SHOPS Project Kenya - Capitation Quality Assurance / Monitoring & Evaluation Consultant
Purpose of Assignment: The purpose of the assignment is to provide technical assistance in the development and implementation of a monitoring and evaluation (M&E) Plan and monitor the insurer, provider and client perspectives for a capitation pilot in a health insurance company. The insurer intends to switch from a fee-for-service (FFS) reimbursement system to a capitation mode of payment for their corporate medical products covering out-patient care.
Rationale / Justification for Assignment: Since FY 2013, SHOPS Kenya has been offering TA to an insurer on building their capacity for marketing and distribution. As continuation of this technical assistance, SHOPS Kenya will support the insurer as it pilots a capitation model of paying their network healthcare providers. Brief Background: In FY2014, SHOPS will continue to provide technical assistance to the insurer to facilitate the roll-out of their health insurance product in accordance to the distribution as well as marketing strategies. In addition, SHOPS will support the insurer design and pilot a capitation mode of payment.
Introducing prospective provider payment mechanisms such as capitation controls the negative provider incentives associated with FFS and presents a significant opportunity to control claims ratios
and administration costs for insurers. On the provider end, prospective payments give the advantage of pre-negotiated payments with a lower administrative burden and a predictable revenue stream. Capitation payment systems also allow providers to spend more time on patient care, which frequently increases patient and provider satisfaction.
This being a new concept, the insurer intends to monitor and document the capitation pilot to learn from the experience as they transition from FFS to capitation for all their clients, and support the improvement of the capitation model in subsequent iterations. SHOPS therefore intends to support the insurer with technical assistance to develop systems to identify indicators for continuous monitoring of insurer, provider, and client perspectives. SHOPS will also assist the insurer to develop systems that identify and mitigate challenges that arise during the pilot. SHOPS researchers will assemble this information in an end-term evaluation of the capitation pilot that may be used to advocate for future policy changes.
1. Under the guidance of the SHOPS capitation research lead, support the insurer to identify the challenges associated with capitation and indicators for monitoring the capitation pilot. This will include (but not be limited to) collecting data on the following:
a. Insurer: utilization data, claims incidence, diagnoses, claims ratios, administration costs, challenges and recommendations for improving capitation, comprehension of capitation, and other information relevant to informing rate negotiations with healthcare providers.
b. Providers: satisfaction and motivation in response to the capitation pilot, administration costs (at the beginning and through the duration of the pilot term), profits and sustainability of capitation payments (relative to FFS), challenges and recommendations for improving capitation, comprehension of capitation, and other information relevant to informing rate negotiations with insurance providers.
c. Clients: patient satisfaction, out-of-pocket spending, wait times, access and utilization of needed care, perceived coordination of care
2. Train insurers, providers, and survey teams to implement monitoring tools for use during the capitation pilot. This includes an audit checklist/tool for insurers that will ensure that providers deliver high quality services to clients, a customer satisfaction monitoring tool for a survey of capitated clients, and a survey for health facility administrators and providers around their experiences with participating in the capitation pilot.
a. Coordinate the collection of survey data through phone or facility interviews.
b. Manage a short-term team of data collectors to implement the survey.
3. Assist the SHOPS capitation research lead to develop a quality assurance/monitoring and evaluation plan for use during the capitation pilot and beyond the pilot as the insurer transitions from FFS
4. Implement a training program for the insurer managerial staff on how to use the indicators identified, tools designed and the quality assurance/monitoring plan.
5. Support the insurer in the monitoring of these indicators during the capitation pilot.
6. Provide inputs to an end-term evaluation of the capitation pilot including a report to document findings, lessons, successes and challenges (from insurer, provider, and client perspectives).
Key Deliverables & Expected Outputs:
1. Identify indicators, design tools and develop a plan to monitor the capitation pilot along the insurer, provider and client perspectives
a. While overseeing a team of data collectors, the consultant will be responsible for the creation and cleaning of the following datasets (at baseline, mid-line, and endline):
i. Patient satisfaction survey
ii. Insurer satisfaction survey
iii. Provider satisfaction survey
2. Training of the insurer’s team on indicators and tools designed to monitor the pilot.
3. During the capitation pilot, the consultant will provide ongoing supervision and feedback to the insurer’s team for monitoring the pilot and quality assurance.
4. An end term evaluation that will document the pilot’s lessons, successes and challenges for future learning as the insurer fully transitions to capitation.
Profile / Type of Consultants Required:
This role demands an entrepreneurial individual with a high level of empathy, self-motivation, and
flexibility. Our pace is fast, our processes fluid, and our environment less than traditional. We are looking for someone who is quick, enthusiastic, and has an extremely high level of detail and
organization. He/she will represent SHOPS in a spirited and professional manner, both internally and with partners receiving technical assistance to develop innovative models for health care financing.
No two days are alike, and this individual is navigating his/her way through it all with confidence, problem-solving, and hopefully, a sense of humour. 5 years professional experience of Quality Assurance of hospital departments, care management and customer service with insurance, providers or HMOsMonitoring and evaluation experience such as identifying and tracking health system indicators, developing and implementing surveys is an added advantageClinicians with medical or nursing bachelor’s degreesReceived on job training in quality assurance, care management and customer serviceMasters’ degree in either MPH, MMED an advantageReporting & Timing of Consultancy: May 1, 2014 – February 28, 2015
Total expected level of effort: 60 days
Duty Station / Location: Nairobi, KenyaTo apply to this position, please send a cover letter and your CV to shopskenyainfo@shopsproject.com. In your application, please highlight relevant past experience.
