THE FUTURE OF FINANCING OF HOSPITAL HEALTHCARE, TRENDS IN EUROPE

Transcription

1 THE FUTURE OF FINANCING OF HOSPITAL HEALTHCARE, TRENDS IN EUROPE Marc Czarka, MD, FBCPM Scientific associate Magali Pirson, RN, Ph.D Professor Centre de recherche en Economie de la Santé, Gestion des Institutions de Soins et Sciences Infirmières

2 DISCLOSURE 2

3 DISCLOSURE «In compliance with full disclosure, I m required to tell you that I m really not sure about any of this stuff» 3

4 CURRENT SITUATION FROM ADOPTION OF FEE FOR SERVICE ONLY PROs CONs PATIENT HAS FULL FREEDOM OF CHOICE PROVIDER HAS HIGH LEVEL OF INDEPENDANCE EASY TO MEASURE AND KEEP TRACK OF RISK OF INFLATION POTENTIAL CONFLICT OF INTEREST BETWEEN PATIENT AND PROVIDER POORLY ADAPTED TO CARE OFFER REGULATION NEED FOR CLOSE FOLLOW- UP TO AVOID CODING OBSOLESCENCE 4

5 CURRENT SITUATION TO ADOPTION OF GLOBAL BUDGETS PROs CONs EXTREME SIMPLICITY OF OPERATION ESPECIALLY FOR BUDGET HOLDERS AN EFFECTIVE SYSTEM FOR RATIONING PUBLIC FUNDING OF HEALTHCARE INSTITUTIONS A RIGID FRAME WHICH LIMITS THE DEVELOPMENT OF ACTIVITIES AND TECHNOLOGICAL INNOVATION SYSTEM THAT LACKS CONSIDERATION FOR THE ACTIVITY HENCE UNFAIR 5

6 CURRENT SITUATION TO DATE, NO FUNDING SYSTEM HAS BEEN ENTIRELY SATISFACTORY CONVERGENCE IS TAKING SHAPE IN THE FORM OF A PROSPECTIVE LUMP SUM PRICING PATHOLOGY BASED SYSTEM OR ALL-IN 6

7 ALL-IN PRINCIPLES PRODUCTION THE HOSPITAL IS AN ENTREPRISE WITH A VERY SPECIFIC PRODUCTION (CARE OF VARIOUS NATURE AND INTENSITY WITH VARIABLE LENGTH OF STAY AND FOR PATIENTS WHOSE NEEDS DIFFER) THIS PRODUCTION IS REPRESENTED BY HOMOGENEOUS GROUPS OF PATIENTS RECEIVING SIMILAR CARE TYPE (DRG). EACH AND EVERY PATIENT BELONGS TO A SPECIFIC DRG BY ILLNESS AND CARE FINANCING STAY OF EACH PATIENT PAID ON THE BASIS OF AVERAGE PRICE OF CASES IN THE DRG TO WHICH IT BELONGS THE HOSPITAL BUDGET = AVERAGE PRICE OF CASES IN EACH DRG X RESPECTIVE EXPECTED NUMBER OF CASES (CASE MIX) 7

8 THE FRENCH DEFINITION ACTIVITY-BASED TARIFICATION (T2A) IS A METHOD OF FINANCING OF HEALTH FACILITIES FROM FRENCH HOSPITAL REFORM OF HOSPITAL 2007 PLAN WHICH AIMS TO MEDICALIZE FUNDING BY TAKING ACTIVITY INTO ACCOUNT WHILE BALANCING THE ALLOCATION OF FINANCIAL RESOURCES AND EMPOWERING HEALTH ACTORS BY GIVING THEM RESPONSIBILITY ON RESOURCE UTILIZATION 8

9 CURRENT TRENDS THE IMPLEMENTATION OF ALL-IN SYSTEMS IS A TREND THAT IS BECOMING MORE AND MORE POPULAR IN EUROPEAN COUNTRIES (FRANCE, GERMANY, THE NORDIC COUNTRIES, SWITZERLAND, ETC.) FINANCING SYSTEMS ARE STILL RATHER DIFFERENT FROM ONE COUNTRY TO ANOTHER 9

