Case-Mix System and Health Financing

(1)

Role of Pharmacists in Implementation of Casemix System/UNU-CBG for Provider Payment in Social

Health Insurance

Professor Dr Syed Mohamed Aljunid

MD (UKM) MSc (Public Health)( Singapore) PhD (London);

DLSHTM (London); FAMM

Professor of Health Economics & Consultant Public Health Medicine

United Nations University-International Institute For Global Health

Kuala Lumpur

International Institute For Global Health (UNU-IIGH)

Copyright of United Nations University-IIGH

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Outline

 What is Universal Coverage?

 Challenges in Achieving Universal Coverage

 Major issues in Social Health Insurance

 Why Provider Payment Is Important?

 What is Casemix System?

 Role of Pharmacists in Implementation of UNU-CBG/INA-CBG

 Conclusion Copyright of United Nations University-IIGH

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What is Universal Coverage?

 “a situation where the whole population of a country has access to good quality services according to needs and

preferences, regardless of income level, social status, or residency”

 Anne Mills (2007)

(4)

4

SCOPE OF UNIVERSAL COVERAGE Depth, Height and Breadth

4 Low

High

High High

Population coverage:

% population covered Financial risk protection:

magnitude of out of pocket and catastrophic health spending

Low

High

High High

Service coverage:

Utilization rates

(5)

Universal Coverage

Technology Health Facilities

Financing Health Human Resource

Policy &

Governance

Political Support

Challenges in Achieving Universal

Coverage

(6)

Obstacles to Universal Coverage

 Raised in health care cost

 Emerging and re-emerging diseases

 Increasing prevalence of chronic diseases

 Poor distribution of Health Human Resource

 Lack of sustainable health financing system

(7)

Universal Coverage & SHI

 Indonesia target to achieve universal coverage by 2014

 BPJS is established to organise health

financing system towards universal coverage

 Efficiency in SHI is key issue in achieving and sustaining universal coverage

 Provider payment is important component of social health insurance scheme.

(8)

Why Health Financing is Important?

 Provide coverage from catastrophic expenditure

 Increase flow of resources in health sector

 Reduce Out of Pocket Payment

(9)

UC in Indonesia through SHI

(10)

(11)

Challenges in health financing schemes in developing countries

 Low coverage

 Inadequate resources especially for social insurance

 High Premium especially for private insurance

 High level of inefficiency

 High administrative cost

 Moral Hazards of Consumers

 Moral Hazards of Providers

 Poor Provider Payment Mechanisms

 Use of retrospective payment methods

 Fee for service

 Itemised billings

(12)

Ensuring Sustainability of Social Health Insurance

 Administrative Cost

– Low administative 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

 Efficient provider payment mechanism

 Regular Review the Benefit Package

 Include new services

 Exclude non-essential services

 Accepted by Stakeholders

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Importance of Provider Payment Mechanism

 Cost Containment Measures

 Enhance Efficiency

 Influence Provision of Services

 Incentives or disincentives

 Preventive vs Curative Services

 Basic Health Services

 Influence Quality of Care

 Technical Quality

 Client Satisfaction

 Viability of Health Financing Scheme

 Disbursement of funds

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Payment Methods:

Retrospective vs Prospective

 Retrospective

 Fee-for-service

 Payment per itemised bill

 Payment per diem

 Strengths

 Favoured by providers

 Weaknesses

 Prone to supplier induced demand

 High Administrative cost

 Prospective

 Capitation payment

 Global budget

 Case-mix payment

 Strengths

 Good cost containment

 Low admin cost

 Weaknesses

 Need high technical capacity to develop

 Reduce Providers clinical freedom (need to legislate)

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What is Casemix System?

