JLN PPM/IT Collaborative on Claims Analytics for Monitoring Provider Payment Systems

Transcription

1 JLN PPM/IT Collaborative on Claims Analytics for Monitoring Provider Payment Systems vision? Develop capacity around data analytics using provider payment key performance indicators that national health leaders need to readily measure the effects of their provider payment systems on health system goals. situation? Several JLN member countries are either in the midst of or planning provider payment reform pilots or major national efforts, including Ghana, Indonesia, and Vietnam. Other countries are implementing ongoing provider payment policy refinements, including Kenya, Malaysia, India, and the Philippines. Given the powerful effects provider financial incentives have on resource allocation and all UHC outcomes, key performance indicators to measure and monitor quality and effectiveness and to detect unintended consequences of payment systems are critical. Policymakers and purchasing managers also face questions and have concerns about fraud, usage, and abuse of current payment systems by providers. All of the countries are seeking to put in place appropriate monitoring and evaluation systems, but M&E for provider payment is rarely adequate in practice, and there is very little guidance available from international experience. Although the health sector generates a wealth of data from claims, routine statistics, etc., this data is rarely stored, mined and analyzed to improve daily system operations or fully exploited for secondary purposes such as monitoring provider payment systems. Globally, countries are looking for business management tools to pull the data from their systems and manage the performance and sustainability of their healthcare systems. Yet today, few data warehouse and analytics systems have been deployed to automatically generate easily digestible data, such as dashboards. Some of the reasons that routine data are not fully exploited are that the most useful variables to monitor are not known, claims data is rarely automated, and data reporting is incomplete. Also, within a country, the information systems may not be interoperable between providers of health services and the purchasers. proposed solution? The IT and PPM initiatives of the Joint Learning Network propose to convene a collaborative of JLN countries to develop the guidelines and framework for building claims data analytics capacity. The collaborative will use the example of provider payment M&E as the use case for claims analytics. Vietnam and Ghana are at critical points of provider payment reform focusing on capitation and have identified an urgent need for establishing rapid response monitoring tools and early warning systems. In-depth work with these countries through the JLN IT and PPM initiatives will be used to generate experience to inform and guide the JLNwide collaborative process. 1 P a g e

2 Why focus on provider payment? The relationship between purchasers and providers which services providers agree to deliver, how these services are paid for, and what information is reported--ultimately determines the services patients receive, the quality of those services, and the overall financial sustainability of the system. The way healthcare providers are paid for the services they deliver is the fundamental lever guiding how funds are used in insurance and other health purchasing systems. JLN countries identified provider payment as one of the top technical challenges they face in achieving and sustaining universal health coverage within limited resources. Providers respond to payment methodologies in a number of different ways, some of which can have negative consequences on the quality of services and financial sustainability of the system delivering too many or too few services, inappropriately referring patients, or falsifying claims. Analyzing claims data to gain a better understanding of how providers are responding to payment methodologies will provide intelligence to the purchaser on the single most important factor in the operations and solvency of the system, as well as the quality and efficiency of services delivered to the covered population. proposed scope of work? The specific work in Ghana and Vietnam will support the development of a claims analytics framework with clearly outlined steps that will meet the specific objectives of each country, but also that any country could adopt to develop data analytics capacity, using specific examples from provider payment. Specific steps in the framework will include: - Prioritize questions: Outline the types of questions that the purchaser needs answered and how to prioritize them - Identify indicators and data sources : o Identify the specific indicators that can help answer the questions o Break the indicators down into data elements o Identify data sources and any potential issues with data availability and accuracy o Prioritize indicators if necessary based on importance/value (high, medium, low) and ease of generating (easy, medium, hard) - Guidance on creating a reporting and analytics infrastructure o Outline the steps needed to pull the information systems together into a format that can be analyzed o Consider data cleanliness issues and potential solutions or work-arounds o Consideration of infrastructure for reporting databases and data warehouses, and the evaluation of commercially available software for analysis and reporting o Consideration of organizational requirements, capacity, roles, and structure for reporting and analytics including training and skillset requirements for end users - Define the provider payment monitoring output format (i.e. reports, dashboards, etc). o Define how the indicators will be reported on and what formats would be required o Identify how results will be interpreted through consensus-building and used for action 2 P a g e

