Utvecklingsavdelningen. Evaluation of Patient Choice Systems. in Stockholm County 4 October Michael Högberg. michael.hogberg@sll.

Transcription

1 1 Evaluation of Patient Choice Systems in Stockholm County 4 October 2013 Michael Högberg michael.hogberg@sll.se

2 2 Evaluation of Patient Choice Systems in Stockholm County Agenda: Patient choice in Stockholm county Impressions of patient choice in Sweden Reimbursement models Cost containment Innovation New projects

3 3 Stockholm County Council Health care budget 49 Billion SEK Approx contracts (Local traffic) (Culture) 26 municipalities 2.1 million inhabitants (~22% of the population in Sweden) 3

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5 5 What distinguish patient choice in Stockholm? Medical centres/general practitioners

6 6 SCC: Implemented patient choice programs Child welfare clinics Hip and knee Obstetric care Vaccination Spec. gynecology arthroplasty Antenatal care Cataract extraction Obstetric ultrasound Primary hearing rehab Spec. dermatology out-patient care Chiroprody Medical centers/family doctors and home care Physicians in residential homes for elderly Speech therapy Vaccination pandemia (ended 2010) Fundus photography for diabetics (incl. in spec. eye out-patient care from 2012) Planned spec. rehabilitation for neurology, onchology and lymphoma Specialist dental care for children and youth Spec. eye outpatient care General dental care for children and youth Spec. physiotherapy Spec. ear-nosethroat out-patient care Dental surgery for children and youth Primary care rehab

7 7 Vårdval Stockholm: Objectives and measures Improved access Choices and multiple provider structure Competition ( neutrality btw public and private GPs ) Payment: Ca 40% capitation based on age (no socio-economic indicators) Remaining payment: per type of visit, extra payment for homevisits, interpreter, and some geographical areas. Patient fees are kept by providers, but reduced from payment from the county council, the high-cost protection is paid by the county council Ceiling for reimbursement, reduced after 1,9 visits per listed (average), after 4 visits/listed only patient fee. Some medical services is included in the reimbursement

8 8 Evaluation of the Patient Choice Reform - Health Economics perspective (Source: C Rehnberg, Karolinska institutet) Cost containment Efficiency/productivity Distribution and Equity Quality/Patient satisfaction Ownership and contracts

9 9 The development of costs in GP services, Stockholm county council, ) Korrigerat med LPI

10 10 Productivity (cost per contact),

11 11 Total cost (blue bars) and cost per capita (red line) per year for Medical Centres in PC in SCC. SEK. Fixed prices : Total cost: + 4 % Population: + 11 % Cost per capita: - 7 %

12 12 Number of visits to Doctor at Medical Centers per age and year in SCC

13 13 Change in Number of visits to Doctor at Medical Centers for different Diagnosis (=blue bars) compared to the Whole Population (=green bar) in SCC COPD(KOL) Diabetes Asthma High bloodpressure(högt blodtryck) Heart disease(hjärt- och kärlsjukdom) Rheumatoid arthritis

14 14 The Lorenz-curve distribution of utilization per income area Cumulative share of performance 100% 80% 60% 40% 20% O B C 20% 40% 60% 80% 100% Cumulative share of population (ranking from poorest to richest)

15 15 The distribution of doctor visits per income quartile (geogr areas) Lowest = = Highest income

16 16 The distribution of visits to doctors, nurses and costs across low and high income areas * = A positive value(+) indicates a higher utilization in rich geographical areas, and a negative value (-) indicates a higher utilization in poor areas.

17 17 SCC: Private and public share of total costs in 2007

18 18 SCC: Private and public share of total costs in 2008

19 19 SCC: Privat och offentlig andel av kostnader 2011 Private and public share of total costs in % 90% 80% 81% 80% P r o c e n t 70% 60% 50% 40% 30% 20% 19% 20% 60% 40% 51% 50% 64% 36% 67% 68% 34% 32% 10% 0% Somatisk specialistvård Psykiatri Primärvård Geriatrik Övrig hälso- och sjukvård Verksamhetsområde Tandvård Totalt Privat prod SLL prod (inkl andra landting, kommuner och stat

20 20 Ownership distribution SLSO = public providers

21 21 Evaluation of patient choice reform in SCC Karolinska Institutet: Follow-up of GP system Cost increase under control Increased access Increased use of care (mainly GP) Increased productivity, 5-6 % Reduced cost per capita (immigration) Increase of performance for all ages Positive correlation between productivity and patient satisfaction Increased share of private GPs New establishments both in the city and in suburbs Patients in more severe conditions have increased the consumption of care No proof of cost-shifting to other care and medical service Karolinska Institutet: Follow-up of GP system 2010: Cost per capita in fixed price unchanged No. of visits to GPs increased 3 % (incl all ages) No change in patient satisfaction Productivity increase 2,1 % Patients in socioeconomically weak areas consumed a larger share of the service More patients from these areas get listed in richer areas No sign of cost-shifting