 A tool to classify varieties of patient conditions into groups according to resource consumed as approximated by LOS, episode cost, or cost of daily services

 more generic term of patient classification system

 Characteristics: Iso-resource and clinical charactestics

 Use in many forms in more than 100 countries worldwide especially for Provider Payment

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Casemix System in Indonesia

 Casemix system is implemented in Indonesia under JAMKESMAS (Social Health Insurance Scheme for the Poor) since 2006

 Used by around 1,350 public and private hospitals

 Coverage around 75 million people

 Since 2010- INA-CBG was implemented to replace INA-DRGs

 Casemix System will be used to cover all other Social Insurance Scheme by 2014 under plan for universal coverage- 240 million people

 National Health Insurance Agency (BPJS) will coordinate all SHI programmes in Indonesia

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JAMKESMAS: Health Financing for The Poor in Indonesia (72 million)

(18)

Casemix

EFFICIENCY

INFORMATION QUALITY

Benefits of Casemix

(19)

Components of Casemix System

Disease Classifications

Costing

Casemix

(20)

Global Use of Case-mix (2011)

(21)

Casemix System in Developing Countries:

The Obstacles

 Lack of capacity

 Technical skills on Case-Mix System

 Lack of financial resources

 Limitations in health information system

 Quality of disease coding

 Limited availability of costing data

 Lack of political will

• Policy makers were ill-advised on potential of case-mix system

• Influence by Clinicians comfortable with Fee-For-Service Payment Methods

 Limited Access to Casemix Tool

• Casemix Groupers are mainly proprietary owned

• Difficult to be customised for local need

• Most casemix system is developed only for Acute diseases

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UNITED NATIONS UNIVERSITY Mission

 To contribute, through Research and Capacity

Building, to effort to resolve the pressing global problem that are the concern of UN, its People and Member

States

(23)

UNU Casemix Grouper

 An international grouper

 Priority to developing countries

 Packaged with capacity building programme

 Comes with accessory software

 Based on Open Source Concept

 Provided at low cost to poor countries

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IMPLEMENTATION OF UNU-IIGH CASEMIX SYSTEM IN DEVELOPING COUNTRIES

Disease &

Procedure Codes

Financial Data

CCM

UNU-DRG- Grouper

Cost-Weights

CUSTOMISED Casemix GROUPER

Base Rate

Casemix Cost Case-Mix Index

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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

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What is UNU-CBG 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

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EIGHT COMPONENTS OF UNU-CASEMIX GROUPER (Plus Dental)

GROUPERUNU- ACUTE

ACUTESUB-

CHRONIC

DENTAL (Development)

SPECIAL PROCEDURES

SPECIAL PROSTHESES

SPECIAL DRUGS

SPECIAL INVESTIGATIONS

Ambulatory Package

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Components of UNU Casemix System

UNU- CBG

CCM

CODE ASSIST

National Cost Weights DATA

PRO

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Countries working with UNU- IIGH/ITCC on Casemix

 Asia

 Indonesia

 Philippines

 Mongolia

 Vietnam

 Malaysia

 Middle East

 Yemen

 United Arab Emirates

 Saudi Arabia

 I.R of Iran

 South America

 Uruguay

 Chile

 Africa

 Ghana

 Sudan

 Tanzania

 Europe

 Turkey

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UNU- CBG

DRGsMn-

INA-CBG

DRGMY-

DRGsPh-

DRGsUr- DRGsVn-

Saudi- DRGs DRGsUAE-

Chile- DRGs

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Role of Pharmacists in

Implementation of UNU-CBG

 Development of Special CMGs in UNU- CBG

 Active Participation in Development of Clinical Pathways

 Promote Generic Prescribing

 Support development of PE Guidelines

 Promote Evidence Based Practice

 Monitoring of INA-CBG ImplementationCopyright of United Nations University-IIGH

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Pharmaceutical Industry Annual Sales

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Total expenditure on pharmaceuticals and other medical non-durables, % total expenditure on health, THE

(OECD)

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MOH Malaysia Pharmaceutical Supplies and Operating Expenditures 1997-2009 (RM Million)

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Cost Components

(Medical Cases In UKMMC)

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Cost Components

(Surgical Cases In UKMMC)

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Cost of Drug R&D

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Role of Pharmacists in UNU-CBG

 Special CMG on Drugs

 Develop Criteria for Special Drugs

 Identify drugs in the list

 Provide information on drug cost

 Monitor drug utilisation

 Identify abuse/unnecessary use

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Role of Pharmacists in UNU- CBG

 Active Participation in Clinical Pathways

 CP is important component of casemix

 Help to reduce variation of care

 Improve quality and efficiency

 High cost and high volume conditions

 Select effective and efficient drugs in CPs

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What is Clinical Pathway?

