Using performance information in National Health Insurance, Korea
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Transcript of Using performance information in National Health Insurance, Korea
USING PERFORMANCE INFORMATION IN
NATIONAL HEALTH INSURANCE, KOREA
Kyohyun KIM MD, MPH
HIRA Research Institute
OECD Meeting on Sustainability of Health Systems
Paris, France, 4-5 February 2016
People Providers
Single Payer (NHIS, collecting & pooling)
• Patients can access specialists and hospitals without referrals (no registration with GP, no gate keeping)
MoH designing health system
Purchasing (HIRA, claim review)
Notify Payment amount
Co-insurance rate
Health Insurance Policy Deliberative Committee
Benefit package, insurance rate, relative fees for service
• All providers are automatically contracted • 95.8 % of facilities (hospital, clinics, etc) are owned by private sector
• Payment system • FFS 93% • DRG 3% • per diem 4%
• MoH : Ministry of Health and Welfare • NHIS : National Health Insurance Service • HIRA : Health Insurance and Assessment Service • FFE : Fee for Service, DRG : Diagnosis Related Group
• OVERVIEW
• BACKGROUND OF NHI’S MEASURING AND USING PERFORMANCE INFORMATION
• HIRA’S ROLE AND MEASURING AND USING OF PERFORMANCE INFORMATION
PERFORMANCE ASSESSMENT
SYSTEM
People Providers
Single Payer (NHIS, collecting & pooling)
Informed with performance information Healthcare resources
Purchasing (HIRA, claim review and QA)
MFDS (pharma, device)
Licensing Examination
Institute
Measuring performance information (since 2000)
NECA(HTA) (services)
Notify Payment adjustment
Structural requirements
• KCDC : Korea Centers for disease control and prevention • MFDS : Ministry of Food and Drug Safety • NECA : National Evidence-based Healthcare Collaborating Agency • KOIHA : Korea Institute for Healthcare Accreditation
Public Reporting
Quality Assessment Coordinating Committee
Lump sum payment scheme
Professional associations Developing the clinical guideline
KOIHA Accreditation for
facility
Reporting performance information
KCDC (health status,
health behaviors)
Health Insurance Policy Deliberative Committee Differential fee scheme
(Acute care, Long term care, tertiary care,, emergency care)
MoH designing system
Supplementary
• OVERALL SNAPSHOT
• MEASURING PERFORMANCE INFORMATION
OVERARCHING RULE, INDICATORS MANAGEMENT, EVOLUTION (2000-2015)
MEASURING
PERFORMANCE INFORMATION
50
210
86
346
Office (clinic, 28,883) Hospital Acute care hospital (1,804) Long-term
care hospital (1,337)
Mental care hosp. (170)
Special care
Financed by Public(56%) and Private(44%) (Public : NHI (90.7%), Medical Aids(9.3%))
Primary care
Financing
Basic Allocating System
(No. of facility)
(Payment system)
Measuring Performance Information
(No. of indicators)
FFS
Using Performance information
Feedback to providers
Structure Process
Outcome
0 55 0
All indicators
Inpatient care Outpatient
care Inpatient
care
FFS FFS DRG
FFS(main)/ DRG
FFS Per diem (main) FFS
FFS Per diem
Office or outpatient care Items: 11 (HTN, DM, etc)
Acute care Item: 22 (IHD, stroke, cancer,etc)
Non-acute care Item: 3 (LTC, ESRD, etc)
Structure Process
Outcome
24 134 55
Structure Process
Outcome
26 21 31
Total 55 Total 213 Total 78
Public reporting
Structure
Process
Outcome
Total
36
121
27
184
53% of all indicators
Structure
Process
Outcome
Total
14
67
15
96
28% of all indicators
Structure
Process
Outcome
Total
1
22
0
23
7% of all indicators
Structure
Process
Outcome
Total
14
66
15
95
27% of all indicators
Structure
Process
Outcome
Total
Pay for performance (some indicators are used twice) Lump sum payment
scheme(a) Total (a+b) Differential fee scheme (b)
62 % of all indicators 23 % of all indicators 16 % of all indicators
Items : 36
Structure Process
Outcome
50 210 86
Total 346
All indicators
• Above figure describes all indicators of HIRA’s Quality Assessment Program only. • Differential fee scheme integrating some of above indicators and indicators from other sources
SECTOR AREA Item Indicators 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Acute care
(mainly for hospital)
Ischemic Heart dz (integrated) 3 48
(AMI, 2013) (1) (16)
(CABG, 2013) (1) (14)
Acute stroke 1 25
Prophylactic antibiotics for surgery 1 12
Volume of surgical/procedural care 1 1
Colon caner 1 21
Breast cancer 1 20
Lung cancer 1 22
Gastric cancer 1 19
Hepatic cancer 1 2
Pneumonia 1 15
Intensive care unit care 1 13
