Dutch bundled payments for integrated chronic care

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Juliet Palmer
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1 Dutch bundled payments for integrated chronic care Bert Vrijhoef Professor of Chronic Care at Tilburg University & Professor of Health Systems and Policy at National University of Singapore 15th European Health Forum Gastein, 3-6 October 2012

Professor of Health Systems and Policy at National

2 Agenda Challenges in Chronic Care Dutch Approach on Integration of Care Findings from national evaluation committee bundled payments Conclusions Challenges in Chronic Care Existing system is primarily designed to address acute health problems Modus operandi of most professionals: reactive Emphasis on diagnosis and cure in stead of health/wellbeing and prevention Poor interdisciplinary collaboration between professionals working in primary care, secundary care and social care

problems Modus operandi of most professionals: reactive Emphasis on diagnosis and cure in stead of health/wellbeing and

3 more... Challenges in Chronic Care Increasing demand for chronic care and care for elderly people Passive role of most patients in decision making, selfmanagement and evaluation of healthcare services Inefficient use of ICT to share information and improve process Redesigning healthcare Dutch approach on Integration of Care Incremental reform of healthcare system with focus on financial dimension (2006 now): universal mandatory health insurance, insurers compete for insured & insured press insurers to contract low price/ high quality Incremental reform of care for chronically ill persons: programmatic approach (2008 now): organizational and financial dimensions

Incremental reform of healthcare system with focus on financial dimension (2006 now): universal mandatory health insurance, insurers compete for insured & insured

4 Dutch approach on Integration of Care Cornerstones : 1. Bundled payment: a single fee paid by insurers to their principal contracting partner (care group) to cover an integrated bundle of care for a specific chronic disease over a period of 1 year 2. Care group:legal entity consisting predominantly of GPs and affiliated professionals who freely negotiate on the prices for the bundles of chronic care services with insurers. They may subcontract other care providers. 3. Care standard:document stipulating the minimal required patient services to be covered and authorized by caregiver organizations, patient associations and public authorities. A care standard is disease specific and the basis for contracting. Dutch approach on Integration of Care What is in/out the bundled payment? IN Primary care and outpatient specialist care (consultative) as described in care standards for the specific disease OUT Primary care cost for other complaints/diseases of patients Medication costs Hospital costs

Care group:legal entity consisting predominantly of GPs and affiliated professionals who freely negotiate on the prices for the bundles of chronic care services with insurers.

5 Dutch approach on Integration of Care Introduction of incentives by bundled payment system: competition among care groups for contracts with health insurers competition between subcontractors for contracts with care groups providing data on performance indicators as essential condition in the contract Dutch approach on Integration of Care Implementation in daily practice: experiments with 10 groups for diabetes nationwide implementation for diabetes transition period with introduction for COPD and VRM, bundled payment is not obligatory June report by National Evaluation Committe advising the Minister how to proceed

Integration of Care Implementation in daily practice: 2006-2009 -- experiments with 10 groups for diabetes 2010 --nationwide implementation for diabetes

6 Evaluation of bundled payments To provide information regarding: what are the main+side effects of bundled payments? what are the conditions for bundled payments? how to proceed in supporting integration of care? Evaluation approach: review of grey and white literature stakeholder meetings (open invitation) cost impact analysis (by Nat Institute Publ Health Envir) Evaluation of bundled payments

how to proceed in supporting integration of care?

7 Evaluation of bundled payments Too early for final assessment as cost data lag behind: only data of experimental situation before 2010 and only for diabetes Care is more and better organized : nationwide network of care groups being paid with bundled payments for diabetes (80%), COPD (30%), and VRM only occaionally having structural collaborations between GPs, practice nurses, physiotherapists, podotherapists, endocrinologists, ophtalmologists Evaluation of bundled payments Small to moderate effects on quality of care: better guideline adherence substition of secondary care by primary care (-25%) however: large variation between and within care groups Initially higher costs (+3%) investments costs in primary care hospital costs did not decrease despite less patients double payments to care groups variation between and within care groups

physiotherapists, podotherapists, endocrinologists, ophtalmologists Evaluation of bundled payments Small to moderate effects on quality of care: better guideline adherence substition of secondary

8 Evaluation of bundled payment What is in/out the bundled payment? IN Primary care and outpatient specialist care (consultative) as described in care standards for the specific disease OUT Primary care cost for other complaints/diseases of patients Medication costs Hospital costs Av. 400 Av Evaluation of bundled payments Improvements are possible and needed Position of patients needs to be strengthened Issues around competition Comorbidity and prevention

disease OUT Primary care cost for other complaints/diseases of patients Medication costs Hospital costs Av. 400 Av.

9 Conclusions Transition period takes more time than anticipated Before applying bundled payments a set of predefined requirements needs to be met Bundled payments are an intermediate step towards financing or real integrated care for a regionally defined population Conclusions a. Fee for service b. Fee for service with add-ons c. Single disease bundled payment d. Multiple disease bundled payment e. Population based payments Payment Per discipline, per service Per discipline, per service + allowance for coodination Per patient with disease Per patient with (multiple) diseases Per patient Contracts Insurer/provider Insurer/ provider with add on for collaboaration Principal contractor with insurer, principal contractor and subcontractor Principal contractor with insurer, principal contractor and subcontractor Principal contractor with insurer, principal contractor and subcontractor Quality assurance Monodisciplinary Monodisciplinary Multidisciplinary Multidisciplinary Multidisciplinary Transparancy Per service Per service Indicators Indicators Indicators Role patient Self-coordinated Depends Disease based care plan incl. selfmanagement Disease exceeding care plan incl. selfmanagement Patient oriented care plan, incl. selfmanagement and prevention

10 Thank you Please feel free to contact me for additional information:

Bundled payment for integrated chronic care: the Dutch experience

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