| 4. In which ways is the initiative creative and innovative?
Strategic Element 1: Consultations, Committee Formation, Strategy development
The first phase of the C-section reduction initiative set the foundation for action including the convening of stakeholders, building the evidence base, and outlining a strategy.
In 2000, HIRA is granted the authority to conduct quality assessments under the National Insurance Act. The Ministry of Health and Welfare establishes the Central Assessment Committee whose mission is to establish the strategy, objectives, and plan for quality assessment of which C-sections are identified as one of three priority areas.
In 2001, a nationwide assessment of C-section is conducted and reveals high rates of C-sections and high variability between healthcare facilities.
In 2002, a C-section reduction committee is formed of stakeholders and experts. They develop an action plan to reduce C-section rates, which is approved by Central Assessment Committee and the Ministry of Health and Welfare. The plan is published online and informational sessions are held with hospitals. HIRA is identified as the lead agency to execute implementation.
Strategic Element 2: Development and application of Risk-Adjusted C-section rates, scores, and quality assessment.
-In 2002, HIRA commissions the development of a statistical model to calculate risk-adjusted C-section target rates for all hospitals with over 30 deliveries. The model is developed by clinical (OB/GYN) academic experts and approved by the Central Assessment committee.
-HIRA begins work to collect and review data from all target hospitals and applies the model to calculate target C-section rates.
-By 2002, each hospital has a target C-section rate and C-section quality score based the difference between target and actual rates. This quality score, in turn, contributes to the overall annual quality assessment rating of hospitals.
-The annual quality assessment is performed according to the annual assessment plan, which is developed at each year-end by the Central Assessment Committee and approved by Ministry of Health.
Strategic Element 3: Assessment Results Reporting to Hospitals
-Starting in 2002, hospitals receive an annual assessment report from HIRA that includes the C-section quality score and benchmarking data to improve their quality of service.
-HIRA conducts briefing sessions with individual hospitals to discuss assessment outcome and specific areas of improvement.
-Starting in 2007, HIRA initiated quality assessment support consultations that provide training sessions to healthcare facilities to improve scores.
Strategic Element 4: Public Reporting and Awareness Activities
-By 2002, the assessment result of individual hospitals is posted on HIRA’s website for citizens to consider when selecting health facilities.
-In September 2005, HIRA begins public reporting of 179 health facilities with good C-section quality scores.
- HIRA organizes public hearings, campaigns, press releases, and advertisements annually promoting
awareness of C-section ratings of hospitals.
- HIRA and women’s groups also organize events, advertisements, and material promoting greater awareness and information on natural births and C-sections to help women make better-informed decisions.
Strategic Element 5: Value Incentive Program
- Central Assessment Committee decides that more needs to be done to improve quality in hospitals. C-section reduction is selected as one of two priority quality improvement areas for a pilot Value-Initiative Program (VIP) to create financial incentives and disincentives to further reduce the rate of C-sections at tertiary hospitals.
- The pilot project is initiated in 2007 with 43 tertiary hospitals whose performance was evaluated in 2008 and 2009.
- In 2009, incentive payments are given to top grade and quality-improved institutions.
- January 2010: Lowest grade facilities are visited by HIRA for counseling
-Following success of VIP pilot, the program is expanded in 2010 to include all general hospitals with over 200 deliveries.
In 2010, the Quality Assessment service and VIP project are presented at the OECD Conference of Health Ministers.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
This initiative relied heavily on the cooperation of a diverse range of stakeholders:
The expertise of medical groups was critical to ensure that the main objectives, strategy, and overall approach were evidence-based and feasible. The Korean Medical Association, Korean Hospital Association, Korean Dental Association, Association of Korean Medicine, The Korean Pharmaceutical Association, the Korean Nurses Association are represented in the Central Assessment Committee. The Korean Medical Association and the Korean Hospital Association are also represented in the Committee for the Reduction of C-sections.
HIRA staff and members of the Board of HIRA (including MOHW) represent approximately half of the members of the Central Assessment Committee and are represented in the Committee for C-Section reduction. As lead implementing agency, HIRA officials played a very active role in all steps of the process from design, implementation, to monitoring and evaluation.
The National Health Insurance Service was represented in the Committee for C-section reduction.
The Ministry of Health and Welfare was represented in the Central Assessment Committee and Committee for C-section reduction.
The Korea National Council of Consumer Organizations provided the important viewpoint of public concerns both in the Central Assessment Committee and the Committee to reduce C-sections. The Korean YMCA also was represented in the Committee for C-section reduction. The Korea Women’s Association was an important stakeholder in the C-section reduction Committee and led its own efforts to raise public awareness of C-sections as a maternal and child health issue.
| 6. How was the strategy implemented and what resources were mobilized?
The C-section reduction initiative was one of the three main measures for quality ratings of healthcare facilities, thus the financial and staff resources for this initiative came primarily from the Quality Assessment department of HIRA. The Quality Assessment department has 3-4 staff dedicated to C-section assessment and 1 IT support staff. The department has an annual budget of approximately $366,000 USD (not including staff salaries). Funding towards specific activities for this initiative included:
-Contract with university professors to develop statistical model for estimation of target rates,
-Salary and costs associated with data collection and analysis to develop target C-section rates, and
-Salary and costs outreach activities including consultations, informational sessions, assessment results reporting, and audits.
