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10th Caribbean Health Financing Conference
Turks and Caicos IslandsOctober 28, 2015
Dr. Natalia Castillo-Rodriguez
Belize’s National Health Insurance Scheme
Celebrates it’s 14th anniversary
July 2001-2015
NHI: A GATEWAY TO BETTER HEALTH FOR ALL 2001
NHI was formally launched South Side Belize City Introduction of the Contract Model and the Payment Members
Per Month (PMPM) was introduced This initial project consisted of NHI/SSB contracting services
from:
-Primary Care Providers(Private/Public Mix)
-Pharmacy Providers (Private)
-Imaging Providers (Private)
-Laboratory Providers (Private)
-Ophthalmology Providers-NGO and Private (Cataract Surgeries)
-Hospital Providers-Private (Hernia Repairs, Gall Bladder Surgeries, Hysterectomies and Deliveries)
NHI: A GATEWAY TO BETTER HEALTH FOR ALL
SSB funded (2001-2008) project $54 millions Initial Pilot Project evaluation 2002 Package of services were reduced in 2003 Hospital Surgical Procedures were discontinued
NHI: A GATEWAY TO BETTER HEALTH FOR ALL 2004
Monthly Incentive Indicators
Annual Key Performance Indicators were introduced
NHI: A GATEWAY TO BETTER HEALTH FOR ALL 2006
NHI extended to Southern Region 2 Districts- Primary Care Providers and Satellites in Rural Areaso Contracting Model was different than the SS modelo All Providers are Public facilities managed by the
MOHo PMPM included payment for all serviceso (PCP, Lab, Imaging and Pharmacy)o Pre-Elections Fever: Roll out to entire Country 2007o NO Strategic Sustainable Plan
NHI: A GATEWAY TO BETTER HEALTH FOR ALL 2008
Elections New Administration GOB Funded from General Revenue MOF Fund continues to be administered by SSB
National Health Insurance Scheme Pilot Project ended in 2009 NHI has strengthened its Monitoring and Evaluation of
contracted Providers Standardization of Medical Record and Chronic care
forms Facility Evaluations Patient Satisfaction Surveys Medical Records Audits Clinical Management of Chronic Patients Lab Audits Pharmacy Audits
FIRST of it’s kind Geriatric Center in Belize; Servicing the elderly exclusively in 2011
Mercy clinic
2011BUILDING Block Approach was implemented:
Block 1: called for the standardization and organization of the Medical Records. This was a critical first step in the clinical management of all patients and an area that needed strengthening. Working Sessions were carried out and with the direct input of the PCP physicians the medical records were standardized, piloted and implemented.
Block 2: called for the proper Classification and Treatment of DM, HTN, Asthma. To achieve this, protocols were reviewed and all health personnel re-trained in these with emphasis on those two criteria. A clinical audit tool was developed, shared with all relevant parties and adopted for the purpose of the audit.
Hypertension Clinical Audit –After Introduction of Block ApproachBelize City
BFLA BMA BHP MR MC
84%
37%
100% 100%
74%
100% 100% 100% 100% 100%
Comparison 2011/2014
2011 2014
Diabetes Clinical Audit-After Block ApproachBelize City
BFLA BMA BHP MR MC
2011 0.789473684210526
0.315789473684211
0.842105263157895
0.736842105263158
0.789473684210526
2014 1 1 1 1 1
5%
15%
25%
35%
45%
55%
65%
75%
85%
95%
Comparing 2011/2014
Patient Satisfaction SurveyBelize City
BFLA BMA BHP MR MC
2013 0.865740740740741 0.908212560386474 0.89 0.896969696969697 0.974358974358974
2014 0.88 0.87 0.9 0.89 0.99
81%
83%
85%
87%
89%
91%
93%
95%
97%
99%
Comparing Scores for 2013/2014
Facility Evaluation SS Belize City
