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