Kanal Pengetahuan | Reportase Kongres InaHEA ke 3 Eddie
HOSPITAL CARE QUALITY IN
INDONESIA’S UHC: ACCREDITATION
OR PAYMENT SYSTEM?
Edhie S Rahmat – HSS Specialist
USAID Indonesia/Office of Health
BACKGROUND
•
Two major health reforms: 2002 Decentralization and 2014 National Health Insurance (JKN)
•
Ambitious goal in 2019: total coverage to access Quality & Comprehensive Health care
•
MoH Strategic Plan to move forward with at least one accredited hospital in each district/city
•
Two Studies:
• HAPIE Study: Does accreditation have a strong impact on Quality of Care?
• Health Governance Review: Do JKN policies incentivize Quality of Care?
DOES ACCREDITATION IMPACT
QUALITY
IN EARLY ROLLOUT OF JKN?
Hospital Accreditation Process and Impact Evaluation (HAPIE) Study, implemented by URC
(ASSIST) & CFW-UI:
•
Compare 9 top hospitals undergoing different accreditation processes (JCI, KARS, none)
•
Patient perception of Quality: Exit Interviews of 30 randomly selected patients/care-givers in
each of 4 wards (pediatric, surgery, OBG, internal medicine), total 2,167 in all hospitals for
period of August 2013 vs July 2014 i, ii
•
Collecting hospital secondary data (LOS, Care Costs paid by patient and deaths) from 4
wards (pediatric, surgery, OBG, internal medicine) in 9 hospitals for period Jan-March 2014
vs. Jan-March 2015 iiI
---------------------i.
Latief, K., Nandiaty, F., Pawestri, E.A., Wahyuni, S., Rianty, T., Achadi, A. 2015. Presentation in 2015 APACH Conference “Patient satisfaction at the early stage
of National Health Insurance (NHI) implementation: A comparative study before and after NHI implementation at nine class A public hospitals in Indonesia “ in
Bandung, October 22, 2015.
ii.
Broughton E, Achadi A, Latief K, Nandiaty F, Nurhaidah, Qomariyah SN, Rianty T, Wahyuni S, Eskaning AP. 2015. Hospital accreditation process impact
evaluation: Midline report. Technical Report. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).
iii. Broughton, E., Anhari, A.. 2015. Recent presentation of HAPIE midline findings to BPJS –Health “What questions can BPJS data answer in the HAPIE Study?”
in Jakarta, December 12, 2015. Data was collected from BPJS database.
PERCEPTIONS OF DECREASED QUALITY OF
MEDICAL CARE UNDER JKN
G#2. % Change in Doctor’s competence
(p≤0.05)
G#1. % Change in Quality of medical Care
(p≤0.05)
20
20
15
15
Percentage
10
10
5
5
0
0
A
B*
C
D
E*
F*
G*
H
I
Percentage
A*
All
-5
-5
-10
-10
-15
-15
-20
-20
B*
C
D
E*
F*
G*
H*
I
All*
Decreased Perception of Quality regardless of accreditation status, with exception of C & D hospitals. Not
ready for sharply increased # of patients
PERCEPTIONS OF DECREASED QUALITY OF
NURSING SERVICES IN EARLY ROLLED OUT OF JKN
G#3. % Change in Quality of
Nursing service (p≤0.05)
G#4. % Change in Nurse/Midwife’s
competence (p≤0.05)
10
20
Percentage
5
15
Percentage
10
0
A
-5
B
C
D
E*
F*
G*
H*
I*
All*
5
0
A
-10
B
C*
D*
E*
F
G*
H
I
-5
-10
-15
-20
-15
-20
Decreased Perception of Quality regardless of accreditation status, with
exception of C & D hospitals. Not ready for sharply increased # of patients
All*
DECREASED PATIENT SATISFACTION
WITH HOSPITAL CARE IN EARLY
ROLLED OUT OF JKN
G#5. % Change in Satisfaction (p≤0.05)
20
15
Percentage
10
5
0
A
B
C
D
E
F*
G*
H*
I
All*
-5
-10
-15
-20
Satisfaction somewhat decreased, regardless of accreditation status, with
exception of A & D hospitals.
