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Ensuring quality care

Daman's goal is to ensure that our patients get the best quality of care from our network providers while ensuring that costs are allocated efficiently. To help achieve this goal, Daman is implementing an Evidence-Based Reimbursement (EBRP) programme to evaluate the performance of network providers as a basis for making adjustments in payment levels. Daman will use a number of metrics to produce a recommended performance-based Payment Factor Adjustment (RPFA) for each provider.

Evidence Based Reimbursement Programme (EBRP)

The RPFA will be derived from a combination of the Clinical Performance Score, Structural Performance Score and Financial Performance Score. In phase one of the programme, Daman will be rolling out the metrics to start collecting the baseline data of Measurement year mid 2014-mid 2015 with selected hospitals. Daman has selected a series of metrics designed to evaluate the performance of health care providers. The metrics include:

  • Structural Metrics, that reflect the conditions in which providers care for patients, and evaluate the capacity of the provider to deliver contracted health services.
  • Clinical Metrics, that show the quality of clinical care the provider is administering. There are two categories within the clinical metrics:

- Process Metrics, that show whether evidence-based practices are followed correctly and evaluate whether a specific action was completed.

- Outcome Metrics, that present the actual results of care and evaluate how well the provider is helping patients achieve good health.

  • Financial Metrics that broadly captures indicators of cost and efficiency of health care provision.

Daman will be collecting the structural metric data by observing the providers’ facilities, behaviour, trend, and capabilities. Daman will collect data on the clinical and financial metrics through claims submitted for patient services. A provider’s performance on applicable metrics will determine whether patients are receiving efficient and quality care.

Daman will monitor provider performance on the metrics, and will study their correlation to broader health outcomes, such as patients’ quality of life, long-term health outcomes, and overall cost of care. Daman will use this analysis to refine the selection and weights of metrics and to provide performance feedback to providers.

Metrics Overview

For each provider, Daman will calculate a score that incorporates the structural, clinical and financial metrics described above, using the EBRP tool. Click here to see the full list of the available metrics.

 

For further clarification, please contact your Provider Relations Officer or PRDqueries 02 614 9702 for Providers in Abu Dhabi. You may also email us at prdqueries@damanhealth.ae.

Frequently asked questions

1. Where does provider performance stand today?

We monitor providers' performance through a wide range of clinical, structural, and financial parameters in different care settings. We share and discuss the performance results on a bi-yearly basis. The purpose is to give timely feedback on Quality Improvement areas, thereby supporting the gradual increase of quality in the Abu Dhabi health system. Providers participate in this program as it provides useful insights to their performance, gives them an opportunity to provide feedback and take suitable action.

 

2. How are the results of provider performance going to be used?

The emphasis is on making the performance transparent (i.e., the “Evidence-Based”) to providers and help them identify their areas of improvement.

 

3. How does the provider performance metric cycle look like?

We have a standardized process for Metric Selection, Development, Measurement, Review & maintenance cycle, and the data is refreshed biannually. Addition of new metrics and retirement of the old ones continue to happen throughout the life of the program based on the current practice and market need.

 

4. Are the metrics Daman uses sound?

Yes, the metrics are selected from internationally recognized quality assurance systems such as National Committee for Quality Assurance(US), Agency for Healthcare Research and Quality (US), Care Quality Commission (UK) etc. All clinical metrics have been validated by the latest evidence in literature through Advisory Board, Cochrane Reviews. Outcome metrics are risk adjusted using a reliable tested methodology.

 

5. Where can I find out more about the measure specifications and other important details about the program?

All details related to measure specifications, risk adjustment methodology, scoring aggregation and other important details are available in the Provider Performance Metric Specification Manual.

 

6. Our scores look bad as we see really sick patients. How are patients’ factors excluded from this analysis?

Risk adjustment allows for an "apples-to-apples" comparison between providers by adjusting for differences in patient mix. The goal is to isolate provider performance in a metric from other patient risk factors, like age and gender composition of the patient mix.

 

7. There is lack of clarity of details of the risk adjustment methodology. Is it possible to reproduce the results with the same methodology in-house?

 

The risk adjustment methodology is detailed in the Provider Performance Metric Specification Manual. Important variables that affect the risk adjusted outcome for any specific metric can be shared on request. However, it will not be possible to recreate exact provider specific results without the results of other providers.

 

8. How can my physicians be held accountable for patients lack of compliance? Our patient population consists largely out of basic patients and they don’t comply with medication use?

The physician has the responsibility to take the time to educate the patient about his/her medical condition. With proper education, there will be a very few cases in which they will not be compliant. These exceptions would not impact the scoring.

 

9. Will our results be compared to the same provider type?

We calculate and aggregate scores at the market level. However, our reports provide the ability to view provider performance not only by provider 'Type' but also by 'Cluster' (based on similar facility characteristics).

 

10. What benchmark is used to see the relative placement of the provider on the scoring scale?

Local benchmarks are used for quartile placement of the providers for comparison with the market and likely peers. They're challenging, but achievable to motivate improvement in certain areas for providers who fall behind in performance and wish to keep up with other providers who are performing well.

International benchmarks are obtained from clinical data registries, payers (such as the CMS MIPS quality benchmarks(www.cms.gov)) and accreditors (such as the National Committee for Quality Assurance [NCQA] (www.ncqa.org), Healthcare Effectiveness Data and Information Set [HEDIS]. Currently, international benchmarks are used for informational purpose only and are not used to rank provider performance.