Yosuf Veriava
School of Rural Health and School of Clinical Medicine,
Faculty of Health Sciences,
University of W itwatersrand.
Chairperson of Council
Council For medical Schemes .
REGULATING CLINICAL
QUALITY
LOCAL CONTEXT:
PRIVATE HEALTH CARE EXPENDITURE
• Bulk of benefits paid to the following disciplines:
• Private hospitals (40.5%)
• Specialists (23.6%)
• Medicine (13.9%)
• In 2012, these three components accounted for 78% of
the health care benefits paid from the risk pool
• Where must we focus?
Our focus must not only be on lowering health care
costs, but also on achieving high value for patients,
with value defined as the health outcomes
achieved per rand spent.
Porter ME
Value = Quality/Cost
PRESENTATION
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Concept of Quality
Evaluation of quality.
The need to regulate quality.
Responsibility to ensure quality health care
The present initiatives in evaluating quality.
The way forward.
The operational definition of quality of
care is a reflection of values and goals
current in medical care system and in
larger society of which it is part
QUALITY DIMENSIONS
CLINICAL/SCIENTIFIC
ETHICAL
Appropriate process of
care in diagnosis and
management
Infrastructural
Outcomes
Recovery
Restoration of
function
Survival
Patient Experience
QUALITY MEASURES/PERFORMANCE INDICATORS
• Process measures
• Outcomes
• Infrastructure
AIM OF USING PERFORMANCE
INDICATORS
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Inform policy making or strategy
Improve quality of care at health care facility
Monitor performance of health care funders
Identify poor performance to protect public
safety
• Provide consumer information to facilitate
choice of health care provider
Jonathan Mant
OUTCOME MEASURES
• Advantages:
• Measures something that is important in its own right.
• Reflect all aspects of the process of care and not simply
those that are measurable
• The data to construct simple rates are available from
routine information systems
• Causes of variations
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Differences in type of patient
Differences in measurement
Chance
Differences in quality of care
Jonathan Mant
OUTCOME MEASURES
• When to use outcome measures
• When variation in quality of care might lead to
significant variation in outcome
• Whether the outcome indicator is likely to have the
statistical power to detect differences in quality
• Whether there are any practical alternatives to using
outcome indicators in any given area.
Jonathan Mant
QUALITY STANDARD FOR PATIENT
EXPERIENCE
• Quality statement
• Patients are supported by health care professionals to
understand relevant treatment options, including
benefits, risks and potential consequences
• Quality measure
• Structure: Evidence of local arrangements to ensure
that health care professionals support patients in this
regard
• Outcome: Evidence from patient experience surveys
and feedback in this regard.
NICE guidelines
PROCESS MEASURES
• Advantages of process measures
• More sensitive than outcome measures to differences
in quality of care.
• Easy to interpret eg use of aspirin in AMI is a direct
measure of quality, where as hospital specific mortality
for AMI is an indirect measure.
• Process measures are valid indicators if
correlated with positive clinical outcomes and
endorsed by nationally credible consensus
guidelines
Jonathan Mant
PROCESS MEASURES
CONDITION
PERFORMANCE
MEASURE
MEASURES
DESCRIPTION
Acute Myocardial
Infarction
Aspirin prescribed on
arrival
Aspirin on arrival
Aspirin prescribed on
discharge
Aspirin on Discharge
ACE –I for LVSD
Ace –I on discharge
B Blocker on discharge
B Blocker on Discharge
OBSTACLES TO REPORTING
PERFORMANCE STANDARDS
• Managed care services may be rendered by
more than one managed care company
• Regulatory requirements do not include
guidance in the type of data to be captured, the
format or means of collecting such data
• Clinical information not being provided routinely
by service providers
• Systems cater only to capture claim information
• Clinical information received via application are
scanned or kept in hard copy.
MANAGED CARE ORGANIZATIONS
• Most MCO are able to demonstrate the
following:
• Evidence based medicine used in compiling protocols
• Cost effectiveness and affordability studies
• Cost vs benefit ratios
• Savings
LEGISLATIVE REQUIREMENT
ACCREDITATION OF MANAGED CARE
ACTIVITIES
• Managed care organisations are accredited in compliance with
Section 67(1)(m) of the Medical Schemes Act and Chapter 5 of
Regulations
• Comprehensive standards developed over time with roleplayers
involved to ensure consistency
• Section 7 (c) of the Act outlines one of the functions of the Council to
“...make recommendations to the Minister on criteria for the
measurement of quality and outcomes of the relevant health
services provided for by medical schemes…”
Furthermore Section 7 (e) mandates “...collection and
dissemination of information about performance of private health
care...”
• The above provisions drive the health and quality outcomes
framework currently being developed by CMS
EVALUATING QUALITY - RESPONSIBILITY
• Managed Care organizations
• Medical schemes/ Trustees
• Outsourced administrators for medical schemes
PRESENT INITIATIVES
• Health Quality Assessment (HQA)
• Some Schemes
• CMS
HQA PROCESS INDICATORS
• Primary care including screening
• Chronic disease management
• Management of pregnant mothers and their
newborns.
HQA
• Primary care:
• Pneumococcal vaccine industry average 0.49%
• Chronic disease management
• The coverage with respect to the process indicators for
diabetes mellitus were on the average all below 50%. (HbA1C
48.37%)
• The process indicators for hypertension
• Creatinine 39.82%
• Cholesterol 22 %
• ECG 22%
INDUSTRY TECHNICAL ADVISORY PANEL
(ITAP)
• Commenced in 2012 to determine and explore
the value of managed care services provided
by accredited entities to beneficiaries of
medical schemes, through the development of
data specifications to enable the office to
collect appropriate data to enable satisfactory
reporting of the value of managed care.
ITAP - AIMS
• ITAP is a Technical Advisory Panel:
• Of industry experts
• Advising on specific technical issues and projects agreed with
CMS
• Helping with the collection of data
• And development of methodologies
• With the object of increasing understanding and publishing
objective, industry wide results
WAY FORWARD
• Accreditation and Research and Monitoring Units at CMS
will drive the process
• Prepare the industry to collect relevant data
• Define outcomes, process indicators, quality, and the
value component by CDL / disease management program
(DTP’s later)
• Design minimum data specifications for each CDL /
disease management program
23
WAY FORWARD
• Focus on Chronic Disease List conditions with
clear link to the disease programs
• Selection of CDL conditions linked to the top 10
prevalent chronic conditions
• First step is to focus on process indicators
• Collection of data/process indictors have to be
feasible and practical.
• Selection of process indicators/outcomes evidence
based.
• Transparency and inclusive of stake holders.
ACKNOWLEDGEMENTS
• Accreditation and Research and Monitoring Units at
CMS
• Ms Tania Booth
• Dr Anton Devilliers
• Mr Danie Kolwer
THANK YOU