Introduction to the Disease
Management Funding
approach
Jacob Hofdijk
EFMI president
Ministry of Health – Integrated Funding Team
Care continuum with silo’s
Reasons for Reform in 1994
• Two contra productive business models
• Hospital tries to keep within the budget
• Physician on fee for service
• Involvement of Government too restrictive
• Growing costs, but no metrics of the outcome
• 1994 Biesheuvel Report Modernising Curative
Care
• The start of Paradigm Shift from supply to
demand orientation
Performance based hospital funding
• Demand orientation Health issue patient
• Combine diagnostics and treatment
• Payment of Hospital / Medical specialist
• Requires data collection by patient by health
issue
• New dimension in health information systems
• System designed by major stakeholders
• After preparation introduction for funding 2005
Health Insurance Act 2006
• Mandatory Insurance scheme for all
• After 30 years of political discussion !
• Competing private insurance companies
• Insurance company contracts health
providers of choice
• Central role for Insurance companies
• Focus on Quality Improvement
• Sustainable health care system
Impact contracted careproducts
The Dutch DBC Funding results
More market and transparency
Patients can choose
Process of CHANGE !
DBC-systems works
7
The 2030 Long Term Care Crisisgrowth of chronic diseases since 2005
0
10
20
30
40
50
60
70
80
90
Diabe
tes
Diab+
BM
I
Har
tinfa
rct
Ber
oerte (C
VA)
Har
tfalen
Col
onka
nker
Lon
gkan
ker
Bor
stka
nker
Astm
a
COPD
Osteo
poro
se
%
Mannen
Vrouwen
Chronic Disease Costs > 70%
Major Causes of Chronic
Diseases
Diabetes Care Standard
11
Care Standard is Special
• Developed by Care Providers and Patients
• Based on Guidelines / Protocols / Lifestyle
• Defines what Good Chronic Care is for patiënt
• Not who should perform
• Combines Prevention and Care
• Defines Quality Performance Indicators
• Base for Task substitution
• Involvement Patient
2005 National Diabetes taskforce
• Diabetes Care is growing
• The system will not be able to cope
• The NDF Diabetes Care Standard • Agreed by professionals and patient organisation
• Only applied to 40 % of the patients
ACTION is needed
13
2006 Diabetes funding Experiment
• Performance based funding for Diabetes
• Based on the Care Product Approach
• Contracting by Insurance Companies
• With Multidisciplinary Care Team
• Represented by a Care Group, a legal entity
• Reporting of Process and Outcome
• Care based on the NDF Care standard
• First step to Integrated Care Delivery
• Experiment with 10 groups
The Dutch Chronic Care Funding Model
Carestandard for
Good Diabetes Care
Process
Outcome
Patient CQ
Caregroup InsurerContract
15
PatientPatientCare
Providers
• Care group responsible for outcome
• Focus on education and continuous learning
• Documentation of care process and outcome
• IT support still in its infancy, but good examples
• Quality improvement process stimulated
• The contracting process is new for all
Result Experiment
In Green en White areas with
lower then expected foot
amputations a disease mgt
approach was applied.
The black and red areas have
Higher then expected
amputations
First indications of result
Next Step
Integrated Care Funding
introduction for chronic diseases
Preparation started in 2009
18
Integrated Care Funding 2010
• Integrated Funding for chronic conditions1. Diabetes2. Cardio Vascular Risk Management3. COPD
• Based on Authorized Care Standards• Contract on Price / Performance Indicators• Free pricing• Transparency by Reporting Chronic Dataset• Focus on Prevention • Patient part of the team – Lifestyle changes
19
Integrated Care in and exclusions
Integrated Care Product
Incidental Medical
Specialist Care
Physiotherapy
program
Indication
Indication
Ex
clusion
In
clusion
Integrated care & care standard
21
Care StandardMedical
Specialists
PATIENT
Dietist
Physiotherapies
Podotherapist
GP Pharmasists
Laboratory
Imaging Dept
Home Care
A meta standard for care standards
• Care standard development was hot
• National Platform for care standards
• Develop a model for care standards
• Define what care should be provided
• Care standard base for individualised care
• Define Obligate Parameters
• Process and outcome measures
• Implementation aspects
22
Focus Care Standard
Healthy
At R
isk
Dia
gnosis
Chro
nic
ally
Ill
23
Care Standard Model
Indexed
PreventionCare related
Prevention & treatment
IT requirements
• Multidisciplinary team of primary (GP’s, Nurses
, paramedical specialist) and secundary care (
medical specialist)
• Patiënt is part of the care team
• Individual Proactive Treatment plan
• Semantic Interoperable Data
• Cross institutional solution
• Annual Reporting Dataset by patient
Documentation Parameters (DCM)
Each submodule has a number of Obligate Parameters
Document these in a Detailed Clinical Model DCM
The DCM is the base for registration , Exchange of Data and
Reporting
DCM are part of the care standard
DCM will be maintained nationally
DCM have two dimensions
Modeling clinical content to clinical datamodel
Translating Clinical datamodel to implementation standards
Care Standard Model +
Indexed
PreventionCare related
Prevention & treatment
Specification
Parameters DCM
Implementation Dimensions
Reporting
Datasets
eHealthRequirements
I
N
T
E
G
R
A
T
E
D
Result
• Care standard
Care Process
Interventions
Quality Indicators
• Annex to the Care Standard
• Funding arrangement
• Contracting
• Documentation
• Specification Clinical Parameters
• Reporting dataset
• ICT requirement
Website to support
New health delivery model –
phase 1
Integrated DBC funding
Diabetes
CardioVascularRisc Management
Take Home Message
• Active involvement of Patient, individual
treatment plan based on
• Care standards ( Clinicians Consumer Patients)
with integrated eHealth standards
• Interlinking of prevention and care
• New business model focused on quality
• Reorientation Health Delivery System
substitution
• Challenges providers and insurers
• European Approach seems needed !
Healthy
At R
isk
Dia
gn
osis
Ch
ron
ica
lly Ill
34
Find the Motivation