ina cbg role of pharmacist final syedaljunid

8/14/2019 INA CBG Role of Pharmacist Final SyedAljunid

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

Health Insurance

Professor Dr Syed Mohamed AljunidMD (UKM) MSc (Public Health)( Singapore) PhD (London);DLSHTM (London); FAMMProfessor of Health Economics & Consultant PublicHealth MedicineUnited Nations University-International Institute ForGlobal HealthKuala Lumpur

International Institute For Global Health (UNU-IIGH)

Copyright of United NationsUniversity-IIGH


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OutlineWhat is Universal Coverage?Challenges in Achieving Universal

CoverageMajor issues in Social Health InsuranceWhy Provider Payment Is Important?

What is Casemix System?Role of Pharmacists in Implementationof UNU-CBG/INA-CBGConclusion



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What is Universal Coverage?

a situation where the whole populationof a country has access to good qualityservices according to needs andpreferences, regardless of income level,social status, or residency

Anne Mills (2007)


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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 pocketand catastrophic healthspending

Low

High

High

High

Service coverage :Utilization rates


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Three Dimensions of UniversalCoverage



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UniversalCoverageTechnology

HealthFacilities

FinancingHealthHuman

Resource

Policy &Governance

PoliticalSupport

Challenges in Achieving Universal

Coverage


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Without Universal Coverage. 150 million people suffer from financialcatastrophe every year100 million people pushed into povertybecause of direct payment to healthcare services1% (4million people) of OECD countriessuffer catastrophic spendingUSA: 62% of of bankruptcies due tomedical bills in 2008



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Obstacles to Universal

CoverageRaised in health care costEmerging and re-emerging diseasesIncreasing prevalence of chronicdiseasesPoor distribution of Health HumanResourceLack of sustainable health financingsystem


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Universal Coverage & SHI

Indonesia target to achieve universalcoverage by 2014

BPJS is established to organise healthfinancing system towards universal coverageEfficiency in SHI is key issue in achieving andsustaining universal coverageProvider payment is important component ofsocial health insurance scheme.



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Why Health Financing is

Important?Provide coverage from catastrophicexpenditureIncrease flow of resources in healthsectorReduce Out of Pocket Payment



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UC in Indonesia through SHI



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Challenges in health financing

schemes in developing countriesLow coverage

Inadequate resources especially for social insuranceHigh Premium especially for private insurance

High level of inefficiencyHigh administrative costMoral Hazards of ConsumersMoral Hazards of Providers

Poor Provider Payment MechanismsUse of retrospective payment methodsFee for serviceItemised billings


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Ensuring Sustainability of SocialHealth 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-paymentProviders: Utilisation Review, Medical Audit

Efficient provider payment mechanismRegular Review the Benefit Package

Include new servicesExclude non-essential services

Accepted by Stakeholders


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Importance of Provider

Payment MechanismCost Containment Measures

Enhance Efficiency

Influence Provision of ServicesIncentives or disincentives

Preventive vs Curative ServicesBasic Health Services

Influence Quality of CareTechnical QualityClient Satisfaction

Viability of Health Financing SchemeDisbursement of funds


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Payment Methods:

Retrospective vs ProspectiveRetrospectiveFee-for-servicePayment per itemised bill

Payment per diemStrengths

Favoured by providers

WeaknessesProne to supplier induced demand

High Administrative cost

ProspectiveCapitation paymentGlobal budget

Case-mix paymentStrengths

Good cost containmentLow admin cost

WeaknessesNeed high technical capacityto developReduce Providers clinicalfreedom (need to legislate)


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What is Casemix System?

A tool to classify varieties of patient conditionsinto groups according to resource consumed as

approximated by LOS, episode cost, or cost ofdaily services more generic term of patient classification system

Characteristics: Iso-resource and clinical charactestics

Use in many forms in more than 100 countriesworldwide especially for Provider Payment


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Casemix System in Indonesia

Casemix system is implemented in Indonesiaunder JAMKESMAS (Social Health InsuranceScheme for the Poor) since 2006Used by around 1,350 public and private hospitalsCoverage around 75 million peopleSince 2010- INA-CBG was implemented to replaceINA-DRGsCasemix System will be used to cover all otherSocial Insurance Scheme by 2014 under plan foruniversal coverage- 240 million peopleNational 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)



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Casemix

EFFICIENCY

INFORMATIONQUALITY

Benefits of Casemix


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Components of Casemix SystemDisease

Classifications

Costing

Casemix


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Global Use of Case-mix (2011)


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Casemix System in Developing Countries:The Obstacles

Lack of capacityTechnical skills on Case-Mix System

Lack of financial resources

Limitations in health information systemQuality of disease codingLimited 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

MissionTo contribute, throughResearch and Capacity

Building, to effort to resolvethe pressing global problemthat are the concern of UN,its People and Member

States


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UNU Casemix Grouper

An international grouperPriority to developing countries

Packaged with capacity buildingprogrammeComes with accessory softwareBased on Open Source ConceptProvided at low cost to poor countries


IMPLEMENTATION OF UNU IIGH CASEMIX


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IMPLEMENTATION OF UNU-IIGH CASEMIXSYSTEM IN DEVELOPING COUNTRIES

Disease &Procedure Codes

FinancialData

CCM

UNU-DRG-

Grouper

Cost-Weights

CUSTOMISEDCasemix

GROUPER

Base

Rate

Casemix Cost

Case-Mix Index


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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 countrySeverity level is not static Depending on types of patient care

I to IIII to IVI to IXI to X

Very refined classifications

Advance GrouperCan be used with future changes in diagnosis and procedure classifications (ICD-11 and ICHI classifications


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EIGHT COMPONENTS OF UNU-CASEMIXGROUPER (Plus Dental)