TIMELINESS OF SERVICE & PATIENT PERCEPTION
OF HOW THEY ARE TREATED BY STAFFS
G#6. % Change in Timeliness of
Service (p≤0.05)
G#7. % Change in Treatment
(p≤0.05)
25
20
Percentage
15
Percentage
15
10
5
5
-5
0
A
B
C*
D*
E*
F*
G*
H*
I*
A*
B*
C*
D*
E*
F*
G*
H*
I*
All*
All*
-5
-15
-10
-15
-20
-25
-35
JCI hospitals have better timeliness of service, but in general hospital staff were
perceived to provide worse treatment in all hospitals. Not ready for sharply
increased # of patients
INCREASED LOS & TOTAL COSTS AT
HOSPITALS
T#1. % Change in Length Of Stay
Patients across 9
hospitals
Patients in 3 JCI hospitals
22% increase p < 0.001
11% increase
p < 0.001
Differences
8%
p = 0.272
Patients stayed longer in all hospitals, but somewhat shorter in JCI ones
T#2. % Change in Total Costs
Patients across 9
hospitals
Patients in 3 JCI hospitals
Differences
4.5%
increase
8% increase
50%
Costs increased more in JCI than non-JCI hospitals
p < 0.280
p < 0.001
p < 0.001
DEATHS AMONG INPATIENTS
T#3 % Change in Deaths
2014
2015
Patients in 6 non-JCI
3.61
3.82
p < 0.034
hospitals
Patients in 3 JCI
3.92
5.72
hospitals*
*Controlling for dx & age; Patients in JCI hospitals have a 37% higher risk of death
Differences*
49%
(p150 Key
Informants from 65 institutions on Health Governance in
early JKN implementation
- Identified regulatory incentives for Hospital Care Quality
(Accreditation)**
- Identified opportunities for performance-related payments***
- Identified information system that could track hospital
performance****
*Hatt, L., Altea, C., Chee, G., Ergo, A., Fuad, A., Gigli, S., Hensley, L., Laird, K., Ramchandani, N., Simatupang, R.,
Tarantino, L., Wright, J., Zuwasti, U. December 2015. Rapid Analytical Review and Assessment of Health System
Opportunities and Gaps in Indonesia. Bethesda, MD: Health Finance and Governance Project, Abt Associates Inc. This
is available for public access in
https://dec.usaid.gov/dec/content/Detail.aspx?ctID=ODVhZjk4NWQtM2YyMi00YjRmLTkxNjktZTcxMjM2NDBmY2Uy&r
ID=MzczMDYx
**See section on Service Delivery of Public and Private Sector”
***See section on Health Financing
PAYMENTS LINKED TO
PERFORMANCE
•
Quality Outcome Framework: UK-NHS rewards practices for the
provision of quality of care & good practices*
•
Hospital Value-Based Purchasing (US Medicare) adjusts hospitals’
payments based on 4 domains of quality: the clinical process of care
domain, the patient experience of care domain, the outcome domain,
and the efficiency domain**
•
Inpatient Prospective Payment System (IPPS – US Medicare) to
reduce re-admission of heart attack, heart failure, pneumonia, hip/knee
replacement, and COPD***
•
Incentives for achieving certain public health indicators (Ghana etc.)****
•
Compensation tied to performance (service volumes, rates of referral,
population service coverage, health outcome measures, and efficiency
measures)*****
•
Benchmarking indicators for performance within claims database (PCSI Case-mix funding models)
* http://www.hscic.gov.uk/qof
** https://www.medicare.gov/hospitalcompare/data/hospital-vbp.html
*** https://www.medicare.gov/hospitalcompare/readmission-reduction-program.html
**** https://www.rbfhealth.org/project/ghana
***** Eichler, R. & De, S. 2008: Paying for Performance in Health: A guide to developing the Blueprint.
Bethesda: Health systems 20/20 project, Abt Associates Inc.
