Reimbursement models in the County Council of Stockholm, Sweden. Definition Development Models. Knee/hip replacement surgery

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1 Reimbursement models in the County Council of Stockholm, Definition Development Models Sweden Knee/hip replacement surgery Michael Högberg, health economist 1

2 Definition: What is a reimbursement system? A tool to influence and manage the direction of an enterprise (producticity, quality, service, etc.) Focus on incentive and driving forces A tool for cost control and the use of scarce resources Contains the description of what will be done and on what terms A method/technique to reimburse care-givers 2

3 Definition: Health care system and management The reimbursement system is a part of a comprehensive management of the health care (other parts are legislation, rules, budgets, planning, health targets, needs assessments, quality measurement, follow-up, etc.) A successful management of the health care is a multi-dimensional act of balance and must use several tools 3

4 Development of reimbursement models 4

5 The Reimbursement system 5

6 Reimbursement system in Stockholm 6

7 Future model? Health-related reimbursement (prevention) Objective-related reimbursement (medical results) Production-based reimbursement (DRG) Commission - based Fixed reimbursement?%?%?%?% 7

8 Reimbursement systems and effects Reimbursement system Fixed or variable Related per procedure Timeperspective High productivity Low production costs High quality of care Good service Risk for creamskimming Cost control Fee for service Variable Retrospective Low risk - - In advance Variable Prospective High risk - decided reimbursementlevel per procedure Reimbursement per group of products (eg DRG) Variable Prospective Risk - Related per result Goal-related reimbursement Variable Prospective Risk + Related per individual Capitation Fixed Prospective High risk ++ Related per period Global budget Fixed Prospective/ Retrospective No risk + 8

9 New challenges Vårdval Stockholm Free entrance for authorized providers and freedom of choice for patients More possibilities for the patients Able to chose the provider Accessible for everyone Available whenever I need = All this will increase the production! 12

10 Reimbursement: Emergency hospitals (1) Environment Patient choice Quality Major part, DRG SEK, $ Volume Structural part Commission 15

11 Totalersättning i avtal Sjukhusens ersättning kommer i den nya modellen från sex olika delar Bild 1 X Förbättrad ersättningsmekanism Vårdvalsdel Kvalitet (innehållen) Miljö Ungefärlig andel Ca 3 10 % av sjukhusens totala produktion 0-2 % respektive 0.5 % av totalersättning i avtal Beskrivning Rörlig ersättning till gemensamt pris för auktoriserade vårdgivare Initialt knä- och höftplastik, förlossning, katarakt Ytterligare potentiella områden med tidtabell specificeras i avtal Ersättning kopplad till utfall på kvalitets- och miljöparametrar Huvuddel DRG Ca % av totalersättning avtal Gemensamt DRG-pris för produktion enligt avtalat uppdrag Målvolym på sjukhusnivå Marginalersättning om 30 % för all vård runt målvolym Ersättning för kostnadsytterfall Strukturersättning Ca 5 15 % av totalersättning avtal Fast ersättning som förklarar skillnader i DRG-pris Merkostnadsersättning för mer komplexa fall Jourberedskap Nettokostnad för utbildningsuppdrag, hyresskillnader Särskilda uppdrag Sidoavtal 16

12 Reimbursement of knee/hip replacement surgery (Patient choice Vårdval ) Elective care Only ASA* 1-2 patients A single price per operation Bonus-penalty 3% Responsibility for reoperations within 2 years from first operation Price covers up to 2,2 % revision/reop. *ASA=American Society of Anaesthesiology 20

13 Reimbursement of knee/hip replacement surgery Patient choice and the DRG-system q ASA 1-2(?) μ ASA 3-4(?) 21

14 Knee/hip replacement surgery calculation of price DRG price > SEK in emergency hospitals in SLL (Stockholm County Council) Average price in 2007 in SLL for knee/hip replacement surgery was SEK Includes the more expensive procedures for patients in ASA 3 and 4 22

Knee/hip replacement surgery sources of information Existing procured contracts with providers in SLL and other counties Article in magazine with comparison of prices in Sweden (Läkartidningen no

15 Knee/hip replacement surgery sources of information Existing procured contracts with providers in SLL and other counties Article in magazine with comparison of prices in Sweden (Läkartidningen no 48/2007) Descriptive statistics from Lsf/AVI in SLL and from SKL (SALAR, Swedish association of local authorities and regions) and the national hip joint registry Contacts with representatives from other counties Contact with manager of the National Hip joint registry Contact with representatives from SLL, Hearings with providers, Specialist adviser (Spesak), Lsf (Utvecklingskansliet, AVI och Lsf-IT), ERSMO 23

16 Calculation of price for knee/hip replacement surgery ASA 1 and 2 SKL has no CPP (cost per patient) statistics per ASA-class Quality of the national CPP-statistics is questionnable No similar experience in other counties e.g. Region Skåne and Västra Götalandsregionen Recent offer from emergency hospital regarding 2008 concerning knee/hip replacement surgery for ASA 1-2 Procured contract with private caregiver regarding ASA 1-2, including rehab equal to Patient choice 24

Calculation of No. of op. for knee/hip replacement surgery, ASA 1 and 2 Information from providers of estimated share of patients in ASA 1-2 = 60-70 %.

17 Calculation of No. of op. for knee/hip replacement surgery, ASA 1 and 2 Information from providers of estimated share of patients in ASA 1-2 = %. Equivalent to interval between operations. Median = operations. Information from Vårdgarantikansliet (office of care time guarantee) of current No. of individuals waiting for op. Volume of operations during one year is estimated to 3 300, which is within limits of care time guarantee. Total cost estimated to 200 million SEK. 25

18 Knee/hip replacement surgery revision/reop Med. Specialist adviser (Spesak): estimation of No. of revisions approx. 2-3 % 2-3 % reasonable level compared to National Hip joint registry Revisions + another 10 % more operations Information of cost of revision from Nat. Hip joint registry. Average cost = SEK. 10 % added reop. Average cost = SEK Per total of operations a year: No. of revisions = 66 and 10 % reop. = 7 26

19 Knee/hip replacement surgery calculation of cost for revision/reop Cost (SEK) of revision/reop: 66 * = * = S:A Average cost for operations = SEK 27

20 Reimbursement of Knee/hip replacement surgery, Price in SEK for ASA 1-2(?) Publicly owned providers County-owned companies and private pecialists Comment Price Price incl bonus 6 % compensation for VAT Based on Total price * *Incl. VATcompensation Price SEK includes SEK for compensation of calculated cost for 2,2 % revision/reoperation 28

21 Reimbursement of Drugs Provider responsible for cost of Drugs in out-patient care (20% - 100%??) in 2010 Different solutions (case-mix, primary care, psychiatry, orphan drugs,...) Should match existing reimbursement model Hospitals Orphan Highspecial Special Primary care Base drugs 29

22 Reimbursement models in the County Council of Stockholm, Sweden KIITOS! TACK! 30

2013-10-04 1 Utvecklingsavdelningen. Evaluation of Patient Choice Systems. in Stockholm County 4 October 2013. Michael Högberg. michael.hogberg@sll.

2013-10-04 1 Utvecklingsavdelningen. Evaluation of Patient Choice Systems. in Stockholm County 4 October 2013. Michael Högberg. michael.hogberg@sll. 1 Evaluation of Patient Choice Systems in Stockholm County 4 October 2013 Michael Högberg michael.hogberg@sll.se 2 Evaluation of Patient Choice Systems in Stockholm County Agenda: Patient choice in Stockholm