1. 2017 WIC Melbourne
The Performance Management System of the Korean Healthcare Sector: Development, Challenges, and Future Tasks
May 4th 2017
Yoon Kim, MD
Professor, Dept. of Health Policy and Management,
Seoul National University College of Medicine

2. Contents Why quality? Development Challenges and future tasks
What to measure
How to use performance results
How to govern system
Final thought

3. Why quality?

4. Access without Quality
Health

5. Unacceptable quality variation - 4 times difference in inpatient mortality among hospitals -
HSMRs (Hospital Standardized Mortality Ratios) of 66 large general hospitals (≥ 700 beds) in Korea

6. Relationship between Cost and Mortality - Risk-adjusted inpatient mortality and cost in cardiovascular diseases -
Positive correlation between cost and mortality
Regression : y = x (R² = 0.239)

7. Inhalation Bronchodilator prescription rate among asthma patients
Total
Tertiary
hospital
General hospital
Hospital
Nursing home
Clinic

8. Development

9. HIRA Health Insurance Review and Assessment Service
Established in 2000
National Health Insurance Act
Major Functions
Claims Review
Benefit Decision
Quality Assessment and improvement
Performance measures
More than 30 topics, about 400 measures

10. HIRA - Milestone 2002 Antibiotics and injection prescription rate
st public reporting
2005 New measures such as AMI quality
Pay-for-performance demonstration AMI, hypertension and diabetes, long-term care
2015 New pay-for-performance scheme for general hospitals (0.5 billion US$)
2017 Patient experience survey Hospital standardized mortality ratio

11. Evolutionary Expansion of Measures
2008
2010
Prescription
Prophylactic antibiotics
Surgical volume
Acute myocardial infarction
Acute stroke
Caesarian section
CABG
Long-term care hospitals
Hemo-dialysis
Mental hospital service for medical aid
Hypertension
30-day mortality of stomach/colon/liver cancer
Diabetes
Colorectal cancer
Breast cancer
Acute otitis media
2012
Number of high-priced drugs added in prescription
Caesarian section
Surgical volume
Acute myocardial infarction
Knee arthroplasty CT
Transfusion
CABG
Acute stroke
Prophylactic antibiotics for surgery
Long-term care hospital
Prescription
Caesarian section
Prophylactic antibiotics for surgery
Surgical volume
Acute myocardial infarction
Acute stroke
Transfusion
CABG(Coronary artery bypass graft)
Long-term care hospital
Hemo-dialysis
Mental hospitals service
Hypertension 11

12. Hospital Accreditation Health Insurance Review and Assessment Service
2005 Hospital evaluation program
Mandatory for large general hospitals
2010 Hospital accreditation program (KOIHA)
Replaced the existing mandatory program
Voluntary in general, but mandatory for tertiary, teaching hospital, and long-term care hospitals
,769 accredited hospitals
335 acute care hospital : about less than 20%
1,235 long-term care hospital

13. Challenges and future tasks

14. Use - Policy Levers Measurement and feedback
Learning and technical assistance
Public reporting
Pay for performance
Certification
Accreditation
Consumer incentive
Innovation and diffusion

15. Challenge [1] Biased distribution of measures - HIRA Quality Measures
(As of 2009)

16. Improving patient safety
Task [1] Systematic development of measures based on national quality strategy
Goal
Objective
Measure
Target
↓ Readmission
↓ all-cause readmission rate in 30 days after discharge
↓ 20%
Improving patient safety
↓ HAI
UTI
CLABSI
SSI
↓ 40%
These areas include obstetrical early elective deliveries (OB-EED), readmissions, adverse drug events (ADE), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLABSI). In the other six areas, to date, the evaluation has found mixed evidence, meaning some datasets show decreases, while others show no change, or even worsening, including venous thromboembolism (VTE), catheter-associated urinary tract infection (CAUTI), other OB adverse events (OB-Other), pressure ulcers, surgical site infections (SSI), and falls.
↓ ADR
DDI
Overdose
Renal dosing
↓ 30%

17. Public reporting and quality improvement - Three Pathways -
Public reporting and Feedback
[1] Selection Pathway
Patient referral
Consumer choice
[3] Reputation Pathway
Self-improvement
Hospital QI
[2] Improvement Pathway
Quality Improvement

18. Antibiotics Prescription Rate for URI
Feedback
Public reporting %
Clinic
Hospital 분기
General hospital
Tertiary hospital
(quarter)
*URI - Upper Respiratory Infections

19. Challenge [2] Poor public awareness on reporting

20. Task [2] Public Reporting Strategy
Improve awareness on public reporting
Public marketing, dedicated website, usability testing
Salience
E.g. cancer: surgical mortality vs. 5-year survival
Easy-to-understand
Avoid jargons, cognitive testing: consumer group
Trust in the sponsoring organization
Partnership with professional organizations

21. HIRA pay for performance
Empirical results: Quality Score Change in AMI

22. Improvement of AMI quality results

23. 30 Day Fatality of AMI

24. [3] Task : Pay-for-performance Design
Absolute vs. Relative Threshold
Single vs. Tiered thresholds – Goal Gradient
Tied vs. Untied Incentive
Combine tied and untied incentive
Appropriate incentive size – more than 5%
Significant size and percentage of incentive

25. [4] Poor Quality Governance
No national quality strategy
No national authority to coordinate quality improvement policies/programs at the national level
No department dedicated to quality within MOHW
No national committee for coordination and stakeholder buy-in
Poor alignment of healthcare policies with QI policies
Designation of tertiary hospitals, Benefit design, Claims review

26. Task [4] Establish quality governance National Quality Improvement Committee
Develop a national quality strategy
Establish clear goals and objectives
Facilitate the development of institutional quality strategy based on the national strategy
Coordinate policies and programs among various quality improvement organizations
Enhance collaboration and avoid duplication among QI organizations
Facilitate the use of performance results in other policies

27. Some additional task More use of outcome measures
c.f. Korea AMI mortality
c.f. UK QOF experience
Engaging clinical leaders
Intrinsic motivation
Monitoring unintended consequences
Gaming: e.g. exception reporting

28. Final thoughts

29. Professionalism and Behavioral economics

30. Thank you