Vladimir Zelensky Director, Moscow State Health Insurance Fund IT tools supporting transition of Moscow public health care to value-based model Vladimir Zelensky Director, Moscow State Health Insurance Fund

Moscow Health Care Landscape Mandatory State Health Insurance (MSHI) covers 95% of medical services Moscow State Health Insurance Fund (MSHIF) is the payer for all medical services included in MSHI for providers located in Moscow Annually: > 9 mln patients receiving health services > 500 mln outpatient services through 350 providers > 2 mln inpatient services through 100 hospitals > 4 mln emergency ambulance services

Fragmentation leads to waste Two payment models are used: Capitation for outpatient services DRG-like for inpatient services Lack of coordination between healthcare providers and different payment models result in lack of quality, waste of resources and difficulties in care control

Combined efforts are the only way Well-informed patients choose quality Providers push high-outcomes through competition Payer maintains supervision and assistance to both patients and providers Value-based healthcare Patients Payer (MSHIF) Providers

Creating patient—centered model From 2015 MSHIF provided free access for all patients in Moscow to data about their clinical encounters which they can evaluate (PANDORA project) Additional free services – e-pillbox with drug-checking options Mid 2018 – MSHIF will provide patients with a unified messenger for interacting with physicians Value-based healthcare Patients Payer (MSHIF) Providers

Motivation for healthcare providers In 2018 MSHIF introduced bundle payment for health services regarding pregnancy and delivery Bundle includes both inpatient and outpatient services with a fixed price Main conditions to receive a bundle: Following a certain patient pathway (incl screening tests and pregnancy monitoring) All health services in one healthcare unit (building a center of responsibility) Value-based healthcare Patients Payer (MSHIF) Providers

Global payer supervision MSHIF moving from collection of monthly claims to utilization of clinical data We use SAS Episode Analytics for grouping individual encounters into episodes of care and identifying services related to potentially preventable complications Automated Care Quality Control System powered by FairIsaac software is used for identification of suspicious claims and targeting audit procedures Value-based healthcare Patients Payer (MSHIF) Providers

Changing the way of thinking IT-systems and alternative payment models are just an instrument Patients, providers and payers are partners and not enemies Quality control, provider competition and patient-engagement result in high outcomes

Thank you! Vladimir Zelensky Director, Moscow State Health Insurance Fund ZELENSKY@MGFOMS.RU