Applications are due May 5, 2014.
Purpose of Assignment: The purpose of the assignment is to provide technical assistance in the development and implementation of a monitoring and evaluation (M&E) Plan and monitor the insurer, provider and client perspectives for a capitation pilot in a health insurance company. The insurer intends to switch from a fee-for-service (FFS) reimbursement system to a capitation mode of payment for their corporate medical products covering out-patient care.
Rationale / Justification for Assignment: Since FY 2013, SHOPS Kenya has been offering TA to an insurer on building their capacity for marketing and distribution. As continuation of this technical assistance, SHOPS Kenya will support the insurer as it pilots a capitation model of paying their network healthcare providers. Brief Background: In FY2014, SHOPS will continue to provide technical assistance to the insurer to facilitate the roll-out of their health insurance product in accordance to the distribution as well as marketing strategies. In addition, SHOPS will support the insurer design and pilot a capitation mode of payment.
Introducing prospective provider payment mechanisms such as capitation controls the negative provider incentives associated with FFS and presents a significant opportunity to control claims ratios
and administration costs for insurers. On the provider end, prospective payments give the advantage of pre-negotiated payments with a lower administrative burden and a predictable revenue stream. Capitation payment systems also allow providers to spend more time on patient care, which frequently increases patient and provider satisfaction.
This being a new concept, the insurer intends to monitor and document the capitation pilot to learn from the experience as they transition from FFS to capitation for all their clients, and support the improvement of the capitation model in subsequent iterations. SHOPS therefore intends to support the insurer with technical assistance to develop systems to identify indicators for continuous monitoring of insurer, provider, and client perspectives. SHOPS will also assist the insurer to develop systems that identify and mitigate challenges that arise during the pilot. SHOPS researchers will assemble this information in an end-term evaluation of the capitation pilot that may be used to advocate for future policy changes.
1. Under the guidance of the SHOPS capitation research lead, support the insurer to identify the challenges associated with capitation and indicators for monitoring the capitation pilot. This will include (but not be limited to) collecting data on the following:
a. Insurer: utilization data, claims incidence, diagnoses, claims ratios, administration costs, challenges and recommendations for improving capitation, comprehension of capitation, and other information relevant to informing rate negotiations with healthcare providers.
b. Providers: satisfaction and motivation in response to the capitation pilot, administration costs (at the beginning and through the duration of the pilot term), profits and sustainability of capitation payments (relative to FFS), challenges and recommendations for improving capitation, comprehension of capitation, and other information relevant to informing rate negotiations with insurance providers.
c. Clients: patient satisfaction, out-of-pocket spending, wait times, access and utilization of needed care, perceived coordination of care
2. Train insurers, providers, and survey teams to implement monitoring tools for use during the capitation pilot. This includes an audit checklist/tool for insurers that will ensure that providers deliver high quality services to clients, a customer satisfaction monitoring tool for a survey of capitated clients, and a survey for health facility administrators and providers around their experiences with participating in the capitation pilot.
a. Coordinate the collection of survey data through phone or facility interviews.
b. Manage a short-term team of data collectors to implement the survey.
3. Assist the SHOPS capitation research lead to develop a quality assurance/monitoring and evaluation plan for use during the capitation pilot and beyond the pilot as the insurer transitions from FFS
4. Implement a training program for the insurer managerial staff on how to use the indicators identified, tools designed and the quality assurance/monitoring plan.
5. Support the insurer in the monitoring of these indicators during the capitation pilot.
6. Provide inputs to an end-term evaluation of the capitation pilot including a report to document findings, lessons, successes and challenges (from insurer, provider, and client perspectives).
Key Deliverables & Expected Outputs:
1. Identify indicators, design tools and develop a plan to monitor the capitation pilot along the insurer, provider and client perspectives
a. While overseeing a team of data collectors, the consultant will be responsible for the creation and cleaning of the following datasets (at baseline, mid-line, and endline):
i. Patient satisfaction survey
ii. Insurer satisfaction survey
iii. Provider satisfaction survey
2. Training of the insurer’s team on indicators and tools designed to monitor the pilot.
3. During the capitation pilot, the consultant will provide ongoing supervision and feedback to the insurer’s team for monitoring the pilot and quality assurance.
4. An end term evaluation that will document the pilot’s lessons, successes and challenges for future learning as the insurer fully transitions to capitation.
Profile / Type of Consultants Required:
This role demands an entrepreneurial individual with a high level of empathy, self-motivation, and
flexibility. Our pace is fast, our processes fluid, and our environment less than traditional. We are looking for someone who is quick, enthusiastic, and has an extremely high level of detail and
organization. He/she will represent SHOPS in a spirited and professional manner, both internally and with partners receiving technical assistance to develop innovative models for health care financing.
No two days are alike, and this individual is navigating his/her way through it all with confidence, problem-solving, and hopefully, a sense of humour. 5 years professional experience of Quality Assurance of hospital departments, care management and customer service with insurance, providers or HMOsMonitoring and evaluation experience such as identifying and tracking health system indicators, developing and implementing surveys is an added advantageClinicians with medical or nursing bachelor’s degreesReceived on job training in quality assurance, care management and customer serviceMasters’ degree in either MPH, MMED an advantageReporting & Timing of Consultancy: May 1, 2014 – February 28, 2015
Total expected level of effort: 60 days
Duty Station / Location: Nairobi, KenyaTo apply to this position, please send a cover letter and your CV to shopskenyainfo@shopsproject.com. In your application, please highlight relevant past experience.
Applications are due May 5, 2014.
