Challenges in Social Health Insurance Schemes in Developing Countries

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1 International Institute For Global Health (UNU-IIGH) UNU-CBG: New Casemix System Tool To Enhance Quality and Efficiency in Developing Countries Professor Dr Syed Mohamed Aljunid MD (UKM) MSc (Public Health)( Singapore) PhD (London); DLSHTM (London); FAMM Professor of Health Economics & Consultant Public Health Medicine Senior Research Fellow United Nations University-International Institute For Global Health Kuala Lumpur Challenges in Social Health Insurance Schemes in Developing Countries Low coverage (breath and depth) Inadequate resources especially for social insurance Unaffordable Premium especially for poor and near poor Limited Benefit package High level of inefficiency High administrative cost Moral Hazards of Consumers and Providers Delay in claim processing Poor Provider Payment Mechanisms Use of retrospective payment methods (e.g. FFS/Itemised bill) Services Of Poor Quality Lack of proper review and monitoring Low patient satisfaction 1

2 Reduce Administrative Cost Should not be more than 10% of operating cost Control of moral hazards Effective and efficient ways of controlling moral hazards Consumers: Co-payment Providers: Utilisation Review, Medical Audit Use efficient provider payment mechanism Regular Review of Benefit Package Include new services Exclude non-essential services Work with the Stakeholders Increase acceptance of consumers & providers What is Casemix System? Casemix System is a classification of patient treatment episodes designed to create classes which are relatively homogenous in respect of the resources used and which contain patients with similar clinical characteristics. (George Palmer, Beth Reid,2000) 2

3 What is Casemix? Refers to the Type and Range of Cases treated in hospitals and clinics Defines Hospital Final Output, Classified into Predetermined Categories Provides Information on Resource Use and Quality Describes patients characteristics including outcome of care Can be used as standards for comparison Benefits of Using Casemix System Improve Efficiency of Health Care Services health Identify unnecessary services Reduce wastages and Cost Savings Improve Quality of Care Enhance Quality Assurance Programme Facilitate Benchmarking Exercise Improve Patient Satisfaction Improve Health Management Information System Provide high quality data on patient care Provide information for review and monitoring Promote Better Decision Making Encourage Evidence-Based Practice 3

4 Case-mix System Reimbursement: Advantages Risk shared between funders and providers Remove incentive to over treat patients Payment based on package Fair remuneration to providers Payment based on severity level Payment based on productivity Payment based on intensity of care not just volumes Enhance Quality Assurance Programme Transparency and objective in computation of tariff Case-mix System Reimbursement: Advantages Faster and easier to Process Payment Easier to verify claims Tariff can be easily updated Annual updating of Hospital Base-Rates Annual/Bi-Annual updating of Cost-weights Fraudulence Claims can be detected and avoided Assignment of severity level by grouper Random checking can be easily done 4

5 Global Use of Case-mix (2010) Case-mix System in Developing Countries: The Obstacles Lack of capacity Technical skills on Case-Mix System Managerial Capacity on the application of case-mix System Limitations in health information system Quality of disease coding Diagnosis and procedure coding Limited costing data Unit cost data 5

6 Casemix System in Developing Countries: The Obstacles Limited Access to Casemix Tool Casemix Groupers are mainly proprietary owned Difficult to be customised for local need Need access to source code for customisation Lack of Financial Resources Case-Mix Consultants are expensive Commercial Case-Mix Softwares are costly Slow acceptance by Practitioners No capacity to refine or expand case-mix groupings No groupings for chronic diseases/subacute cases Tariff not updated No continuous refinement of DRGs groupings not refined What Do We Do in UNU-IIGH?... Build human resource capacity in Casemix Series of Training Workshops E-learning Programme Support local development of casemix system Provide access to Casemix Tool Casemix Grouper Digital Coding Tool Clinical Costing Software 6

7 Implementation of Case-Mix System in Developing Countries Disease & Procedure Codes DRG- Grouper Financial Data Case-Mix Index Cost-Weights CCM Hospital Base Rate CUSTOMISED DRG GROUPER NATIONAL HOSPITAL TARIFF Softwares in Case-Mix System Digital Coding Tool Data Tool- Assist to enhance productivity of Coders UNU-Code Assist- Assist in Verifications of Casemix coding and grouping Case-Mix Grouper UNU-CMG Grouper Costing Tool CCM Version 2.0-UKM/UNU Costing Template for Hospital Base-Rates Costing Template for National Tariff 7

8 What is Case-Mix Grouper? Computer software used to carry out grouping of patients into casemix groups or DRGs based on the grouping algorithms Grouper used all the information in the minimum data set to group the cases Output of the grouper is the coded casemix groups Why do we need Case-Mix Grouper? Case-mix algorithm is complex and cannot be done manually Algorithm has many variables Grouper can do the grouping accurately and efficiently Grouper can detect errors which can be later rectified 8

9 Weaknesses of Current Casemix Groupers.. Not designed to group sub-acute and chronic cases Sub-acute cases Very complicated Cases Moderately long stay cases Chronic cases Mental illness Long term rehabilitation Social welfare cases Very long stay cases Weaknesses of Current Casemix Groupers Produced unhomogenous DRG groups Tariff developed unsuitable for payment of Chronic Cases Cases with Prostheses E.g Hip Replacement. Below Knee Amputation Cases with special investigations E.g MRI/CT Scan Cases with special medications Chemotherapy Groupers do not have local costweights International Cost-weight international does not reflect actual cost locally Tariff using uncustomised costweights are unstable 9