 Multidisciplinary plans (or blue print for a plan of care) of best clinical practice for specified groups of

patients with particular diagnosis that aid in the coordination

&delivery of high quality of care.

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Patients of A common type

Outcome Continuous Quality

Improvement Process improvement

Single Process

Using Clinical Pathway

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 ST Elevation Myocardial Infarction (STEMI)

 Percutaneous Coronary Intervention (PCI)

 Thrombolysis

 Chronic Obstructive Pulmonary Disease (COPD)

 Elective Lower Segment Caesarean Section(LSCS)

 Elective Total Knee Replacement.(TKR)

11/21/2012 43

Clinical Pathways in UKMMC

(44)

National University of Malaysia

(UKM) Medical Centre

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Length of stay of STEMI (PCI)

11/21/2012 45

CP (n=79)

Non CP (n=78)

ALOS 5.52±1.42 8.15±2.25

p < 0.001

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ANNUAL COST SAVINGS (RM) in

UKMMC

Cost Saving per Case

(RM)

No. Cases

per Year Annual Savings (RM)

STEMI

• PCI

• Thrombolysis 367

142 50

100 18,350.00 14,200.00

LSCS 135 1300 176,761.00

COPD 179 250 44,690.00

TOTAL 254,001.40

11/21/2012 46

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Role of Pharmacists in INA- CBG

 Promote Generic Prescribing

 Lowering drug expenditure

 Control Moral Hazards of Providers

 Support Rational Prescribing

 Provide greater access to essential drugs

(48)

Prescribing Practice and Drug Costs among Cardiology Cases in UKMMC

(2007)

 Database: Casemix Database for cases admitted in UKKM from July 2002- June 2004

 Total of 3,022 Cardiology Patients Admitted

 135 randomly selected for detail review

 1,020 types of drugs prescribed

 Generic Prescription Rate is 45.2%

 Average No of Drugs prescribed is 7.6

 Total drug cost is RM 28, 879

 90% of the cost is due to branded drugs.

Source: Aljunid et all (Feb 2007) MMJ

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Prescribing Practice and Drug Costs among Cardiology Cases in

UKMMC (2007)

Prescribers N Mean Rank of GPR

MO/Specialists 29 70.84

MO & Specialists 27 70.83

MO & Consultants 36 78.82

Specialist & Consultants 11 31.68

MO, Specialist & Consultants 32 63.34

Source: Aljunid et all ( Feb 2007) MMJ

p = 0.011

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% of Countries With Legal Provisions to Promote Generic

Substitution in the Private Sector, 2007

Source: MDG Gap Task Force Report:

MDG 8(2008)

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Role of Pharmacists in UNU- CBG/Casemix System

 Support Development of

Pharmacoeconomic (PE) Guidelines

 Technical document to guide economic evaluation of pharmaceuticals

 Developed by authorities with participation of stakeholders

 Assist in preparing supporting documents for drug listing/submission

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Global Scenario of PE

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Benefits of PE Guidelines

 Standardized methods/approach of Economic Evaluation

 Enhanced quality of PE data for drug submission

 Promote use of local data in economic evaluation studies

 Improved decision making process – Evidence-Based Policy DecisionCopyright of United Nations

University-IIGH

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UNU-IIGH Certificate Course in Casemix Management

 Module 1

 Orientation and Introduction to Case-Mix

 Module 2

 Coding of diagnosis and procedures

 Module 3

 Installation and Maintenance of Case-mix Sofware

 Module 4

 Case-Mix Costing

 Module 5

 Development of Clinical Pathways

 Module 6

 Coded Data Analysis

 Module 7

 Costing Data Analysis

 Module 8

 Analysis of Clinical Pathway data

 Module 9

 Development of Case-Mix Index and Cost-Weights

 Module 10

 Preparation for National Roll-out

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Conclusion

 Universal coverage is the ultimate goal of health system in most countries now including Indonesia

 Achievement and sustainability of UC depends on resilient, robust and efficient health financing system

 Casemix system can help countries to achieve UC through enhancement in efficiency and quality of care

 UNU-CBG/INA-CBG is a special casemix system developed by taking into account the healthcare system of developing

countries

 Pharmacists can play important roles to enhance

implementation of Casemix system to achieve Universal Coverage

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[email protected] [email protected]

http://iigh.unu.edu/http://unuiigh- casemixonline.org