Edhie S Rahmat – HSS Specialist
USAID Indonesia/Office of Health
HOSPITAL CARE QUALITY IN
BACKGROUND
• Two major health reforms: 2002 Decentralization and 2014 National Health Insurance (JKN)
• Ambitious goal in 2019: total coverage to access Quality & Comprehensive Health care
• MoH Strategic Plan to move forward with at least one accredited hospital in each district/city
• Two Studies:
• HAPIE Study: Does accreditation have a strong impact on Quality of Care?
DOES ACCREDITATION IMPACT
QUALITY
IN EARLY ROLLOUT OF JKN?
Hospital Accreditation Process and Impact Evaluation (HAPIE) Study, implemented by URC (ASSIST) & CFW-UI:
• Compare 9 top hospitals undergoing different accreditation processes (JCI, KARS, none)
• Patient perception of Quality: Exit Interviews of 30 randomly selected patients/care-givers in each of 4 wards (pediatric, surgery, OBG, internal medicine), total 2,167 in all hospitals for period of August 2013 vs July 2014i, ii
• Collecting hospital secondary data (LOS, Care Costs paid by patient and deaths) from 4 wards (pediatric, surgery, OBG, internal medicine) in 9 hospitals for period Jan-March 2014 vs. Jan-March 2015 iiI
---i. Latief, K., Nandiaty, F., Pawestri, E.A., Wahyuni, S., Rianty, T., Achadi, A. 2015. Presentation in 2015 APACH Conference “Patient satisfaction at the early stage of National Health Insurance (NHI) implementation: A comparative study before and after NHI implementation at nine class A public hospitals in Indonesia “ in Bandung, October 22, 2015.
ii. Broughton E, Achadi A, Latief K, Nandiaty F, Nurhaidah, Qomariyah SN, Rianty T, Wahyuni S, Eskaning AP. 2015. Hospital accreditation process impact evaluation: Midline report. Technical Report.Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).
A* B* C D E* F* G* H* I All* -20 -15 -10 -5 0 5 10 15 20 Per-centage
A B* C D E* F* G* H I All
-20 -15 -10 -5 0 5 10 15 20 Per-centage
PERCEPTIONS OF DECREASED QUALITY OF
MEDICAL CARE UNDER JKN
G#1. % Change in Quality of medical Care (p≤0.05)
G#2. % Change in Doctor’s competence
(p≤0.05)
A B C* D* E* F G* H I All* -20 -15 -10 -5 0 5 10 15 20 Per- cen-tage
A B C D E* F* G* H* I* All*
-20 -15 -10 -5 0 5 10 Per- cen-tage
PERCEPTIONS OF DECREASED QUALITY OF
NURSING SERVICES IN EARLY ROLLED OUT OF JKN
G#3. % Change in Quality of Nursing service (p≤0.05)
G#4. % Change in Nurse/Midwife’s competence (p≤0.05)
A B C D E F* G* H* I All*
-20 -15 -10 -5 0 5 10 15 20
Per- cen-tage
DECREASED PATIENT SATISFACTION
WITH HOSPITAL CARE IN EARLY
ROLLED OUT OF JKN
G#5. % Change in Satisfaction (p≤0.05)
Satisfaction somewhat decreased, regardless of accreditation status, with
A* B* C* D* E* F* G* H* I* All* -35 -25 -15 -5 5 15 25 Per- cen-tage
A B C* D* E* F* G* H* I* All*
-20 -15 -10 -5 0 5 10 15 20 Per- cen-tage
TIMELINESS OF SERVICE & PATIENT PERCEPTION
OF HOW THEY ARE TREATED BY STAFFS
G#6. % Change in Timeliness of Service (p≤0.05)
G#7. % Change in Treatment (p≤0.05)
JCI hospitals have better timeliness of service, but in general hospital staff were perceived to provide worse treatment in all hospitals. Not ready for sharply
Patients across 9
hospitals
4.5%
increase
p < 0.280
Patients in 3 JCI hospitals
8% increase
p < 0.001
Differences
50%
p < 0.001
Patients across 9
hospitals
22% increase p < 0.001
Patients in 3 JCI hospitals
11% increase
p < 0.001
Differences
8%
p = 0.272
INCREASED LOS & TOTAL COSTS AT
HOSPITALS
T#1. % Change in Length Of Stay
T#2. % Change in Total Costs
Costs increased more in JCI than non-JCI hospitals
Mortality in
2014
Changes in
2015
Pediatric
Pneumonia
9.1 % (n=152) 28% decreased P = 0.029
AMI
9.3% (n=339)
4% increased
P <0.001
Hip Fractures*
1.5% (n=4)
5% increased
P =0.350
Normal delivery*
0.1% (n=6)
53% increased
P< 0.106
2014
2015
Patients in 6 non-JCI
hospitals
3.61
3.82
p < 0.034
Patients in 3 JCI
hospitals*
3.92
5.72
Differences*
49%
p = 0.194
DEATHS AMONG INPATIENTS
T#3 % Change in Deaths
T#4 Change in Risk of Deaths
*Controlling for dx & age; Patients in JCI hospitals have a 37% higher risk of death (p<0.001); **Risk of death increased 49% more in JCI Hospitals
Do JKN policies incentivize Quality?