3 - Develop a Claims Analytics for Monitoring Provider Payment Implementations guidance and tool-kit o Document guidance and learnings that will be relevant to any country developing data analytics capabilities, which may be applied to other indicators and other data sources o Use Ghana and Vietnam experience as case studies for the guide The framework will be implemented in Ghana for capitation monitoring to pilot test and refine the steps for a generalizable tool to bring to the JLN M&E Collaborative. specific use case? What outcomes will result from funding this effort? The specific case that will be used to build and test the claims analytics framework will be monitoring the effects of capitation in Ghana and Vietnam. It is anticipated, however, that the framework will be generalizable to other countries, other data sources, and other provider payment systems. Capitation pays providers a fixed amount to cover all agreed services for each registered person over a specific period of time. Ghana has been piloting capitation in one region since 2012 and is now rolling out the payment system to three additional regions. Vietnam also has been piloting capitation for several years and has just begun a pilot in three provinces of an updated version of the capitation model. Capitation has the potential advantage of supporting cost containment for the purchaser, offering some guaranteed income and simplified claims reporting for providers, and allowing more flexible and responsive services for patients. But capitation can also create some negative consequences. Once providers have their guaranteed income, they may underprovide services or be more likely to refer patients for services that they have already been paid to provide. Also, because capitation payment is not tied to claims, the purchaser needs to identify some key information that still must be reported by providers as a condition of payment in order to monitor service provision. The purchasers and policymakers in both Ghana and Vietnam need to identify the key questions and generate the supporting data to get routine intelligence on the effects of capitation to inform adjustments to their models and to serve as an early warning system for potential negative consequences. The following outcomes will result from the Collaborative Meeting and Demonstrations in Ghana and Vietnam: 1. JLN countries will develop and document a framework including a set of questions and indicators that matter for provider payment monitoring. 2. Countries will be able to collect a prioritized set of indicators, and be able to access/use them to improve their own provider payment systems. 3. Countries will be able to identify their available data sources. 4. Countries will develop a set of joint functional requirements that drive their reporting and analytic software solutions. 5. Countries will understand how to create a reporting and analytics infrastructure and which commercial choices for software tools could most easily be adapted to meet their needs. 3 P a g e

4 6. JLN countries will contribute to the global evidence base on the experience with different payment systems, the impacts on service delivery, resource use, and financial sustainability of health systems What principles guide this scope? The proposed approach was developed based on the following tenets: 1. Framework that will both meet specific country needs and contribute to the global knowledge base. 2. Focus on capacity to understand what information systems exist 1 and could be used. This activity is focused squarely on improving the ability of national and global level health personnel to articulate what they need for reporting and analytics capabilities from existing information systems and plan for that capability considering the connections between all levels of data flows (i.e. facility, district, province, national & global). If data requirements are identified that are not available in current information systems, those can be documented and used to inform future requirements. 3. Building a replicable process that is tested for one use case but is not a study or oneoff monitoring/evaluation report 4. Collaborative process to share and synthesize experience across countries 5. Hands on approach What are the specific activities? 1. Develop a draft framework with steps for prioritizing questions, identifying and linking data sources, developing analytical programs and reports, and using actionable information. 2. Support Ghana and Vietnam to test the draft framework to learn what works/doesn t work. 3. Share draft framework for feedback with selected provider payment and IT technical track members who are working on similar challenges for input. 4. Document with Ghanaian and Vietnamese authors the lessons learned. 5. Create guidance on how to create and support a reporting and analytics infrastructure. 6. Research what claims analytic software tools are being used and collect 4-5 that can be considered as options by countries. 7. Convene interested subset of JLN countries in November for a joint PPM/IT track collaborative meeting. 1 The focus here will be a quick methodology for countries to map their existing information systems and what works/doesn t work. This work has been completed at the global level under the landscape analysis. 4 P a g e

