Audit of medical care in Rio Negro Argentina
SUMMARY
Health care auditing is a basic component of the population's health care process whose objective is to monitor the results of health interventions tending to achieve the highest possible quality in the given situation. The experience of applying the behavioral auditing model in an Argentine province is presented, highlighting the results obtained, and the difficulties observed. The fundamental requirements for the application of the model and the stages of its implementation are described.
INTRODUCTION
The Argentine Republic has undergone in the last fifteen years a reform of the state promoted and sustained by the liberal concept of small and disregarding state, which resulted in a chain of privatizations of public companies and sale of national companies to transnational capitals. This reform, although with particular limitations, also reached the Social Works System, which slowly began to incorporate concepts such as reengineering, continuous quality control, and total quality into the analysis of its operation.
This model (Deming, Juran, and Crosby) focused on client / patient assessment of quality is widely resisted by most physicians and medical societies, who perceive it as the inappropriate meddling of uninitiated in reserved areas only to doctors. Its greatest development in our country is observed in the managed systems, which were born as a mechanism to allow the transfer of risk from social works to providers. This strategy was applied with the aim of achieving the containment of spending that was growing continuously, and not as a true attempt to reform the social security system, so its significance in terms of concrete results was low.
The concepts of Avedis Donabedian, who systematized the quality assessment approach (structure, process, and results) starting from the same health system began to spread in our country in the late 1980s, as an alternative to oppose the quality search strategy extrapolated from the industrial area. This model called the medical model was enthusiastically accepted by medical societies, which thus found a type of analysis close to the traditional clinical method (mixture of induction and deduction) that allowed them to adapt more easily to the change in health paradigms that seemed inexorable.
Today, the audit of medical care is debated in Argentina between two clearly defined approaches:
1. From the medical organizations the decision to aggiornary is observed, establishing minimum standards of professional quality, therapeutic norms, responsibilities, etc; and there is only moderate concern about the volume of spending.
2. From the political level of the state, and the managerial level of the prepaid medicine companies, the emphasis is placed on the inefficiency of the health system, the low quality of the services it provides, and the high levels of corruption that run through it.
With the aim of achieving a reduction in the cost of benefits, the traditional modality of payment by medical act has been modified for a large part of social security, introducing the mechanism of payment by capitation or fixed portfolio. The creation of the managers (a new level of intermediation between those who provide the service and those who finance it), who did not have their own providers and had to contract them, generated the appearance of heterogeneous types of contracts, and various forms of payment; At this time, different payment mechanisms coexist that condition different behaviors in the providers, and seem to require different approaches in the audit.
EXPERIENCE IN RIO NEGRO
In 1994 the INSSJP (social work for retirees, with more than three million beneficiaries throughout the country) signed in the province of Río Negro the first capitan agreement for the medical care of its members that involved the transfer of economic risk to the contractor.
Almost immediately union social works, and then the provincial social work proposed capitate agreements of the same type, with the aim of being able to control spending on welfare benefits that showed a constantly increasing trend, thus in 1998 80% of the beneficiaries of the Social security in Río Negro received their healthcare coverage through risk agreements.
The two medical union organizations of the province that gathered all the providers (FECLIR and FMRN) decided to assume the commitment of managing the capitan agreements that the social works began to propose with the initial objective of ensuring their own survival by guaranteeing their associates the ability to offer your work in an organized way.
First one, and then the other, they were forced to create management structures that would allow them to successfully face the challenge of providing services with a previously known budget. By 1998, both medical union organizations, which already managed the care of 80% of the social security affiliates living in Río Negro, decided to merge both management structures creating a single organization called ACI with the ultimate goal of forming an integrated network of providers., and to make viable a provincial sanitary model that would allow associating public providers with private ones.
From the small initial objective, a surpassing objective had been achieved by entering the field of designing an adequate network of healthcare services.
In order to serve the administration needs of this network, it was necessary to form an appropriate Medical Audit Department to meet the demand for monitoring and control caused by the performance of 950 doctors and 41 healthcare facilities. The population to be covered was 180,000 people distributed in a territory of 200,000 square km (Río Negro province)
The premises of the entrusted task included:
1) Development of a model for monitoring the activity of providers
2) Development of a model for monitoring the behavior of the assisted population
3) Development of a model for evaluating health outcomes obtained
4) Development of intervention measures to correct deviations in provider activity and population behavior
5) Development of a model that would allow the incorporation of Rio Negro public establishments as providers
6) Development and application of preventive strategies to reduce the major causes of population morbidity
7) Development and Application of an adequate remuneration model to pay for the services provided, with a limited and previously known budget.
