SNO | Indicator | Numerator | Denominator | Disaggregations |
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1 | Number/value of all claims entered in openIMIS |
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2 | Number of individuals/hhs with claims |
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3 | Average Value claimed per member/HH with claims | Value of all claims | Number of members with claims |
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4 | Incurred Claims per capita | Total value of claims | total number of enrolled persons | gives overview of cost of coverage |
5 | Average claim value | Value of all claims |
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6 | Number of HHs hitting ceiling | e.g. Number of HHS whose claims add up to 50000 NPR |
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7 | % of HHs hitting ceiling through families with claims should be very useful as well | Total Number of HHs hitting ceiling during time period | families with claims during time period |
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8 | Number/value of rejected claims |
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| Disaggregation by facility type needed |
9 | Number/value of submitted claims during period of time |
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| Disaggregation by facility type needed |
10 | Number/Value of pending claims | Total Number of pending claims |
| Disaggregation by facility type needed |
11 | Number/value of claims reimbursed by other districts during time period |
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| Disaggregation by facility type needed |
12 | Total number/value of claims reimbursed during time period |
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| Disaggregation by facility type needed |
13 | Ratio number/value of claims reimbursed by other districts by total number/value of reimbursed claims during time period | From total number/value of reimbursed claims subtract total number/value of claims reimbursed by own district (during time period) | Total number/value of claims reimbursed during time period |
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14 | Proportion pending/reimbursed claims of total claims during time period | Total Number of pending or reimbursed claims during time period | Total Number of submitted claims during time period | by facility type needed |
15 | Rejection rate of claims (automated/by claims review) | Total Number of rejected claims during time period | Total number of claims during time period | Disaggregation by facility type needed, and by type of claim: emergency, OPD, IPD, Referral.. |
16 | Total Revenue in Health Insurance Fund | Premium plus subsidy from public fund/MoF plus other private sources (eg donations) | NA |
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17 | Proportion of revenue from HHs contribution | Total premium collected from HHs | Total revenue in Health Insurance fund |
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18 | Proportion of revenue from Government subsidy | Total premium received from MoF | Total revenue in Health Insurance fund | to cover the premium for extreme poor and poor |
19 | Total numbers of types of claims | (Saurav: OPD, Emergency, IPD, Referral) |
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20 | Rates of types of claims by value/number | value/number of claims type | Total number/value of all types of claims |
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21 | Top 10 Diagnoses during timeframe | Number of claims per diagnosis |
| or longer List? Top 50? Top 100? |
22 | Trend of Diagnoses-Groups, i.e. NCD | Number of Claims for Treatment of Diagn.Group in one year | several possible: Number of Claims for Diagn. Group in year before, average of several years before | Claims need to have indicator for Diagnoses-Group |
23 | List of number/value of type of service per period of time per level |
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| i.e. Diagnostic, surgery, emergency, inpatient, outpatient |
23.1 | Can this be linked to Utilization level? | Total # of visits or services in defined time period | Total # of enrolled individuals |
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24 | List of Numbers/Value of most prescribed drugs per period of time | Numbers/Value of most prescribed drugs per period of time |
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25 | List of Numbers/Value of most prescribed drugs per period of time as % of total Number/Value of claims | List of Numbers/Value of most prescribed drugs per period of time | Total Number/Value of all claims |
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26 | List of Numbers/Value of most prescribed drugs per period of time as % of total Number/Value of claims which perscribed drugs | List of Numbers/Value of most prescribed drugs per period of time | Total Number/Value of all claims which perscribed drugs |
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27 | Number/Value of Claims by public and private Facilities + type of facility |
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| conditional on quota of number of this type of facility of all facilities? |
28 | Number/Value of Claims reviewed/valuated by public and private Facility + type of facility |
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| Disaggregation down to Claim reviewer Level needed |
29 | List of % of Claims(Number/Value) reviewed/valuated by public and private Facility + type of facility as share of total claims | Total Number/Value of claims reviewed/valuated of single facility-type | Total Number/Value of all claims submitted by this facility-type | Disaggregation down to Claim reviewer Level needed |
30 | Total Value/number of (valuated- already paid for?) reviewed claims by gender | Value/Number of claims concerning female patients and vice versa | Total Value/Number of claims | should show conditional on male/female quota of enrollees, otherwise statistic only meaningful if enroled people are exactly 50% female, 50% male - also: costs for gender specific costs like maternal health care to be included or excluded? |
31 | Total Value/number of (valuated- already paid for?)reviewed claims by age group |
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32 | Valuated Value of claims as share of total value of submitted claims | aggregated Value of claims after being revised (include rejected claims?) | aggregated Value of all submitted claims | for facility types |
33 | Incurred administration expense ratio | total value of incurred administation expenses | total value of collected contributions+subsidies | shows administrative efficiency |
34 | Incurred claims ratio | total value of incurred claims | total value of earned contributions+subsidies | value to the beneficiaries and programme viability |
35 | OOP ratio | total sum of OOP spending | total sum of health expenditure = OOP + claims | measures impact on target population. To measure this, treatment costs which patients pay for by themselves would have to be entered into OI |
36 | Benefit coverage rate | Number of accepted claims | total number of reported medical cases | Quality of the programme indicator. To measure this, hospitals would have to send data accordingly/ OI would need to register other cases |
37 | Complaint ratio | total number of complaints | total number of covered individuals | importance for OI? |
38 | Promptness of claim approval | period of time between submission and approval of a claim | / |
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39 | Health infrastructure | number of health facilities/health personnel | number of population | OI doesnt know total number of population but can provide number of health personnel and so on |
40 | Waiting time for procedures |
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40.1 | Should we include average waiting perid and proportion of people waiting delays out of total enrolled individuals |
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41 | Average cost per (inpatient) visit | Total Value of all (inpatient) claims | total number of inpatients |
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42 | Number of cases for specific diseases |
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| HIV, DM, measles, DTP,… |
42.1 | Payment allocation by diseases and its severity/Inpatient admissions/Primary health care sensitive diagnosis/tracer conditions | Total payments in the defined time period | Total enrolled population in the defined time period |
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42.2 | Ratio of highly complex to less complex patients. | Total # of highly complex patients seen in the defined area during the defined time period | Total # of low complexity patients seen in the defined area during the defined time period |
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43 | Net income(profit) ratio | Total Value of collected (premiums + subsidies) - paid claims | total amount of collected premiums + subsidies | viability - negative indicator shows that programme will not be viable, poisitive indicator means programme is viable. Largely positive indicator means re-evaluation of contributions and benefits. |
Additional Indicators Proposed based on review of all indicator sources |
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| Provider payment related indicators | Do we also need to consider payments made to each practitioner/provider/ or Total payments made to practtioner/provider will do? |
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| Promptness of payment to providers | Time taken in payment to the providers from the date claim was incurred |
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| Referral Rate | Total referrals made by providers in a defined time period | Total visits in the defined time period |
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| Patient satisfaction rate | # of individuals who report that they are satisfied with the services they receive in the defined time period | Total # of individuals receiving services |
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| Expansion of provider network | Percentage of previously accredited facilities that renew or retain their accreditation |
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| Expansion of provider network | Percentage of newly accredited facilities |
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| Accessibility of provider network | Health facilities per 10,000 beneficiaries |
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| Quality of care | Average number of readmissions within 30 days |
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| Quality of care | Number of deaths per 1,000 hospital admissions |
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