Clalit Health Services

Transcription

1 TPG International Health Academy (TPG-IHA) Israel CEO Trade/Study Mission March 2014 Clalit Health Services Haim Bitterman MD Chief Physician

2 The idea to establish a mutual aid healthcare organization was the result of a work accident in which a laborer named Baruch Priver lost an arm while working in an orchard Prof. Shifra Shvartz

3 Labor Federation of Agricultural Workers in Judea established the first health plan (later known as Clalit ) to provide care to workers and their families and to employ immigrant doctors.

4 1931- Amamit health fund established by Hadassa and the Farmers Association Leumit health fund established by the Revisionist Movement General Zionists fund established by the General Zionists movement Maccabi health fund is established Meuhedet health fund established by the consolidation of Amamit and the General Zionists

5 The Knesset passed the NHI Law in June 1994 and it came into effect in January 1995 Key components: Universal coverage. Defined package of benefits to ensure access to needed services and to clarify the obligations of the health plans to their members. The institution of a capitation formula to ensure that the health plans have incentives to compete for elderly and poor people A commitment to monitor the Law s impact sets aside 0.1% of the health tax for relevant research coordinated by the NIHP. Responsibility for psychiatric, geriatric and preventive care is transferred to the health plans during a 3-year transition period, ending on 1 January 1998.

6 Key components: Universal coverage Defined package of benefits to ensure access to needed services and to clarify the obligations of the health plans to their members The institution of a capitation formula to ensure that the health plans have incentives to compete for elderly and poor people A commitment to monitor the Law s impact sets aside 0.1% of the health tax for relevant research coordinated by the NIHP Responsibility for psychiatric, geriatric and preventive care will be transferred to the health plans during a 3-year transition period, ending on 1 January 1998

7 Collection of progressive premiums by the NII rather than by health funds The requirement that health plans must accept all applicants, together with the capitation formula, is meant to eliminate or drastically reduce cream-skimming A Government s commitment to fund health services at a level reflecting the cost of the benefits package; this provision is meant to ensure the financial stability of the health care system

8 National health insurance (NHI) system that provides a broad benefits package to the population Free choice among four competing, non-profit-making health plans that receive NHI funds from the Government according to a capitation formula The health plans must provide their members with access to a benefits package that is specified within the NHI Law The system is financed primarily from public sources via payroll and general tax revenues

9 In addition to its regulatory, planning and policy-making roles, the Ministry of Health also owns and operates about half of the nation s acute care hospital beds The largest health plan (Clalit) operates another third of the beds, and the remainder are operated by means of a mix of non-profit making and profit-making organizations The Ministry of Finance has multiple points of significant influence over Israeli health care The NHI system is financed primarily from public sources a mixed system of payroll tax and general tax revenue

10 Healthcare in Israel Population: ~8 Million Health Insurance: Mandatory, capitation based state funding Healthcare provision: 1 of 4 sick funds (insurer/provider) Emphasis on community clinic primary care Non-for-profits 90% are happy or very happy with their health plan

11 Healthcare in Israel Low spending, good outcomes Total Expenditure on Health (% of GDP) Life expectancy Infant Mortality Rates Female Male 11

12 Healthcare in Israel Increasing demands, limited resources

13 Primary medical care: physician-led clinics which provide generalist medical care including health promotion and preventive interventions. Secondary (specialist) community-based care: specialist-based medical services working partly in the community (general internists, paediatric specialists and surgical specialists, etc.) Other community-based clinical services: a wide range of services including community mental health clinics, family health centres (Tipat Halav), emergency care centres and community pharmacy services, etc

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15 Israel has established one of the most enviable health care systems among OECD countries Primary care in Israel is welldeveloped, accessible geographically and financially, and of high quality Israel s impressive life expectancy gains and low premature mortality from chronic conditions reflect the contribution of its primary care system Low number of admissions to hospitals for uncontrolled diabetes, while reductions in complications demonstrate ongoing efforts to improve quality of care provided to patients with diabetes Published: 2012

16 Israel s community-focused information system sets an international benchmark in excellence and demonstrates commitment to quality monitoring and improvement Published: 2012

17 Israeli Health Services - Market Share % Clalit Maccabi 9% Leumit 52% Meuhedet 25%

18 Clalit Health Services: 52% Market Share (>4M members) Overrepresentation of the sick, poor and elderly ~2000 community clinics, 14 hospitals (30% of Israel s general hospital beds) Electronic information (EMRs) since 1980 s

19 The Only Health Organization in Israel that Runs its Own Public Hospitals Community outreach National centers of excellence Children s hospital Comprehensive cancer center Organ transplant center Rehabilitation centers All general hospitals are accredited by the JCI

