Council for Medical Schemes



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|ITAP MANAGED CARE WORKING GROUP |

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

|– CHRONIC RENAL FAILURE – |

|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 chronic renal failure 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 agreed health quality outcomes

(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 beneficiaries that have Chronic Renal Failure / or registered on a managed care program

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

Identification of beneficiaries registered on the program may include

• Registered on chronic / disease management programs

• ICD-10 Codes

• Anatomical Therapeutic Chemical Classification System (ATC Class)

• National stock numbers (State stock code)

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

The level of Active Management of chronic renal failure will depend on the nature of the contract, the level of services covered and the fee structure for those services, e.g. screening, medication, procedures 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).

• Diagnosis

The diagnosis of Chronic Renal Failure is made by the specified registered provider.

• Investigations

o Pathology (Blood)

▪ Full Blood Count (haematocrit, platelets, RBC etc.)

▪ Creatinine

▪ Albumin

▪ Calcium

▪ Phosphate

▪ HB

▪ Parathyroid Hormone

▪ Iron Studies

▪ Reticulocytes

▪ Total Cholesterol

Pathology (Urine)

▪ Glomerular filtration

▪ Microalbuminuria

▪ Protein

o Radiology

▪ Renal Ultrasound

- Glomerular Filtration rate

- Management of Diabetes Mellitus and Hypertension progression in stages 3 and 4

• Discipline Type

The service providers must be registered with their relevant statutory bodies and as indicated by discipline coded list provided by BHF.

4) Treatment – Chronic Renal Failure

- B05D - Peritoneal Dialytic

- B05Z – Haemodialytic and Hemofiltrates

- B03XA01 - Erythropoietin 

- V03AE - Drugs for treatment of hyperkalemia and hyperphosphatemia

- A11CC - Vitamin D and analogues

- L04A - Immunosuppressant’s

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

* The above is merely the initial phase of the ITAP project and as such is not exhaustive.

5) Clinical Outcomes measures

• Number of chronic renal disease related hospital admissions

• Number of all cause admissions

• Number of casualty visits

• Number of doctor visits

• Number of

-Peritoneal or haemodialysis

▪ Less than 3 sessions per week

▪ More than 3 sessions per week

• Stage of disease

• All-cause mortality

* 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

- Age (Age of the beneficiary is to be calculated as the Year of Reporting - Year of Birth)

1. Program Demographics

|Year: |Actual Number of |No of beneficiaries per stage of Chronic Renal Disease. |Number of New |Number of |

|Bi-Annual |Beneficiaries | |Registrations in the |Beneficiaries who left|

| |registered for a | |period |program * |

| |Chronic Renal Failure | | | |

| |on the Pharmacy | | | |

| |Benefit and or Active | | | |

| |disease management | | | |

| |program (Longer than 6| | | |

| |months on program) | | | |

| | |Stage 1 |Stage 2|Stage 3 |Stage 4 |Stage 5 |

| | |eGFR > 90 |eGFR |eGFR 30-59 |eGFR 15-29 |eGFR ................
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