so cia l h e a l t h in su r a n c e

r epo r t s o n t h e c l inic a l p r a c t i c e g uid e l i n e s (c p g) o p t io n s a n d p r o t o c o l s

d e l iv e r a b l e n o. 8

This report was made possible through support provided by the U. S. Agency for International Development, under the terms of Contract No. HRN-I-00-98-00033-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U. S. Agency for International Development.

CONTENTS

I Focus Group Discussion Protocol (Revised, April 2002) Key Informant Interview Protocol (Revised) II Suggested Amendments to the Proposal in Response to a Request for Short-Term Technical Assistance on Strategic Options for the Use of Clinical Practice Guidelines (CPGs) for the Philippine Health Insurance Corporation (PhilHealth) (Musts and Wants to Evaluate CPG Options and Protocols)

I
Strategic Options for the Use of Clinical Practice Guidelines (CPGs) for the Philippine Health Insurance Corporation (PhilHealth)
Focus Group Discussion Protocol (Revised, April 2002) 1. Introduction

Two factors that have been identified to contribute to the intensive research and policy activity on Clinical Practice Guidelines (CPGs) in the United States are the wide variations noted in the treatment of certain common diseases among physicians as well as an interest among insurers and payers to implement guidelines that improve patient outcomes while controlling the costs of health care delivery. CPGs are developed by health professionals of a particular specialty society to which a particular disease state is commonly diagnosed. There have been varied experiences in the United States on the use of these guidelines among insurers and health maintenance organizations. Guidelines are widely accepted to contribute to improved care if they succeed in moving actual practice closer to the behaviors in the guidelines recommended. In addition, practice guidelines also have the potential to reduce the number of malpractice cases and the costs of settling them. Although in the Philippines, medical malpractice is not yet a common occurrence. The limited studies that have been done in the US and Europe point to varying results in relation to the effectives of the use of CPGs for cost control and improvement of care. Most of these studies however articulate certain necessary requirements in order for these guidelines to achieve its objectives of economic efficiency and improvement of care. The question therefore arises: Will the physicians, who are seen to be the primary users of CPGs, comply with proposed regulations on the use of guidelines that may be required by private and public insurers of medical care? 2. Objectives: a. b. To determine physicians readiness and willingness to use CPGs in their own clinical practice in compliance of possible proposed requirements by PhilHealth; To generate suggestions on possible enabling and hindering factors to be considered in the implementation of the use of CPGs by physicians and by PhilHealth.

3.

Respondents

Two FGDs are being planned, each group consisting of eight (8) to ten (10) participants. A representative group of physicians from various specialties working largely in the public and private sector will be invited. The list of respondents will be chosen among selected members from six professional societies, namely, the Philippine Medical Association (PMA), Philippine College of Physicians (PCP), Philippine College of Surgeons (PCS), Philippine Pediatric Society (PPS), Philippine Obstetric and Gynecological Society (POGS) and the Philippine Academy of

Family Physicians (PAFP). Preferably, the chosen participants will be from among the general membership of these organizations and not from among the officers, chapter and committee heads. The reason for this is so that the sentiments, perceptions and ideas of the ordinary member would be elicited and not the leadership. Thus, findings from the FGD will be able to provide insight on an ordinary PhilHealth-accredited physicians perception and opinion will be as related to CPGs. 4. Methodology

The FGDs will be conducted after the Key Informant Interviews have been completed. In so doing, some of the date and information that will be generated by the interviews can also be validated in the FGDs. The 2 FGDs will be conducted simultaneously in one half day. Each group will have a facilitator and documentor. Discussions should not go beyond 1.5 hours to ensure that interest and participation are maintained. Prior to the actual FGD, all facilitators and documentors will be given a half day orientation to include topics such as defining CPGs, what they are commonly used for, what PhilHealth is and what its functions are, and what questions are to be asked. Basic ground rules and preliminary steps prior to the discussion proper will also be presented and agreed upon. Prior to the actual discussion, vignettes or sample cases and situations involving possible experiences that physicians may encounter in relation to possible uses of CPGs by PhilHealth will be presented. After these, the actual FGD will be started and trigger questions will then be asked by the facilitator. The FGD tool will be pilot tested with a small group (3 persons) of physicians. Documentation will be aided by the use of a cassette recorder, upon agreement of the participants. Although content of the discussion will be the main focus of documentation, some observations on process will also be made. A consolidated report for each FGD will be prepared jointly by the documentor and facilitator. 5. FGD Tool Vignette: Mang Ariel, a 38 year old machine operator consulted with Dr. Adriano, a general practitioner, for intermittent, tolerable to severe hypogastric pain, painful and frequent urination of 7 days duration. During the interview, Mang Ariel pointed out that this is the first time he experienced such symptoms. No other symptoms other than those mentioned -- no urinary discharge, no abdominal pain, no fever. He claims to be sexually active with one sexual partner his wife. Past medical history and family medical history are unremarkable. Physical examination showed normal physical findings. With a working diagnosis of Urinary Tract Infection, Dr. Adriano decided to confine Mang Ariel to the hospital and the doctor requested that a urinalysis, KUB-IVP and renal ultrasound be done. Urinalysis results showed significant pyuria (10wbc/hpf) while KUB-IVP and renal

