Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health

The Health Insurance Organizationof Egypt

Utilization and Case ManagementThomas Schwark, Abt Associates, Inc.

Mohsen George, Chief Medical Officer, HIO, EgyptGlobal Health Council

June 16, 2011

Health Insurance Organization (HIO)

The social health insurance system (HIO) in Egypt has been in existence since 1964

HIO was the outcome of many legislations started in the early decades of the 20th century

Total Number of Beneficiaries (in thousands)

45004

38817

36659

26834

20671

4359

3225

1651

521

318

140

1965

1970

1975

1980

1985

1990

1995

2000

2005

2007

2010

56%

8.3%

0.5%

Number of beneficiaries (in millions)

18.474

14.488

4.795 4.386

2.290.564

Census: June 2010

Percentage of beneficiaries according to LAWS

1.3%5.1%9.7%

10.7%

32.2%

41%Students

Preschool

L79

L32

Pensioners

Widows

Census: June 2010

HIO provides services to beneficiaries all over Egypt from Alexandria to Aswan

HIO Owns:

37 hospitals

600 clinics

78 work related injury centers

34 general medical committees

Thousands of school clinics

Outsourcing: (640 hospitals – 1141out-patient clinics)

Main problems facing current HIO

Near one half of population has no health insurance coverage

Different laws & systems dealing with beneficiaries “The more laws the less justice”, Marcus Tullius Cicero

Unrealistic rates of premium that have been fixed and unchanged since 1964 (financial sustainability is at risk)

HIO is the payer and service provider

Health insurance reform in Egypt

Aiming at:

Universal coverage

Sustainable financing resources

High level quality health care

Unifying the laws

Payer/provider split

HIO will be EXCLUSIVELY a payer

HIO will no longer operate hospitals or clinics

HIO will contract with health care facilities to provide care to HIO beneficiaries

HIO must ensure compliance with contract requirements and accreditation standards relating to quality and safety

In the near future …

Being the payer, HIO must ensure that the care for which it pays for is: Medically Necessary Appropriate (means that the treatment proposed is the one most

likely to be effective for the patient’s condition)

of High Quality

Provided Efficiently

Safe

In the near future …

To ensure those dimensions of care, HIO must have: A Medical Management Process

Medical Auditing

Utilization and Case Management

In the near future …

Utilization management: Definition

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:

Admission

Treatment and investigations

Length of stay Discharge (criteria – needs)

Prospective Approach (pre-certification – pre-authorization)

Concurrent Approach (assignment and tracking of length of stay – information gathering – hospital rounding – discharge planning)

Retrospective Approach (claims review – pattern review)

Utilization management: Approaches

Case management: Meet the patient’s health needs efficiently

Concurrent Review, during hospital stay

Is a collaborative and communicative process of the assessment, planning, and facilitation of the services by assessing: Any delays in treatment, investigations, or consultation Length of stay (LOS) Discharge needs Discharge criteria

Special case management

Comprehensive contact with patient and family during and after hospitalization

To optimize care for HIO members with complex or chronic medical needs

Intent is to reduce frequency of hospitalization or emergency room visits

Primarily a financial tool

Supports quality care

Unnecessary admissions or procedures places patients at risk

Helps identify complications and adverse outcomes

Why utilization and case management?

Why utilization and case management?

Reduces financial risk of inappropriate use of services (excessive LOS – delayed investigations – delayed consultation)

Most important to the risk-bearing entity (HIO or hospitals)

1. Critical to the hospital if they receive “Package Price”

2. Critical to HIO for those cases when they pay “Fee for Service”

Utilization and case management training

Classroom sessions Introductory course on Utilization Management (UM) and Case

Management (CM) (1 day) Theoretical and hands-on medical records training (3 days)

Practical training in hospitals Demonstration by expert – participants are observers (3 days) Participants conduct the process – expert observing them (3 days)

Final written exam

Certification Utilization and case managers (57 of 61)

Outcome of UM/CM in Gharbia governorate: 36% decline in spending on medications

Medications

5095462

79006737665693

6030132

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

9000000

2006-2007 2007-2008 2008-2009 2009-2010

Established protocols & guidelines for the top diagnoses & procedures.Concurrent review.

EgyptianPounds

Outcome of UM/CM in Gharbia governorate:24% decline in payments to hospitals contracted by HIO

Outsourcing

72342236

95517251

50395869

80649089

0

20000000

40000000

60000000

80000000

100000000

120000000

2006-2007 2007-2008 2008-2009 2009-2010

EgyptianPounds

1. Precertification2. Preauthorization3. Case Management Office4. Structured retrospective utilization review of claims & medical records.

Conclusion

UM/CM program is a critical and necessary system for the HIO

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

Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health

Thank you

www.HealthSystems2020.org