20 Chronic diseases in Clalit s members Age 45-65, 2 Chronic diseases Age>65, >5 Chronic diseases

21 Data in Clalit Centralized Data Warehouse real-time data: Electronic information since late 1980 s Single EMR Coverage in all community clinics Inpatient and outpatient detailed data Smoking, BMI, BP measures Detailed Socio-demographic data Labs, Pharmacies, Imaging Full data on Costs >100 chronic disease registries

22 Data in Clalit Centralized Data Warehouse real-time data: Electronic information since late 1980 s Single EMR Coverage in all community clinics Inpatient and outpatient detailed data Smoking, BMI, BP measures Detailed Socio-demographic data Labs, Pharmacies, Imaging Full data on Costs >100 chronic disease registries Decades of full life-span, ID-tagged, Geo-coded, EMR-based data on > 4M people

23 Number of Quality Indicators 80 Essential Indicators Optional Indicators

24 Relative weights of Quality Indicators Preventive Medicine 29% CHF 8% Diabetes 28% Other Chronic Conditions 19% Hyperlipidemia 6% Subspecialties 12% Elderly 2% Pediatrics 10% Asthma 2% Hypertention 3%

25 Quality indicators (2013) Health promotion Cancer Children and adolescents Elderly Asthma Cardiovascular health Diabetes BMI Smoking cessation Breast cancer screening Colon cancer screening Anemia screening (infants) Weight and height documentation Influenza vaccination (seasonal) Pneumoc. vaccination Secondary prevention Appropriate use of control medication Influenza vaccination (seasonal) Primary prevention Cholesterol assessment Blood pressure documentation Secondary prevention LDL modifier use Effectiveness of care Cholesterol control Secondary prevention Cholesterol documentation Blood pressure documentation BMI Blood glucose documentation Eye exam Kidney care Influenza vaccination (seasonal) Pneumococcal vaccination Effectiveness of care Cholesterol control Blood glucose control Blood pressure control

26 BINA Quality Indicator Results Knowledge management link

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28 BINA Patient Focused List Knowledge management link

29 Diabetes care

30 Hospitals - Internal Medicine Data source WT Target Indicator name High is good No. Unit Self report (Sample) 4% 90% Delivering antibiotics 6 hours after admission in the ER Yes 1 Self report (Sample) 1% 90% Recommendations at discharge for ACE or ARB after MI Yes 2 Self report (Sample) 1% 90% Recommendations at discharge for Statins after MI Yes 3 Internal Self report (Sample) 4% 90% Recommendations at discharge for Aspirin after MI Yes 4 Operational Systems Operational Systems 2% 20% Planned discharge to the community for the relevant population Yes 5 6% 85% Performing PCI within 90 Yes 6 Cardiology minutes after admission in the ER with diagnosis of MI 18% Total

31 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 PCI within 90 minutes

32 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hip fracture Operation within 48 hours

33 Gynecology Glucose tolerance test during pregnancy 90% 87.3% 84.0% 85.4% 85.5% 87.4% 80% 70% 73.3% 73.5% 67.0% 60% 50% A B C D E F G H

34 Gastroenterology Colonoscopy in patients with family history of colorectal cancer 60% 55% 53.1% 55.9% 53.6% 55.3% 53.6% 50% 45% 49.7% 47.7% 47.1% 40% A B C D E F G H

35 Continuity of Care Planned Hospital Discharge program Home Treatment multidisciplinary teams OFEK system Hospital-Community IT crosswalk South District - Experimental unified governance

36 Continuity of Care in Oncology Time from Breast Cancer Diagnosis to Initiation of Curative Therapy as a Quality Indicator Primary Diagnosis Imaging Physical examination Confirmation Biopsy Curative Therapy Radiotherapy Chemotherapy Hormonal Treatment

37 Continuity of Care in Oncology Findings )30,45,60 Days) 80% 60% 40% 66.3% 58.9% 48.4% 61.8% 54.0% 42.9% 69.6% 59.9% 47.7% 63.1% 53.2% 40.4% 20% 0% 2008_1 (N=1,096) 2008_2 (N=1,111) 2009_1 (N=1,105) 2009_2 (N=1,236)

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39 The Israeli National Health Insurance Law The law defines a basic basket of health services to be supplied by the health plans (National List of Health Services- NLHS) The health plans are required to supply all the services in the NLHS, within reasonable time and distance from the insured persons homes

40 The National List of Health Services Prior to the enactment of National Health Insurance Law, each health plan determined its own basket of health services individually With the implementation of the NHIL, all separate mechanisms for determining the health plans' basket of services were replaced by the uniform NLHS

41 The National List of Health Services In setting the initial NLHS in 1995, the NHIL adopted the official list of Clalit Health Services. In order to maintain an acceptable quality of care, it is necessary to update the NLHS according to technological progress The law mentions that expanding the NLHS beyond the basic list depends on allocation of special funds for this purpose

