INA CBG Role of Pharmacist Final SyedAljunid

International Institute For Global Health (UNU-IIGH)
Role of Pharmacists in Implementation of Casemix System/UNU-CBG for Provider Payment in Social Health Insurance
Professor Dr Syed Mohamed Aljunid
MD (UKM) MSc (Public Health)( Singapore) PhD (London); DLSHTM (London); FAMM Professor of Health Economics & Consultant Public Health Medicine
United Nations University-International Institute For Global Health Kuala Lumpur
Copyright of United Nations University-IIGH
Outline

What is Universal Coverage? Challenges in Achieving Universal Coverage Major issues in Social Health Insurance Why Provider Payment Is Important? What is Casemix System? Role of Pharmacists in Implementation of UNU-CBG/INA-CBG Copyright of United Nations University-IIGH Conclusion
What is Universal Coverage?
a situation where the whole population of a country has access to good quality services according to needs and preferences, regardless of income level, social status, or residency
Anne Mills (2007)
SCOPE OF UNIVERSAL COVERAGE Depth, Height and Breadth
High
Financial risk protection: magnitude of out of pocket and catastrophic health spending
High
Service coverage: Utilization rates
Low
Population coverage: % population covered
High
Three Dimensions of Universal Coverage
Challenges in Achieving Universal Coverage

Financing Health Human Resource Policy & Governance
Health Facilities
Technology
Universal Coverage
Political Support
Without Universal Coverage.
150 million people suffer from financial catastrophe every year 100 million people pushed into poverty because of direct payment to health care services 1% (4million people) of OECD countries suffer catastrophic spending USA: 62% of of bankruptcies due to Copyright of United Nations University-IIGH medical bills in 2008
Obstacles to Universal Coverage

Raised in health care cost Emerging and re-emerging diseases Increasing prevalence of chronic diseases Poor distribution of Health Human Resource Lack of sustainable health financing system
Universal Coverage & SHI
Indonesia target to achieve universal coverage by 2014 BPJS is established to organise health financing system towards universal coverage Efficiency in SHI is key issue in achieving and sustaining universal coverage Provider payment is important component of social health insurance scheme.
Why Health Financing is Important?
Provide coverage from catastrophic expenditure Increase flow of resources in health sector Reduce Out of Pocket Payment
UC in Indonesia through SHI
Challenges in health financing schemes in developing countries
Low coverage

Inadequate resources especially for social insurance High Premium especially for private insurance High administrative cost Moral Hazards of Consumers Moral Hazards of Providers Use of retrospective payment methods

High level of inefficiency

Poor Provider Payment Mechanisms
Fee for service Itemised billings
Ensuring Sustainability of Social Health 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-payment Providers: Utilisation Review, Medical Audit
Efficient provider payment mechanism Regular Review the Benefit Package

Include new services Exclude non-essential services
Accepted by Stakeholders
Importance of Provider Payment Mechanism
Cost Containment Measures
Enhance Efficiency Incentives or disincentives

Influence Provision of Services
Preventive vs Curative Services Basic Health Services
Influence Quality of Care

Technical Quality Client Satisfaction Disbursement of funds
Viability of Health Financing Scheme
Retrospective

Payment Methods: Retrospective vs Prospective
Fee-for-service Payment per itemised bill Payment per diem
Prospective

Strengths
Capitation payment Global budget Case-mix payment
Favoured by providers
Prone to supplier induced demand High Administrative cost
Strengths

Weaknesses

Good cost containment Low admin cost
Weaknesses Need high technical capacity to develop Reduce Providers clinical freedom (need to legislate)
What is Casemix System?
A tool to classify varieties of patient conditions into groups according to resource consumed as approximated by LOS, episode cost, or cost of daily services

more generic term of patient classification system Characteristics: Iso-resource and clinical charactestics
Use in many forms in more than 100 countries worldwide especially for Provider Payment
Casemix System in Indonesia
Casemix system is implemented in Indonesia under JAMKESMAS (Social Health Insurance Scheme for the Poor) since 2006 Used by around 1,350 public and private hospitals Coverage around 75 million people Since 2010- INA-CBG was implemented to replace INA-DRGs Casemix System will be used to cover all other Social Insurance Scheme by 2014 under plan for universal coverage- 240 million people National Health Insurance Agency (BPJS) will coordinate all SHI programmes in Indonesia
JAMKESMAS: Health Financing for The Poor in Indonesia (72 million)
Benefits of Casemix
EFFICIENCY
Casemix
QUALITY
INFORMATION
Components of Casemix System

Disease Classifications
Casemix
Costing
Global Use of Case-mix (2011)
Casemix System in Developing Countries: The Obstacles
Lack of capacity
Technical skills on Case-Mix System
Lack of financial resources Limitations in health information system

Quality of disease coding Limited 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
UNITED NATIONS UNIVERSITY Mission
To contribute, through Research and Capacity Building, to effort to resolve the pressing global problem that are the concern of UN, its People and Member States
UNU Casemix Grouper
An international grouper Priority to developing countries Packaged with capacity building programme Comes with accessory software Based on Open Source Concept Provided at low cost to poor countries
IMPLEMENTATION OF UNU-IIGH CASEMIX SYSTEM IN DEVELOPING COUNTRIES

