This presentation was made by Kyohyun KIM, Korea, at the 5th Meeting of the joint OECD DELSA/GOV Network on Fiscal Sustainability of Health Systems held on 4-5 February 2016 at the OECD Conference Centre in Paris.

1. USING PERFORMANCE INFORMATION IN
NATIONAL HEALTH INSURANCE, KOREA
Kyohyun KIM MD, MPH
HIRA Research Institute
OECD Meeting on Sustainability of Health Systems
Paris, France, 4-5 February 2016

4. People Providers
Single Payer
(NHIS, collecting & pooling)
• Patients can access specialists and
hospitals without referrals
(no registration with GP, no gate keeping)
MoH
designing health system
Purchasing
(HIRA, claim review)
Notify
Payment amount
Co-insurance rate
Health Insurance Policy Deliberative Committee
Benefit package, insurance rate, relative fees for service
• All providers are automatically
contracted
• 95.8 % of facilities (hospital, clinics,
etc) are owned by private sector
• Payment system
• FFS 93%
• DRG 3%
• per diem 4%
• MoH : Ministry of Health and Welfare
• NHIS : National Health Insurance Service
• HIRA : Health Insurance and Assessment Service
• FFE : Fee for Service, DRG : Diagnosis Related Group

5. • OVERVIEW
• BACKGROUND OF NHI’S MEASURING AND USING PERFORMANCE INFORMATION
• HIRA’S ROLE AND MEASURING AND USING OF PERFORMANCE INFORMATION
PERFORMANCE ASSESSMENT
SYSTEM

7. People Providers
Single Payer
(NHIS, collecting & pooling)
Informed with
performance information Healthcare resources
Purchasing
(HIRA, claim review and QA)
MFDS
(pharma, device)
Licensing
Examination
Institute
Measuring performance
information (since2000)
NECA(HTA)
(services)
Notify
Payment adjustment
Structural requirements
• KCDC : Korea Centers for disease control and prevention
• MFDS : Ministry of Food and Drug Safety
• NECA : National Evidence-based Healthcare Collaborating Agency
• KOIHA : Korea Institute for Healthcare Accreditation
Public
Reporting
Quality Assessment
Coordinating
Committee
Lump sum
payment scheme
Professional associations
Developing the clinical guideline
KOIHA
Accreditation for
facility
Reporting
performance
information
KCDC
(health status,
health
behaviors)
Health Insurance Policy Deliberative Committee
Differential fee scheme
(Acutecare,Longterm care,tertiary care,,emergencycare)
MoH
designing system

8. Supplementary

10. • OVERALL SNAPSHOT
• MEASURING PERFORMANCE INFORMATION
OVERARCHING RULE, INDICATORS MANAGEMENT, EVOLUTION (2000-2015)
MEASURING
PERFORMANCE INFORMATION

11. 50
210
86
346
Office (clinic, 28,883) Hospital
Acute care hospital (1,804) Long-term
care hospital
(1,337)
Mental
care
hosp.
(170)
Special
care
Financed by Public(56%) and Private(44%)
(Public : NHI (90.7%), Medical Aids(9.3%))
Primary
care
Financing
Basic
Allocating
System
(No. of facility)
(Payment
system)
Measuring
Performance
Information
(No. of indicators)
FFS
Using
Performance
information
Feedback to
providers
Structure
Process
Outcome
0
55
0
All indicators
Inpatient care
Outpatient
care
Inpatient
care
FFS FFS
DRG
FFS(main)/
DRG
FFS Per diem (main)
FFS
FFS
Per diem
Office or outpatient care
Items: 11 (HTN, DM, etc)
Acute care
Item: 22 (IHD, stroke, cancer,etc)
Non-acute care
Item: 3 (LTC, ESRD, etc)
Structure
Process
Outcome
24
134
55
Structure
Process
Outcome
26
21
31
Total 55 Total 213 Total 78
Public reporting
Structure
Process
Outcome
Total
36
121
27
184
53% of all indicators
Structure
Process
Outcome
Total
14
67
15
96
28% of all indicators
Structure
Process
Outcome
Total
1
22
0
23
7% of all indicators
Structure
Process
Outcome
Total
14
66
15
95
27% of all indicators
Structure
Process
Outcome
Total
Pay for performance (some indicators are used twice)
Lump sum payment
scheme(a)Total (a+b)
Differential fee
scheme (b)
62 % of all indicators 23 % of all indicators16 % of all indicators
Items : 36
Structure
Process
Outcome
50
210
86
Total 346
All indicators
• Above figure describes all indicators of HIRA’s Quality Assessment Program only.
• Differential fee scheme integrating some of above indicators and indicators from other sources

14. SECTOR AREA Item Indicators 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Acute care
(mainly for
hospital)
Ischemic Heart dz (integrated) 3 48
(AMI, 2013) (1) (16)
(CABG, 2013) (1) (14)
Acute stroke 1 25
Prophylactic antibiotics for surgery 1 12
Volume of surgical/procedural care 1 1
Colon caner 1 21
Breast cancer 1 20
Lung cancer 1 22
Gastric cancer 1 19
Hepatic cancer 1 2
Pneumonia 1 15
Intensive care unit care 1 13
Overall mortality & readmission rate 2 2
DRGs for 7 surgical cares 7 13
Non- acute
care
Long term care hospital 1 35
Mental care hospital (Medical Aids) 1 25
Hemodialysis 1 18
Outpatient
care
Hypertension 1 12
Diabetes 1 10
Asthma 1 7
COPD 1 6
Use of pharmaceutics 6 15
Use of antibiotics for AOM (<15 year old) 1 5
Discontinued (Cesarean delivery rate, 2013) (1) (3)
Total (2015) 36 346
Measuring
36 items
Public reporting
23 item
Lump sum payment scheme
7 items
Differential fee scheme
11 items