ultrasound yielded normal results. Dr. Adrianos final diagnosis: Urinary Tract Infection, uncomplicated. Dr. Adriano then prescribed Cephalexin 500mg three times a day for 7 days and Ibuprofen 500mg once a day for pain. He likewise advised Mang Ariel to increase oral fluid intake and to practice perineal hygiene. Patient was discharged after 5 days confinement and advised to come back to the doctors clinic after a week. Questions: 1. Situationer: When Dr. Adriano inquired about his professional fees from PhilHealth for the care he rendered to Mang Ariel, he was informed by the accounting office of the hospital that PhilHealth rejected the claim and returned it to the hospital. The following are the reasons for rejection: a. Laboratory Tests requested were more than what is prescribed by the PhilHealth accredited CPG on UTI in males. b. The prescribed medicines were not the drug of choice as recommended by the CPG on UTI in males. c. The duration of stay in the hospital was more than determined average stay for an uncomplicated case of UTI. 2. 3. 4. 5. What are your thoughts and reactions on these reasons for rejection? If you were in Dr. Adrianos shoes and you are knowledgeable about the CPG even prior to treating Mang Ariel, would you still have done what he did knowing that these were beyond the guidelines? Why? Are the reasons for rejection justifiable? Why or why not? What are your thoughts about the possibility of PhilHealth adapting the CPGs in fulfilling some of their key functions like processing claims, accrediting doctors and hospitals?

The questions will not be asked by the facilitator all at once. The presentation of the various situations will be given in a staggered fashion, moving only to the next after the facilitator feels sufficiently satisfied that the discussion has exhausted the issue. All possible measures will be used to ensure a good attendance in the FGDs. However, in the event that the projected number of at least sixteen (16) participants will not be reached, efforts will be done to ensure that at least one FGD will be conducted. 6. Reference Philippine Society for Microbiology and Infectious Diseases (PSMID).The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections Volume 1 (1998).

Strategic Options for the Use of Clinical Practice Guidelines (CPGs) for the Philippine Health Insurance Corporation (PhilHealth)
Key Informant Interview Protocol (Revised) 1. Introduction

Different options on the use of CPGs by PhilHealth will only be successful in achieving its objectives if the key users of the guidelines, the physicians, will comply with the guidelines in rendering medical care to their patients. In the Philippines, physicians are considered among the most powerful and influential sector of the health care delivery system. Thus, since the physicians are important stakeholders and partners of PhilHealth, their thoughts, opinions, ideas and plans on proposed uses of CPGs to perform better the different insurance functions needs to be gathered. 2. Objectives a. b. c. To elicit from the key leaders of professional medical societies their ideas and opinions on how CPGs can be used by PhilHealth; To find out general thrusts and plans of the professional societies in relation to CPG formulation and use; To generate suggestions on possible enabling and hindering factors to be considered in the implementation of the use of CPGs by physicians and hospitals.

3.

Respondents

A total of four (4) Key Informant Interviews will be conducted. An officer of the 4 major professional medical societies, preferably the president or the head of the Quality Assurance Committee, of the Philippine Academy of Family Physicians, the Philippine College of Physicians, the Philippine College of Surgeons and the Philippine Pediatric Society. 4. Methodology

The interview tool will be pilot tested on one randomly selected officer of a professional medical society. Upon completion of the final interview form, the interviewer will then set the necessary appointments with the selected respondents. The interview will then be conducted. If the respondent agrees, the interview will be taped using a cassette recorder. Answers and notes with some observations will then be consolidated by the interviewer and submitted.

5.

