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 Universitys School of Public Health The Health Insurance Organization of Egypt Utilization and Case Management Thomas Schwark, Abt Associates, Inc. Mohsen George, Chief Medical Officer, HIO, Egypt Global 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 20 th century

Total Number of Beneficiaries (in thousands) 56% 8.3% 0.5%

Number of beneficiaries (in millions) Census: June 2010

Percentage of beneficiaries according to LAWS 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 patients 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 patients 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 f inancial tool Supports quality care Unnecessary admissions or procedures places patients at risk Helps identify complications and adverse outcomes 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 Established protocols & guidelines for the top diagnoses & procedures. Concurrent review. Egyptian Pounds

Outcome of UM/CM in Gharbia governorate: 24% decline in payments to hospitals contracted by HIO Egyptian Pounds 1.Precertification 2.Preauthorization 3.Case Management Office 4.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 Universitys School of Public Health Thank you