42 The Public National Advisory Committee (PNAC) Towards the end of 1998, following the governmental recognition of the need for regular annual updates of the NLHS, the Ministry of Health decided to establish a formal priority-setting process for the addition of new technologies to the NLHS This process is based on two main elements: A Health Technology Assessment (HTA) process in which each candidate technology is evaluated by the MOH, A decision-making process that is undertaken by an ad-hoc Public National Advisory Committee (PNAC)

43 The PNAC includes 16 members: senior officials from the MOH, the Ministry of Finance (MOF), the four health plans and representatives of the public The PNAC is appointed by the Ministers of Health and Finance All PNAC decisions are made by way of a consensus committee, with the consent of all members

44 The annual updating process Every year, as part of the annual budgeting process, the government determines the additional budget that will be available to fund new health technologies This budget is determined by the financial ability and priorities of the government at the time of the budgetary decisions and does not consider the number, cost or need for new health technologies that year

45 Budgets Allocated for Updating the NLHS from 1995 to 2012 (Million NISs)

46 The annual updating budget The total Cost of NHI basket (2012): billion NIS Pharmaceuticals and health care supplies: 7.8 billion NIS (20%) In : Annual updating budget remains constant: 300 million NIS ( $85 million)

47 The Process of Updating the Israeli National List of Health Services Each NLHS updating cycle starts with a call for proposals for new medical technologies published at the beginning of the calendar year by the Director General of the Ministry of Health Applications to fund new technologies are accepted from the pharmaceutical and medical device companies, health plans, patient s societies, and individuals (usually physicians), with the vast majority of technologies being proposed by the industry Every year, the MOH receives hundreds of requests to include new technologies in the NLHS at an estimated total cost of 1-2 billion NIS

48 The technology sponsors are required by the MOH to submit a formal dossier providing details mainly on: The efficacy of the proposed technology, Its advantage over existing technologies already included in the NLHS The projected annual budget needed to fund it

49 The General Outline of Updating the NLHS Process January Call for proposals for new technologies March Technology applications accepted + rapid assessment by the MOH April- September Comprehensive HTA evaluation by the MOH June-December The PNAC sub-committee gathers to determine technologies' budget-impact October-December Priority setting deliberations of the PNAC

50 The PNAC s discussions The PNAC's first round of prioritization decisions are based only on the clinical information provided for each technology At this stage the committee members are not exposed to economic data and prices Only at an advanced stage of the final deliberations, the committee is presented with the economic and pricing data, and then finalizes the prioritization of the technologies to fit into the pre-defined allocated budget

51 In Israel: An unmet need + a proven significant clinical benefit + a reasonable budget-impact >> incremental cost-effectiveness threshold

52 At the end of the PNAC's deliberations, the committee's recommendations are brought to approval by the Israeli government Following the governmental approval of the PNAC prioritized list, the health plans are required by law to supply the entire demand for the approved technologies, in accordance with the indications and criteria by which the technologies were added to the NLHS Rate of adoption of new drugs in the NLHS by physicians & patients: very fast in oncology: immediate.

53 uniqueness of the Israeli updating process In most western countries, each technology is considered for reimbursement by itself, while in Israel, all technologies are assessed simultaneously and compete with each other for inclusion in the NLHS according to the budget that was preallocated for this purpose.

54 NLHS 2014 update Allocated budget: 300 million NIS Oncology+ Hemato-oncology: 42% Fast & Early adopters! Brentuximab (Adcetris )- Hodgkin s lymphoma Ibrutinib (Imbruvica )- Mantle cell lymphoma Carfilzomob (Kyprolis ), Pomalidomide (Pomalyst)- MM Afatinib (Giotrif )- NSCLC Trastuzumab-emtansine (Kadcyla )- HER2+ Metastatic BC Abiraterone (Zytiga ), Alpharadine (Xofigo )- Prostate cancer Dabrafenib (Tafinlar )- Melanoma

55 Online care Personal Health Record & Personal Services Lab work results Lab work scheduling Medical scheduling (MDs, RNs) Requests for test referrals Prescription renewal Medication history Hypersensitivities Diagnoses Hospital & ER discharge letters Billing Tele-Medicine (synchronous & a-synchronous) Preventive medicine recommendations & reminders

56 Personal Health Record & Personal Services 3.5 million scheduling uses 4 million lab work uses (referrals 12.5% & results 87.5%) 710 K preventive medicine uses 220 K online sick-leave certificate uses *one unique evisit normally includes several different uses

57 Personal Health Record & Personal Services 5 million annual uses Mobile app (180 K+ downloads) Pregnancy management apps (mobile only) Child development screening (mobile only) Mobile web-based responsive escheduling Mobile map-based search engine

58 Resurrecting the Doctor s Home Visit 100 K+ annual tele-consultations 36% of use video, mostly on smartphone 98% patient s approval rating 78% of consultations dealt with online without the need for further ER or clinic visits

59 Thank you!