Integrating care by bundled payments in the Netherlands
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1 Integrating care by bundled payments in the Netherlands Jeroen N Struijs, PhD National Institute of Public Health and the Environment (RIVM), Department of Quality of Care and Health Economics 1
2 Content lectures Lecture 1: Integrating care by bundled payments Introduction Dutch health care system (in a nutshell) Bundled payment: Basic premises Results (health care delivery process, quality and spending) - Population management - Pioneer sites - Early results (organization and early experiences) 2 24/09/2015
3 Content lectures (II) Lecture 2: Cross-nation comparison of payment reforms US: Medicare Shared Savings Program Alternative Quality Contract England Clinical Commissioning Groups The Netherlands Bundled Payments Basic features, design and early results 3 24/09/2015
4 Introduction DUTCH HEALTH CARE SYSTEM 4 24/09/2015
5 Background of Dutch health care system Health care insurance is mandatory (about 0.2% uninsured) Broad basic benefit package 4 insurers have 90% of the market Advanced risk adjustment system Mandatory deductible: 375 euro in 2014 Health care cost: 12% of GDP (2 nd highest in the world after the US) High public spending on long term care (3.8% of GDP) Strong primary care system
6 Dutch managed competition model Insurer Purchasing market govern ment Insurance market Providers Health care delivery market Patient/ consumer 6
7 Primary care system, some key facts d guide GP: in principle mandatory - No copayments (visit to hospital without consulting GP: 50 euro) - in principle free to choose your own GP GPs are paid by mixed payment system - Fixed capitation fee per enrollee: 57 euro - Small additional fee for each consult: 9 euros - on average 2500 enrollee per GP - 60% of inhabitants: longer than 10 years enrolled
8 Introduction BUNDLED PAYMENT MODEL 8 24/09/2015
9 Background BP Fragmentary funding hampered the establishment of long-term integrated care programs on a national level. 2007: a bundled payment (BP) approach was introduced, first on experimental basis. 2010: BP system structurally implemented for diabetes, vascular risk management and COPD : Scientific Evaluation Committee on BP: monitoring prerequisites to end transitional period 2015: evaluating effect on mortality, hospital utilization and medical spending 9
10 Bundled Payment (BP) system Single payment for all services across providers for one chronic disease Content of BP is in conformity with Health Care Standard (HCS) HCS describes activities (the what, not the who, where and the how ), and is agreed on by all national provider and patients organizations Fees for BP contracts and subcontractors are freely negotiable Negotiations with dominant insurer Mostly primary care services: not simultaneously with a hospital payment 10 24/09/2015
11 Outline of BP model Insurers BP contract based on Care Group Health Care Standard Multidisciplinary protocol contract contract contract employee contract GP SPEC LAB DIET PROVIDER i PN 11 24/09/2015
12 Insurer New situation Health care insurance market Patient/ consumer Health care purchasing market 1 Health care delivery market Health care purchasing market 2 CG GP LAB HCP n 12 24/09/2015
13 Dutch managed competition model Insurer Purchasing market Insurance market CG Health care delivery market Patient/ consumer GP LAB HCP n 13
14 Geographical diffusion of CGs with catchment area for diabetes 14 24/09/2015
15 How are diabetes care groups organised? Care groups exclusively owned by General Practitioners (GP) (conflict of interest of GP) Sharp increase in the number of associated GPs All CGs supplied reflective information their subcontracted care providers (benchmarking) All CGs supplied accountability information to their preferred insurer 15 Care groups differ how they are organized (three examples) 24/09/
16 CG5=Limited Partnership (GP) INT LAB GP PN DIET DSN Support PN (complex care) Support PN (complex care) 3mnth check up Foot exam Yearly check-up (GP/PN) Lab tests Eye exam Consultation 16 werknemers Experimenting with bundled payments for diabetes 30 August 2011
17 CG8 = Cooperative (GP) GP Practice nurse HOSP DN OPTH INT DIET 3mnth check-up (insulin) Eye exam Consultation Dietary counselling DIET 3mnth check-up Foot exams Yearly check up (GP/PN) 17 HOSP Experimenting with bundled payments for diabetes 30 August 2011
18 CG3 = Private limited liability company (GP + care combination of hosp, home care and Nursing and Caring) PODO HOSP GP FOUND DIET POH DIET DSN Dietary counseling 3mnth checkups Foot exam Yearly checkup (GP/PN) INT Consultation OPTH Eye exam Supplementary foot exam 18 Experimenting with bundled payments for diabetes 30 August 2011
19 Content and fees of BP contracts? Fee : per patient per year (beginning years) Always included: Checkups (annual and 3-months) Eye and footexams Dietary counseling new patients (Lab tests) Consultation specialist Always excluded: Medication Supervised exercise programs Education/ self management 19 Experimenting with bundled payments for diabetes 30 August 2011
20 Does BP create incentives to reallocate and delegate tasks? Yes! GP practice nurse Opthamologist optometrist Dietician or diabetes nurse practice nurse Altered duties of GP towards more supervision More providers are working on top of their license 20 24/09/