Overall mortality & readmission rate 2 2
DRGs for 7 surgical cares 7 13
Non- acute care
Long term care hospital 1 35
Mental care hospital (Medical Aids) 1 25
Hemodialysis 1 18
Outpatient care
Hypertension 1 12
Diabetes 1 10
Asthma 1 7
COPD 1 6
Use of pharmaceutics 6 15
Use of antibiotics for AOM (<15 year old) 1 5
Discontinued (Cesarean delivery rate, 2013) (1) (3)
Total (2015) 36 346
Measuring 36 items
346 indicators
Public reporting 23 item
184 indicators
Lump sum payment scheme 7 items
23 indicators
Differential fee scheme 11 items
95 indicators
• OVERVIEW
• PUBLIC REPORTING
• TWO PARALLEL P4P SCHEMES : INTRODUCTION
LUMP SUM PAYMENT SCHEME
DIFFERENTIAL FEE SCHEME
USING
PERFORMANCE INFORMATION
For supporting patient informed choice
Name of
facilities
Performance
grade
Location of
facilities
ITEMs
For supporting patient informed choice
Name of
facilities
Values of
individual
indicators
LUMP SUM PAYMENT SCHEME
LUMP SUM PAYMENT SCHEME
※ Amounts of incentives for Lump Sum Payment Scheme (for 7 items, 2014-2015)
LUMP SUM PAYMENT SCHEME
No. of
Indicators
Eligibility for
bonuses
Stroke
(2012~) Structure 1
Process 10
•Top 20% of composite scores
• Improvement of composite
scores (+10 points)
Hypertension (2013~)
Process 2 (continuity of
prescription)
Prescription
of medicine (2014~, 3 items)
Eligibility for
penalties
• A composite score of 55
points
Diabetes (2013~)
Process 2 (continuity of
prescription)
ITEMS
(Targets)
LUMP SUM PAYMENT SCHEME
Incentive size
± 1 %
(of insurance
payment)
Prophylactic antibiotics for
surgeries (2013~)
Process 6 •A composite score of 97 points
• Improvement of composite
scores (+30 points)
• A composite score of 40
points
± 5 %
(of insurance
payment)
•Absolute target of two indicators
(80% for both) No penalty
Proportional to patient volume
(about 4 % of office
visit fee)
•Absolute target of two indicators
(80% and 90% for each) No penalty
Proportional to patient volume
(about 4 % of office
visit fee)
Process 3 (1 indicator per 1 item)
(overuse)
•Top 11% by indicators
•Improvement of ranking
•Two consecutive bottom
11% by indicators and
absolute value
Proportional to patient volume
(about 4 % of office
visit fee)
C-Section (2009~2013)
Outcome 2 •Top 22% of composite scores
• Improver
• A composite score of
previous year’s bottom 22% ± 2 %
(of insurance payment)
AMI (2009~2013)
Process 5
Outcome 1
•Top 22% of composite scores
• Improver
• A composite score of
previous year’s bottom 22% ± 2 %
(of insurance payment)
DIFFERENTIAL FEE SCHEME
DIFFERENTIAL FEE SCHEME
DIFFERENTIAL FEE SCHEME
• PROGRESS OF MEASURING AND USING PERFORMANCE INFORMATION PROGRAM
• OUTCOMES OF THE PROGRAM : PERFORMANCE IMPROVEMENT
• EVERLASTING CHALLENGES : MAINTAINING PARTNERSHIP WITH PROVIDERS
• ACHIEVEMENTS AND PLAN FOR 2016
• CHALLENGES (BEYOND EXPANSION)
ACHIEVEMENTS AND CHALLENGES
Introductory Stage
(~Mid 2000s)
Expanding Stage
(mid 2000s~2015)
Indicators Structure, Process
Increasing the number of
indicators
Adding outcome, safety,
efficiency
Data
source Claims data (mainly)
Resource data
Adding provider reported data
Patient-reported data (in pilot phase)
P4P
Consolidating Stage
(to be achieved)
Selecting significant
indicators
EHR linked data (in pilot phase)
Public
reporting
Feedback to providers
Disclosing high performers
(only)
Disclosing all performers
(only for some of indicators)
Disclosing all indicators
while addressing
unintended consequences
Lump sum payment scheme
By relative target mainly
(ranking)
Adding differential fee
scheme
By relative target (ranking)
Improving predictability
Consolidating two schemes
aspect
stage
Reflecting feasibility, acceptability by providers, and social needs
Source : Comprehensive Quality Report of NHI, 2012 (HIRA, 2013, Korean) Comprehensive Quality Report of NHI, 2014 (HIRA, 2015, English)
Proportion of 3rd or higher generation
ceph-antibiotics use
Use of prophylactic antibiotics within 1 hour before skin
incision
Proportion of aminoglycosides
use
Use of antibiotics more
than 1
Use of antibiotics at
discharge
Days of antibiotics use
(average)
Acknowledgement
Sunmin Kim, MD, PhD, Commissioner for Healthcare Assessment Coordinating Committee, HIRA
Choonseon Park, RN, PhD, Head of Quality Research Team, HIRA
Jeesook Choi, PhD, Associate research fellow, Benefit Policy Research Team, HIRA
Soo-Hee Hwang, PhD, Associate research fellow, Quality Research Team, HIRA