10 DIFFERENCES IN COVERAGE ACTIVITIES - IN- AND DAY CARE PATIENTS ARE INCLUDED IN THE SYSTEM IN MOST COUNTRIES - SOME ACTIVITIES ARE STILL EXCLUDED FROM THE SYSTEM AND HAVE A SPECIFIC FUNDING (OUTPATIENTS, PSYCHIATRIC PATIENTS, REHABILITATION, ETC.) INSTITUTIONS SOME HOSPITALS MAY BE FINANCED SEPARATELY, EITHER BECAUSE THEIR ACTIVITY DOES NOT LEND ITSELF TO A LUMP SUM FUNDING, OR FOR POLITICAL REASONS 10

11 DIFFERENCES IN COVERAGE COSTS - MOST COUNTRIES HAVE OPTED FOR THE ALL-IN SYSTEM, DESIGNED TO COVER ALL COSTS INCURRED BY THE HOSPITAL TO SUPPORT THE PATIENT DURING HIS STAY - SOME EXPENSES ARE STILL OFTEN FUNDED SPECIFICALLY (LIKE EXPENSIVE DRUGS AND MEDICAL DEVICES, EDUCATION AND RESEARCH, INVESTMENT...) PERCENTAGE OF FUNDING DRG-BASED VARIES BETWEEN COUNTRIES (TRANSITION AND / OR MAINTENANCE OF A DUAL SYSTEM COMBINING DRGs AND OTHER CRITERIA) 11

12 ALL-IN FINANCING NO PROSPECTIVE PAYMENT SYSTEM (PPS) YET ALTHOUGH SOME DRG-BASED LUMP-SUMS ARE IN PLACE (PHARMA ) PARTS OF BMF: FINANCING IMPACTED BY DRGs YES SINCE 2004 PPS «T2A» YES SINCE 2003 PPS «GERMAN DRG-SYSTEM» 12

13 PROPORTION OF FINANCING INFLUENCED BY DRGs 55% OF ALL HOSPITAL ACTIVITIES AND 77% OF THE T2A KEEPING A SPECIFIC BUDGET (MISSIONS D INTERET GENERAL MIGAC) FOR SPECIFIC NEEDS (INNOVATION, ETC.) 93% OF HOSPITAL BUDGETS (ACUTE HOSPITALS ONLY) WERE PAID BY DRGs IN 2007 OBJECTIVE : TO MINIMIZE ACTIVITIES PAID OUTSIDE OF DRGs Information based on a think tank on prospective payment case-mix based (The scope of DRG funding in the following countries : Belgium, England, France, Germany, Ireland, Netherlands, Norway and Switzerland. Oslo 2008) 13

14 WHICH PERIMETER? WHICH PERIMETER? ADMINISTRATION? HOTEL COSTS? NURSING? PHARMACEUTICALS? MEDICAL PROCEDURES CLINICAL WORK? COST OF PRACTICE? 14

15 PHYSICIAN COMPENSATION IN THE FOR PROFIT SECTOR (20% OF HOSPITAL BEDS): FEE FOR SERVICE (FFS) IN THE NOT FOR PROFIT SECTOR PRIVATE AND PUBLIC (80% OF HOSPITAL BEDS): ALL-IN INCLUDING CLINICIANS SALARY BUT FOR NEONATOLOGY, ICU WITH A DAILY RATE FEE BASED FOR DIALYSIS, RADIOTHERAPY, PETSCANS Kimberly et al. The Globalization of Managerial Innovation in Health Care. Cambridge University press 2008 (p133) 15

16 PHYSICIAN COMPENSATION WHATEVER THE HOSPITAL ORGANISATION (PUBLIC OR PRIVATE, FOR OR NOT FOR PROFIT) CLINICIANS AND NURSING ARE EMPLOYEES CLINICIANS AND NURSING COSTS ARE INCLUDED IN DRGs BUT FOR: DIALYSIS EXCEPTIONAL PROCEDURES (ARTIFICIAL HEART, ETC.) ICU, OUTPATIENTS, ETC. Kimberly et al. The Globalization of Managerial Innovation in Health Care. Cambridge University press 2008, p155 et p

17 PHYSICIAN COMPENSATION MEDICARE PPS BUT FFS AS PHYSICIAN S FEES ARE NOT INCLUDED IN THE DRG PAYMENT SYSTEM Roger-France et al. Case-Mix: Global views, local actions IOS Press 2001 (p168) 17