22 22 Impressions of patient choice in Sweden sources: National Board of Health and Welfare Swedish Agency for Health and Care Services Analysis Karolinska Institutet Swedish Association of Local Authorities and Regions (SALAR) Reports from several county councils Other

23 23 Share of patients that could visit the GP within 7 days in private and public care in Sweden (Source: Waiting times in Healthcare Database, SALAR) 96% 95% 94% 93% 92% Privat Offentligt 91% 90% 89% 88% Våren 2009 Hösten 2009 Våren 2010 Hösten 2010 Våren 2011 Hösten 2011 Våren 2012 Hösten 2012

24 Confidence in Medical Centers in Sweden according to population questionnaire (Source: Vårdbarometern, SALAR) (1) Very low (2) Rather low (3) Neither-nor (4) Rather high (5) Very high

25 Million SEK Share in per cent The Counties purchase of services per type of provider, private and public, million SEK and share of total net cost (Source: SALAR) Köp av verksamhet från privata leverantörer Köp av verksamhet från offentliga leverantörer Share of net cost

26 26 Impressions of patient choice in Sweden - results The patients value freedom of choice those who made active choices were more satisfied Patient satisfaction seems to have increased (with increased freedom of choice) The patients choice of provider were based on short distance and reputation not medical results Cost controlled during implementation of patient choice in PC No signs of cost-shifting But all of the population have increased the use of care in a larger extent than individuals with great need of care Co-operation between PC and other care (incl social services) more difficult due to versatility of providers Patient choice contracts more flexible than procurement Potential for improvement knowledge of structure for decisions information to citizens of patient choice and informed decisions follow-up (reporting of statistics, implementing validated goals for quality) stimulate co-operation between providers across administrative boarders

27 27 Better, faster, cheaper health care

28 Reimbursement models for patient choice (vårdval) in primary care (Source: Anell & SALAR) Capitation - Fixed reimbursement per listed individual. Age wheight. Adjusted Clinical Groups (ACG). Adjustment for diagnose classification Case-mix Care Need Index (CNI) socioeconomic wheight, describes the expected risk of illness. Reimbursement per visit GP, nurse etc. Goal related reimbursement Variable reimbursement based on result. Geography Adjustment for localization of medical centre. Coverage Adjustment according to listed persons visits in PC in relation to total number of out-patient visits. Responsibility for cost for visiting other providers, drugs, medical service etc

29 29 Patient choice and reimbursement models in primary care (Source: Anell & SALAR) Principles of reimbursement: (fixed/variable, visit/procedure-related and goal-related reimbursement) Fixed reimbursement varies from 40 to 80% of total 13 counties adjust for age, 8 for ACG (5 combines) 16 counties adjust for difference in socioeconomy (CNI etc.) 14 counties adjust for localization of medical center 15 counties adjust for coverage (definitions varies!) Stockholm CC and Uppsala CC highest share of reimbursement per visit All counties except one use goal-related reimbursement (2-5%)

30 30 Cost containment (Source: Anell & SALAR) Rationing demand Unspecified problems Responsibility for remittance and cost Specified problems Assessment of need/illness Differentiated patient fees Guidelines against indication creep Rationing supply Low reimbursement for PC-visits Episode of care/bundle price if possible Retroactively reduced price Maximum procedure per patient (or provider) Guidelines/standardization Episode of care/bundle price/ /capitation Retroactively reduced price Maximum procedure per patient (or provider) Guidelines/standardization Need for supplementary management and follow-up!

31 31 Additional objectives with patient choice system in PC and specialized care Stimulate innovation and new ways to organize the care Get a larger variety of providers Stimulate coherent chains of care (elderly PC hospital care, etc.)

32 32 New projects with reimbursement models - Valuebased healthcare & episodes of disease (bundled payment) - Patient centered & health related outcomes - Case management & disease management - Integrated care Hip/knee arthroplasty (complication guarantee) Spine & neck surgery (10% health outcome based) Rheumatoid Arthritis (chronic care, valuebased, patient centered, disease episode, e-health, drug cost, DRG) COPD (care chain, episode, guidelines, incentives, DRG) Aktiv Hälso Styrning (AHS) (case & disease management) - coaching: Multicontacts emergency hospitals, CHF, COPD New Karolinska university hospital & future healthcare system

33 33 Prometheus model (US) 1. Base reimbursement 2. Reimbursement additional costs 3. Reimbursement for PAC 4. Reimbursement for outcome 4 Retrospective Prospective 3 Outcome reimbursement Potentially Avoidable Complications 2 Known additional costs Expected additional costs 1 Base reimbursement

34 34 Bundled payment model > Lump-sum reimbursement > Outcome reimbursement > Provider warranty > Patient informed provider choice > Freedom of establishment Value based competition Value = Health Outcomes Cost of treatment Sick patient First visit Operation Rehabilitation Revisit 1 month Healthy patient complication Bundled price = X SEK + outcomebased reimbursement Spine surgery +10% of X SEK for health outcome

35 35 Value-based reimbursement rheumatoid arthritis (RA) Research questions Which outcome measures concerning patients and cost can be used to operationalize value? What in the healthcare is experienced as value by the patient with RA? How are incentives for continuous innovation created in the care to increase value for the patient? Can a value-based reimbursement act as incentive to increase the value for patients with RA?