Interview Tool

Strategic Options for the Use of Clinical Practice Guidelines (CPGs) for the Philippine Health Insurance Corporation (PhilHealth) In-Depth Interview Guide for Heads of Societies Introductory Remarks I am _________________________from ______________________ General Purpose of the Study Aim of the Interview How long it will last I would like to go over certain general rules for our conversation. There are no correct answers Want your opinion Confidentiality Minimal interruptions Do you have any questions at this point? Warm Up What is your present position in your society/hospital? How long have you been in that position? What are your major roles and functions? PHIC and Your Private Practice Are you PHIC accredited? Have you had any problems with PHIC claims in the past? What are those problems? Please elaborate. How do you thinks these problems should be addressed? (Now lets us talk more specifics) Laboratory Procedures What laboratory procedures do you think should be routinely reimbursed by PHIC? How should PHIC decide on which procedures to reimburse? What should be the basis for this decision and why? What role should the physician play in this process?

Drugs What drugs do you think should be routinely reimbursed by PHIC? How should PHIC decide on which procedures to reimburse? What should be the basis for this decision and why? What role should the physician play in this process? Surgical Procedures What surgical procedures do you think should be routinely reimbursed by PHIC? How should PHIC decide on which procedures to reimburse? What should be the basis for this decision and why? What role should the physician play in this process? (The advent of EBM has led to the development of Clinical Practice Guidelines, as you have mentioned ) Perceptions of Society Members on Clinical Practice Guidelines Can you describe some of the perceptions of your society members on CPGs? Probe: What do they think about CPGs? How to they use the CPGs? What is your view on this matter? What is the societys stand on the use of CPGs? Development of CPGs Can you describe to us the role of the society in the development of CPGs? Probe: What are the CPGs adopted or being supported by your society? What was the participation of the society in their development? What was your participation? How do you think the society and its member participate in the development of CPGs in the future? Dissemination and Promotion of Use of CPGs How do you think CPGs should be disseminated and promoted among physicians? Probe: What activities were carried out by your society to disseminate and encourage the use of CPGs? Who do you think should be responsible to do these tasks? What roles should the society assume in the dissemination of CPGs? What do you think are the best strategies to disseminate and encourage

the use of CPGs among your members? Among other physicians?

Incorporating CPGS into the PHIC Insurance System Probe: What is the societys stand on the incorporation of the CPGs in to the PHIC system? What is your personal opinion on this matter? How do you think should PHIC incorporate CPGs in their system? What aspect of the insurance system should it be incorporated? (claims, reimbursements, accreditation, quality assurance monitoring, etc?

Comments Is there anything else that we have not covered that you think that you want to tell me about CPGs and its use in practice and in PHIC system? Closing Thank you.

II
Strategic Options for the Use of Clinical Practice Guidelines (CPGs) for the Philippine Health Insurance Corporation (PhilHealth)
Suggested Amendments to the Proposal in Response to a Request for Short Term Technical Assistance
Subcontract No. HSRTAP-FPLC-007 between Management Sciences for Health, Inc. and Ateneo de Manila University Graduate School of Business (Health Programs)

I.

CONTEXT

Upon submission of the research protocol on February 25, 2002, a technical meeting was called to validate with the PhilHealth representative whether the information that would be generated from the submitted Focus Group Discussion guide and Key Informant Interview tool sufficiently covered the needs and concerns of PhilHealth in relation to the CPGs. In this meeting, Dr. Eduardo Banzon of PhilHealth articulated that the research tools should not dwell so much on the stakeholders knowledge and use of the CPGs but instead should explore at great length their perceptions, opinions and willingness to comply with possible requirements and regulations that may be generated by PhilHealth as it relates to using CPGs in the performance of key insurance functions like claims processing, physician and hospital accreditation and fraud detection. In the light of these comments, a sub-amendment (Number 1) was signed and approved by MSHHSRTAP to revise the schedule and nature of deliverables since the revised research instruments and protocol could not be finalized until after the research team has completed its initial brainstorming of the top five options to be recommended. The next activities of the team therefore focused on finalizing these recommendations using important must and want criteria to narrow down the initial long list of possible choices. On 25 March 2002, a meeting was held among representatives of PHIC, MSH, and the Ateneo CPG Research Team to discuss the criteria to be used to evaluate and rank the CPG strategic options to be included in the study. In this meeting, it was agreed that the Must and Wants criteria to be used are as follows: MUSTS: Within PHICs domain and mandate to implement after CPG development. Strategy should be implementable within 2 years (tenure of GMA). Strategy's impact must be measurable by PHIC. WANTS: in order of importance Technically feasible Improve efficiency of PHIC operations Reduce total cost of medical care Politically acceptable to external stakeholders Acceptable returns to investment Total: Weights 30% 30 20 12 8 100%

