Outcome Measurement and Health Insurance. Madelon Pijls-Johannesma (on behalf of Jolyn van Vuuren)

Transcription

1 Outcome Measurement and Health Insurance Madelon Pijls-Johannesma (on behalf of Jolyn van Vuuren)

2 The CZ-group is the third largest Dutch health insurer and our label CZ has the most insured The facts Number of insured: 3.4 million Market share: 20% 3 Labels: Insurance premium: Operating costs: 8.4 billion 324 million As % of premium: 3.9 % Solvability %: 286 % Employees: Customer satisfaction: 7.9 Bron: Jaarverslag 2013

3 Our license to operate is to maintain high-quality, accessibility and affordability within the Dutch healthcare system What drives us CZ represents solidarity in health care. As health insurer it is our public responsibility to keep healthcare available, now and in the future. What we do CZ wants the best possible care for it s insured. Creating more patient value through value based healthcare procurement is our core business. Procurement decisions are based on outcome measures reflecting the goals of the patient. The patient is truly the focus of our work at CZ. How we do it CZ wants to make the difference. We dare to organize care in a complete different way with a clear vision. We don t avoid discussions. All of this on behalf of our insured. 3

4 CZ defines the best possible care as care which creates the most patient value Founding father of the concept of value is Michael E. Porter Value is defined as Quality Cost But it s not a simple equation: further operationalization of the concept of value was needed 4

5 Creating patient value is equal to attaining the health outcomes patients pursue through care utilisation at the lowest costs possible Cost Quantity of care Patient Value Cost per unit of care Health Outcomes Quality Patient centeredness 5

6 The CZ Value Framework is the roadmap to value based healthcare procurement Goals of the patient Relevant value drivers Indicators for driver Norm for Data on Decision on which value is delivered by provider Consequ ences for assigned price and volume The first step towards value based healthcare procurement is defining the pursued health outcomes of the patient. 6

7 Next step is to define the value drivers, the elements that influence outcome or costs Practice variation Cost Quality Quantity of care Cost per unit of care Health Outcomes Horizontal Referrals Parallel delivered care Substitution Secondary conditions Health status Disutility of care process Well coordinated care process Value drivers elements in care delivery that contribute to attaining goals elements which stand in the way of attaining goals give insight in actual care delivery provide opportunities to adjust care delivery so more patient value can be created Patient centeredness Timeliness Ability to orchestrate your own care 7

8 Indicators are at the core of the Value Framework Goals of the patient Relevant value drivers Indicators for driver Norm for Data on Decision on which value is delivered by provider Consequ ences for assigned price and volume Challenges: Lack of valid and relevant s and outcome data Field support for chosen s A combination of outcome and process s is made, because patients derive value from: the health outcome, and the way care is delivered to them. 8

9 Indicators are measured for all providers, which gives us the ability to benchmark Goals of the patient Relevant value drivers Indicators for driver Norm for Data on Decision on which value is delivered by provider Consequ ences for assigned price and volume Ability to benchmark Insight in the relative performance of providers Incentive for providers to improve 10

10 The realised value has consequences for the procurement conditions Goals of the patient Relevant value drivers Indicators for driver Norm for Data on Decision on which value is delivered by provider Consequ ences for assigned price and volume Challenge: Proportionality of the consequences Consequences in procurement In- or exclusion of healthcare providers Rewarding providers for realizing higher value through higher volume or price adjustments 11

11 Example: Selection and classification of breastcancer centers using a set of s YES Preconditions NO If preconditions are fulfilled, the Contract Room for Improvement No Contract classification of health care providers in 4 categories is made using s: Volume Good Care Quality s 4 Categories The 6 s are not Very Good Care distinctly individual, but are cumulatively judged Best Care Improvement s 12

12 Process Outcome Pay for performance in ParkinsonNet by using outcome s Health Insurer Main contractor 3 integrated care products fixed price per patiënt based on phase PD 1 contractor promote collaboration Providers Value institute ParkinsonNet Benchmarking data on outcome and costs o Improve overall quality of care o Reduce unwanted variations Source: ParkinsonNet 13

13 Agreements on goals and Triple Aim s Indicator CQ Index Parkinson Qualtiy of Life (QOL) Quality agreement The average score on the CQ index is higher in comparison to hospitals outside the network (average scores are above 75th percentile) The average QOL of patients measured 6, 18, 30 etc. months after the first consult is higher in comparison to hospitals outside the network (average scores are above 75th percentile) Health Gain % nursing home % of admissions in nursing home is lower in comparison to hospitals outside the network (average scores are below 25th percentile) % hospitalization % of hospitalization is lower in comparison to hospitals outside the network (average scores are below 25th percentile) Quality of Care % hip fracture % patients with a hip fracture is below the Dutch average Yearly healthcare cost Healthcare costs are lower than in hospitals outside the network (averages are below 25th percentile) Costs Source: ParkinsonInzicht

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