UNU-DRGGrouper
Disease & Procedure Codes
Financial Data
Case-Mix Index
Cost-Weights
CCM
CUSTOMISED Casemix GROUPER
Casemix Cost
Base Rate
UNU-CBG: The New Casemix Grouper
Grouper developed by researchers from United Nations University

UNU-International Institute For Global Health (Kuala Lumpur) UNU-International Institute For Software Technology (Macau)
Research and Collaboration
ITCC- International Training Centre on Case-Mix and Clinical Coding MOH of Developing Countries Asia Pacific Network of FIC WHO-FIC (ICD-10 and Procedure Classifications)
Owned and Maintained by United Nations University United Nations University

United Nations Agency Non-for Profit and No Commercial Interest Priority to support developing countries to achieve MDGs
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 country Severity level is not static Depending on types of patient care I to III I to IV I to IX I to X Very refined classifications
Can be used with future changes in diagnosis and procedure classifications (ICD11 and ICHI classifications
Advance Grouper
EIGHT COMPONENTS OF UNU-CASEMIX GROUPER (Plus Dental)

(Development) CHRONIC DENTAL
SPECIAL PROCEDURES
SPECIAL PROSTHESES
SPECIAL DRUGS
SUBACUTE
SPECIAL INVESTIGATIONS
ACUTE
UNUGROUPER
Ambulatory Package
Components of UNU Casemix System

CCM
DATA PRO
UNUCBG
National Cost Weights
CODE ASSIST
Countries working with UNUIIGH/ITCC on Casemix
Asia

South America

Indonesia Philippines Mongolia Vietnam Malaysia
Uruguay Chile
Africa
Middle East
Ghana Sudan Tanzania Yemen Europe United Arab Emirates Turkey Saudi Arabia I.R of Iran
ChileDRGs
MnDRGs
INACBG
UAEDRGs
UNUCBG
MYDRG
SaudiDRGs
VnDRGs UrDRGs
PhDRGs
Role of Pharmacists in Implementation of UNU-CBG
Development of Special CMGs in UNUCBG Active Participation in Development of Clinical Pathways Promote Generic Prescribing Support development of PE Guidelines Promote Evidence Based Practice Copyright of United Nations Monitoring of INA-CBG Implementation
University-IIGH
Pharmaceutical Industry Annual Sales
Total expenditure on pharmaceuticals and other medical non-durables, % total expenditure on health, THE (OECD)
MOH Malaysia Pharmaceutical Supplies and Operating Expenditures 1997-2009 (RM Million)
Cost Components (Medical Cases In UKMMC)
Cost Components (Surgical Cases In UKMMC)
Cost of Drug R&D
Role of Pharmacists in UNU-CBG
Special CMG on Drugs

Develop Criteria for Special Drugs Identify drugs in the list Provide information on drug cost Monitor drug utilisation Identify abuse/unnecessary use
Role of Pharmacists in UNUCBG
Active Participation in Clinical Pathways

CP is important component of casemix Help to reduce variation of care Improve quality and efficiency High cost and high volume conditions Select effective and efficient drugs in CPs
What is Clinical Pathway?
Multidisciplinary plans (or blue print for a plan of care) of best clinical practice for specified groups of
patients with particular diagnosis that aid in the coordination
&delivery of high quality of care.
Using Clinical Pathway

Process improvement Patients of A common type
Single Process
Outcome
Continuous Quality Improvement
Clinical Pathways in UKMMC
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)
4/10/2013 45
National University of Malaysia (UKM) Medical Centre
Length of stay of STEMI (PCI)
CP (n=79) ALOS
4/10/2013
Non CP (n=78) 8.152.25 p < 0.001

47
5.521.42
ANNUAL COST SAVINGS (RM) in UKMMC

Cost Saving per Case (RM) No. Cases per Year Annual Savings (RM)
STEMI
PCI Thrombolysis
367 142 135 179
50 100 1300 250
18,350.00 14,200.00 176,761.00 44,690.00
LSCS COPD
TOTAL
254,001.40
4/10/2013
48
Ten Leading Causes Inefficiency..
Source: WHO Report 2010: Financing for Universal Coverage
Ten Leading Causes Inefficiency..
Source: WHO Report 2010: Financing for Universal Coverage
Role of Pharmacists in INACBG
Promote Generic Prescribing

Lowering drug expenditure Control Moral Hazards of Providers Support Rational Prescribing Provide greater access to essential drugs
Prescribing Practice and Drug Costs among Cardiology Cases in UKMMC (2007)
Database: Casemix Database for cases admitted in UKKM from July 2002- June 2004

Total of 3,022 Cardiology Patients Admitted 135 randomly selected for detail review 1,020 types of drugs prescribed Generic Prescription Rate is 45.2% Average No of Drugs prescribed is 7.6 Total drug cost is RM 28, 879
90% of the cost is due to branded drugs.

