Report Back from Working Group Danie Kolver Background The Council and National Department of Health requested the office to undertake a projects to explore in depth the following issues What is the role of managed care organisations in the medical schemes industry ID: 915298
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Measuring the value of managed care interventions
Report Back from Working Group
Danie Kolver
Slide2Background
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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Slide3Managed 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
Slide4Current 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
Slide5Regulators 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
Slide6Project Scope
To
collect quantitative and qualitative data from managed care
organisationsTo understand quantitative value of managed care interventionsTo understand the cost effectiveness thereofProject Scope
Slide7History
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
Slide8Project
After
initial analyses decided to focus where resources and data allows progress
CDL process progressed Task teams 2 and 3 on hold Project History
Slide9Collect 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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Slide10Measuring 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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Slide11Progress 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
Slide12Progress 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
Slide13Progress 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
Slide14Finalise 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
Slide15Collect
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
Slide16CDL’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
Slide17TASK 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
Slide18END
Thank you
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