Council for Medical Schemes



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|ITAP MANAGED CARE WORKING GROUP |

|TASK TEAM 1: CHRONIC DISEASE CONDITIONS (CDL’s) |

|–CORONARY ARTERY DISEASE (CAD) and ISCHAEMIC HEART DISEASE (IHD) and HYPERLIPDAEMIA – |

|Explanatory note to the Managed Care minimum reporting data specification (excel spreadsheet) |

The aim of the project is to report on the value added by managed care organisations, who by means of capturing, measuring and reporting on clinical indicators that will demonstrate clinical outcome/s achieved. Hence this is by no means a representation of the full protocol, policy or guideline on cardiovascular management.

Additionally, these indicators will be included within the Annual statutory return to be completed by the Scheme.

1) Goal

The value of managing a disease is to determine goals that would enable the user to measure, record and report on an achieved outcome

(Diagnosis, treatment and care of all beneficiaries in line with evidence base medicine, cost effectiveness and affordability).

• Prevent complications and or optimally manage the progression of disease.

2) Identification of CAD / IHD / Hyperlipidaemia beneficiaries by means of data mining (i.t.o. the contractual arrangement with the MCO)

Please ensure the relevant consent and confidentially has been addressed when obtaining personal health information.

Identification of beneficiaries with the relevant disease may include

• Registered on chronic / disease management programs

• ICD-10 Codes

• Anatomical Therapeutic Chemical Classification System (ATC Class)

• National stock numbers

3) Minimum data specification: Process indicators, clinical outcomes and data

The level of Active Disease Management services for CAD / IHD / Hyperlipidaemia will depend on the nature of the contract, the level of services covered and the fee structure for those services, e.g. Screening, medicine management and hospital benefit management etc.

The minimum required fields for the effective collection of appropriate data to demonstrate the value of the managed care interventions for the below mentioned categories are detailed by way of process indicators (see attached spreadsheet for details).

▪ Screening

Pending the benefits and agreement in place, if screening will be managed and reported on and if so by which entity.

▪ Diagnosis

The diagnosis to be made by the specified provider.

▪ Baseline Investigations

▪ Doctor Rooms

- Blood Pressure measurement

- ECG

▪ Laboratory Tests

- Lipid profile

- Glucose

- Serum Electrolytes

- Prothrombin Index (PI)

*see condition specific spreadsheet for full details

▪ Procedures

- Percutaneous transluminal angioplasty

- Coronary artery bypass graft

▪ Discipline Type

The service provider to be adequately registered with their relevant statutory bodies and indicated as such by discipline coded list provided by BHF.

4) Treatment – Pending the condition

|Coronary Artery Disease |Cardiomyopathy / Heart Failure |Hyperlipidaemia |

|Organic nitrates |Beta blocking agents |Serum lipid reducing agents |

|Antihypertensive |Agents acting on the renin-angiotensin system | |

|Diuretics |Digoxin | |

|Beta blocking agents |Organic nitrates | |

|Calcium channel blockers |Hydrazinophthalazine derivatives | |

|Agents acting on the renin-angiotensin system |Diuretics | |

|Lipid Modifying Agents |  | |

|Platelet aggregation inhibitors excl. heparin |  | |

• Vaccinations

o Flu Vaccine

o Pneumococcal vaccines

* Formulary Items per scheme and should include consumables.

* Please note these recommendations do not replace the published algorithms, PMB entitlements etc. It is a means of measuring the value provided by the managed care process.

5) Clinical Outcomes

• Number of cardiac related hospital admissions

• Number of casualty visit/s

• Number of

o Revascularisation procedures

o Invasive cardiology

o Open heart surgery / CABG / PCI

• Number of comorbidities

o Cerebral vascular disease

o Heart Failure

o Diabetes

o Hypertension

• Number of beneficiaries on

|C09AA |ACE inhibitors, plain |

|C09BA |ACE inhibitors and diuretics |

|C09BB |ACE inhibitors and calcium channel blockers |

|C09BX |ACE inhibitors, other combinations |

|C09CA |Angiotensin II antagonists, plain |

|C09DA |Angiotensin II antagonists and diuretics |

|C09DB |Angiotensin II antagonists and calcium channel blockers |

|C09DX |Angiotensin II antagonists, other combinations |

|C09X |Other agents acting on the renin-angiotensin system |

• All-cause mortality

Clinical Measures

• % that reached goal - LDL (Initial scoring new patient vs current reading).

• Target / scoring documented Low / moderate / high risk

* Information in regards to ICD-10 coding may be found on the following site



6) Reporting (MCO and Scheme)

*Definitions will be the same utilised within the Annual statutory returns – see circular 10 of 2015.

All reports to be submitted to the Scheme for inclusion in the Annual Statutory Returns. Please complete the section relevant to the service rendered.

1. By Managed Care Organisation: Management out of hospital

- Time period: Benefit year (Reporting period – Start and end)

- Per benefit option

- Per Scheme

- Member

- Beneficiary

- Service Date (Benefit Year)

- Gender – Male / Female

6.1.1 Demographics

|Year: Bi-Annual |Total Number of Beneficiaries per |Number of New Registrations |Total Number of Beneficiaries |Total Number of Beneficiaries |

| |option (scheme) | |identified with CAD / IHD / |identified with 2 or more |

| | | |Hyperlipidaemia |co-morbidities |

| |Male |Female |Male |Female |

|1 to 4 | | | | |

|4 to 9 | | | | |

|10 to 14 | | | | |

|15 to 19 | | | | |

|20 to 24 | | | | |

|25 to 29 | | | | |

|30 to 34 | | | | |

|35 to 39 | | | | |

|40 to 44 | | | | |

|45 to 49 | | | | |

|50 to 54 | | | | |

|55 to 59 | | | | |

|60 to 64 | | | | |

|65 to 69 | | | | |

|70 to 74 | | | | |

|75 to 79 | | | | |

|80 to 84 | | | | |

|85 and above | | | | |

|Total | | | | |

Left the program – This may include a range of reason codes: left the scheme, death, suspensions etc.

Co-morbidities

o Cerebral vascular disease

o Heart Failure

o Diabetes

o Hypertension

6.1.2 Clinical Management – reported per disease registered

|Year: Bi-Annual |Number of on program|Number of New Registrations |Total Number of test performed |Total Number of Procedures performed |

| |

6.2.1 Hospital Category: Day Case

Scheme |Total Number of Admissions (All Cause) |Total Number of Admissions (Cardiac Related)

|Admission Per Category |Mortality (Exit Codes = Expire) |Claimed Amount |Risk Paid Amount | | | | |Surgical |Medical | | | | | | | |Male |Female |Male |Female | | | | | |

6.2.2 Hospital Category: Long Stay

Scheme |Total Number of Admissions (All Cause) |Total Number of Admissions (Cardiac) Related

|Admission Per Category |Mortality (Exit Codes = Expire) |Claimed Amount |Risk Paid Amount | | | | |Surgical |Medical

| | | | | | | |Male |Female |Male |Female |  |  |  | |

6.2.3 Hospital Category: Re-admission

Scheme |Total Number of Admissions (All Cause) |Total Number of Admissions (Cardiac) Related

|Admission Per Category |Mortality (Exit Codes = Expire) |Claimed Amount |Risk Paid Amount | | | | |Surgical |Medical | | | | | | | |Male |Female |Male |Female |  |  |  | |

7) References

- 2013 09 HeFSSA chronic Heart Failure Guideline Final SAMJ

- HeFSSA chronic Heart failure guideline poster

- SA Lipid Guidelines SAMJ March 2012

- South African Guidelines of Congestive Heart Failure

- State EDL

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