Despite there being a general agreement in the South African healthcare sector that the establishment of an outcomes measurement and reporting (OMR) system is a key requirement to improve the quality and outcomes of patient care and reduce the country’s astronomically high healthcare costs, not much has been achieved to date. Role-players such as some funders and professional organisations have developed their own outcome measurement tools in a very fragmented way with little of this information being published, standardised or applied and used to achieve the objectives of quality, cost-effective care.

This was highlighted in the Health Market Inquiry Report that found among others that appropriate information on the quality of healthcare in both the public and private sector was seriously lacking and that available healthcare data are not standardised, risk-adjusted or scientifically verified. The report stressed the need for an OMR system that is provider-driven and free of economic and political interference, adding that the lack of such a system is constraining efforts to move to a value-based purchasing system.

According to Dr Rajesh Patel, Head of Health System Strengthening at the Board of Healthcare Funders (pictured above), several factors are hampering the lack of progress. These include a lack of leadership and stewardship from government and regulators to drive the implementation of an OMR system, medical schools’ failure to include it into their curriculum, the wording of the Medical Schemes Act on the business of medical schemes and the absence of accountability among the different role-players involved in the delivery of care. Dr Patel will be one of the speakers at the upcoming Outcomes Measurement and Reporting Conference that will be taking place virtually from 4 to 5 September.

“It is critical that all role-players including healthcare professionals, medical schemes and hospitals take accountability for their activities and report and publish their outcome results in a transparent way,” Dr Patel stressed.  This, he says will enable the continuing monitoring and measurement of the effectiveness of healthcare interventions to guide clinical and funding decisions that will ensure better outcomes.

“Yes, our results will not be great initially, but we need to know and understand what is happening at baseline. We need that data to develop scoring systems and indexes that can be used as measuring tools to determine if the interventions are producing the required results and learn what else should be done to improve on that,” Dr Patel notes.

The role of funders

From a funding perspective, the starting point of the problem is the Medical Schemes Act as it only describes the business of medical schemes as collecting members’ premiums to pay for health-related expenses, Dr Patel says. However, nothing is said about funders’ responsibility to look after the health of their members and ensuring that they receive the quality of care that is required for improving outcomes.

“If the regulator doesn’t see it fit to focus on health outcomes and quality, schemes’ uptake of measures to change that is going to be very slow,” Dr Patel observes.

Some schemes use claims data to establish whether clinical guidelines were followed to establish for instance if the right tests were requested in diagnosing and treating a patient, but not much is done to establish what the results were and share that data with healthcare providers.

In and effort to change this, BHF has developed a measurement and assessment tool that has been adapted from the so-called Effective Coverage model. Aimed at measuring health system performance at different levels in the move towards Universal Health Coverage (UHC), the Effective Coverage metric comprises of three components namely need, use and quality of care to provide a better understanding of whether and how well health systems are delivering services to the population and the health gains that are achieved.

“Effective coverage can be implemented as an accountability tool for medical schemes but can also be used as a tool for marketing communication to healthcare providers, employers and the public on the results that are being achieved and the areas that need improvement,” Dr Patel explains.

With the tool you measure the extent to which your at-risk population have received the required intervention that would influence outcomes. The proportion of people who has received those interventions is then measured to see if they remain adverse-outcome free. This data can then be presented as an index result or a percentage to assess the effectiveness of the intervention.

Dr Patel says the BHF has adapted the tool for schemes in such a way that they can use their claims and preauthorization data to get results that will enable them to measure and assess the effectiveness of interventions.

Effective Coverage can also be adapted to be used by healthcare providers to measure and assess the effectiveness of their interventions on the outcomes of their patients and compare it to that of their colleagues.

The mandate of regulators such as the Council for Medical Schemes and the HPCSA is to protect the public but without the fundamentals of quality assessment and measuring in place to do outcomes research, it is impossible to pinpoint where the problems are and what interventions are needed, Dr Patel pointed out.

Importantly, Dr Patel says, is that strong stewardship and leadership are needed to push for the implementation of an OMR system that is focused on improved outcomes including from the Department of Health, the CMS, the HPCSA, the Pharmacy Council and the Nursing Council.

“You cannot say that you are responsible for protecting the public and regulating providers if you don’t collect any data about the quality of the care that is delivered and published and shared it in a transparent way. Everyone should be accountable for the country’s health outcomes and that means that you know the processes to achieve better outcomes, know the outcomes, report on it and be transparent about it,” Dr Patel concluded.