Document

Ziekenhuisfinanciering 2.0. Een visie van een gezondheidseconoom Lieven Annemans Universiteit Gent, VUB

November 2013

Inhoud I. II. III. IV.

Wat is het probleem? Hervorming van de gezondheidszorg Hervorming van de ziekenhuisfinanciering Finale bedenkingen

2

I. Wat is het probleem? 1. Health expenditure has been growing faster than the economy 2. Too much unnecessary care and large variability in care (incl. undertreatment) 3. Lack of coordination: 1st line – 2nd line; preventioncure; ... 4. Increasing problems with equal access to care

source: OECD 2009 3

Probleem! de gezondheidssector groeit(de) sneller dan de economie

OECD Health Policy Studies. Value for Money in Health Spending, 2010, 204pp

4

-15.0%

Iceland

Switzerland

Germany

Norway

Hungary

Poland

United States

Austria

Netherlands

Sweden

Canada

Belgium

Finland

France

Denmark

Australia

Spain

United Kingdom

Italy

Czech Republic

Estonia

Portugal

Slovak Republic

-5.0%

Ireland

Greece

 Overal nadruk op besparingen Jaarlijkse groeicijfers vd gezondheidssector in diverse landen

15.0%

10.0%

5.0%

2001-2009

0.0%

OESO statistieken 2013

2010-2011

-10.0%

5

Maar impact van de vergrijzing & nieuwe technologie Vergrijzing +technologieën

Enkel vergrijzing

Itinera, 2010, Planbureau 2012 6

“Health is a value in itself. It is also a precondition for economic prosperity. People’s health influences economic outcomes in terms of productivity, labour supply, human capital and public spending.”

I. Wat is het probleem? 1. Health expenditure has been growing faster than the economy 2. Too much unnecessary care and large variability in care (incl. undertreatment) 3. Lack of coordination: 1st line – 2nd line; preventioncure; ... 4. Increasing problems with equal access to care

source: OECD 2009 8

Recent study in Belgian hospitals • 34 hospitals (IMS database) • MCD and Financial information for all stays • 2 substudies: – Readmissions for same reason as index stay within 1-3 months – Hospital acquired infections

9

Results re-admissions • 2.1% readmissions (n = 27,000) within 3 months after original hospitalisation • total cost to the health insurance = € 280 Mln • Wide variability between hospitals (1.17 - 6.40%)

Results HAI • 5.9% of the hospital stays associated with a HAI (+/75,000 cases of HAIs). • Total cost of HAI in Belgium is estimated at € 533 Mln • Variability between hospitals (3.77-9.78%). 10

Bizarre financiering 40% Budget financiële middelen

Werkingskosten Verblijfskosten Verpleegkundigen Verzorgenden …

40% Afhoudingen op inkomsten van de artsen

Op basis van betaling per prestatie

15%

5%

Pharma Op basis van afgedwongen kortingen

11

Inhoud I. II. III. IV.

Wat is het probleem Hervorming van de gezondheidszorg Hervorming van de ziekenhuisfinanciering Finale bedenkingen

12

5 solutions for a performant health care system 1. 2. 3. 4. 5.

Setting goals and targets Revising structures and processes Search for cost-effectiveness in all what we do Invest in a perfect ICT system Revising the way healthcare providers are paid

13

1. The primary goal of health care policies • to maximize the health of the population within the limits of the available resources, and within an ethical framework built on equity and solidarity principles. Report of the Belgian EU Presidency, endorsed by the EU Council of Ministers of Health in Dec 2010

Must be translated in concrete SMART objectives

14

2. Change the structures & processes • A mandatory GP (medical coach) for everyone • Integrated care networks and case managers for multimorbidity (supervised by the medical coach) • “Goal oriented care” • More telemedicine and –prevention • Patient responsibility & self-monitoring • New professions (physician assistants, practice nurses, nurse-specialists) • …

15

16

The benefits of primary care oriented health systems

• • • • • • •

Less hospital admissions Less emergency visits* Less non-evidence based surgery Less readmissions Better self reported health More prevention …. 17

Kost

3. Kosten-effectiviteit Niet C-Eff NIEUW

Huidige aanpak

C-Eff NIEUW

NIEUW

Dominant

Gezondheidseffect (QALYs) 18

Annemans L. Health economics for non-economists. AcademiaPress, 2008

4. Perfect health information system

“ If you do not have all information for all the patients , all the time you are wasting your money ”

George Halvorson, CEO,Kaiser Permanente intreview http://vimeo.com/4039344

19

Improving quality and reducing costs - Is it possible ? Latest news from Kaiser Permanente • Cut Serious heart attacks by 62% in 10 years • Cut Heart attacks by 24 % in 10 years

• Cut fractures in osteoporotic patients by 37%

• Cut hospitalization in patients with co-morbidity by 70 %!!!

25% lower medical costs

10 % lower insurance primes

Investing in IT: € 30 per member/year 20

5. Change the way we pay “Fee for Service” • Overconsumption (supplier induced demand) Prospective payments (Pay per stay) “ALL-IN” • Cost shifting • Risk selection • Quality  • Unbundling • Outliers problems • … 21

Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physicianinitiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation (due to reduced cost sharing) indicate limited evidence for moral hazard.

22

More “Capitation”? • Fixed amount per patient per time period + + + + -

decreased risk for overconsumption improved access more focus on prevention patient empowerment undertreatment? attractivity of young healthy patients? cost shifts?

Not shown by KCE

(KCE rapport , 2009) 23

Inhoud I. II. III. IV.

Wat is het probleem Hervorming van de gezondheidszorg Hervorming van de ziekenhuisfinanciering Finale bedenkingen

24

Towards pay for quality?

“From Paying to do things To Paying to do things right And Paying to do the right things” 25

Evidence on effects Targets with above 5% positive effect

title

26

27

Cfr. Quality indicators Flanders http://www.zorg-engezondheid.be/Beleid/Kwaliteit/Basisset2012/#indicatoren • Moeder en kind • Oncologie • Orthopedie • Cardiologie • Ziekenhuisbreed domein 28

BUT: some pitfalls of P4Q 1. Poor definition of quality: structure, process and outcomes indicators 2. Not involving the physicians, lack of communication 3. Size and type of the financial reward/penalty not well studied 4. Problem with engaging physicians continuously 5. Patient case-mix

29

Opties voor ziekenhuisfinanciering Forfait per APRDRG per verblijf incl. 1 maand post

P4Q

Idem maar excl. artsen

forfait voor intellectuele prestatie artsen

P4Q

Idem maar excl. artsen

FFS voor intellectuele prestatie artsen

P4Q

! Geen afhoudingen meer

30

IV. Final thoughts • Economisch denken in de zorg moet ten dienste staan en niet ten koste gaan van kwaliteit. • Eeen systeem met perverse financiële prikkels kan nooit performant zijn • Er is nog veel ruimte voor verbetering inzake kosteneffectiviteit • In de toekomst zal fee for service geleidelijk aan plaatsmaken voor “capitation” en P4Q • De toekomstige ziekenhuissector zal relatief kleiner en financieel gezonder moeten zijn • Een visie 2025 is nodig voor de ganse gezondheidssector.

31

Vanaf midden Februari 2014

32

Ziekenhuisfinanciering 2.0. Een visie van een gezondheidseconoom Lieven Annemans Universiteit Gent, VUB

November 2013