

Prevalence number of beneficiaries per CDL initially and if possible expand it to other risk factors

Admissions rates and days in hospital for CDL prevalence beneficiaries

Collect process indicators per CDL Benchmark admission rates and process indicators over all the benefit options and/or cluster types of benefit options and even reimbursement modelsUse benchmark results and analyse relevant protocols (baskets of care; medicines) to understand why certain benefit options / programme’s perform better than othersBefore we compare, adjust for differences in risk profiles at benefit option level (option type, risk profile, etc.)

Ultimately define outcomes and measure value

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Measuring Outcomes

Define outcomes for each CDL

Ask the schemes for data to measure their outcomes (in-house analysis of data),

alternativelyAsk schemes / managed care entity to demonstrate the value of their program (part of accreditation process)Measure the minimum data (available at managed care entity and scheme/administrator)“Compliance”: Process indicatorsOutcomes: HIV: They must demonstrate that there was a significant improvement in the CD4 count after six and twelve months of diagnosis; Viral load not detectable Outcomes: Survival analysis, trend analysis, paired tests, control charts, etc.CMS must create the framework (define outcomes, value, data spec, etc.)

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Progress to date

We have noted that CDL algorithms are outdated

However, we focussed on what is appropriate taking into account existing guidelines

Finalised entry level criteria, process indicators and outcomes for HIV, Cardiac Failure and Cardiomyopathy, Hypertension, Hyperlipidaemia, Bipolar Mood Disorder, Diabetes Mellitus Types 1 & 2 and Respiratory diseases (Asthma, COPD and Bronchiectasis)Discussion document to be circulated to industry for comments.11

Progress to date

Indicators and minimum data specifications in respect of treating HIV/AIDS incorporate:

REF criteria

ICD-10 entry criteriaClinical process indicators (tariff codes, description and frequency)Discipline and consultation frequencyDisease management programmeAlgorithms applicableData specifications / outcomes12

Progress to date

Prepared detail Word format and Excel spreadsheet process indicators diagram

Circulated to participants for comments

Comments to be considered by working group and thereafter publication to industry as working document for comments13

Finalise HIV document and sensitise industry to participate

Finalise remaining CDL conditions and follow similar process with regard to roll out

Design

minimum data specifications Collect incidence rates admission rates to hospital for prevalence specific beneficiariesWay forward

Collect

process indicator information

Adjust

current value-added template over time. Ask schemes / managed care entities to demonstrate the value (clinical and financial) of their programs Split aggregated managed healthcare cost per service at benefit option levelCompare (within context)Way forward

CDL’s for consideration during next financial year:

Asthma

Chronic renal disease

3.

Rheumatoid arthritis

4.

Crohn’s

disease and ulcerative colitis

5.

Bipolar mood disorder

Way forward

TASK TEAM 2: BENEFICIARY REGISTERY FOR HIGH COST INTERVENTIONS/EVENTS

Resolved not to continue with the project at present due to challenges of entry criteria and hosting of the registry

TASK TEAM 3: UTILISATION MANAGEMENT REVIEW (UMR)

Resolved not to continue with the project following Council’s prioritising of the value project and budget constraints

Remaining ITAP projects

END

Thank you

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