JKN POLICIES/REGULATIONS IN
2015
•
Facility credentialing*:
• Public hospitals: automatically credentialed, regardless of
accreditation status
• Private hospitals: Providers previously contracted by Askes
automatically credentialed, New providers are credentialed based
on meeting human resources, facility, and equipment standards
•
Comprehensive benefits with some negative lists – no priorities to
certain public health concerns**
•
INA-CBG***:
• Bundled coding for Claim Reimbursement
• No performance related indicators, unless un-bundled
• Not updated costs – no incentive for good practices
• Over & under compensation for certain clinical interventions
•
Efforts focus on cost containment by instituting committees (BPJS,
HTA), but decisions lie with other agencies**
*See Hatt, L. et al on section “Service Delivery in Public & Private sector”
** section on Health Financing
*** section on HIS
CURRENT DEVELOPMENTS
• MoH:
• Capacity Building for Case-mix team (PPJK)
• Grouper Revision (PPJK) in INA-CBG (starting with eye
diseases)
• Hospital cost survey (NIHRD)
• BPJS:
• Observe risks of fraud
• Monitor some performance indicators (most diagnosis &
intervention, higher cost of intervention)
• Promotion & Prevention for diseases with highest costs
• External survey to capture satisfaction of JKN patient.
SUMMARY
Findings
Suggestions
1.
Accreditation has less
impact on Perception of
Quality and Patient
Outcomes
1.
Incentivize Good practices
through payments
2.
Accreditation as condition for
Re-Credentialing
Though mandatory, not
much incentive for
undergoing accreditation
3.
Unbundling INA-CBGs to show
certain benchmark indicators
4.
Thinking of global budget to
hospitals, but linked to
performance
5.
Start with admission rate to
observe performance and
expand gradually
2.
3.
Bundled INA-CBG does not
show performance
4.
No incentive for good
practices
INDONESIA’S UHC: ACCREDITATION
OR PAYMENT SYSTEM?
Edhie S Rahmat – HSS Specialist
USAID Indonesia/Office of Health
BACKGROUND
•
Two major health reforms: 2002 Decentralization and 2014 National Health Insurance (JKN)
•
Ambitious goal in 2019: total coverage to access Quality & Comprehensive Health care
•
MoH Strategic Plan to move forward with at least one accredited hospital in each district/city
•
Two Studies:
• HAPIE Study: Does accreditation have a strong impact on Quality of Care?
• Health Governance Review: Do JKN policies incentivize Quality of Care?
DOES ACCREDITATION IMPACT
QUALITY
IN EARLY ROLLOUT OF JKN?
Hospital Accreditation Process and Impact Evaluation (HAPIE) Study, implemented by URC
(ASSIST) & CFW-UI:
•
Compare 9 top hospitals undergoing different accreditation processes (JCI, KARS, none)
•
Patient perception of Quality: Exit Interviews of 30 randomly selected patients/care-givers in
each of 4 wards (pediatric, surgery, OBG, internal medicine), total 2,167 in all hospitals for
period of August 2013 vs July 2014 i, ii
•
Collecting hospital secondary data (LOS, Care Costs paid by patient and deaths) from 4
wards (pediatric, surgery, OBG, internal medicine) in 9 hospitals for period Jan-March 2014
vs. Jan-March 2015 iiI
---------------------i.
Latief, K., Nandiaty, F., Pawestri, E.A., Wahyuni, S., Rianty, T., Achadi, A. 2015. Presentation in 2015 APACH Conference “Patient satisfaction at the early stage
of National Health Insurance (NHI) implementation: A comparative study before and after NHI implementation at nine class A public hospitals in Indonesia “ in
Bandung, October 22, 2015.
ii.