8) Application of measures in the framework of the least possible conflict.
9) Development of an epidemiological database of the provincial population
The activity began assuming the following premise:
The health system that serves the social security affiliates that live in the province is inadequate and must be reformulated with the voluntary assistance of providers; progressively achieving behavior modification of system users (beneficiaries, doctors, clinics, hospitals, social works). The mission of the Medical Audit Department is to prepare and implement the technical instruments necessary to achieve the objective, monitoring the result of its application.
The implementation and monitoring of the proposed reforms from the decision-making levels required the Medical Audit Department to carry out the activities necessary to fulfill the following functions:
1. Formulation of the minimum standards required of providers
In the beginning (1994); all the doctors who were members of the FMRN (90% of the total of the doctors in the province) were providers of the system, and all the member clinics of FECLIR (100% of the clinics and sanitariums of the province) were providers of the system in equal footing. This decision was necessary because no establishment was categorized, and there was no law on medical specialties in the province of Río Negro.
In order to solve this gibberish, all the healthcare facilities in the province were categorized by establishing six different levels of complexity (I to VI).
The FMRN member doctors were grouped by specialty after the evaluation of their backgrounds by a mixed body (public and private) called COPEM (Provincial Committee of Medical Specialties). Both evaluations were recognized as the only valid ones by the Secretary of State for Health of Río Negro, which is the body that exercises the police power of professional enrollment and health establishments.
Thus, in a gradual and slow way, it has been possible to apply the authorization of benefits according to the category of the establishment and the specialty of the requesting professional, thus achieving a categorization of the required healthcare benefits according to the minimum level of complexity necessary to solve the pathology of each particular patient.
2. Continuous monitoring of affiliates, providers, and benefits
An adequate information system was designed and applied to know the behavior of demand throughout the province. Data on outpatient benefits were collected by 18 outlets distributed throughout the province, and data on hospitalizations and benefits of III Level were collected by the central administration.
All the data is collected when the beneficiary requests each benefit and is stored in the form of data tables that are permanently available. The information system has a search engine that tracks the "healthcare history" of each member, or the "performance history" of each establishment each time it is requested. This information is available at the outlet of your locality of residence, and in the central administration. In this way, deviations in expected behavior can be detected early. The analysis of these "abnormal" events reveals: accessibility failures, excess consumption, diversions in providers, low-quality services, etc.
One of the most interesting applications of the information system has been the retrospective monitoring of cancer cases in the assisted population. This information was then elaborated with epidemiological criteria, thus allowing the detection of the circumstances that prevented the early diagnosis of the clinical case.
Based on this information, a preventive program for the two most prevalent cancers in the population (breast cancer and cervical cancer) was developed (in conjunction with the provincial social work) that has been applied since the beginning of 2001.
The "performance history" of each provider is available in a central audit where individual deviations are analyzed monthly, by specialty, by locality, and by region. The data obtained also allows budget adjustments to be made; construct the population demand profile according to its geographical location and age group. In this way, the reformulation of the provider system is being carried out with the aim of adapting it to the real needs of the population to be covered.
Traditionally, the Argentine provider system has tried to adjust according to theoretical designs or extrapolated from other countries, and in general the results have been unsatisfactory. The method applied in Río Negro, although slower in its application, is carried out from the constant observation of concrete reality, for which reason its results are more adequate.
3. Construction of service utilization indicators
The province of Río Negro has partial indicators on the medical care of the inhabitants who attend public hospitals, but it lacked data on the medical care carried out in other effectors, and its consequences.
The ACI Medical Audit Department develops monthly production indicators in 25 different benefit groups, which have allowed us to know relevant data to contribute to the design of a provider system suitable for the population to be served, and financially viable. Taking into account that the covered population reproduces the population distribution of the province's population, and that its volume (180,000 people) represents 40% of the total provincial population, the data can be extrapolated to obtain a specific profile of health demand.
4. Preparation of proposals for standards of care and therapeutic guidelines
The initial anarchy of the provider system, the territorial extension of the covered area, and the uneven quality of the service offer have been the cause of diagnostic and therapeutic interventions, more related to tradition than to scientific knowledge. This conduct, in addition to providing low-quality health services to the population, did so at a higher cost than expected.