18 IMPACT OF ALL-IN ON CARE QUALITY AND POTENTIAL ADVERSE EFFECTS SELECTION OF LOW RISK PATIENTS SPECIALIZATION TOWARDS STANDARDIZED PROCEDURES PROLIFERATION OF BETTER PAID TECHNICAL PROCEDURES CODING MANIPULATION (aka DRG CREEP) PREMATURE RETURN OF PATIENTS TO THEIR HOMES OR OTHER CARE FACILITIES FRAGMENTING STAYS INCREASING NON-JUSTIFIED ACTIVITIES CHANGING THE COMPOSITION OF CARE BY ABANDONING CERTAIN ACTIVITIES DEEMED UNPROFITABLE AND REFERING (AT BEST) TO THE UPSTREAM OR DOWNSTREAM STRUCTURES PROBLEM OF ACCESS TO CARE ETC. 18

19 IRDES REPORTS CARE QUALITY AND T2A : FOR BETTER OR WORSE? (DECEMBER 2012) ACTIVITY, PRODUCTIVITY AND CARE QUALITY IN HOSPITALS BEFORE AND AFTER T2A (APRIL 2013) IRDES: Institut de recherche et documentation en économie de la santé 19

20 IRDES OBSERVATIONS INFORMATION ON THE OUTCOME OF CARE IS EXTREMELY DIFFICULT TO OBTAIN IN FRANCE AS IN MOST COUNTRIES, WHETHER IN EUROPE OR THE U.S. INDICATORS OF NON-QUALITY ARE MOST OFTEN USED, SUCH AS MORTALITY RATES OR THE RATE OF EARLY READMISSIONS 20

21 IN FRANCE GEOGRAPHICAL SPECIALIZATION IN THE PROVISION OF CARE (TREND WAS PRESENT BEFORE THE INTRODUCTION OF THE T2A) HOSPITAL MORTALITY (30 DAYS) DECREASED FOR CARDIOVASCULAR PROBLEMS (MYOCARDIAL INFARCTION AND STROKE) AND CANCER (COLIC CANCER SURGERY) READMISSION RATES AT 30 DAYS APPEAR TO BE INCREASING IN RECENT YEARS FOR THESE CONDITIONS 21

22 IN FRANCE NO OBSERVATION SUGGESTING A SELECTION/DISCRIMINATION STRATEGY FROM INSTITUTIONS OF OLDER AND/OR POLYPATHOLOGY PATIENTS SHARP INCREASE IN RATES OF MINOR WELL PAID PROCEDURES SUGGESTING THE POSSIBILITY OF DEMAND INDUCTION... 22

23 IN GERMANY SURVEY OF 30 HOSPITALS IN LOWER SAXONY: THE INTRODUCTION OF THE ALL-IN SYSTEM DID NOT RESULT IN SELECTION OF PATIENTS OR PROBLEMS OF EARLY OR PREMATURE RETURN OF PATIENTS TO THEIR HOMES OR OTHER CARE FACILITIES IN THESE HOSPITALS QUALITY OF SERVICES REMAINED APPARENTLY STABLE AFTER THE IMPLEMENTATION OF THE SYSTEM AND HAS SUPPOSEDLY EVEN IMPROVED DUE TO BETTER ORGANIZATION OF CARE 23

24 IN BELGIUM CAREFUL BECAUSE THIS TYPE OF FINANCING MAY LEAD TO ADVERSE EFFECTS, WHICH, IF NOT ANTICIPATED IN THE FUNDING RULES, MAY IMPACT THE QUALITY OF CARE GIVEN TO PATIENTS TO ANTICIPATE AND TO PLAN IS TO GOVERN AND TO LEAD THIS IS WHAT A GROUP OF 15 HOSPITALS* and ULB ARE DOING IN ORDER TO PROVIDE ENOUGH INSIGHTS TO SET-UP A SYSTEM THAT WILL BE FINANCIALLY MANAGEABLE WHILE MAINTAINING OR IMPROVING QUALITY OF CARE * PACHA project: Prof. Pirson, Prof. Leclercq 24

25 CONCLUSION IN A REVOLUTION, AS IN A NOVEL, THE MOST DIFFICULT PART TO INVENT IS THE END Alexis de Tocqueville 25