Transcript Why utilization and case management?

The Health Insurance Organization
of Egypt
Utilization and Case Management
Thomas Schwark, Abt Associates, Inc.
Mohsen George, Chief Medical Officer, HIO, Egypt
Global Health Council
June 16, 2011
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health
Health Insurance Organization
(HIO)
 The social health insurance system (HIO) in
Egypt has been in existence since 1964
 HIO was the outcome of many legislations
started in the early decades of the 20th century
5
6
19
0
7
19
5
7
19
0
8
19
3225
1651
521
318
140
0.5%
5
8
19
45004
38817
56%
4359
8.3%
20671
26834
36659
Total Number of Beneficiaries (in thousands)
0
9
19
5
9
19
0
0
20
5
0
20
7
0
20
0
1
20
Number of beneficiaries (in millions)
18.474
14.488
4.795 4.386
2.29
on
e
ns
i
Pe
s
W
id
ow
rs
2
L3
9
L7
l
ch
oo
Pr
es
St
ud
en
ts
0.564
Census: June 2010
Percentage of beneficiaries according to LAWS
5.1% 1.3%
9.7%
41%
10.7%
32.2%
Students
Preschool
L79
L32
Pensioners
Widows
Census: June 2010
HIO provides services to beneficiaries all over
Egypt from Alexandria to Aswan
HIO Owns:
 37 hospitals
 600 clinics
 78 work related injury centers
 34 general medical committees
 Thousands of school clinics
Outsourcing: (640 hospitals – 1141out-patient clinics)
Main problems facing current HIO
 Near one half of population has no health insurance
coverage
 Different laws & systems dealing with beneficiaries
“The more laws the less justice”, Marcus Tullius Cicero
 Unrealistic rates of premium that have been fixed
and unchanged since 1964 (financial sustainability is
at risk)
 HIO is the payer and service provider
Health insurance reform in Egypt
Aiming at:
 Universal coverage
 Sustainable financing resources
 High level quality health care
 Unifying the laws
 Payer/provider split
In the near future …
 HIO will be EXCLUSIVELY a payer
 HIO will no longer operate hospitals or clinics
 HIO will contract with health care facilities to provide
care to HIO beneficiaries
 HIO must ensure compliance with contract
requirements and accreditation standards relating to
quality and safety
In the near future …
 Being the payer, HIO must ensure that the
care for which it pays for is:
 Medically Necessary
 Appropriate (means that the treatment proposed is the one most
likely to be effective for the patient’s condition)
 of High Quality
 Provided Efficiently
 Safe
In the near future …
 To ensure those dimensions of care, HIO
must have:
 A Medical Management Process
 Medical Auditing
 Utilization and Case Management
Utilization management: Definition
 Technique used by the payer of health care to manage
costs (primarily a financial tool) through analysis of
the medical necessity and appropriateness of care,
including appropriateness of:
 Admission
 Treatment and investigations
 Length of stay
 Discharge (criteria – needs)
Utilization management: Approaches
 Prospective Approach (pre-certification – preauthorization)
 Concurrent Approach (assignment and tracking of length
of stay – information gathering – hospital rounding – discharge
planning)
 Retrospective Approach (claims review – pattern
review)
Case management:
Meet the patient’s health needs efficiently
 Concurrent Review, during hospital stay
 Is a collaborative and communicative process of the
assessment, planning, and facilitation of the services by
assessing:
 Any delays in treatment, investigations, or consultation
 Length of stay (LOS)
 Discharge needs
 Discharge criteria
Special case management
 Comprehensive contact with patient and family
during and after hospitalization
 To optimize care for HIO members with complex or
chronic medical needs
 Intent is to reduce frequency of hospitalization or
emergency room visits
Why utilization and case management?
 Primarily a financial tool
 Supports quality care
 Unnecessary admissions or procedures places
patients at risk
 Helps identify complications and adverse outcomes
Why utilization and case management?
 Reduces financial risk of inappropriate use of services
(excessive LOS – delayed investigations – delayed
consultation)
 Most important to the risk-bearing entity (HIO or
hospitals)
1. Critical to the hospital if they receive “Package Price”
2. Critical to HIO for those cases when they pay “Fee for Service”
Utilization and case management
training
 Classroom sessions
 Introductory course on Utilization Management (UM) and Case
Management (CM) (1 day)
 Theoretical and hands-on medical records training (3 days)
 Practical training in hospitals
 Demonstration by expert – participants are observers (3 days)
 Participants conduct the process – expert observing them (3 days)
 Final written exam
 Certification
 Utilization and case managers (57 of 61)
Outcome of UM/CM in Gharbia governorate:
36% decline in spending on medications
Egyptian
Pounds
Medications
9000000
7665693
8000000
7900673
7000000
6000000
5000000
6030132
4000000
5095462
Established protocols &
guidelines for the top
diagnoses & procedures.
Concurrent review.
3000000
2000000
1000000
0
2006-2007
2007-2008
2008-2009
2009-2010
Outcome of UM/CM in Gharbia governorate:
24% decline in payments to hospitals contracted
by HIO
Egyptian
Pounds 120000000
Outsourcing
95517251
100000000
80649089
80000000
72342236
60000000
40000000
50395869
20000000
1.
2.
3.
4.
Precertification
Preauthorization
Case Management Office
Structured retrospective utilization
review of claims & medical records
.
0
2006-2007
2007-2008
2008-2009
2009-2010
Conclusion
 UM/CM program is a critical and necessary system
for the HIO
 When fully implemented and rolled out to HIO and
contracted facilities, financial and quality implications
will result in reduced costs and unnecessary LOS
and re-admission
Thank you
www.HealthSystems2020.org
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health