Review of Health Care Governance:
-
Part of the 2015 Rapid Health System Assessment –
conducted by Health Finance & Governance project (Abt
Associates)*
-
Reviewed >50 documents & interviewed >150 Key
Informants from 65 institutions on Health Governance in
early JKN implementation
-
Identified regulatory incentives for Hospital Care Quality
(Accreditation)**
-
Identified opportunities for performance-related payments***
-
Identified information system that could track hospital
performance****
*Hatt, L., Altea, C., Chee, G., Ergo, A., Fuad, A., Gigli, S., Hensley, L., Laird, K., Ramchandani, N., Simatupang, R., Tarantino, L., Wright, J., Zuwasti, U. December 2015. Rapid Analytical Review and Assessment of Health System Opportunities and Gaps in Indonesia. Bethesda, MD: Health Finance and Governance Project, Abt Associates Inc. This is available for public access in
https://dec.usaid.gov/dec/content/Detail.aspx?ctID=ODVhZjk4NWQtM2YyMi00YjRmLTkxNjktZTcxMjM2NDBmY2Uy&r ID=MzczMDYx
**See section on Service Delivery of Public and Private Sector” ***See section on Health Financing
PAYMENTS LINKED TO
PERFORMANCE
• Quality Outcome Framework: UK-NHS rewards practices for the
provision of quality of care & good practices*
• Hospital Value-Based Purchasing (US Medicare) adjusts hospitals’
payments based on 4 domains of quality: the clinical process of care domain, the patient experience of care domain, the outcome domain, and the efficiency domain**
• Inpatient Prospective Payment System (IPPS – US Medicare) to
reduce re-admission of heart attack, heart failure, pneumonia, hip/knee replacement, and COPD***
• Incentives for achieving certain public health indicators (Ghana etc.)****
• Compensation tied to performance (service volumes, rates of referral,
population service coverage, health outcome measures, and efficiency measures)*****
• Benchmarking indicators for performance within claims database (PCSI -
Case-mix funding models) * http://www.hscic.gov.uk/qof
** https://www.medicare.gov/hospitalcompare/data/hospital-vbp.html
*** https://www.medicare.gov/hospitalcompare/readmission-reduction-program.html
**** https://www.rbfhealth.org/project/ghana
JKN POLICIES/REGULATIONS IN
2015
• Facility credentialing*:
• Public hospitals: automatically credentialed, regardless of
accreditation status
• Private hospitals: Providers previously contracted by Askes
automatically credentialed, New providers are credentialed based on meeting human resources, facility, and equipment standards
• Comprehensive benefits with some negative lists – no priorities to
certain public health concerns**
• INA-CBG***:
• Bundled coding for Claim Reimbursement
• No performance related indicators, unless un-bundled
• Not updated costs – no incentive for good practices
• Over & under compensation for certain clinical interventions
• Efforts focus on cost containment by instituting committees (BPJS,
HTA), but decisions lie with other agencies**
*See Hatt, L. et al on section “Service Delivery in Public & Private sector” ** section on Health Financing
CURRENT DEVELOPMENTS
•
MoH:
•
Capacity Building for Case-mix team (PPJK)
•
Grouper Revision (PPJK) in INA-CBG (starting with eye
diseases)
•
Hospital cost survey (NIHRD)
•
BPJS:
•
Observe risks of fraud
•
Monitor some performance indicators (most diagnosis &
intervention, higher cost of intervention)
•
Promotion & Prevention for diseases with highest costs
1. Incentivize Good practices through payments
2. Accreditation as condition for
Re-Credentialing
3. Unbundling INA-CBGs to show
certain benchmark indicators
4. Thinking of global budget to
hospitals, but linked to performance
5. Start with admission rate to
observe performance and expand gradually
1. Accreditation has less
impact on Perception of Quality and Patient
Outcomes
2. Though mandatory, not
much incentive for
undergoing accreditation
3. Bundled INA-CBG does not
show performance
4. No incentive for good
practices