UNU-GROUPER ACUTE

SUB- ACUTE

CHRONIC

DENTAL( Development)

SPECIALPROCEDURES

SPECIALPROSTHESES

SPECIALDRUGS

SPECIALINVESTIGATIONS

AmbulatoryPackage


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Components of UNUCasemix System

UNU-CBG

CCM

CODE ASSIST

NationalCost

Weights

DATAPRO


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Countries working with UNU-IIGH/ITCC on Casemix

AsiaIndonesia

PhilippinesMongolia VietnamMalaysia

Middle East YemenUnited Arab EmiratesSaudi ArabiaI.R of Iran

South AmericaUruguay

Chile Africa

GhanaSudan

TanzaniaEurope

Turkey


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UNU-CBG

Mn-DRGs

INA-

CBG

MY-

DRG

Ph-DRGs

Ur-

DRGs

Vn-

DRGs

Saudi-DRGs

UAE-

DRGs

Chile-

DRGs


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Role of Pharmacists inImplementation of UNU-CBG

Development of Special CMGs in UNU-CBG

Active Participation in Development ofClinical PathwaysPromote Generic PrescribingSupport development of PE GuidelinesPromote Evidence Based PracticeMonitoring of INA-CBG ImplementationCopyright of United Nations

University-IIGH

Pharmaceutical Industry


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Pharmaceutical Industry Annual Sales

Copyright of United Nations

University-IIGH


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Total expenditure on pharmaceuticals and other medicalnon-durables, % total expenditure on health, THE(OECD)


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

Cost Components


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Cost Components(Medical Cases In UKMMC)


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Cost Components(Surgical Cases In UKMMC)


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University-IIGH


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Cost of Drug R&D


University-IIGH


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Role of Pharmacists in UNU-CBG

Special CMG on DrugsDevelop Criteria for Special Drugs

Identify drugs in the listProvide information on drug costMonitor drug utilisation

Identify abuse/unnecessary use


University-IIGH


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Role of Pharmacists in UNU-CBG

Active Participation in Clinical PathwaysCP is important component of casemix

Help to reduce variation of careImprove quality and efficiencyHigh cost and high volume conditions

Select effective and efficient drugs in CPs


University-IIGH


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What is Clinical Pathway?Multidisciplinary plans (or blue printfor a plan of care ) of best clinical

practice for specified groups ofpatients with particular diagnosisthat aid in the coordination&delivery of high quality of care.


University-IIGH


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Patients ofA commontype

Outcome ContinuousQualityImprovement

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)

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Clinical Pathways in UKMMC


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National University of Malaysia(UKM) Medical Centre


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Length of stay of STEMI (PCI)

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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) inUKMMC

Cost Savingper Case(RM)

No. Casesper Year Annual Savings(RM)

STEMI PCI Thrombolysis

367142

50100

18,350.0014,200.00

LSCS 135 1300 176,761.00

COPD 179 250 44,690.00TOTAL 254,001.40

4/10/2013 48


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Ten Leading Causes Inefficiency..


University-IIGHSource: WHO Report 2010: Financing for

Universal Coverage


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Role of Pharmacists in INA-CBG

Promote Generic PrescribingLowering drug expenditure

Control Moral Hazards of ProvidersSupport Rational PrescribingProvide greater access to essential drugs


University-IIGH

Prescribing Practice and Drug Costs


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Prescribing Practice and Drug Costsamong Cardiology Cases in UKMMC

(2007)Database: Casemix Database for casesadmitted in UKKM from July 2002- June2004

Total of 3,022 Cardiology Patients Admitted135 randomly selected for detail review1,020 types of drugs prescribed

Generic Prescription Rate is 45.2% Average No of Drugs prescribed is 7.6Total drug cost is RM 28, 879

90% of the cost is due to branded drugs.Copyright of United Nations

University-IIGHSource: Aljunid et all (Feb 2007) MMJ

rescr ng rac ce an rug


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rescr ng rac ce an rugCosts 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 78.82Specialist & Consultants 11 31.68

MO, Specialist & Consultants 32 63.34

Copyright of United NationsUniversity-IIGHSource: Aljunid et all ( Feb 2007) MMJ

p = 0.011


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% of Countries With Legal Provisions toPromote 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 ofPharmacoeconomic (PE) Guidelines

Technical document to guide economicevaluation of pharmaceuticalsDeveloped by authorities with participationof stakeholders

Assist in preparing supporting documentsfor drug listing/submission


University-IIGH


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Global Scenario of PE


University-IIGH


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Benefits of PE Guidelines

Standardized methods/approach ofEconomic Evaluation

Enhanced quality of PE data for drugsubmissionPromote use of local data in economicevaluation studiesImproved decision making process Evidence-Based Policy Decision


University-IIGH


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UNU-IIGH Certificate Course inCasemix Management

Module 1Orientation and Introductionto Case-Mix

Module 2

Coding of diagnosis andproceduresModule 3

Installation and Maintenanceof Case-mix Sofware

Module 4Case-Mix Costing

Module 5Development of ClinicalPathways

Module 6Coded Data Analysis

Module 7Costing Data Analysis

Module 8 Analysis of Clinical Pathway dataModule 9

Development of Case-Mix Indexand Cost-Weights

Module 10Preparation for National Roll-out


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ConclusionUniversal coverage is the ultimate goal of health system in mostcountries now including Indonesia

Achievement and sustainability of UC depends on resilient,

robust and efficient health financing systemCasemix system can help countries to achieve UC throughenhancement in efficiency and quality of careUNU-CBG/INA-CBG is a special casemix system developed bytaking into account the healthcare system of developing

countriesPharmacists can play important roles to enhanceimplementation of Casemix system to achieve UniversalCoverage


University-IIGH


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

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ina cbg role of pharmacist final syedaljunid

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