21 Experience of stakeholders Managers Perceived quality improvements in process of care Better understanding in individual care needs More transparency Negotiations with insurers difficult and time consuming IT hindering factor Insurers insurers positive about quality of care increased transparency about quality of care still too monodisciplinary (solely GPs) 21 24/09/
22 Experience of stakeholders (II) Care providers improvements in health care delivery process Reflective information = succes factor! Some providers: BP is obstacle for patientcenteredness Administrative burden considered heavy IT constrains Risk of negative consequences of task reallocation Communication of GPs needs improvements Patients High satisfaction with delivery of care, continuity of care 22 24/09/
23 Overall conclusions / take home messages Nationwide implementation of care groups The organization and process of care improved Less patients enrolled in a care program used hospital care Evidence suggest that BP resulted lower mortality and lower medical spending Underlying mechanisms need to be studied Variation in quality as well as spending holds potential room for improvements? 23 24/09/2015
24 So what s next? Pioneer sites Population management 24 24/09/2015
25 Triple Aim by Triple Method applied for the Netherlands DMP BP PM 25
26 National monitor Pioneer sites Shift from BP towards Population Management 9 regions selected as pioneer sites of population management Pioneer sites are enrolled in the National Monitor of Population Management All aiming to improve the TA 26
27 Where are we? Thema s Thema s & Thema s updates & Themes updates & updates & updates Follow-up report: Process and outcomes
28 Objectives National Monitor PM 4 overall research questions: 1. How is population management designed? 2. What are the barriers and facilitators in PM? 3. How is health, quality of care and costs developed over time? 4. What is the association between these outcome measures? Mixed methods 28
29 Organisation Early 2015, pioneer sites are partnerships of (at least two or more) health care organizations and the dominant insurer No legal entity (yet) Agreements were signed to confirm the intended cooperation within the partnership Organisations are under development Additional partners, such as mental care organizations, are more often involved. Some regions explore the potentials / design legal entities Key question: Dutch Accountable Care Organizations? 29
30
31 Organisation: involved actors Schools/ Sports Employer GGD Municipality Home care Youth care Mental care GPs Long term care Hospitals Others Patient representatives Health care insurers A say Co-produce Advice Consult/ inform 31
32 Current Interventions Prevention Lifestyle interventions Selfmanagement Awareness Selfmanagement capacity Integrated care Frailty Maternity care Mental care Diabetes COPD VRM Others Substitution Farmacy 1,5 care Concentration&specialisation Diagnostics Precondition Teamclimate Community involvement Data-infrastructure Transition towards population management 26 maart 2015
33 Population Rest NL Population Sexe (% male) 48,5 49,8 49,5 49,3 48, ,1 50,2 51,6 49,1 Age (% 65+) 23,6 23,2 27,6 25,2 18,4 21,4 23,1 22,8 23,2 20,8 Education (% low) 8 7,3 11 9,4 6,6 6,4 5,2 6,7 8,7 8 Income (% high ) 20,9 16,7 24, ,8 23,5 26, ,4 24,9 Employed (%) 57,3 60,8 59,8 55,4 65,4 62, ,4 62,7 63,2 Disablled to work (% totally disabled) 5,8 3,2 4,5 6,9 2,2 4,8 4,6 4 3,2 3,9 33 Transition towards population management 26 maart 2015
34 Population health Blauwe Zorg Friesland Voorop Goed Leven Mijn Zorg PZF Rijnland Pelgrim SSiZ SmZ Vitaal Vechtdal Rest NL Experienced health (% more or less-bad ) Disabilities (% 1 or more) Chronic conditions (% at least 1) 26,2 19,2 26,7 32, ,7 22,4 24,5 21,9 23,6 14,8 12,4 17,5 18,9 11,2 13,8 11,9 15,5 14,9 14,9 62, ,1 69, ,5 57,3 57,9 57,1 60,4 Anxiety and depression (% high risk) 6 3,9 5,2 7,7 4,7 6,4 4,3 5,8 4 5,7 BMI (% overgewicht) 46,5 47,4 53,5 54,4 42,1 48,1 45,1 48,4 51,3 48,3 Mortality (per ) *red = significant unhealthier; green= significant healthier compared to other regions **Not standardized results. 34 Transition towards population management 26 maart 2015
35 Costs total Zvw costs per inhabitant per pioneer site (2011) general population( per capita) Rest NL Transition towards population management 26 maart 2015
36 Costs per sector per pioneer site (2012) general population (100=NL gem) E.g. this region has higher secondary care but lower mental care costs compared to average Regions with high farmacy costs GGZ tweedelijn Ziekenhuiszorg NL gem Farmacie 36
37 To conclude; new era of delivery reforms has begun Pioneer sites focus on building the fundaments ; how to align the overall Triple Aim and the individual goals Corporate governance is in development; role municipilaties and insurers? Payment reforms are expected on pioneer site level are expected in the near future; discussion mainly focusing on shared savings contracts The health, quality and cost vary between regions and subgroups Rigorous evaluations of these PM initiatives are key to derive transferable lessons 37
38 End Part /09/2015
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