5 Work with countries during the meeting to identify what parts of the framework are country-specific and what parts of the framework can be adapted to be common and used by many. Get specific feedback on the draft framework and also what analytic software tools are being used by each of them. 8. Support other JLN countries remotely to implement parts of the framework. 9. Document specific examples from other countries. 10. Pull together and package the framework into a tools booklet. Format will be loosely modeled on PATH s how to plan an ICT booklet as common model. What is done by when? June July 2014 Work with colleagues in Ghana and Vietnam to develop draft framework and steps July October 2014 Nov 2014 Jan 2015 Jan December 2015 March 2016 Implement the framework in Ghana and Vietnam Research claims analytic software tools being used and collect 4-5 that can be considered as options by countries Collect information from other JLN countries about experience and approaches to using data analytics to monitor provider payment policy implementation Synthesize experience in Ghana and Vietnam Convene JLN PPM/IT Collaborative Meeting Support other JLN countries remotely to implement parts of the framework. Document specific examples from other countries Convene collaborative meetings to develop tools booklet Finalize tools booklet. Final dissemination meeting Who are the critical parters and what are the proposed roles of each? R4D s role PATH/PharmAccess s role As the technical facilitator of the JLN PPM technical initiative, R4D will provide technical support to frame the provider payment policy issues and identify appropriate indicators, analytical reports and use strategies. As the technical facilitators for the JLN IT technical initiative, PATH and PharmAccess will provide support to break down indicators into the data elements required and source systems, outline the specific steps on the ICT side to create and support a reporting 5 P a g e

6 and analytics infrastructure, and analyze existing software solutions typically used for claims data analytics and visualization. Vietnam/HSPI s role as M&E Collaborative Coordinator Ghana and Vietnam s role as country learning laboratories Vietnam s Health Strategy and Policy Institute (HSPI) has funding from the Rockefeller Foundation to provide coordination for a JLN Collaborative on M&E of Provider Payment Systems. In that role, HSPI will provide overall coordination for the network-wide part of this activity, which will include: Identifying the JLN country participants in the Collaborative and establishing routine communication with the group Contributing to further developing the vision and workplan for this activity Coordinating the process of gathering country input on the framework Providing support to synthesize the experience from Vietnam and Ghana Convening and managing the in-person Collaborative meetings HSPI will receive direct support from the R4D technical facilitators to carry out this role, with the secondment of Kyle Beaulieu for the first 6 months (through the first network-wide meeting of the Collaborative). Convene the appropriate stakeholders to guide the process of prioritizing key questions, identifying data sources, implementing the ICT steps in the framework, and producing the dashboard of actionable information for monitoring the results of capitation. What resources do we have and what resources do we need? Rockefeller Foundation grants to PATH/PharmAccess and R4D to facilitate the JLN IT and PPM initiatives will provide financing for the core support to develop the framework. Complementary resources from USAID will support the test of the framework in Ghana and developing dashboards, and complementary resources from Rockefeller Foundation in a grant to the HSPI will support the HSPI in the role of Collaborative Coordinator and for the test of the framework in Vietnam. Suggested Next Steps Establish M&E Collaborative o Review and finalize concept note with Vietnam HSPI and Ghana NHIA o Circulate this concept note to the IT and PPM TCTs o Technical facilitators work with JLN countries to identify appropriate representatives for the collaborative (maximum of 2-3 per country) Initiate country tests 6 P a g e

7 o o o JLN IT and PPM tracks confirm with HSPI and Ghana NHIA their interest in participating in the Collaborative as country learning laboratories Each country forms a working group that will carry out the process of adapting and testing the framework in-country JLN IT and PPM tracks make initial visits to Ghana and Vietnam to develop workplan and initiate the activity 7 P a g e

8 Appendix I. Relationship between Country-Specific Activities and the JLN PPM/IT Collaborative on Data Analytics for Monitoring Provider Payment Policy Implementation Coordination between Ghana Monitoring and IT activities and the JLN PPM/IT Collaborative Ghana: Generating evidence for health purchasing HFG: Executive dashboard NHIA: Corporate-wide M&E system Introduction of Sharepoint platform for dashboard Country-specific dashboards and rapid response monitoring systems for capitation pilot in Ghana and Vietnam JLN PPM/IT Initiative: Collaborative on claims analytics for monitoring provider payment policy implementation Process: workshop, expert guidance, countries share experience on developing data analytics capabilities and using claims analytics for monitoring provider payment policy Product: guidance kit on claims analytics for provider payment policy drawing on Ghana and Vietnam experience 8 P a g e

9 Coordination between Vietnam Monitoring and IT activities and the JLN PPM/IT Collaborative Vietnam: M&E of the Capitation Pilot JLN PPM/IT Initiative: Collaborative on claims analytics for monitoring provider payment policy HSPI M&E framework and indicators HFG: Support for IT system development Country-specific dashboards and rapid response monitoring systems for capitation pilot in Ghana and Vietnam Process: workshop, expert guidance, countries share experience on developing data analytics capabilities and using claims analytics for monitoring provider payment policy Product: guidance kit on claims analytics for provider payment policy drawing on Ghana and Vietnam experience 9 P a g e