In particular, the VIP project was a special initiative that incurred additional costs that was also funded by the Quality Assessment department. This included 19 staff members and a budget of $70,000 USD for workshops, public hearings, and trainings. An external company was contracted to conduct surveys of consumers and professionals at a cost of $55,000 USD.
Stakeholders from other public agencies like the MOHW as well as consumer groups also contributed substantial time and resources to this initiative.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1.Nationwide establishment of evidence-based C-section rate targets and standardized C-section quality scores
As of 2012, 642 health facilities (all facilities with 30+ deliveries annually) were assessed including 44 tertiary hospitals, 79 general hospitals, 127 mid-sized hospitals and 392 clinics. These facilities were categorized into low (C-section rate lower than predicted), ordinary (rate falls within predicted range), and high grades (rate higher than predicted). The standardization of C-section quality scores allows for fair comparison between health facilities regardless of patient profile. This information allows 1) healthcare facilities to assess whether their C-section rate is within predicted range and how it compares to national average, 2) HIRA to identify worst-performing health facilities as a target for quality improvement, 3) gives policymakers an aggregate view of nationwide trends and performance that can be used for evidence-based decision-making.
2.Quality Assessment ratings based on C-section scores
Quality ratings of healthcare institutions are a tremendous incentive to change provider behavior and improve efficiency. Reduced C-section rates were identified as one of the top indicators of quality in health services since the quality assessment function was granted to HIRA. It has been used in quality ratings every year since 2001-2013 – over a decade.
3.Public Reporting of Quality Assessments and C-section rates.
Public reporting has been a major incentive to behavior change for healthcare facilities. Reporting on HIRA’s website along with press releases and public campaigns is an effective tool to induce behavior change without imposing direct rules or regulation. A 2005 Health Policy Monitor report assessed that public reporting of C-section rates in South Korea would have a strong impact on the quality of health care services and cost-efficiency.
4.Application of Financial Incentives and Disincentives through the Value-Incentive Program.
The VIP program was created as an additional strategy to influence provider behavior to reduce C-section rates in hospitals. Health facilities that meet or are below target rates of C-sections as well as those showing marked quality improvement receive financial incentives; worst-performing institutions receive a penalty and are targeted for quality improvement consultations by HIRA.
The pilot VIP program demonstrated success in further reducing C-section rates to the participating facilities. This led to full adoption of the program in 2010 and further expansion to general hospitals in 2011. In 2012, approximately $679,500 USD was paid in incentives to 41 institutions, while 4 institutions were penalized in the amount of $21,0000.
| 8. What were the most successful outputs and why was the initiative effective?
The initiative to reduce C-sections has robust monitoring and evaluation mechanisms primarily through the role of the Central Assessment Committee. During the initial stages, the Central Assessment Committee was responsible for reviewing and approving the strategy and the action plan proposed by the C-section reduction committee and HIRA. Through monthly meetings, the Central Assessment Committee monitored the development of the statistical model, the information sessions that were held for providers and the public regarding the initiative, and the reporting of the first results to healthcare facilities. Within HIRA, the leading department would identify major activities, targets for all hospitals, the indicators to be used and then send to committee for review. Final approval was given by the Ministry of Health and Welfare.
As the initiative is now an integral part of the quality assessment function of HIRA, the Central Assessment Committee reviews on an annual basis each step of the quality assessment procedure including the final results and subsequent actions (e.g. consultations to health facilities).
After 5 years of using standardized C-section quality scores, a first comprehensive evaluation report was published in 2007 detailing the trends of C-section rates nationwide and the impact of the initiative on reducing C-section rates.
It was from the results of this report that the Central Assessment Committee and policymakers pursued the Value-Incentive Program to further induce reductions in C-section rates nationwide. An evaluation of the Value Incentive Program, which showed initial successes led to the decision to further expand the program in 2010.
| 9. What were the main obstacles encountered and how were they overcome?
The medical establishment recognized that there was a nationwide problem of high rates of medically unnecessary C-sections, but were concerned that there was a significant “gray area” where clinical judgment could differ in deciding whether to perform a C-section. Many physicians felt that in cases of even slight risk to mother or baby, a C-section should be performed. In particular, they were concerned about questions of medical malpractice if harm came to mother or newborn because of a decision to pursue natural delivery instead of a C-section.
As these concerns were significant not only in the case of C-sections, but in other medical issues, HIRA made the recommendation for the formation of an organization to deal with matters of medical malpractice. By a mandate from the National Assembly, in 2012, the Medical Dispute Mediation and Arbitration Agency was established for fast mediation, fast arbitration, and credible dispute resolution. Both patients and providers can solicit the intervention of the agency to help resolve medical disputes.
Another concern of healthcare providers and facilities was the lower payments for natural births compared to C-sections. C -sections generate higher revenues for health facilities because they are major surgeries requiring prolonged in-patient stays and are quicker to perform (i.e. beds are freed so more operations can be performed). HIRA acknowledged the financial considerations of health providers and further incentivized natural deliveries by increasing the insurance reimbursement for doctor’s service fees for natural deliveries compared to C-sections.