BFLA BMA BHP MR MC
2014 0.99 0.9891 0.9828 1 0.9735
2013 0.9825 0.9866 0.945 1 0.9902
92%
93%
94%
95%
96%
97%
98%
99%
100%
Comparing Total Scores 2014/2013
KPI’s 2014 Belize CityIndicators Target Score
BFLA
MRPC
BMA
BHP
Compliance with Hypertension Protocol Implementation Block 2
85% 15%
100%
100%
100%
100%
Compliance with Diabetes Protocol Implementation Block 2
85% 15%
100%
100%
100%
100%
Compliance with Medical Record Block 1 85% 15%
100%
100%
100%
100%
At least 85 percent of PCP patients expressed full satisfaction with regard to services received from the PCP
85% 15%
88%
89%
87%
90%
Percentage of pregnant women with 1 prenatal care visits during the first trimester
60%
15%
117/184
64%
88/132
68%
149/172
87%
116/181
65%
Conduct at least #12 Community Outreach Activities for the year
100%
15%
37/12
100%
15/12
100%
25/12
100%
15/12
100%
Conduct at least #12 CMEs and Staff Development Activities which should include yearly revision of NCD protocols
100%
10%
25/12
100%
13/12
100%
25/12
100%
12/12
100%
KPI Pass 80% 100%
Pharmacy Audit Belize City5 years
MOH 1st Choice Brodies BMA BHP Good Care Mercy CDS BDS50.00
55.00
60.00
65.00
70.00
75.00
80.00
85.00
90.00
95.00
100.00
Comparison of Totals 2013/2014
Lab Audit Belize City3 years
BML BHP BMA CML
2012 0.89 0.74 0.77 0.79
2013 0.91 0.62 0.93 0.87
2014 0.84 0.908 0.835 0.89
53%
57%
63%
68%
73%
78%
83%
88%
93%
98%
Lab Audit Comparative Scores
2010 Southern Region Medical Record Audit
Indicator DAN IND PG SA
Demographics and Administrative Information (10%)
8% 7% 8% 8%Medical History (20%)
9% 7% 14% 13%
Physical Examination (20%) 12% 8% 11% 12%
Diagnosis (20%) 14% 12% 17% 17%
Diagnostics (10%) 2% 2% 6% 5%
Treatment and Management (20%) 10% 6% 13% 11%
Average Weight Score 55% 42% 69% 66%
Total number of records that met the standard (80%) 1 0 3 3
% of records that met the minimum standard (80%) 5% 0% 16% 16%
Southern Region2013-2015
Adapted Standardized Medical Record Forms Training Sessions of Clinical Management of
Chronic Diseases, Audit Tools, KPI’s Exchange of Best Practices Belizean Doctors in SR Introduction of Building Block Approach NHI has been able to monitor and evaluate as per
contractual agreement Support of PAPU Director, now DHS
SINCE 2006 NO SALARY ADJUSTMENTS, NO BENEFIT PAYMENTS TO STAFF PAID THROUGH NHI FUND.
ALL PUBLIC SERVANTS PAID BY GOB HAVE NOW SURPASSED THE SALARY/BENEFITS OF NHI/PAID STAFF.
DISATISFACTION OF PERSONNEL
DIFICULTY ATTRACTING STAFF TO WORK IN REMOTE AREAS
Increase of PMPM for SR, 2014
Southern Region -After Block Method Approach * 3 of 4 providers met targets of KPI’s - 2014
Description DAN Pomona Hopkins
# of records assessed 19 10 10
# of records that met the minimum standard (75%)
19 8 9
Total % score 100% 80% 90%
Average Score 90%
2014 Southern Region
Description INDSan Juan Placencia
Bella Vista
# of records assessed 19 10 10 10
# of records that met the minimum standard (75%)
18 4 9 4
Total % score 95% 40% 90% 40%
Average % score for PCP and Satellites 66%
2014 Southern Region
Description PGBig
FallsSanta Ana
# of records assessed 19 10 10
# of records that met the minimum standard (75%)
18 7 7
Total % score 95% 70% 70%
Average Score: 78%
RAWA 2015
Software has been upgraded to a more robust purchasing and planning health information system that is able to monitor service utilization trends and create reports for planning
Registration of Clinical Activities Web-Application (RAWA)
Web-Based Purchasing and Planning Tool providing real-
time data.
