the health insurance organization of egypt: utilization and case management
TRANSCRIPT
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
The Health Insurance Organizationof Egypt
Utilization and Case ManagementThomas Schwark, Abt Associates, Inc.
Mohsen George, Chief Medical Officer, HIO, EgyptGlobal Health Council
June 16, 2011
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
Total Number of Beneficiaries (in thousands)
45004
38817
36659
26834
20671
4359
3225
1651
521
318
140
1965
1970
1975
1980
1985
1990
1995
2000
2005
2007
2010
56%
8.3%
0.5%
Number of beneficiaries (in millions)
18.474
14.488
4.795 4.386
2.290.564
Census: June 2010
Percentage of beneficiaries according to LAWS
1.3%5.1%9.7%
10.7%
32.2%
41%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
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
In the near future …
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)
Prospective Approach (pre-certification – pre-authorization)
Concurrent Approach (assignment and tracking of length of stay – information gathering – hospital rounding – discharge planning)
Retrospective Approach (claims review – pattern review)
Utilization management: Approaches
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
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?
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
Medications
5095462
79006737665693
6030132
0
1000000
2000000
3000000
4000000
5000000
6000000
7000000
8000000
9000000
2006-2007 2007-2008 2008-2009 2009-2010
Established protocols & guidelines for the top diagnoses & procedures.Concurrent review.
EgyptianPounds
Outcome of UM/CM in Gharbia governorate:24% decline in payments to hospitals contracted by HIO
Outsourcing
72342236
95517251
50395869
80649089
0
20000000
40000000
60000000
80000000
100000000
120000000
2006-2007 2007-2008 2008-2009 2009-2010
EgyptianPounds
1. Precertification2. Preauthorization3. Case Management Office4. Structured retrospective utilization review of claims & medical records.
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
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
Thank you
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