Post on 14-Jan-2016
description
Ziekenhuisfinanciering 2.0.Een visie van een
gezondheidseconoom
Lieven AnnemansUniversiteit Gent, VUB
November 2013
InhoudI. Wat is het probleem?II. Hervorming van de gezondheidszorgIII. Hervorming van de ziekenhuisfinancieringIV. Finale bedenkingen
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I. Wat is het probleem? 1. Health expenditure has been growing faster than
the economy2. Too much unnecessary care and large variability in
care (incl. undertreatment)3. Lack of coordination: 1st line – 2nd line; prevention-
cure; ...4. Increasing problems with equal access to care
source: OECD 20093
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Probleem! de gezondheidssector groeit(de) sneller dan de economie
OECD Health Policy Studies. Value for Money in Health Spending, 2010, 204pp
Overal nadruk op besparingen
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Jaarlijkse groeicijfers vd gezondheidssector in diverse landen
-15.0%
-10.0%
-5.0%
0.0%
5.0%
10.0%
15.0%
Gre
ece
Irela
nd
Icel
and
Slov
ak R
epub
lic
Port
ugal
Esto
nia
Czec
h Re
publ
ic
Italy
Uni
ted
King
dom
Spai
n
Aust
ralia
Den
mar
k
Fran
ce
Finl
and
Belg
ium
Cana
da
Swed
en
Net
herla
nds
Aust
ria
Uni
ted
Stat
es
Pola
nd
Hun
gary
Nor
way
Ger
man
y
Switz
erla
nd
2001-2009
2010-2011
OESO statistieken 2013
Maar impact van de vergrijzing & nieuwe technologie
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Itinera, 2010, Planbureau 2012
Enkel vergrijzing
Vergrijzing+technolo-gieën
“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 economy2. Too much unnecessary care and large variability
in care (incl. undertreatment)3. Lack of coordination: 1st line – 2nd line; prevention-
cure; ...4. Increasing problems with equal access to care
source: OECD 20098
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
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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%)
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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%).
Bizarre financiering
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Budget financiële middelen
WerkingskostenVerblijfskostenVerpleegkundigenVerzorgenden…
Op basis van betaling per prestatie
Afhoudingen op inkomsten van de artsen
Op basis van afgedwongenkortingen
Pharma
40% 40% 15% 5%
InhoudI. Wat is het probleem II. Hervorming van de gezondheidszorgIII. Hervorming van de ziekenhuisfinancieringIV. Finale bedenkingen
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5 solutions for a performant health care system
1. Setting goals and targets2. Revising structures and processes3. Search for cost-effectiveness in all what we do4. Invest in a perfect ICT system5. Revising the way healthcare providers are paid
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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.
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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
2. Change the structures & processes• A mandatory GP (medical coach) for everyone• Integrated care networks and case managers for multi-
morbidity (supervised by the medical coach)• “Goal oriented care”• More telemedicine and –prevention• Patient responsibility & self-monitoring• New professions (physician assistants, practice nurses,
nurse-specialists)• …
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• Less hospital admissions• Less emergency visits*• Less non-evidence based surgery• Less readmissions• Better self reported health• More prevention• ….
EenvastehuisartsvoorIEDEREEN
The benefits of primary care oriented health systems
3. Kosten-effectiviteitK
ost
Gezondheidseffect (QALYs)
Huidigeaanpak C-Eff
Threshold (+/- 40.000/QALY)
Annemans L. Health economics for non-economists. AcademiaPress, 200818
Dominant
Niet C-Eff
NIEUW
NIEUW
NIEUW
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“ If you do not have all information for all the patients , all the time
you are wasting your money ”
George Halvorson, CEO,Kaiser Permanenteintreview http://vimeo.com/4039344
4. Perfect health information system
10 % lower insurance primes
25% lower medical costs
Improving quality and reducing costs - Is it possible ?
• 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 %!!!
Latest news from Kaiser Permanente
Investing in IT: € 30 per member/year
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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 • …
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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 physician-initiated 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.
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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?
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(KCE rapport , 2009)
Not shown by KCE
InhoudI. Wat is het probleem II. Hervorming van de gezondheidszorgIII. Hervorming van de ziekenhuisfinancieringIV. Finale bedenkingen
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Towards pay for quality?
“From Paying to do things ToPaying to do things right
And Paying to do the right things”
Evidence on effects
title 26
Targets with above 5% positive effect
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Cfr. Quality indicators Flanders
http://www.zorg-en-gezondheid.be/Beleid/Kwaliteit/Basisset-2012/#indicatoren •Moeder en kind•Oncologie•Orthopedie•Cardiologie•Ziekenhuisbreed domein
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BUT: some pitfalls of P4Q
1. Poor definition of quality: structure, process and outcomes indicators
2. Not involving the physicians, lack of communication3. Size and type of the financial reward/penalty not well
studied4. Problem with engaging physicians continuously5. Patient case-mix
Opties voor ziekenhuisfinanciering
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Forfait per APRDRG per verblijf incl. 1 maand post P4Q
Idem maar excl. artsen P4Qforfait voor intellectuele prestatie artsen
Idem maar excl. artsen P4QFFS voor intellectuele prestatie artsen
! Geen afhoudingen meer
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 kosten-
effectiviteit• 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.
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VanafmiddenFebruari
2014
Ziekenhuisfinanciering 2.0.Een visie van een
gezondheidseconoom
Lieven AnnemansUniversiteit Gent, VUB
November 2013