Source: Aljunid et all (Feb 2007) MMJ
Prescribing Practice and Drug Costs among Cardiology Cases in UKMMC (2007)
Prescribers MO/Specialists MO & Specialists MO & Consultants Specialist & Consultants MO, Specialist & Consultants N 29 27 36 11 32 Mean Rank of GPR 70.84 70.83 78.82 31.68 63.34
p = 0.011
Source: Aljunid et all ( Feb 2007) MMJ
% of Countries With Legal Provisions to Promote Generic Substitution in the Private Sector, 2007
Source: MDG Gap Task Force Report: MDG 8(2008)
Role of Pharmacists in UNUCBG/Casemix System
Support Development of Pharmacoeconomic (PE) Guidelines
Technical document to guide economic evaluation of pharmaceuticals Developed by authorities with participation of stakeholders Assist in preparing supporting documents for drug listing/submission
Global Scenario of PE
Benefits of PE Guidelines
Standardized methods/approach of Economic Evaluation Enhanced quality of PE data for drug submission Promote use of local data in economic evaluation studies Improved decision making process Evidence-Based Policy Decision Copyright of United Nations
University-IIGH
UNU-IIGH Certificate Course in Casemix Management
Module 1 Orientation and Introduction to Case-Mix Module 2 Coding of diagnosis and procedures Module 3 Installation and Maintenance of Case-mix Sofware Module 4 Case-Mix Costing Module 5 Development of Clinical Pathways
Module 6 Coded Data Analysis Module 7 Costing Data Analysis Module 8 Analysis of Clinical Pathway data Module 9 Development of Case-Mix Index and Cost-Weights Module 10 Preparation for National Roll-out
Conclusion

Universal coverage is the ultimate goal of health system in most countries now including Indonesia Achievement and sustainability of UC depends on resilient, robust and efficient health financing system Casemix system can help countries to achieve UC through enhancement in efficiency and quality of care UNU-CBG/INA-CBG is a special casemix system developed by taking into account the healthcare system of developing countries Pharmacists can play important roles to enhance implementation of Casemix system to achieve Universal Coverage
syed.aljunid@unu.edu saljunid@gmail.com http://iigh.unu.edu/http://unuiighcasemixonline.org


INA CBG Role of Pharmacist Final SyedAljunid

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INA CBG Role of Pharmacist Final SyedAljunid

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International Institute For Global Health (UNU-IIGH)

What is Universal Coverage?

Anne Mills (2007)

SCOPE OF UNIVERSAL COVERAGE Depth, Height and Breadth

Service coverage: Utilization rates

Population coverage: % population covered

Three Dimensions of Universal Coverage

Copyright of United Nations University-IIGH

Challenges in Achieving Universal Coverage

Without Universal Coverage.

Obstacles to Universal Coverage

Universal Coverage & SHI

Why Health Financing is Important?

Copyright of United Nations University-IIGH

UC in Indonesia through SHI

Copyright of United Nations University-IIGH

Copyright of United Nations University-IIGH

Challenges in health financing schemes in developing countries

High level of inefficiency

Poor Provider Payment Mechanisms

Fee for service Itemised billings

Ensuring Sustainability of Social Health Insurance

Should not be more than 10% of operating cost

Control of moral hazards

Consumers: Co-payment Providers: Utilisation Review, Medical Audit

Efficient provider payment mechanism Regular Review the Benefit Package

Include new services Exclude non-essential services

Importance of Provider Payment Mechanism

Cost Containment Measures

Enhance Efficiency Incentives or disincentives

Influence Provision of Services

Preventive vs Curative Services Basic Health Services

Influence Quality of Care

Technical Quality Client Satisfaction Disbursement of funds

Viability of Health Financing Scheme

Payment Methods: Retrospective vs Prospective

Fee-for-service Payment per itemised bill Payment per diem

Capitation payment Global budget Case-mix payment

Good cost containment Low admin cost

What is Casemix System?

Casemix System in Indonesia

JAMKESMAS: Health Financing for The Poor in Indonesia (72 million)

Copyright of United Nations University-IIGH

Components of Casemix System

Global Use of Case-mix (2011)

Casemix System in Developing Countries: The Obstacles

Technical skills on Case-Mix System

Lack of financial resources Limitations in health information system

Limited Access to Casemix Tool

UNITED NATIONS UNIVERSITY Mission

UNU Casemix Grouper

IMPLEMENTATION OF UNU-IIGH CASEMIX SYSTEM IN DEVELOPING COUNTRIES

Disease & Procedure Codes

CUSTOMISED Casemix GROUPER

UNU-CBG: The New Casemix Grouper

Grouper developed by researchers from United Nations University

Research and Collaboration

Owned and Maintained by United Nations University United Nations University

What is UNU-CBG Grouper?

EIGHT COMPONENTS OF UNU-CASEMIX GROUPER (Plus Dental)

Components of UNU Casemix System

Countries working with UNUIIGH/ITCC on Casemix

Indonesia Philippines Mongolia Vietnam Malaysia