Bundled payment for integrated chronic care: the Dutch experience

Transcription

1 Bundled payment for integrated chronic care: the Dutch experience Maureen Rutten-van Mölken, PhD Professor of Economic Evaluations of Innovative Health Care for Chronic Diseases ibmg/imta, Erasmus University Rotterdam

2 Overview How is bundled payment in the Netherlands organized? Has it improved quality of care? Has it reduced (healthcare) costs? Where are we heading?

3 Bundled payment (since 2010) Bundled payment is a single payment for all multidisciplinary care required by a patient for one particular chronic disease during a predefined period of time

4 General practice Outpatient hospital care Other health care profession Incentives on purchase markets VWS Insurer has incentive to contract best care package CVZ for lowest price NZa Health insurer Purchase integrated care on health care provider market Care group Health insurer Care group Provider X Caregiver organizations Patient associations Care group has incentive to reduce payment to subcontractor Contract individual providers on the health care provider sub-market Cash flow Cooperation Control Care standards GP Specialist Physiotherapist Assistant GP Specialist nurse Dietician Specialist nurse Labs Podiatrist Tsiachristas et al., Health Policy, 2011

5 Payment systems integrated care programs in ZonMw program DMCZ

6 Diabetes process indicators improved (n=53 out of ~100 care groups) Source: Landelijke Organisatie Ketenzorg, sept 2013

7 Wide variation in diabetes process indicators between care groups Percentage of diabetes patients with all measurement/checks: 2012 (n=70 out of ~100 care groups) Source: Landelijke Organisatie Ketenzorg, sept 2013

8 Diabetes outcome indicators (n=53 out of ~100 care groups) Source: Landelijke Organisatie Ketenzorg, sept 2013

9 COPD process indicators improved (n= <45 out of ~ 100 care groups) Source: Landelijke Organisatie Ketenzorg, sept 2013

10 Quality indicators increasingly used in negotiations, but.. Cause of differences unclear: unclear in- and exclusion criteria, case-mix, registration and extraction problems, true differences in care delivered Too much focus on process indicators Little room for improvement in process indicators once the registration is good (in time they become less useful) No specific indicators for integration of care Important outcome indicators missing: e.g. micro- and macrovascular complications diabetes Target values of some outcome indicators difficult to define (e.g. % smokers; is a reduction sufficient?) Should outcome indicators become more targeted to the individual patient?

11 Impact bundled payment on healthcare costs in ZonMw DMCZ program No significant change in costs during year 1 Small changes in costs during year 2 CVR (n=550) COPD (n=372) Diabetes (n=174) Mean at baseline Mean Change T0-T2 Range of change across 9 DMPs Mean at baseline Mean Change T0-T2 Range of change across 4 DMPs Mean at baseline Mean Change T0-T2 Range of change across 3 DMPs Primary care ; ; ; 252 Outpatient hospital care Inpatient hospital care $ ; ; ; ; 3,228 2,095-1,113-4,238; 1, ; 1,481 Medication ** -179; ; * -192; 65 Total healthcare utilisation 2, ** -708; 3,254 4,349-1,184-4,088; 977 2, ; 2,049 Costs based on self-reported healthcare utilization

12 Impact payment systems on healthcare expenditure in Europe: DID model Diff. in expenditure before and after introducing payment schemes to improve quality chronic care WHO/OECD intervention, 17 control countries PFC: Pay for coordination (AT,DK,FR,DE,HU) PFP: Pay for performance (EE,FR,HU,PT,UK) All-inclusive: bundled/global payment (DE,NL) Controlled for GDP/care emplo. Tsiachristas et al., submitted Total Hospital Estimate Impact Estimate Impact PFC t % % PFP t % *** -45% ALL t % % PFC t % % PFP t % % ALL t * -68% % PFC t ** -17% *** -182% PFP t % ** -59% ALL t *** 80% *** 257% PFC t *** -27% *** -63% PFP t ** -65% *** -75% ALL t *** 47% 75.12*** 159% N

13 Bundled payment: areas for improvement Bundle is far from complete Secondary care, medication, prevention not included Care not covered by basic health care insurance (e.g. physiotherapy) is not contracted as part of the bundle Bundle focuses on 1 particular disease (overlap between programs) Bundled payment insufficiently based on case mix (risk equalization) Though improvement is seen, still problems with time consuming ICT systems to support communication between professionals, with patients, monitor health outcomes Transparency about care actually delivered Some insurers reluctant to contract integrated care Economies of scale: large investments in developing/ implementing a program for a small target group does not pay off Self-management/tailored care needs more support Change incentives for secondary care

14 INCA model: modular approach Source: Acsion en Casemix, 31 dec 2012

15 Or moving to the next level? population-based payment Proeftuin Blauwe Zorg Met het centrum in de wijk Caberg verwachten wij het 1e jaar al 1,5 miljoen te besparen De Limburger 23 januari 2014