Broughton E, Achadi A, Latief K, Nandiaty F, Nurhaidah, Qomariyah SN, Rianty T, Wahyuni S, Eskaning AP. 2015. Hospital accreditation process impact
evaluation: Midline report. Technical Report. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).
iii. Broughton, E., Anhari, A.. 2015. Recent presentation of HAPIE midline findings to BPJS –Health “What questions can BPJS data answer in the HAPIE Study?”
in Jakarta, December 12, 2015. Data was collected from BPJS database.
PERCEPTIONS OF DECREASED QUALITY OF
MEDICAL CARE UNDER JKN
G#2. % Change in Doctor’s competence
(p≤0.05)
G#1. % Change in Quality of medical Care
(p≤0.05)
20
20
15
15
Percentage
10
10
5
5
0
0
A
B*
C
D
E*
F*
G*
H
I
Percentage
A*
All
-5
-5
-10
-10
-15
-15
-20
-20
B*
C
D
E*
F*
G*
H*
I
All*
Decreased Perception of Quality regardless of accreditation status, with exception of C & D hospitals. Not
ready for sharply increased # of patients
PERCEPTIONS OF DECREASED QUALITY OF
NURSING SERVICES IN EARLY ROLLED OUT OF JKN
G#3. % Change in Quality of
Nursing service (p≤0.05)
G#4. % Change in Nurse/Midwife’s
competence (p≤0.05)
10
20
Percentage
5
15
Percentage
10
0
A
-5
B
C
D
E*
F*
G*
H*
I*
All*
5
0
A
-10
B
C*
D*
E*
F
G*
H
I
-5
-10
-15
-20
-15
-20
Decreased Perception of Quality regardless of accreditation status, with
exception of C & D hospitals. Not ready for sharply increased # of patients
All*
DECREASED PATIENT SATISFACTION
WITH HOSPITAL CARE IN EARLY
ROLLED OUT OF JKN
G#5. % Change in Satisfaction (p≤0.05)
20
15
Percentage
10
5
0
A
B
C
D
E
F*
G*
H*
I
All*
-5
-10
-15
-20
Satisfaction somewhat decreased, regardless of accreditation status, with
exception of A & D hospitals.
TIMELINESS OF SERVICE & PATIENT PERCEPTION
OF HOW THEY ARE TREATED BY STAFFS
G#6. % Change in Timeliness of
Service (p≤0.05)
G#7. % Change in Treatment
(p≤0.05)
25
20
Percentage
15
Percentage
15
10
5
5
-5
0
A
B
C*
D*
E*
F*
G*
H*
I*
A*
B*
C*
D*
E*
F*
G*
H*
I*
All*
All*
-5
-15
-10
-15
-20
-25
-35
JCI hospitals have better timeliness of service, but in general hospital staff were
perceived to provide worse treatment in all hospitals. Not ready for sharply
increased # of patients
INCREASED LOS & TOTAL COSTS AT
HOSPITALS
T#1. % Change in Length Of Stay
Patients across 9
hospitals
Patients in 3 JCI hospitals
22% increase p < 0.001
11% increase
p < 0.001
Differences
8%
p = 0.272
Patients stayed longer in all hospitals, but somewhat shorter in JCI ones
T#2. % Change in Total Costs
Patients across 9
hospitals
Patients in 3 JCI hospitals
Differences
4.5%
increase
8% increase
50%
Costs increased more in JCI than non-JCI hospitals
p < 0.280
p < 0.001
p < 0.001
DEATHS AMONG INPATIENTS
T#3 % Change in Deaths
2014
2015
Patients in 6 non-JCI
3.61
3.82
p < 0.034
hospitals
Patients in 3 JCI
3.92
5.72
hospitals*
*Controlling for dx & age; Patients in JCI hospitals have a 37% higher risk of death
Differences*
49%
(p150 Key
Informants from 65 institutions on Health Governance in
early JKN implementation
- Identified regulatory incentives for Hospital Care Quality
(Accreditation)**
- Identified opportunities for performance-related payments***
- Identified information system that could track hospital
performance****
*Hatt, L., Altea, C., Chee, G., Ergo, A., Fuad, A., Gigli, S., Hensley, L., Laird, K., Ramchandani, N., Simatupang, R.,
Tarantino, L., Wright, J., Zuwasti, U. December 2015. Rapid Analytical Review and Assessment of Health System
