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The Health Insurance Organization of Egypt: Utilization and Case Management

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The Health Insurance Organization of Egypt: Utilization and Case Management

  1. 1. The Health Insurance Organization of Egypt Utilization and Case Management Thomas Schwark, Abt Associates, Inc. Mohsen George , Chief Medical Officer, HIO, Egypt Global Health Council June 16, 2011
  2. 2. Health Insurance Organization (HIO) <ul><li>The social health insurance system (HIO) in Egypt has been in existence since 1964 </li></ul><ul><li>HIO was the outcome of many legislations started in the early decades of the 20 th century </li></ul>
  3. 3. Total Number of Beneficiaries (in thousands) 56% 8.3% 0.5%
  4. 4. Number of beneficiaries (in millions) Census: June 2010
  5. 5. Percentage of beneficiaries according to LAWS Census: June 2010
  6. 6. HIO provides services to beneficiaries all over Egypt from Alexandria to Aswan <ul><li>HIO Owns: </li></ul><ul><li>37 hospitals </li></ul><ul><li>600 clinics </li></ul><ul><li>78 work related injury centers </li></ul><ul><li>34 general medical committees </li></ul><ul><li>Thousands of school clinics  </li></ul><ul><li>Outsourcing: (640 hospitals – 1141out-patient clinics) </li></ul>
  7. 7. Main problems facing current HIO <ul><li>Near one half of population has no health insurance coverage </li></ul><ul><li>Different laws & systems dealing with beneficiaries “The more laws the less justice”, Marcus Tullius Cicero </li></ul><ul><li>Unrealistic rates of premium that have been fixed and unchanged since 1964 (financial sustainability is at risk) </li></ul><ul><li>HIO is the payer and service provider </li></ul>
  8. 8. Health insurance reform in Egypt <ul><li>Aiming at: </li></ul><ul><li>Universal coverage </li></ul><ul><li>Sustainable financing resources </li></ul><ul><li>High level quality health care </li></ul><ul><li>Unifying the laws </li></ul><ul><li>Payer/provider split </li></ul>
  9. 9. <ul><li>HIO will be EXCLUSIVELY a payer </li></ul><ul><li>HIO will no longer operate hospitals or clinics </li></ul><ul><li>HIO will contract with health care facilities to provide care to HIO beneficiaries </li></ul><ul><li>HIO must ensure compliance with contract requirements and accreditation standards relating to quality and safety </li></ul>In the near future …
  10. 10. <ul><li>Being the payer, HIO must ensure that the care for which it pays for is: </li></ul><ul><ul><li>Medically Necessary </li></ul></ul><ul><ul><li>Appropriate (means that the treatment proposed is the one most likely to be effective for the patient’s condition) </li></ul></ul><ul><ul><li>of High Quality </li></ul></ul><ul><ul><li>Provided Efficiently </li></ul></ul><ul><ul><li>Safe </li></ul></ul>In the near future …
  11. 11. <ul><li>To ensure those dimensions of care, HIO must have: </li></ul><ul><ul><li>A Medical Management Process </li></ul></ul><ul><ul><ul><li>Medical Auditing </li></ul></ul></ul><ul><ul><ul><li>Utilization and Case Management </li></ul></ul></ul>In the near future …
  12. 12. Utilization management: Definition <ul><li>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: </li></ul><ul><ul><ul><li>Admission </li></ul></ul></ul><ul><ul><ul><li>Treatment and investigations </li></ul></ul></ul><ul><ul><ul><li>Length of stay </li></ul></ul></ul><ul><ul><ul><li>Discharge (criteria – needs) </li></ul></ul></ul>
  13. 13. <ul><ul><ul><li>Prospective Approach (pre-certification – pre-authorization) </li></ul></ul></ul><ul><ul><ul><li>Concurrent Approach (assignment and tracking of length of stay – information gathering – hospital rounding – discharge planning) </li></ul></ul></ul><ul><ul><ul><li>Retrospective Approach (claims review – pattern review) </li></ul></ul></ul>Utilization management: Approaches
  14. 14. Case management: Meet the patient’s health needs efficiently <ul><li>Concurrent Review , during hospital stay </li></ul><ul><li>Is a collaborative and communicative process of the assessment, planning, and facilitation of the services by assessing: </li></ul><ul><ul><li>Any delays in treatment, investigations, or consultation </li></ul></ul><ul><ul><li>Length of stay (LOS) </li></ul></ul><ul><ul><li>Discharge needs </li></ul></ul><ul><ul><li>Discharge criteria </li></ul></ul>
  15. 15. Special case management <ul><li>Comprehensive contact with patient and family during and after hospitalization </li></ul><ul><li>To optimize care for HIO members with complex or chronic medical needs </li></ul><ul><li>Intent is to reduce frequency of hospitalization or emergency room visits </li></ul>
  16. 16. <ul><li>Primarily a f inancial tool </li></ul><ul><li>Supports quality care </li></ul><ul><ul><li>Unnecessary admissions or procedures places patients at risk </li></ul></ul><ul><ul><li>Helps identify complications and adverse outcomes </li></ul></ul>Why utilization and case management?
  17. 17. Why utilization and case management? <ul><li>Reduces financial risk of inappropriate use of services (excessive LOS – delayed investigations – delayed consultation) </li></ul><ul><li>Most important to the risk-bearing entity (HIO or hospitals) </li></ul><ul><li>Critical to the hospital if they receive “ Package Price ” </li></ul><ul><li>Critical to HIO for those cases when they pay “ Fee for Service ” </li></ul>
  18. 18. Utilization and case management training <ul><li>Classroom sessions </li></ul><ul><ul><li>Introductory course on Utilization Management (UM) and Case Management (CM) (1 day) </li></ul></ul><ul><ul><li>Theoretical and hands-on medical records training (3 days) </li></ul></ul><ul><li>Practical training in hospitals </li></ul><ul><ul><li>Demonstration by expert – participants are observers (3 days) </li></ul></ul><ul><ul><li>Participants conduct the process – expert observing them (3 days) </li></ul></ul><ul><li>Final written exam </li></ul><ul><li>Certification </li></ul><ul><ul><li>Utilization and case managers (57 of 61) </li></ul></ul>
  19. 19. Outcome of UM/CM in Gharbia governorate: 36% decline in spending on medications Established protocols & guidelines for the top diagnoses & procedures. Concurrent review. Egyptian Pounds
  20. 20. Outcome of UM/CM in Gharbia governorate: 24% decline in payments to hospitals contracted by HIO Egyptian Pounds <ul><li>Precertification </li></ul><ul><li>Preauthorization </li></ul><ul><li>Case Management Office </li></ul><ul><li>Structured retrospective utilization </li></ul><ul><li>review of claims & medical records </li></ul><ul><li>. </li></ul>
  21. 21. Conclusion <ul><li>UM/CM program is a critical and necessary system for the HIO </li></ul><ul><li>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 </li></ul>
  22. 22. Thank you www.HealthSystems2020.org

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