meir raz m.d

Meir Raz M.DMeir Raz M.D..

The Impact of The Impact of Information Information

Communication Communication Technology on Technology on

Healthcare ManagementHealthcare Management

Czech Healthcare ForumCzech Healthcare Forum Prague, Prague, Czech RepublicCzech Republic

Sep 2008Sep 2008

Established in 1948 as a social democracy with a

parliamentary multi-party system.

A history of armed conflicts with neighboring Arab countries

and large scale immigration have placed continuing heavy

burden on Israel's economy.

Income inequity is among the highest of developed countries..

Decreasing public financing for the health system

ISRAEL

National Health Insurance (1995) Patient Rights act (1996).

Formal priority setting process for revising the benefit

package based on solid information and a structured

decision-making procedure (1997).

National Quality Measures for Health Funds (2000).

ISRAEL

The Israeli Health Care System

Health Funds provide a uniform legally defined basket of services to which every citizen is entitled

Every citizen is a member of one of four nationwide health funds

Citizens are free to choose and move between health funds

Health funds must accept all applicants for membership

Health funds are financed by government via age-related capitation payments (90% of total), patient charges and other income (10%)

National Health Insurance Law of 1995

IsraelCzech RepublicTotal population - millions 6.810.2

Annual population growth rate2.1%-0.1%

60 +as % of total 200613.0%20.0%200013.2%18.4%

Life Expectancy at birth, both sexes200681.077.0200078.075.0

Probability of dying under age 5 years20065.04.0per 1000 - both sexes20007.05.0

Health expenditures as % of GDP 20057.8%7.1%20008.0%6.5%

Per capita health expenditures in PPP $ 2005$2,143$1,4452000$1,810$980

Private health expenditures as % of total health expenditures200533.5%11.4%

200030.6%9.7%

Government health expenditures as % of total government expenditures200511.2%14.4%

200011.5%14.1%

Maccabi is the second largest health fund in Israel.

Maccabi functions within the framework of the National

Health insurance Law, and is therefore limited by

constraints imposed by the Law.

Members are free to choose their physician and other

services provider from a wide range of participating

providers and may go directly to specialist physicians without

the referral of a family physician

Maccabi Healthcare Services

Members receive services from Maccabi facilities and from independent suppliers. 90% of physicians are independent . More than 50% of medications purchased by members are supplied through Maccabi pharmacies

Maccabi is remunerated on a capitation basis but methods of payment to providers varies:* Physicians: Quarterly visits within global budget* Hospitals: Negotiated Caps within a National Cap* Other providers: Fee-for-service

Co-payments exist for medications, visits to physician specialist clinics and some other services.

Maccabi Healthcare Services

Maccabi’s Vision

Israel's leading and most advanced healthcare organization

aims to achieve Total Health for its members, providing

integrative and personally- tailored health care to each and

every member, and encourages excellence in the quality of

medical care, knowledge and service.

1,800,000 members (24% of total membership of all funds)

9,150 employees , of whom 7,438 are full-time position

3,560 physicians. Most of them are independent physicians.

3,109 clinics.

Maccabi's budget –1.35 billion euro

Maccabi Statistics

The Maccabi Health Fund

(Excluding new technologies)

Age Adjusted Income from Capitation

91% of Maccabi Expenditures are Medical

Physicians24%

Other medical7%

Development1%

Diagnosis 9%

Administration8%

Drugs21%

Hospitals30%

Diagnostics Drugs

Purchasing

Policy

21%21%

Physicians

Payment

Guidelines

24%24%

Oversight

Admin.

Increased

efficiency

NIS 879M NIS1,579MNIS 1,141M NIS 409M NIS 430MNIS 435M

Budgetary Efficiency Processes

9%9% 9%9%

Purchasing

Guidelines

Other

medical

7%7%

Increased

efficiency

Hospitals

Agreements

30%30%

Health Funds’ Financial Performance 2000-2006Millions NIS

HealthFunds

Clalit

Maccabi

Leumit

Meuhedet

Total

2000200120022003200420052006

-242-472-413-1064-347-63

-140-528139-13

-111-204-94-2713-75-76

-21-535-58681319

-514-734-474-17894-410-117

Physicians generate the majority of healthcare expenditure:

Equipping the physicians with means to help them execute the

health fund policy is vital (via intelligent decision support system).

In order to influence market prices one has to be involved in the

market: i.e. Pharmacies, Hospitals, Ambulatory secondary care.

Competition, in order to reduce costs and increase quality

mandates selective contracting with healthcare providers.

Two levels of competition:

1.between the providers in the organization.

2.between the health funds.

In order to maintain a balanced budget :

one needs to manage all parts of the system simultaneously

(multi piston)

one has to use a variety of methods .

shift between the methods periodically in order to avoid “gaming”.

Effective health fund managing necessitates comprehensive Health

Management Information Systems (H.M.I.S.).