The criterion of political acceptability makes up only 12%, while those involving PHICs operations and costs make up 68% (first, second, and last criteria). There is a need, therefore, to realign the scope of work of the Ateneo CPG Research Team which was heavily tilted towards gathering information regarding political acceptability. This paper discusses the kind of work that needs to be done, and the additional resources needed to produce the related output. II. ACTIVITY ANALYSIS

Activity analysis, also known as value analysis, is an approach to operations control that became popular during the 1980s. An activity is any discrete task that an organization undertakes to make or deliver a product or service. Activity analysis includes four steps: 1. Identify the process objectives, as defined by what the customer wants or expects from the process. The customer may be another unit within PHIC (internal customer) or may be a PHIC member, physician, or hospital (external customer) Chart by recording from start to finish the activities used to complete the product or service. This includes the length of each activity, its frequency, the number of personnel involved, forms used and generated, equipment and software used, and any special circumstance surrounding the performance of the activity (e.g., done on an exception basis). Classify activities according to their value-added and efficiency aspects. Each activity will be classified into four types, as shown in the box below. a. A value-added activity is an activity that, if eliminated, would in the long run reduce the products service to the customer. b. Any activity that cannot be classified as value-added is nonvalue-added. Nonvalue-added activities present opportunities for cost reduction without reducing the products service potential to the customer. Eliminating nonvalueadded activities can be done after changing the underlying activity processes. c. Efficient activities are those activities which consume no excess resources. Activities can be assessed for their degree of efficiency through time-motion studies or through competitive benchmarking. Value Added? Yes No Type 1 Type 2 Type 3 Type 4

2.

3.

Yes Efficient? No

4. Cost out each activity using Activity-Based Costing (ABC) system. The resulting costs provide us information on which activities to focus first in terms of eliminating for nonvalue added or improving for efficiency. 5. Decide on what to do with each activity. Type 4 activities can be eliminated outright since they do not add value and are inefficient. Type 2 activities can be eliminated eventually after the sources of efficiencies have been studied and considered for redeployment to value-added activities. Type 3 activities should be assessed for opportunities for efficiencies, even to the extent of redesigning them. This includes using better work flows, simpler workstation layouts, more relevant equipment, better training, and higher authorization levels. Type 1 activities are retained. 6. Determine the impact of the CPG-based strategic options on the cost and efficiency of each activity. III. 1. SCOPE OF WORK AT PHIC The following are assumed regarding the current state of PHIC operations: a. According to the Accenture Study1, reporting relationships and functional delineations are not clear. Issues of centralization and decentralization exist between the Central Office (NCR) and the regional offices. Further, PHICs information system is not integrated across related functional areas. Our interview with Dr. Banzon showed that there is a lack of standardized systems and procedures. Only basic documentation of process work flows and operating performance standards exists. No studies have been done to improve operational efficiency. There is poor institutional memory and lack of continuous process improvements due to the high proportion of contractual and casual employees. In the data presented in the Accenture Study, about two out of three employees were nonregulars.

b.

c.

2.

Claims processing will be the primarily functional area for the Activity Analysis. This covers the Claims Processing Department (NCR) which processes and pays all claims from NCR within 30 days upon receipt. Under this department are the Receiving, Verification, and Medical Evaluation Division, Adjudication Division, Accounting Division, and Administration and Information Division. This also covers the claims processing performed in the 15 Regional Health Insurance Offices. Appendix 2 contains the list of 28 activities performed. The following support functions will also be reviewed insofar as they will be affected by changes in claims processing brought about by the implementation of certain CPG strategic options.

3.

Organizational Manual documents (Volumes 1 to 4) of the Organizational Restructuring Assistance project for PHIC, undertaken by Accenture, with funding from Management Sciences for Health. The study was completed in April 2001.

a.