36 36 Example: RA - phases and targets for value improvement Diagram för långtidsuppföljning från SRQ Årsrapport Genomsnittlig förändring av sjukdomsaktivitet (DAS28) med konfidensintervall över tre år, vid alla månadskontrolltillfällen (MK1-MK36) för RA patienter. Visar att den initiala förbättringen tre månader efter inklusion i kvalitetsregistret tenderar att kvarstå. Prephase, early detection Prephase Short duration of illness Access to reum. clinic Coherent pathway PC reum. clinic Genomsnittlig förändring av sjukdomsaktivitet (DAS28) med konfidensintervall över tre år, vid alla månadskontrolltillfällen (MK1-MK36) för RA patienter. Visar att den initiala förbättringen tre månader efter inklusion i kvalitetsregistret tenderar att kvarstå. Phase 2, keep down Aim phase Genomsnittlig förändring av sjukdomsaktivitet (DAS28) med konfidensintervall över tre år, vid alla månadskontrolltillfällen (MK1-MK36) för RA patienter. Visar att den initiala förbättringen tre månader efter inklusion i kvalitetsregistret tenderar att kvarstå. Phase 1, response Aim phase 1 Quick response Treatment to reach low or no disease activity Good QoL and function Remission Low level of diseaseactivity Physical excercise Smoking cessation Preserved function

37 COPD: Incentives for better health outcome and resource use Objective: To use register data to describe the chain of care for COPD-patients Calculate the cost of the chain of care Analyze the correlation between registered procedures and effects Compare with existing guidelines for care of COPDpatients

38 38 Cost COPD: Incentives for better health outcome and resource use Avoiding unnecessary acute contacts, visits and in-hospital care Investment in PC Incentives for early detection, evidence-based treatment & collaboration Course of disease

39 39 COPD: Expected result An overview of the gap between guidelines and practice in the care of COPD-patients In the analysis outcome will be related to existing reimbursement model to identify if and how existing incentive structure and reimbursement have an impact on the result. Incentives to co-operation and the existence of cost-shifting Ideas for possible improvements of the reimbursement to make it more useful as a steering tool to optimize activities during the episode and to increase the compliance to guidelines Could include principles for reimbursement for longer episodes such as bonus/fines for improvement of co-operation between providers Analysis of adjustment and coordination between incentives in the reimbursement system and other incentives for knowledge management to optimize the care and to implement guidelines Analysis of possible impact on the future health care system

40 Case management and Disease management: A small part of the population accounts for a large part of healthcare expenditures % 10-15% 80% Case Management Most healthcare intensive patient groups Disease Management Most healthcare intensive diseases Population Health Management Risk groups in the population In the County of Stockholm 1 % of adults account for 30 % of total health care spending and 25% of all emergency admissions 1,5 million Swedes suffer from asthma, depression, diabetes, CHF or stroke In Sweden there are: Approx 1,8 million smokers Approx 2,7 million overweight Source: National Registry of Health Care Quality (SALAR), National Registry of Atshma, Health Economics of Depression - Sobocki (2006), National registry of Diabetes, National registry of CHF, National Registry of Stroke, Swedish National Institute of Public Health, Health Navigator analysis 40

41 41 The case management intervention 1. Motivational conversations 2. Self-care support 3. Patient education 4. Coordination of social and medical services

42 42 The result for all patients included during the last 12 months RCT s evaluating case management models in the County of Stockholm Frequent ER* visitors ind Compared with a control group Patients receiving nurse support have % less in-hospital days and slightly increased outpatient care - 19 % or Euro per patient in reduced health care cost CHF** 800 ind 14 % less in-hospital days and slightly increased outpatient care - 9 % or Euro per patient in reduced health care cost COPD*** ind 20 % less in-hospital days and a slightly increased outpatient care - 11 % or Euro per patient in reduced health care cost * ER = emergency room; ** CHF = Congestive Heart Failure; *** COPD = Chronic Obstructive Pulmonary Disease

43 43 Challenges Reimbursement models based on the value for the individual patient More variables concerning the patient s situation incl patient safety & health outcome Adaptation to law concerning secrecy and integrity Coherent pathways episode-based models Bundled payment Quality deficiency never-events cost containment Use and development of existing registers nat. quality registers, etc. Comparability via common validated, standardized data Providers, patients, public Informatics, standardized solutions for compatibility Support for implementing guidelines and evidence-based care Open mind, cooperation between counties & central regional local levels Innovations try out & secure evidence Stimulate research - implementation

44 44 KIITOS!