10 Weaknesses of Current Casemix Groupers Logic of grouper difficult to be modfied when coding rules changed Diagnosis ICD-11 from 2013 (Additional 7,800 codes Dx) Procedure ICHI from 2012 (WHO Procedural Classification) Severity level cannot be modified Severity level remains the same Depend on the private companies Source code held by vendor UNU-CBG: The New Casemix Grouper Grouper developed by researchers from United Nations University UNU-International Institute For Global Health (Kuala Lumpur) UNU-International Institute For Software Technology (Macau) Research and Collaboration ITCC- International Training Centre on Case-Mix and Clinical Coding MOH of Developing Countries Asia Pacific Network of FIC WHO-FIC (ICD-10 and Procedure Classifications) Owned and Maintained by United Nations University United Nations University United Nations Agency Non-for Profit and No Commercial Interest Priority to support developing countries to achieve MDGs 10

11 What is UNU-Case-Mix Grouper? Universal Grouper Cover all types of patients care Acute (In-patient/Outpatient) Sub-Acute (Moderately complex cases) Chronic Case (Long Stay Cases) Dynamic Grouper Total number of CBGs can be set-according to need of the country Severity level is not static Depending on types of patient care I to III I to IV I to IX I to X Very refined classifications Advance Grouper Can be used with future changes in diagnosis and procedure classifications (ICD-11 and ICHI classifications EIGHT COMPONENTS OF UNU-CASEMIX GROUPER SPECIAL PROCEDURES SPECIAL PROSTHESES CHRONIC SPECIAL DRUGS SUB-ACUTE SPECIAL INVESTIGATIONS ACUTE UNU- GROUPER Ambulatory Package 11

12 CASE-MIX MAIN GROUPS (CMGs) CMGs are the first level of classifications Labels in Alphabet (A to Z) Mostly equivalent to Chapters in ICD-10 Correspond to Body Systems and Payment Package 31 CMGs in UNU Grouper 22 Acute Care CMGs 2 Ambulatory CMGs 2 Subacute and Chronic CMGs 4 Special CMGs 1 Error CMGs Total DRGs (CBGs)= 1,220 (Range: 314-1,250) Case-Based Groups (CBGs) Second level of classification Organised in 5 alpha-numeric code One letter and 4 numbers First Digit refers to CMG (Casemix Main Groups) Second Digit refer to Case-Type Third and Fourth Digit refer to specific DRG called CBG Fifth Digit refer to severity level and resource intensity level for specific package Consists of Medical/Surgical/Package Groups 12

13 UNU-IIGH Case-Mix Grouper- SERVICES COVERED Hospital In-patient Day Care Surgery Specialist Clinic Emergency Room General Out-patient Rehabilitation Chemotheraphy and Radiotherapy Mental Health Services and Procedures Chronic cases Long Staying patients Specific Package Groups Package Out Patient Prostheses Drugs Procedures Investigations UNU-IIGH CAPACITY BUILDING PROGRAMME ON CASE-MIX SYSTEM 13

14 UNU-IIGH CAPACITY BUILDING PROGRAMME ON CASE-MIX: The Benefits Softwares Digital Coding Tool-Data Tool Version 2.0 UNU Case-mix CBG Grouper UNU-Code Assist Advance Coding Tool for Verifications Clinical Costing Software- Version 2.1 Costing Template Software for Development of Hospital Base-Rates Costing Template Software for Development of National Tariff Access to DRG Logic of UNU Case-Mix Grouper MOH will have access to the UNU DRG Logic for future development Training of MOH staff to use UNU DRG Logic for refinement of casemix groupings Joint Development of Future Case-Mix Grouper List of UNU-IIGH Training Workshops ( Three Days) Workshop 1 Introduction to Case-Mix System Workshop 2 Coding of Diagnosis and Procedures for Case-Mix Workshop 3 Installation and Maintenance of UNU-IIGH Case-mix Software Workshop 4 Case-mix Costing Workshop 5 Clinical Pathways in Case-Mix Workshop 6 Case-Mix Data Analysis Workshop 7 Case-mix Costing Analysis Workshop 8 Customisation of UNU-IIGH Casemix Software Workshop 9 Development of Case-mix Tariff For Provider Payment Workshop 10 Presentation of Final Results and National Roll-out 14

15 Training and Installation Manuals UNU-IIGH Case-Mix On-line Training Programme Free Introductory Course on Case-Mix Organised by UNU-IIGH and ITCC Online Registration open now Course started in August

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17 UNU-IIGH Case-Mix Grouper 17

18 Clinical Costing Software Countries working with UNU- IIGH on Casemix Asia Indonesia Philippines Mongolia Vietnam Malaysia Middle East Yemen United Arab Emirates Saudi Arabia South America Uruguay Chile 18

19 Conclusion Casemix system is an important tool to ensure sustainability of social health financing programme Lack of capacity and inaccessibility to low cost but reliable groupers are two major obstacles in case-mix implementation Most commercial groupers are costly and cannot be customised to meet needs of developing countries UNU-CBG Case-mix Grouper: Universal, Dynamic and Advance Grouper specially developed to support implementation of case-mix system in developing countries UNU-IIGH offer a complete package (capacity development/ softwares) to facilitate implementation of case-mix system for in developing countries 19