Management Information Systems Department Performs systems analysis and design to determine efficient and systematic manner of handling transactions Prepares documentation, manuals, and guidelines on applications developed Develops applications systems that simplify operating processes and enhance productivity Provides technical assistance to the Database and Network Management Division in the development of utility applications for management reporting and database maintenance. Ensures the integrity of all databases of PHIC Manages the data communication network. Claims Review Unit Reviews statements and documents that would give bearing for possible reconsideration Gives decisions on all appealed claims Recommends for the approval of the President decisions on all appealed claims Corporate Communications Office Prepares news and special releases for tri-media dissemination Establishes and maintains linkages with external publics Conceptualizes, designs and produces print materials on the National Health Insurance Program (NHIP) Designs training modules on various aspects of NHIP for specific audiences Organizes special projects designed to increase members awareness on NHIP and its benefits. Fraud Prevention and Detection Unit Investigates health providers and members suspected of filing fraudulent claims Recommends the filing of complaints against health care providers and members who committed fraudulent acts Undertakes actions to prevent and detect fraud Quality Assurance Research and Policy Development Department Formulates standards on accreditation applied to both professional and institutional health care providers Develops standards of practice of health care providers to ensure they are of desired quality Reviews and evaluates existing medical compensation schemes Studies and develops new compensation packages Develops/formulates policies on the monitoring and evaluation of institutional and professional health care providers Conducts utilization review of claims filed by members Conducts researches on outcomes assessment

b.

c.

d.

e.

4.

Deliverables ACTIVITIES DELIVERABLES Observe, document, and verify work flows and Activity work flows and assign costs for claims processing activities at the cost estimates Central Office (NCR) and one regional office. Classify activities into Type 1 to 4. Activity classification Look for opportunities for greater operational Revised work flow efficiencies and cost savings documentation and estimated cost savings Study impact of CPG strategic options on activity Revised work flow work flows and costs documentation and estimated changes in cost, brought about by CPGs. Study impact of CPG strategic options on support Estimated investment office functions. These will mostly be up-front, costs to be incurred by one-time activities to implement changes in claims these offices. processing Study impact of CPG options on total medical Comparison of total costs medical costs for diagnoses with and without CPGs.

a) b) c) d)

e)

f)

These deliverables will be completed by June 10, 2002, which is the same date for the final deliverable of the CPG Strategic Options Study. 5. Resource Requirement (Please refer to Appendix 2) Some resources will be shifted from away from the key informant surveys and focused group discussions of external stakeholders towards this activity analysis. On top of this, an additional five days each for Alvin dB Marcelo (Process documentor and Medical Informatics Specialist) and Darwin Yu (Financial Management Specialist) will be required.

1.

2.

3.

4.

APPENDIX 1. CLAIMS PROCESSING ACTIVITIES Activity Count: Receiving, Verification and Medical Evaluation Division Receives all filed claims coming from the NCR; 1.1 Receives and logs all claims filed from NCR 1.2 Encodes basic information of claimants to be included in the database Verifies completeness and validity of documents for every filed claim; and 1.3 Counter-checks claims against route slips 1.4 Reviews proper accomplishment of forms 1.5 Checks completeness and validity of documents attached Evaluates and validates medical management given and assigns illness codes and Relative Unit Values (RUV) to claims. 1.6 Reviews and approves medical management given 1.7 Assigns illness codes and RUVs Number of activities: 7 Adjudication Division Computes and approves amount of medicine, room and board, laboratory and professional fee charges to be paid for a certain claim. 2.1 Checks the validity of attached receipts for the charges being claimed 2.2 Computes and encodes total amount of benefits to be paid. Prepares vouchers for claims to be paid 2.3 Checks the accuracy of details and computation of claims that were processed 2.4 Prepares voucher of claims to be paid. Prepares payment notice for beneficiaries 2.5 Prepares payment notice for beneficiaries Number of activities: 5 Accounting Division Reviews vouchers received from Adjudication section 3.1 Re-computes benefit payment of claims submitted by the Adjudication Division 3.2 Checks the number of claims and the beneficiaries against the vouchers prepared by the Adjudication Division Prepares payments and related documents 3.3 Certifies availability of funds 3.4 Prepares checks for members and health care providers 3.5 Prepares summary of withholding tax remitted to BIR 3.6 Issues Certificate of Tax Withheld to professional health care providers 3.7 Acts appropriately on voucher adjustments and check replacements 3.8 Keeps all original filed claims Number of activities: 8 Administration and Information Division External and internal communications 4.1 Acts and responds to all external and internal communication 4.2 Provides information such as claims status, policies, on membership and contributions 4.3 Gives assistance to members with inquiries Claims processing 4.4 Monitors processing of claims

4.5 Screens and forwards claims with adjustments to the Adjudication Division Administration 4.6 Monitors staff performance 4.7 Provides supplies and equipment 4.8 Keeps all records Number of activities: Total Number of activities: 8 28