The constant and disseminated availability of systematized information has allowed the ACI medical audit to know with certainty the places where these events occurred and to provoke interventions aimed at its correction that are carried out following a program applied in different and successive phases:
Initially, the provider's attention is drawn to the anomalous event with an economic sanction (debit), the support of which is explained in a previously agreed area (shared medical audit). The reasons for the anomalous event are discussed, the subject is studied together and a standard accepted by both ACI and the provider is established.
The final decision is established in one or more meetings in which they participate; other providers of the same specialty, and sometimes scientific societies. With this modality, which at first glance seems cumbersome, it has been possible to establish by consensus and maintain accepted standards over time for: admission and discharge of patients to neonatology, preparation of medical records, use of antibiotics in hospitalization, parenteral nutrition, etc. These standards are those that are subsequently used as a guide for authorization of services in medical audits, and as support for debits in case the provider deviates from what is established.
The most important contribution of this mechanism has been to allow the progressive adaptation of the users of the system as the quality of the medical service provided is progressively increased, and with a low level of conflict.
All individual medical providers are reviewed monthly; and only those who stray from the expected average are notified with an explanatory sheet of their situation. This single informative measure has caused substantial changes in the behavior of providers, generally tending towards normalization. Those cases that cannot be corrected in this way are subject to the application of an economic adjustment until they are equal to the average of the rest of the providers of the same specialty.
5. Implementation of mechanisms for the authorization of benefits
The great geographic extension in which the members of the covered population are distributed forced that the mechanisms for authorization of benefits were close to both the patient's and the benefit's home. For this reason, the design of the Medical Audit Department contemplates two clearly differentiated functional units (peripheral and central), with also differentiated missions.
All information traffic was supported, initially on paper. The progressive increase in the population covered forced to decentralize authorization decisions and consequently increase the level of autonomy of peripheral audits, for which adequate training was required. This decentralization has been possible only partially since the shortage of human resources available for auditing in some areas of the province has prevented complete decentralization, and forced the implementation of remote authorization mechanisms (internet portal) that with the improvement of telephone communications in the province has been possible.
The final objective was to achieve benefit authorization mechanisms that are invisible to providers and beneficiaries, that adapt to the behavior of demand, and that are effective in detecting abnormal events with the shortest latency time.
6. Construction and Review of remuneration instruments
The transition from payment mechanisms by medical act to new payment methods has been and still is today one of the most arduous aspects of health reform, especially considering that new payment instruments are perceived by doctors as a loss not only financial, but also their professional autonomy.
The implementation of new payment tools has been gradual and is still incomplete; Thus, currently, instruments for payment by medical act, modulated payment, payment by fixed portfolio, payment with application of correction constants (indices) coexist in the same system. The design of the instruments of remuneration, which is usually outside the scope of decision of the medical audit departments, acquires great relevance in the behavioral audit implemented in Río Negro.
It has been assumed as a reality that Argentina's social work provider system is largely determined by the logic of profit, and therefore, to mobilize professionals towards the desired change, it is essential to modify the system of rewards and punishments incorporating incentives. economic that promote the improvement of the quality of the provision.
CONCLUSIONS
The behavioral audit launched in the province of Río Negro is a medical audit strategy that is based on extensive computer development, applies epidemiological tools to analyze the occurrence of pathological phenomena, and which has allowed the progressive modification of the system social work provider with a low level of conflict.
The fundamental elements learned from the experience carried out are:
o The application of information circuits is required to permanently know and monitor the activity of system users, reaching the objective of achieving the ability to anticipate their demands.
o Training of audit personnel involves learning essential skills for proper management (IT, epidemiological, and management control tools).
o The application of corrective measures to resolve deviations must be based on the accurate diagnosis of anomalous situations, carried out progressively, and taking into account local realities.
o Payment instruments must be modified, incorporating in their design concepts that allow differentiation between different providers according to the use of available resources and the quality of the results obtained.
o The concrete results of the application of the behavior audit are optimized as the greater the mass of the population covered.
Behavioral auditing relieves information by constantly observing the dynamics of the system, applies corrections to deviations in benefits when conditions are favorable, and is effective because it progressively achieves that the actors (patients, social, and professionals) of the process assume the change as a necessary fact granting an environment so that they build consensus to achieve it.
The application of the behavior audit provides lasting results because it allows modifying the behavior of the providers. The biggest challenge this medical audit modality has faced has been finding the balance between the discipline required to induce changes in the provider system, with the flexibility necessary to maintain the health care of beneficiaries during the change process.
Dr. César D. Marina
"… We must demand from each one what each one can do," replied the king.
