Health technology and innovation for UHC by Dr Beatrice Murage, Savanna

Health Technology And Innovation For Universal Healthcare Coverage

Presentation at ACHAP Biennial Conference– 25th Feb 2015

Universal Health Care remains elusive despite huge

potential benefit and impact

“Every year health expenses create severe financial hardship for 150 million people globally and force 25 million households into poverty. This is due largely to the fact that more than three billion people—many of whom are found in the poorest half of the world’s population—pay out of pocket for health services. They are forced to choose between impoverishing fees or foregoing needed services, leaving them at risk of falling into a downward spiral of sickness and poverty..”

The Rockefeller Foundation, 2010

Africa is undergoing various transition that impact

all players in the healthcare industry

Decentralization of government

Economic growth

More private sector focus on development

Increasing literacy & awareness

• Government services shifting more to regional areas e.g. counties

• Counties making different progress in improving livelihoods of citizens

• Governors carrying out various initiatives that are affecting healthcare

• Major investments in infrastructure nationally & regionally

• Growing middle class with more disposable incomes

• Relative economic and political stability promoting economic activities

• Strong private sector has evolved under relatively market friendly policies

• Increasing shift to emerging markets as growth in developed countries slows down

• Private sector investing to take advantage of the growing middle class

• More universities coming up and providing access to higher education

• Mobile and internet penetration have drastically improved creating more channels for literacy & awareness

Yet healthcare financing in a number of countries is

still mainly by government and out of pocket

expenditure

HEALTHCARE FINANCING BREAKDOWN CHALLENGES FACING HEALTHCARE FINANCING

•High out of pocket expenditure in context of a weak risk pooling system

•High burden of disease from both communicable and non-communicable aspects

• Inefficient and ineffective allocation and use of scarce resources:

- Promotive & preventative health used on ~12% of total health expenditure while admin took ~14% expenditure

- WHO estimates ~40% of medical spend lost through waste

Source: Literature review; Open Capital; Deloitte

Case Point: KENYA

Despite challenges in the public sector, it still has

the most facilities

Source: Kenya Service Provision Assessment , 2010

For equitable access to health and UHC, all

stakeholders must be engaged

PublicPrivate

For-profit Not for-profit

Faith Based Organizations

Healthcare financing ( Explore viable models: public/ private/ hybrid insurance?)

Access to healthcare

Quality healthcare (Incentives linked to outcomes)

Efficient allocation & utilization of resources

Health IT innovations have offered solutions for

affordable healthcare financing models around the

globe

Leadership / Governance(Facilitative)

Regulatory Framework (Interoperability, data security)

Knowledge sharing( Academia - Industry Collaboration)

Value Based Healthcare System

Collation of Medical Information

Insights transformed to

clinical guidelines

Continuous medical care

quality improvement

Continuous reduction of

medical costs

More affordable and widespread health

care coverage

e.g.• Sweden has 90

disease registries

• The registries cover 25% of total national health expenditure

• The registries are a tool used to promote improved clinical practise

• Sweden’s National Cataract Register helps minimize

the incidence of postoperative

endopthalimitis

• Projected saving of $ 25 million p.a. in direct costs of treating postoperative endopthalimitis

• Estimated reduced direct healthcare cost of $ 7 Billion over 10 years

Source: BCG, HBR

And we can leverage those lessons to promote UHC

in Africa

• National Hospital Insurance Fund (NHIF)

- Oldest government insurance scheme in Africa

- Largest healthcare risk pool in Kenya

- Mandate is to provide access to quality and affordable healthcare for all Kenyans

- Membership compulsory for all salaried employees

• Premiums

- Calculated on a graduated scale based on income

- Deducted automatically through payroll for salaried employees

- Self employed and other informal sector workers:

‣ Membership is contributory (voluntary)

‣ Fixed premium rate of KES 160 per month

• Coverage:

- ~4.5 million people (11% of Kenya’s population)

- 98% coverage of the formal sector

- 16% coverage for the informal sector – accounts for 80% of Kenya’s population

Source: NHIF; Health Market Innovations; USAID

“NHIF operates under the social principle that the rich should support the poor, the healthy should support the sick and the young should support the old.”

NHIF

NHIF OVERVIEW

Case Point: KENYA

NHIF’s contributions have increased and services

cover most of the country

FINANCIAL OVERVIEW COMMENTS

• NHIF has contracts with about 645 hospitals in the country for provision of in-patient services to members and beneficiaries

• Coverage of 98% of hospital beds in the country

• Provides services through contracts specifying coverage rates or rebate rates with the providers

• Most comprehensive NHIF coverage is at public health hospitals and faith based hospitals

Source: NHIF; Health Market Innovations

NHIF faces various challenges which will limit

Kenya’s ability to achieve UHC

NHIF incurs a lower percentage of contributions on settling claims…

…and incurs more expenses on personnel and administrative costs

Other challenges

Source: AKI; NHIF; UAP; Literature review; Expert Interviews

• Allocation of resources towards more expensive curative services

• Lack of widespread outpatient cover

• Low pay-outs per claim limiting access to healthcare

• Financial sustainability

- Growth in the formal sector saturated at ~98% coverage

- Dependent on informal sector and government contribution for growth

Current process of managing claims creates

several challenges along the value chain…

Pre-authorization challenges

Manual, labour intensive, inefficient and prone to error process

Inconsistencies due to systems challenges

Difficult for hospitals to track what was paid / rejected

Patientvisits

hospital

Hospitalsubmits

Paper claims

Paper claims digitized

Coding of claims into backend

system

Claims analysis

Claims settlement

Inconsistencies detection is costly and in-efficient

Lack of good quality data and analytics to drive to better decision making

Source: Literature review; AKI; Expert interviews

Challenge

• Insurers need to ensure that the right beneficiary receives care so as to reimburse

• Current process consists of:- Phone calls

- Cross checking of Excel files with beneficiary details

- Biometrics

• Paper based and in-efficient:- Hospitals have to submit paper

based claims to insurers.

- They do not have a way of tracking which claims are processed and refunded

• Inconsistences in claims is a common concern across the health insurance sector:- ~20%-40% of claims are deemed

inconsistent

- There has been need to have nurses and medical investigators to follow up

• Paper based and in-efficient:- Claim details are entered

manually into backend systems

- Systems don’t integrate with hospital EMRs

- Errors likely to occur in data entry

Solution

• Point of care pre-authorization - Connects to an online database

and provides hospitals with beneficiary details and cover limits

- Better visibility into what individual benefits and applicable sub-limits

• Online claims submission:- Streamlines and provides

visibility into the entire billing process

- Minimizes paper work and avoids the situation of ‘boxes full of claims’

- Creates an audit trail of every transaction which enables follow up

- Enforces standardization of care which improves health outcomes

• Claim inconsistencies algorithms:- Based on disease management

protocols

- Flags claims which are likely to be inconsistent

- Pro-active management of those inconsistencies of claims helps control claims costs leading to profitability

- Automation increases efficiency

• Improved productivity & efficiency:- Automation increases efficiency

and productivity

- Audit trail increases accountability

• Improved revenue cyclemanagement for providers- Better payment allocation and

reconciliation

- Faster transaction time and claim settlement times

That can be improved through technology to improve

processes, support decision making and move closer

towards UHC

Online claims submission

Pre-authorization / patient identification

Inconsistencies flaggingengine

Claims processing

Thank you

[email protected]

Savannah Informatics provides tools to the healthcare industry to enable better decision making