performance information and health system efficiency in france - ayden tajahmady, france

1 June 2016 - CNAMTS – 37th Annual Meeting of OECD Senior Budget Officials - Stockholm

Performance information and health system efficiency in France

CNAMTS (National Health Insurance Fund for salaried workers)

Ayden Tajahmady – Grégoire de Lagasnerie

Deputy director of the Division of Statistics and Strategic research

37th Annual Meeting of OECD Senior Budget Officials Stockholm, Sweden, 9-10 June 2016

The two ways to implement performance budgeting

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The French health care system:

• Centralized health insurance system • Main issues:

– High Health expenditure as a share of GDP, 2013 : 10,9% (6th OECD country) – Medical practice variation – Equity

Change stakeholders’ behaviors to improve efficiency:

1. Financial incentives towards main health care system’s stakeholders

(professionals, structures and patients) 2. Non Financial incentives thanks to huge data collection: increase

stakeholders’ empowerments to implement medico-economic management

February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

Main challenge : Making sense of the huge amount of data collected to improve efficiency

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Source: http://networkingnerd.files.wordpress.com/


Political decision

Health care professionals’ management

tools

Patients’ empowerment

Indicators

4 February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems

Data and political decision

Data and political decision

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One of the Medico-administrative database in France :

• National Health Insurance Information System (SNIIRAM): exhaustive

anonymous data about >60 millions individuals • Information available on ambulatory care (drugs, medical visits and

procedures, biological tests, dental care, ...), inpatient care, payment for sick leave,...

• Daily reimbursements follow-up

Use of the data for policy decision-making

• Improve healthcare pathways • Contribute to a better management of the health insurance • Contribute to a better management of health policies • Provide healthcare providers with relevant information relative to their

activity, receipts and prescriptions


e.g. Describe the health inequalities due to socioeconomic status in 2013 (a geographic index of deprivation)


Source : SNIIRAM/EGB-PMSI, 2013

2% 3% 4%

6% 8%

11%

14%

20%

26%

35%

42%

48% 49%

3% 5%

7%

10%

13%

17%

21%

27%

32%

39%

45% 48% 45%

0%

10%

20%

30%

40%

50%

Age groups

Prevalence of polypathology

1 (10% les plus favorisés)

2

3

4

5

6

7

8

9

10 (10% les plus défavorisés)

10 % most well-off

10 % least well-off

Map the burden of disease and their costs in France



Cardiovascular diseases, acute

Cardiovascular disease, chronic

Treatment of vascular risk factors (no CVD)

Diabetes Cancers, active

Cancers, surveillance

Psychiatric diseases

Psychiatric treaments

Neurologic diseases

Chronic respiratory

disease

Inflammatory or rare diseases or HIV

Diseases of the liver or pancreas

Maternity

Isolated hospitalisation

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

0 2,000 4,000 6,000 8,000 10,000 12,000

Num

ber o

f pat

ient

s

Average cost per patient (€)

Medicalized approach of expenditure to target specific policies on costly disease: Sick leave

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22%

3% 6% 6% 5% 5%

28%

25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% Soins courants/traitements antalgiques ou anti-inflammatoires

Hospitalisations ponctuelles (avec ou sans pathologies,traitements ou maternité)

Maternité (avec ou sans pathologies)

Autres

Cancers

Diabète (avec ou sans pathologies) ou traitements durisque vasculaire (hors pathologies)

Maladies cardioneurovasculaires

Maladies psychiatriques ou psychotropes

Basic care and treatments with pain killers

Isolated hospitalisations

Maternity (maternity leave excluded)

Others

Cancer

Diabetes and other vascular risk treatments

Cardiovascular diseases

Psychiatric diseases or treatments

Total 10,2 Billion out of 147 Billion € (7%)


Data and health care professionals management tools

Data and health care professionals’ management tools


Financial tools: P4P

Non-financial tools: benchmark and information

Hospital

Financial incentives for quality improvement (IFAQSS)

• Pilot phase • Quality : assessing pain, screening

for denutrition… • Reward : 0 to 0.5 % of previous

year budget

Web platform (http://hospidiag.atih.sante.fr/)

• Activity, Quality, • Organization, Human resources • Finance

Outpatient

Financial incentive for public health targets (ROSP)

• Generalized since 2011 • 29 indicators (organization,

chronic disease follow-up, prevention, efficiency)

• 1300 points / 7€ per point • In 2014, av. 5,900 € / GP • Total expenditure : 376 M€

Medicalized management of spending (maîtrise médicalisée) • Any prescirption is eligible (drugs,

physiotherapist, sick leace…) • Information and benchmark is

procided according to prescription profile

• Prior authorization schemes are possible

http://hospidiag.atih.sante.fr/

Global surgical performance of my hospital ?


Source : ANAP - ATIH © 2015-2016

Global financial performance of my hospital?


Source : ANAP - ATIH © 2015-2016

Medicalized management of spending (maîtrise médicalisée)


Interview with high

prescribing (drugs, cash

allowances…) physicians to

give them some data about their activity in

comparison with « same »

physicians


Data and patients’ empowerment

Data and patients’ empowerment : increase competition between providers

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Lack of information for patients is one of the main cause of inequality in

the health care system

Collection of data should be used to inform patients about the quality of care… • Reluctance from professionals to be ranked and compared according to

subjective indicators

Some tools exist but there is still a large scope for further improvements

• www.annuairesante.ameli.fr/ : information about average costs of different medical procedures billed by the health professional

• http://www.scopesante.fr/ : Help to choose an hospital through organizational and quality indicators (nosocomial illness, organization)


http://www.annuairesante.ameli.fr/



http://www.scopesante.fr/

Increase competition between health care providers by circulating average costs in function of the type of care

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E.g. Choose a dentist: a type of care associated with high out-of-pocket • Dentist A’s tariff for tooth crown on dental implant

• Dentist B’s tariff for tooth crown on dental implant


Source : www.annuairesante.ameli.fr/





Conclusion: how does it contribute to increase the efficiency of

the health care system?

Conclusion

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Difficult to evaluate the impact of these tools…

• For instance: difficulty to estimate the impact of P4P programs

But they may have an impact on patients’ and professionals’ behaviors in mid or long term

To go further: • Political decision

– Health law 2015: Open data for database without risks of re-identification (increase access for researchers to evaluate of health policies …)

• Health care professionals’ management tools and patients’ empowerment – E-Satis: online satisfaction survey after hospital discharges


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Thank you for your attention !



Annex: The French health care system in a nutshell


The French health care system in a nutshell

Source : Health at a glance 2015

Outpatient care :

• Majority of general practitioners and specialists • Fee for services with private practice for physicians

• Pay for performance

• Freedom of establishment for physicians and weak gatekeeping

Inpatient care : • Majority of DRG payment + Global budget for specific missions

(teaching, research, emergency care)

• All hospitals are financed by the public health insurance but managerial autonomy for hospital director

• Majority of public beds (62% of public beds, 14% of private not for profit beds, 24% of private for profit beds)

Supply side


Health expenditure and financing


Expenditures : • Health expenditure per capita, 2013 : 4124 USD PPP (12th

OECD country) • Health expenditure as a share of GDP, 2013 : 10,9% (6th OECD

country) – High share of impatient care : 35% (3rd OECD country)

Financing : • Centralized health insurance funds financed by taxes and

social security contributions : 79% • Private complementary insurance financed by premiums :

14% • Out-of-pocket : 7%

performance information and health system efficiency in france - ayden tajahmady, france

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