Introducing a new tool for Medical Scheme Management
HQA is a not-for-profit (s21) company, with the following founders: ABSA Health, Discovery, Medscheme, Medihelp, MxHealth, Multimed and Old Mutual Health. Membership is currently open to medical schemes and their administrators, and since 2004 HQA has been associated with the BHF. The Board of HQA includes representatives from BHF, the Council for Medical Schemes, the Consumer Union and medical schemes / administrators.
The need for health quality measurement
There are a number of policy initiatives of the Department of Health that increases the need for some form of independent measurement of the quality of health care received by members of medical schemes. These are:
The requirements of PMB legislation, which encourages schemes to have designated service provider networks. Where such DSPs exist, it is now more likely that schemes would enter into alternative reimbursement agreements with networks, which in turn indicates the need for members to be informed of the quality of health care delivered by such networks, particularly if alternative reimbursement arrangements may influence the behaviour of service providers. There has indeed recently been a proliferation of such network agreements in the market and it is important for Trustees to know whether the agreement entered into does indeed provide good quality health outcomes to members. In other words, there is a need to measure the performance of a network in terms of achieving certain health outcomes.
Under the proposed risk equalization fund (REF), it is the intention that there should be a standard basic benefit package (and standardized supplementary benefit packages). Whilst the benefits offered under these packages will be standardized across the industry, and members would therefore find it easier to compare options of different medical schemes in terms of Rand amount of benefits, it will be increasingly difficult for members to compare their entitlement to benefits under the different protocols used by different networks. In other words, the service provider may now be incentivised not to provide treatment under a capitation arrangement and the question is whether the Trustees are in a position to adequately measure health outcomes to prevent this from affecting the health of the member. There is therefore a need to measure the health outcomes achieved by a certain protocol.
When Trustees consider the form of managed care to adopt for a scheme, they will also be interested to know whether, for instance, capitation or per diem arrangements achieve better health outcomes than the treatment that members may obtain under traditional fee-for-service schemes with benefit limits for non-PMB conditions. In other words, there is a need to measure the health outcomes achieved under different forms of managed care.
The introduction of mandatory ICD-10 coding would hopefully make it considerably easier for schemes to collect data on diagnosis. With an increased focus on diagnostic information, it becomes more viable for schemes to relate different episodes of treatment to a particular condition and hence measure the effectiveness of treatment. It is however likely that some service providers may attempt to achieve access to higher PMB benefits offered by schemes by misreporting diagnosis. However, if such service providers know that their health outcomes would be measured and compared against their peers, they may be less inclined to do so, since misreported diagnosis (or “diagnosis creep”) would in many cases create the impression that they are not achieving good quality health outcomes. Furthermore, some managed care providers currently do not collect full data on treatment provided and this makes it difficult for Trustees to evaluate their performance. This would have to change if there is a system of health outcome measurement. In other words, measuring health outcomes would increase the incentive for service providers to provide accurate diagnostic codes, which is in the interests of the entire industry.
Health Quality Assessment Project
Press Release
HQA is making good progress
HQA (Health Quality Assessment) has made excellent progress during the last year and just released the results of its latest Health Metrics Survey, only the third survey since HQA’s inception and the only one of its kind in Southern Africa.
HQA making good progress
PARTICIPATION IN THE 2008 HEALTH QUALITY ASSESSMENT SURVEY
BACKGROUND
Health Quality Assessment (HQA) performs an annual assessment of quality in health care offered by medical schemes. The aim of such assessments is to assist decision-makers, such as trustees and management of medical schemes to evaluate and improve the quality of health care received by members. The complete process of data collection, actuarial analysis and compilation of the industry report and member specific reports is being done independently by Deloitte & Touche on behalf of HQA.