Decision to move towards a fully computerized organization (1983).

Using State I.D. Number as the Maccabi I.D. Number and then introduction of the Magnetic Membership Card to be used in every point of service (1989).

Joint decision by Maccabi and its independent physicians organization to computerize physicians clinics (1988->1994).

Computerization of claims management (1989) .

Computerizing the prescriptions and the pharmacies (1989) - the beginning of the E-prescription era ,controlling utilization and costs.

Computerization of the laboratories (1993)and imaging (1997).

Central Medical Record (1996)

Flexible rule engine (2008)

Maccabi’s Integrated Information SystemMaccabi’s Integrated Information System

Clin

icExtr

an

et

Internet

Intra

net

Members Members Members Members

Medical Control

Admin Control

Payment Control

Reimburse-ment Control

Doc. Clinic

Doc. Clinic

Pharmacy

Specialist

Consultant

Paramedic

Diagnostic Center

Firewall

Backup Computer

Main Computer

IDC

Mgmt. of Insured People

IDC

Mgmt. of the Fund

IDC

Mgmt. of Service Provider

s

Drug consumpt

ion control

Labs control

Tele radiology

Web Services

CMRERP

Imaging

Visits &Hospitalization

Medications

Lab Results

Treatments

Demographic parameters

MedicalHistory

FamilyHistory

Telemedicine: Second opinion with Mass General Hospital-Boston (1997) Tele radiology (1997)CT/MRI consultation (2002)Tele E.C.G. & Holter (2004)Tele ophthalmology (2008) Tele consultation with specialists (2008).

Disease Management for chronic diseases: Registries-D.M.(1999),C.V.(2003) Home care(2005)….. Disease management programs-Asthma(1999),D.M(2000), CHF (2007).

Equal access throughout the country.

On-Line diagnosis .

Extension of service hours.

Reliable diagnosis due to digital tools.

Improved quality control and assurance.

Archiving capabilities for future comparison.

Sharing information among physicians for treatment and

consultation.

Lower cost.

Rational & Feasibility in MaccabiRational & Feasibility in Maccabi

Medical/Control/Peer review

Organization’s drugs index

Prescribing (Patient details / allergies / interactions)

Generic substitute

Preferred therapeutic alternatives

Patient compliance

Integrated Decision Support Systems Integrated Decision Support Systems for Prescriptionsfor Prescriptions

Until 2000, CT utilization rates increased by 20% yearly

2001 Imaging Consultation Center established

Physician referrals online to the Center

Radiology experts access CMR

Approve proposed test or recommend more appropriate and effective modality

CT annual performance rates decreased from 25.9-17.3/1000 (81,223-57,204) -33% decrease

MRI rates decreased from 7-5.6 – decrease of 9%

The cost savings for 2000-2003 were 2.7 million EuroThe cost savings for 2000-2003 were 2.7 million Euro

The set up of ICT support system was 228,000 EuroThe set up of ICT support system was 228,000 Euro

Organizational

Processes (Bureaucrac

y)

Perceived Quality Member

Satisfaction

Quality of Clinical

Care

Meeting Budgetar

y Objective

s

Management Through Setting strategic objectives Management Through Setting strategic objectives and measuring performanceand measuring performanceHealth Value Added (HVA) Health Value Added (HVA)

Managing the

Organization in order to

achieve Total Health

Physician Satisfacti

on

Employee

Satisfaction

Quality of Clinical Care

Cardiovascular Disease

Antibiotics

Diabetes

Depression

Asthma

Immunizations

Mammography

Clinical Care Objectives Clinical Care Objectives

Overall satisfaction with health plan

Growth in the number of new members

Number of members that switch to a competing plan

Satisfaction with healthcare services

Satisfaction with administrative services

Expenditures in accordance with Budget:

Expenditures on Hospital Services

Expenditures on Physician Services

Expenditures on Medications

Overall expenditures

HVA PrinciplesHVA Principles

Consistent measures over time

Targets for both clinical care and perceived quality of care

Targets based on previous years achievement

Progress available “on-line”

Measurement at all levels of the organization:

National

Regional

Local Branch

Physician

Constructive Competition at each level

HVA PrinciplesHVA Principles

Quality Quality indicatorsindicators

DiabetesDiabetes

Members’ Members’ satisfactionsatisfaction

Financial Financial indicatorsindicators

HVA – The ToolHVA – The Tool

To sum up:To sum up:

Health Value Added (HVA)Health Value Added (HVA)

Promoting “total health” throughPromoting “total health” through

quality-based strategic managementquality-based strategic management

utilizing integrated performanceutilizing integrated performance

measurementsmeasurements

Major Contributing Factors:

The “Personal Physician”

Comprehensive Health Information and Communication Technology (ICT)

Strategically Focused Objective-based Performance Measurement (HVA)