Risk management and implementation of a decision-support system for medical controls A case of the National Health Insurance Fund

Transcription

1 Good Practices in Social Security Good practice in operation since: 2014 Risk management and implementation of a decision-support system for medical controls A case of the National Health Insurance Fund National Health Insurance Fund Tunisia Published

2 1 Summary The objectives of the National Health Insurance Fund (Caisse nationale d'assurance sociale (CNAM)) are expenditure control and improving the quality of care. Electronic transmission requirements and medical control prerogatives have made it necessary for the CNAM to invest in the automated processing of medical claim forms. The main objective is the establishment of a decision-support system with a medical knowledge base which would take into account the specificities of each medical claim form. The other objective of this project is to contribute the rationalization of medical prescriptions by tracking the behavior of health professionals and any deviations from predetermined benchmarks as well as identifying professionals with atypical activity. By August 2014, 3,969,641 medical claim forms and 18,287,639 records had been processed using this system. A definitive assessment was made in 85% of the cases and 2,804,737 (15%) cases underwent medical controls. In the second phase, this system will be applied to other benefits. CRITERIA 1 What was the issue/problem/challenge addressed by your good practice? The laws governing health insurance stipulate that the CNAM must have the means of controlling all its operations and the technical means for rationalizing benefit delivery. Risk management, through the monitoring of medical costs, must be an integral part of the medical control process. The implementation of a support system for medical decisions appears indispensable if risks are to be limited. There are several reasons for the implementation of a support-system for medical decisions. 1. The attributions of medical controls Under Decree No of 21 November 2005, the prerogatives of medical control encourage a modification of methods of control used by advising physicians, especially as individual benefit control, although useful in some respects, has its limitations due to increasing numbers of requests for care which monopolize most of the advising physicians' time. 2. Requirements for electronic data transfer

3 2 The CNAM tends to promote automatic processing of medical claim forms. In fact, the CNAM master plan opts for paperless medical claim forms and automatic data transfer. 3. Time management The CNAM is obliged to comply with sectorial agreements and national standards for medical claim form payment terms. 4. Quality of medical decisions Medical control cannot be exercised without up-to-date scientific knowledge. Therefore, decision-support tools based on validated and conclusive data must be made available to advising physicians. 5. The fight against prescription misuse and mistakes The CNAM is committed to improving the quality of care. However the sizeable cost of prescriptions engender mistakes and cost slippage. The decision support system can be an effective tool for preventing risks associated both with the prescription of nomenclature procedures and drug prescription. CRITERIA 2 What were the main objectives and the expected outcomes? The main objective of computerization of medical claim form processing is to implement a decision-support system with a medical knowledge base which allows the specificities of each medical claim form to be taken into account. The system must promote: an improvement in medical control productivity; compliance with quality requirements of control activity; optimization of medical controls. The other objective of this project is to contribute to prescription rationalization by tracking the behavior of health professionals and deviation from predetermined standards. The system should identify professionals with atypical activity and select them on the basis of defined criteria.

4 3 CRITERIA 3 What is the innovative approach/strategy followed to achieve the objectives? The system consists of an all-encompassing medical knowledge base (indications, contraindications, dosages, adverse effects for example). It integrates all the information from processed claims upstream and effects a data control of medical benchmarks, of patient history (beneficiary form) or that of the health care provider (health professionals form). This allows automatic and continuous monitoring and provides warnings which are classified according to their level of importance. Selecting parameters All prescriptions (medical claim forms, requests for prior agreement, occupational risk, social insurance for example) can be analyzed. In the case of medical claim forms, this analysis may include: costs; drug prescriptions; nomenclature procedures; health professionals; beneficiaries. The parameters can also include stakeholders in the health care system (institutions, the insured individual for example) Data sources 1. National references: Drug marketing autorisations (autorisation de mise sur le marché (AMM)) The therapeutic consensus of the Ministry of Health Publications of the Department of Basic Health Care The consensus of learned societies and medical institutions VIDAL dictionary 2. International and related references: Publications of the World Health Organization European, American and other learned medical societies Risk classification

5 4 After verification of the other parameters, the system checks the benchmark for the amount authorized to be paid automatically for each medical claim form without medical controls. 1. Price-related risks The amount is calculated for each item of expenditure (Medical conditions which are fully covered, ordinary diseases, occupational accidents and diseases). It concerns: total daily cost of the medical claim form; daily cost of the prescription; monthly B threshold for laboratory tests; daily cost of the prescription; Z threshold for radiological examinations. 2. Beneficiary-related risks For policyholders with a history of misuse or fraud, the doctor must monitor their claims or sick leave requests carefully. Their requests for reimbursement may be monitored systematically even if they are within the other medical parameters. 3. Prescriber-related risks Requests from health professionals who have a history of misuse or fraud will be systematically examined by medical control. 4. Consultation-related risks To combat nomadism and redundancies. 5. Drug-prescription risks: Pharmaceutical analysis. This analysis focuses on: o dosage o drug interactions o drug redundancy o contra-indications o treatment duration o compliance with standards Prior agreement Specific regulations control Maximum and usual doses control Maximum and usual duration of treatment control Therapeutic duplication detection 1. Nomenclature procedure prescription related risks:

6 5 Prior agreement Maximum number of codes Medical Indication Redundancy of procedures Deadlines between two procedures Warnings typology Proposed warnings are classified into three categories: 1. Warning to facilitate medical claim form payment. 2. Blocking warnings: The occurrence of a warning of this type requires that the advising physician monitor all documents. 3. Quality alerts: This type of warning does not block the payment but requires subsequent controls. CRITERIA 4 Have the resources and inputs been used in an optimal way to achieve the set objectives and the expected outcomes? Please specify what internal or external evaluations of the practice have taken place and what impact/results have been identified/achieved so far. Working groups were formed and trained by experts before implementation. The areas of research are: medication; laboratory testing; radiological exams; functional rehabilitation and physiotherapy; short-term illness; occupational accidents.

7 6 A computer engineer created and fed the knowledge base and set up the interface required for management.. Currently, all medical claim forms related to serious and long-term diseases are processed using this new system. By August 2014, the figures were: Number of medical claim forms: Number of records: Number of decision made by the system: 15,482,902 (85%) Number of records that require medical advice: 2,804,737 (15%) We anticipate that the system will be used for benefits including functional rehabilitation and occupational accidents. CRITERIA 5 What lessons have been learned? To what extent would your good practice be appropriate for replication by other social security institutions? The system proposed here can improve the security of medical claim form processing and therefore can combat prescription misuse and the reimbursement of services which are not medically justified. The current trend in the development of electronic data transmission must be accompanied by medical control updates to adapt to new requirements. We believe that this system could be beneficial to health insurance funds.