Opportunities and Gaps in Indonesia. Bethesda, MD: Health Finance and Governance Project, Abt Associates Inc. This
is available for public access in
https://dec.usaid.gov/dec/content/Detail.aspx?ctID=ODVhZjk4NWQtM2YyMi00YjRmLTkxNjktZTcxMjM2NDBmY2Uy&r
ID=MzczMDYx
**See section on Service Delivery of Public and Private Sector”
***See section on Health Financing
PAYMENTS LINKED TO
PERFORMANCE
•
Quality Outcome Framework: UK-NHS rewards practices for the
provision of quality of care & good practices*
•
Hospital Value-Based Purchasing (US Medicare) adjusts hospitals’
payments based on 4 domains of quality: the clinical process of care
domain, the patient experience of care domain, the outcome domain,
and the efficiency domain**
•
Inpatient Prospective Payment System (IPPS – US Medicare) to
reduce re-admission of heart attack, heart failure, pneumonia, hip/knee
replacement, and COPD***
•
Incentives for achieving certain public health indicators (Ghana etc.)****
•
Compensation tied to performance (service volumes, rates of referral,
population service coverage, health outcome measures, and efficiency
measures)*****
•
Benchmarking indicators for performance within claims database (PCSI Case-mix funding models)
* http://www.hscic.gov.uk/qof
** https://www.medicare.gov/hospitalcompare/data/hospital-vbp.html
*** https://www.medicare.gov/hospitalcompare/readmission-reduction-program.html
**** https://www.rbfhealth.org/project/ghana
***** Eichler, R. & De, S. 2008: Paying for Performance in Health: A guide to developing the Blueprint.
Bethesda: Health systems 20/20 project, Abt Associates Inc.
JKN POLICIES/REGULATIONS IN
2015
•
Facility credentialing*:
• Public hospitals: automatically credentialed, regardless of
accreditation status
• Private hospitals: Providers previously contracted by Askes
automatically credentialed, New providers are credentialed based
on meeting human resources, facility, and equipment standards
•
Comprehensive benefits with some negative lists – no priorities to
certain public health concerns**
•
INA-CBG***:
• Bundled coding for Claim Reimbursement
• No performance related indicators, unless un-bundled
• Not updated costs – no incentive for good practices
• Over & under compensation for certain clinical interventions
•
Efforts focus on cost containment by instituting committees (BPJS,
HTA), but decisions lie with other agencies**
*See Hatt, L. et al on section “Service Delivery in Public & Private sector”
** section on Health Financing
*** section on HIS
CURRENT DEVELOPMENTS
• MoH:
• Capacity Building for Case-mix team (PPJK)
• Grouper Revision (PPJK) in INA-CBG (starting with eye
diseases)
• Hospital cost survey (NIHRD)
• BPJS:
• Observe risks of fraud
• Monitor some performance indicators (most diagnosis &
intervention, higher cost of intervention)
• Promotion & Prevention for diseases with highest costs
• External survey to capture satisfaction of JKN patient.
SUMMARY
Findings
Suggestions
1.
Accreditation has less
impact on Perception of
Quality and Patient
Outcomes
1.
Incentivize Good practices
through payments
2.
Accreditation as condition for
Re-Credentialing
Though mandatory, not
much incentive for
undergoing accreditation
3.
Unbundling INA-CBGs to show
certain benchmark indicators
4.
Thinking of global budget to
hospitals, but linked to
performance
5.
Start with admission rate to
observe performance and
expand gradually
2.
3.
Bundled INA-CBG does not
show performance
4.
No incentive for good
practices