Hospital Performance Assessment in Korea€¦ · Drug Utilization Review(DUR) Onsite investigation...
Transcript of Hospital Performance Assessment in Korea€¦ · Drug Utilization Review(DUR) Onsite investigation...
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27 JUN 2014
Health Insurance Review and Assessment service of Korea
Hospital Performance Assessment in Korea’s National Health Insur-
ance System
SEP 2014
Sun Min Kim, M.D., Ph.D
OECD HCQI Annual Bureau meeting
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Governance of NHI of Korea
Collect contribution
Negotiate with providers for fee level
Promote health and prevent disease
NHIS (National Health Insurance Service)
HIRA (Health Insurance Review & Assessment Ser-
vice)
Make rules for benefit - List, price, coverage
Monitor- Cost and quality
Manage health system infrastructure
Resources generation Purchasing
Ministry of Healthand Welfare
Legislation,NHI organization supervision
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HIRA’s health care purchasing activities
Billing claims
Claims review
Comprehensive man-agement for appropriate medical services
Quality assessment
Drug Utilization Review(DUR)
Onsite investigation
Appeal management
Verification of health care benefit coverage
Public reporting
P4P
Quality Improvement Sup-port
Payment system design-ing
Classification system for benefit
Healthcare resources management
Benefit package listing
Benefit criteria develop-ment
Setting fee schedule
Pricing & post-factum management
Designation of tertiary hospitals & specialized hospitals
Sliding fee scale accord-ing to the staffing level
Healthcare Resources management
Korea Pharmaceutical In-formation System(KPIS)
Healthcare data analysis
Monitoring trends in healthcare utilization
MonitoringRule makingfor benefit
Infrastructure management
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Characteristics of
Quality strategies of Korea’s NHI
Mandatory assessment for all the providers within National Health InsuranceMandatory assessment for all the providers within National Health Insurance
Legal background by the NHI actLegal background by the NHI act
Quality score calculated by the provider levelQuality score calculated by the provider level
Public report of the quality result Public report of the quality result
Pay for performances by the quality scorePay for performances by the quality score
Partnership with the providersPartnership with the providers
Parallel with Hospital AccreditationParallel with Hospital Accreditation
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5• Private hospitals : 93.5% / Public hospitals : 6.5%
Number of healthcare providers
Type Healthcare Providers No.
Total 85,427
Hospitals
Total 64,456
Tertiary 43
General 284
Hospitals (including Dental and Oriental) 1,862
Long-term care hospitals 1,276
Clinics
Medical 28,484
Dental clinicsPublic health centersOriental medicine clinics etc
32,507
Pharmacy Total 20,971
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Quality Assessment Items in 2013
Area Quality Assessment Items
In-pa-tient
Acute Diseases Acute myocardial infarction (AMI) Coronary artery bypass graft (CABG) Ischemic heart disease
Acute stroke
Cancer Diseases Colorectal cancer Breast cancer Lung cancer
Major Surgery Prophylactic antibiotics for surgery Caesarian section Surgical volume
Out-pa-tient
Chronic Diseases Hypertension Diabetes Asthma
Prescription Pharmaceutical benefits Antibiotics for otitis media in infants and children Outpatient prescription incentive program
DRG 7 disease groups of DRGs(hospital and clinics)
Total Institutional Level Long-term care hospital Psychiatric disease (Medicaid) Hemo-dialysis
Adopting 329 quality indicators in total
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Number of indicators
Number
By indicator type Structure 55
Process 188
Outcome 86
By service area Inpatient 183
Outpatient 46
DRG 18
Facility level 82
Total 329
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Examples of AMI Quality Indicators
Number of AMI inpatient cases Number of AMI inpatient cases
Thrombolytic drug administration rate within 60 minutes of arrival at hospitalThrombolytic drug administration rate within 60 minutes of arrival at hospital
Primary PCI performance rate within 120 minutes of arrival at hospitalPrimary PCI performance rate within 120 minutes of arrival at hospital
Aspirin administration rate at hospital arrivalAspirin administration rate at hospital arrival
Aspirin prescription rate at dischargeAspirin prescription rate at discharge
Beta-blocker prescription rate at discharge30-day caseBeta-blocker prescription rate at discharge30-day case
Risk adjusted 30 day case fatality rateRisk adjusted 30 day case fatality rate
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Information flow for Quality Assessment
HospitalProfile
EHRsystem
Providers
Death CertificationSystem
Ministry of PublicAdministration and Security
Fee setting
Claims Review
Quality Assessment
Health careOrganization Profile
EDI system forclaims review
Quality DataAcquisition System
DataWarehouse
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Analysis of quality scores
Risk adjustment according to the patient statusRisk adjustment according to the patient status
Production of quality scores by the facility levelProduction of quality scores by the facility level
Composition of quality indicators by assessment itemsComposition of quality indicators by assessment items
Categorization of hospitals into five groups(or less)Categorization of hospitals into five groups(or less)
Final assessment at the Central Quality Assessment CommitteeFinal assessment at the Central Quality Assessment Committee
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Utilizing Quality Assessment results
Assessment re-sults
Information for Policy Development
Government
Feedback & Education
Provider
Claims Review
HIRA
Public Report for Informed Choices
Insured
Adjust benefit amount
Assessment result
NHIS
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Public report of the Quality Assessment Result of health care providers
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History of HIRA Value Incentive Program
Started Chronic disease management incentive for
doctor’s clinicJul. 2012
Started Long term care hospitals P4P2011~
Outpatient prescription incentive programOct. 2010~
Demonstration VIP for C-sec and AMI for tertiary hospitals2007~ 2010
Extended VIP to general hospitals and acute stroke2011~
Started P4P for Prescription quality assessment for
doctor’s clinic2013
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Model of Value Incentive Program(VIP)
for acute hospitals
+1% Incen-tive
Application Incentive/penaltyDisclosure of thresh-
old/provision of incentive
Incentive/penalty
9th grade
8th grade
7th grade
6th grade
5th grade
4th grade
3rd grade
2nd grade
1st grade
9th grade
8th grade
7th grade
6th grade
5th grade
4th grade
3rd grade
2nd grade
1st grade
9th grade
8th grade
7th grade
6th grade
5th grade
4th grade
3rd grade
2nd grade
1st grade2% Incentive
Penalty threshold -1% penalty
-2% penalty
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Decrease of antibiotics prescription rate for ARI patient
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Decrease of variation of Acute Myocardial Infarction quality score
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Strengths of Korea
in quality strategies
Nation wide single purchasing organization which conducts claims review and quality assessment Nation wide single purchasing organization which conducts claims review and quality assessment
Far advanced ICTFar advanced ICT
Pre-existing Unique Patient IdentifierPre-existing Unique Patient Identifier
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But, confronted with the resistance from the Medical societies, we need
More solid legal background for quality reportMore solid legal background for quality report
Financial support (pay for reporting)Financial support (pay for reporting)
Sound partnership with private providersSound partnership with private providers
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http://www.hira.or.kr/eng