10/10/2016 - 15:00 - 16:30
GT 4 - Direito à Saúde, Políticas Públicas e Especificdade do Ciclo de Vida |
11495 - QUALITY INDICATORS ASSESSMENT AND QUALITY MONITORING PROGRAM IN HEALTH INSURANCE IN BRAZIL
ALUÍSIO GOMES DA SILVA JUNIOR - UFF, GISELE CALDAS ALEXANDRE - UFF, MARCIA GUIMARÃES DE MELLO ALVES - UFF
Apresentação/Introdução
Health care provided by private health plans in Brazil is currently evaluated by a series of different indicators without any possibility of assessment by beneficiaries specific characteristics. Knowing that disease process occurs differently in individuals, it has been recommended that health care data should be evaluated and monitored, at least by gender, age or lifecycle, region of the country and health condition. Specific population groups and a few lines of care according to the Brazilian morbidity and mortality profiles should restructure this monitoring. Besides, Indicators may be used to disseminate quality of care information, both to beneficiaries, in order to increase their ability to choose, as to providers, aiming at the promotion of improvement strategies performance and also to operators of health care private plans, focused on the improvement of health care quality in providers network. The domains evaluated were based on the axes of the Quality Evaluation System for Health Insurance: security; effectiveness; efficiency; equity of care; access and patient centeredness.
Objetivos
To review the current health care quality indicators used by the Brazilian Regulatory Agency.
To propose quality indicators, especially focused on process and results, that may improve managed health care assessment in Health Insurance in Brazil.
To review indicators domains to restructure the Quality Monitoring Program of Service Providers in Health Insurance in order to increase its assessment capacity, availability of information to enable the choice of providers by operators and beneficiaries of health insurance companies.
Metodologia
This study reviewed the best evidence available for the definition of quality care indicators in PubMed and BIREME databases between May and August 2015. There were analyzed national and international experiences focused on the evaluation of service providers and on health care quality monitoring indicators of the Brazilian Ministry of Health (DATASUS); The Oswald Cruz Foundation (PROADESS); the Health Ministry Performance Index (IDSUS); The National Health Service (NHS); The National Committee for Quality Assurance (NCQA) and The Center for Disease Control and Prevention (CDC). There were also evaluated the domains: security; effectiveness; efficiency; equity of care; access and patient centeredness. After a critical review of all these documents, there were suggested some indicators to improve the Health Care Quality Assessment and the Quality Monitoring Program in Health Insurance in Brazil.
Discussão e Resultados
It is suggested that the quality monitoring indicators should contemplate both lines of care and life cycles for medical and dental care. These indicators construction are directly related to the quality of the information that is obtained regarding to consultation, hospital admission, examination, gender and age of the operator's beneficiaries in the period studied. It is recommended to approach the setting of indicators used by the Brazilian Regulatory Agency to Brazilian own experiences, as well as the international ones. There was na important confluence in the experiences for 3 areas related to health services and care provision: Effectiveness, Safety and Patient Experience. As used in others experiences, the Effectiveness domain was strengthened as a potential response to indicators used to evaluate structural and results aspects of health interventions, and the domains Access and Equity of Care were incorporated to it. These changes and the Patient Centeredness could point trends in patient perception in terms of solving their problems. These indicators offer information to fulfill the main goal of the Quality System and the interface between actors of health insurance.
Conclusões/Considerações Finais
The indicators proposed should reflect the best experiences studied, approaching the set of indicators used by the Brazilian Regulatory Agency to those used by NHS; NCQA; IDSUS; DATASUS and PROADESS. In these experiences, all indicators used are analyzed by gender, lifecycle, health condition and health region, although they are not grouped in this way. This proposal should contribute to the improvement of Operators Qualification Program through the better assessment of managed health care in Health Insurance. It was also regrouped the 3 domains indicators towards the main objective, which is to provide healthcare quality information that: enhances better choices by beneficiaries, aids operators in investing in more effective care networks, and enhances health providers processes and performances. It is expected that this proposal favors the Monitoring Quality Program of Service Providers in Health Insurance in Brazil and contributes to the improvement of the Regulatory Agency.
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