Facilitates the eligibility criteria and registration of members assigned to a Primary Care Provider. (Prior the eligibility process was lengthy requiring numerous phone calls and turn-around of the client to and from Social Security and the Primary Care Clinic). Registration has now been streamlined and referrals to Social Security only occurring when absolutely necessary. (eg. Provision of Proof of address and transfers only)
Registration of Clinical Activities Web-Application (RAWA)
The Payment Process has improved significantly. The payment period is selected eliminating the need to import encrypted data files from each of the providers. The latter resulted in high number of inconsistent activities that needed to be validated for payment.
RAWA payment process is now simplified and number of activities to be validated significantly reduced. The activities for validation are minimal but assist in detecting possible fraudulent billing errors at the PCP and support service level respectively
Registration of Clinical Activities Web-Application (RAWA)
During the generation of a referral, the GP can recall an activity and make adjustments if necessary as long as the support service provider has not filled the referral.
A support service provider (usually pharmacy) can also initiate a “change request” which the PCP that initiated that referral can view and make the required adjustments as needed. This eliminates the need for the client to be sent back to a clinic for new or corrected prescription.
RAWA also facilitates the process of refilling a prescription for chronic patients who are compliant without having to re-enter the prescription data.
Registration of Clinical Activities Web-Application (RAWA)
The Robust Reports module significantly improves Key Performance Indicator (KPI) compliance monitoring. The PCP can register clients diagnosed with chronic conditions as well as track coverage of screening services.
RAWA also tracks the population eligible for co-payment exemptions as defined in the NHI package.
The system allows for assigning of specific roles and level of access to the various RAWA modules accordingly.
Extension to Northern District Corozal
January 2014 (Pre-election year)o NHI was given the mandate to extend services to 2 of 4
zones o Contracts were signed December 2014o Christian Based Satellite Clinic (Presbyterian Medical
Clinic)o (4,000 pop)o Corozal PCP (MOH)(19,000)o NHI services have been launched at PMCo RAWA is implemented at PMC
Challenges
Other than the PMPM increase for the SR the Budget for Belize City has not increased
Extension of scheme to only some zones of same geographic area
Clinics have reached maximum membership Monthly Indicators are no longer monitored for
performance Clinics are maxed out
Measures taken
Budget containment: Capped both SS Belize City and SR MOH as Pharmacy, Lab provider 2011 KHMH as an Imaging Provider 2012 Deactivation of members to accommodate the new borns
(population growth)
Challenges
Aging population
Increase in NCD’s
Cost of the Elderly Chronic Patient 3x
Measures taken Buy Pharmaceutical Supplies for Chronic Patients
at tender prices offered to MOH
Duty and GST Exemption granted by MOF
Savings of 50%
LACK OF LEADERSHIP UNDERSTANDING OF THE BASIC GOALS AND PRINCIPLES OF THE REFORM AND THE FUNCTION OF NHI, THERE IS A DISTINCT POSSIBILITY THAT LONG TERM SUSTAINABILITY OF NHI AND ITS COUNTRYWIDE IMPLEMENTATION IS CURTAILED AND THUS RESULT IN THE INABILITY TO MAKE SYSTEMIC IMPROVEMENTS TO HEALTH.
LACK OF PUBLIC INFORMATION AND MARKETING RESULTS OF NHI EXPERIENCE, THERE IS A POSSIBILITY FOR THE GENERAL POPULATION NOT SUPPORTING FINANCIAL POLICY DECISIONS THAT NEED TO BE MADE, RESULTING IN GOVERNMENT RELUCTANCE TO ADOPT A SUSTAINABLE POLICY ON HEALTH SECTOR FINANCING.
LACK OF PROVIDER COMPETITION THERE IS PROBABILITY THAT PROPER INCENTIVES MAY NOT BE INTRODUCED RESULTING IN POOR QUALITY DELIVERY OF SERVICES.
ECONOMIC CHALLENGES THERE IS A STRONG POSSIBILITY THAT FUNDS MAY BE LIMITED AND RESULT IN FAILURE TO CONTINUE IMPLEMENTATION OF SCHEME.
Challenges
Remains the greatest challenge
ADVOCACY…. NATIONAL HEALTH SECTOR STRATEGIC PLAN STAKEHOLDER BUY-IN (NHIC) SPONSOR FOR ADVOCACY AT POLITICAL
LEVEL
POLITICAL STRATEGY DEFINED….
CABINET APPROVAL
Financing Options???
Strategic Plans for Sustainability
THANK YOU