15. • OVERVIEW
• PUBLIC REPORTING
• TWO PARALLEL P4P SCHEMES : INTRODUCTION
LUMP SUM PAYMENT SCHEME
DIFFERENTIAL FEE SCHEME
USING
PERFORMANCE INFORMATION

17. For supporting patient informed choice
Name of
facilities
Performance
grade
Location of
facilities
ITEMs

18. For supporting patient informed choice
Name of
facilities
Values of
individual
indicators

20. LUMP SUM PAYMENT SCHEME

21. LUMP SUM PAYMENT SCHEME

22. ※ Amountsof incentivesforLumpSumPaymentScheme(for7items,2014-2015)
LUMP SUM PAYMENT SCHEME

23. No. of
Indicators
Eligibility for
bonuses
Stroke
(2012~)
Structure 1
Process 10
•Top20%ofcompositescores
• Improvementofcomposite
scores(+10points)
Hypertension
(2013~)
Process 2
(continuityof
prescription)
Prescription
of medicine
(2014~, 3 items)
Eligibility for
penalties
• Acomposite scoreof 55
points
Diabetes
(2013~)
Process 2
(continuityof
prescription)
ITEMS
(Targets)
LUMP SUM PAYMENT SCHEME
Incentive size
± 1 %
(of insurance
payment)
Prophylactic
antibioticsfor
surgeries
(2013~)
Process 6
•Acompositescoreof97points
• Improvementofcomposite
scores(+30points)
• Acomposite scoreof 40
points
± 5 %
(of insurance
payment)
•Absolutetargetoftwoindicators
(80%forboth)
No penalty
Proportional to
patient volume
(about 4%ofoffice
visit fee)
•Absolutetargetoftwoindicators
(80% and90%foreach)
No penalty
Proportional to
patient volume
(about 4%ofoffice
visit fee)
Process 3
(1 indicatorper1item)
(overuse)
•Top11% byindicators
•Improvementofranking
•Two consecutive bottom
11% by indicators and
absolute value
Proportional to
patient volume
(about 4%ofoffice
visit fee)
C-Section
(2009~2013) Outcome 2
•Top22%ofcompositescores
• Improver
• Acomposite scoreof
previous year’s bottom22%
± 2 %
(ofinsurancepayment)
AMI
(2009~2013)
Process 5
Outcome 1
•Top22%ofcompositescores
• Improver
• Acomposite scoreof
previous year’s bottom22%
± 2 %
(ofinsurancepayment)

24. DIFFERENTIAL FEE SCHEME

25. DIFFERENTIAL FEE SCHEME

26. DIFFERENTIAL FEE SCHEME

27. • PROGRESS OF MEASURING AND USING PERFORMANCE INFORMATION PROGRAM
• OUTCOMES OF THE PROGRAM : PERFORMANCE IMPROVEMENT
• EVERLASTING CHALLENGES : MAINTAINING PARTNERSHIP WITH PROVIDERS
• ACHIEVEMENTS AND PLAN FOR 2016
• CHALLENGES (BEYOND EXPANSION)
ACHIEVEMENTS AND CHALLENGES

28. Introductory Stage
(~Mid 2000s)
Expanding Stage
(mid 2000s~2015)
Indicators Structure, Process
Increasingthe numberof
indicators
Addingoutcome, safety,
efficiency
Data
source
Claimsdata (mainly)
Resourcedata
Addingproviderreporteddata
Patient-reported data
(in pilot phase)
P4P
Consolidating Stage
(to be achieved)
Selecting significant
indicators
EHR linked data
(in pilot phase)
Public
reporting
Feedbackto providers
Disclosinghighperformers
(only)
Disclosingallperformers
(onlyfor some of indicators)
Disclosingallindicators
whileaddressing
unintendedconsequences
Lumpsumpaymentscheme
By relativetarget mainly
(ranking)
Addingdifferentialfee
scheme
By relativetarget (ranking)
Improving predictability
Consolidatingtwo schemes
aspect
stage
Reflecting feasibility, acceptability by providers, and social needs

29. Source : Comprehensive Quality Report of NHI, 2012 (HIRA, 2013, Korean)
Comprehensive Quality Report of NHI, 2014 (HIRA, 2015, English)
Proportion of
3rd or higher
generation
ceph-antibiotics
use
Use of prophylactic
antibiotics within 1
hour before skin
incision
Proportion of
aminoglycosides
use
Use of
antibiotics more
than 1
Use of
antibiotics at
discharge
Days of
antibiotics use
(average)

33. kimkh1205@hiramail.net
agzak120511@gmail.com
Acknowledgement
Sunmin Kim, MD, PhD, Commissioner for Healthcare Assessment Coordinating Committee, HIRA
Choonseon Park, RN, PhD, Head of Quality Research Team, HIRA
Jeesook Choi, PhD, Associate research fellow, Benefit Policy Research Team, HIRA
Soo-Hee Hwang, PhD, Associate research fellow, Quality Research Team, HIRA