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 Guidelines/ Standards Implementation Monitoring Analysis

9. NCQA: Diabetes quality improvement It is an ongoing process!

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

11. Healthcare Quality Assessment Indicator typePracticeHospitalMedical Scheme StructureGuideline/ minimum practice equipment Licensing /accreditation Benefits / provider network ProcessTreatment application Infection control and sanitation procedures Member access to benefit Outputs including outcomes Reduced hospitalisation or death rates Infection ratesAdmission rates, Health status of population served

12. Structure: Practice Guidelines 52-55% adherance to guidelines 1,2 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 1.NCQA 2.Disease Management Network 3.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 10% of adults DUR intervention to promote benefit

19. Diabetes: 2005 and 2007 Is 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 CDE Not Case-mix adjusted! 31x 11.5x 4x(US) CDE: n =13312; 7-10% of FFS Diabetics

21. Asthma It’s about reversibility! SA – 4 th 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! Limited treatment options: What about Spiriva into the future? *MAG conference 2002 ?

23. HIV *MAG conference 2002 ?

24. Preventative Care and the PMB IndicatorResult (%) Chlamydia screening 70-75% of infected women are asymptomatic. Less in men. 0 Hepatitis B virus screening in Pregnancy 4.5-30% prevalence of hep (B&C) virus in pregnancy 1 Bone densitometry >65y 40% women and 25% men have osteoporosis related fracture in US. Prevalence in elderly: 30% F; 12% M 0.22 Flu vaccine >65y8.22 Pneumococcal vaccine >65y0.17 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.comlj.botha@iafrica.com