Waar staan België en Nederland in 2020?

Transcription

1 Waar staan België en Nederland in 2020? Lieven Annemans Ghent University, Brussels University January 2014

2 Waar zou België moeten staan in 2020 inzake het betalen voor zorg? Lieven Annemans Ghent University, Brussels University January 2014

3 The key problems in OECD countries 1. Inequity in health and health care more and more people cannot pay their health bills increasing health inequalities 2. Overconsumption & overtreatment unneccesarry care overuse, misuse over medicalizing 3. Undertreatment insufficient care (too) early discharge waiting lists 4. Lack of coordination fragmentation of care mistakes due to poor communication 5. Changing epidemiology demographic changes chronic disease & multimorbidity mental diseases 6. Continuous technology push expensive technologies & medicines expectations by citizens 3

4 Strengths and weaknesses of the Belgian system (KCE 2012, adapted) Excellent Physicians and health care staff (mostly) Hard workers (mostly) Strive to innovate Low cost per intervention Large part of the population covered Good Safety High satisfaction Rat race between hospitals High volumes Inappropriate care Low focus on prevention Increasing inequities, high patient co payment Poor data availability Future shortage of GPs Other determinants of health poorly handled 4

5 Yes, we are happy with our system Eurobarometer 2012 Satisfaction of citizens with the health care sector. +10 = maximum - 10 = minimum Excellent service Rather cheap treatments Very well trained physicians Strive for innovation Everyone insured via income related insurance premiums 5

6 Concerns about sustainability! Public expenditure on health in % of GDP Growth 4,5% Growth 2,8% Growth 2% 0 source: Itinera, Belgium

7 Two ways a government can intervene REACTIVE Fix the budgets, Lower the prices, Increase patient co payment, Forget indexation of salaries, Delay investments in quality Feed back based on median performance, 7

8 But let s not forget our goal The primary goal of health care policy = to maximize the health of the population within the limits of the available resources, and within an ethical framework built on equity and solidarity principles. EFFICIENCY EQUITY Report of the Belgian EU Presidency; Endorsed by the EU Council of Ministers of Health in Dec

9 PROACTIVE! 1. Set health objectives 6. Increase patient empowerment & responsibility 2. Set a growth path for the 7. Invest more in prevention health sector 3. Create better structures 8. Introduce better finance and payment systems 4. Create better processes 9. Apply cost effectiveness everywhere 5. Create new innovation and R&D models 10. Create a perfect health information system 9

10 6 problems, 10 instruments The health reform matrix Instr. 1 Instr. 2 Instr. 3 Instr. 4 Instr. 5 Instr. 6 Instr. 7 Instr. 8 Instr. 9 Instr. 10 Problem 1 Problem 2 Problem 3 Problem 4 Problem 5 Problem 6 10

11 1. Set health objectives 6. Increase patient empowerment & responsibility 2. Set a growth path for the 7. Invest more in prevention health sector 3. Create better structures 8. Introduce better finance and payment systems 4. Create better processes 9. Apply cost effectiveness everywhere 5. Create new innovation and R&D models 10. Create a perfect health information system 11

12 1. change the processes to guide innovation Value deficit The Market usage challenge The development challenge Provide Value for money Add value The Market access challenge 12

13 Concrete: create opportunities for public private partnerships PPP to - stimulate the rigth usage of innovation - identify existing value deficits Value deficit PPP to - stimulate innovation in areas of need - find better/faster ways to demonstrate added value Provide Value for money Add value PPP to - reduce uncertainty regarding value & value for money 13

14 Concrete (2) Apply cost effectiveness analysis in all fields of health care Sign outcomes based market access contracts with companies of which the technology provides uncertainty Apply new technologies in hub and spoke networks Follow up correct use in registries (ehealth) Peer review in case of presumed under or overuse 14

15 Main problems tackled? Inequity in health and health care more and more people cannot pay their health bills increasing health inequalities Overconsumption & overtreatment unneccesarry care overuse, misuse over medicalizing Undertreatment insufficient care early discharge waiting lists Lack of coordination fragmentation of care mistakes due to poor communication Changing epidemiology demographic changes chronic disease & multimorbidity mental diseases Continuous technology push expensive technologies & medicines expectations by citizens 15

16 BUT: problems with such outcomes based schemes! Confounders (e.g. taking other drugs) Case mix; exception reporting Objective measurement of indicator? Workload for physicians Administrative workload Source: Coulton et al

17 2. Change the financing of health care providers and hospitals the current Belgian hospital financing system 40% 40% 15% 5% BFM Bundled payment for operational costs: hotel costs Nursing Patient care Deductions on physician honoraria Based on fee for service Pharma Negotiated Discounts 17

18 Introducing Pay for Quality? From Paying to do things to Paying to do things right And Paying to do the right things 18

19 Resultaten Streefdoelen met min. 5% positief effect title 19

20 Cfr. Kwaliteitsindicatoren Vlaanderen en gezondheid.be/beleid/kwaliteit/basisset 2012/#indicatoren Moeder en kind Oncologie Orthopedie Cardiologie Ziekenhuisbreed domein 20

21 DESIGN Key pitfalls of P4Q 1. Poor definition of quality: structure, process and outcomes indicators 2. Not involving the physicians (continuously) lack of communication 3. Size and type of the financial reward/penalty not well studied (P4 improvement or for reaching target?) 4. Patient case mix OUTCOME 1. Fragmentation 2. Increasing inequities? 3. Cost effective? 21

22 experiment in GPs: breast cancer screening Cahier Welzijnsgids (Y. Nuyens, J. Mertens). Preventie en Gezondheid in Vlaanderen doorgelicht

23 Results Interventie Controle 23

24 MIMIQ: Model for Implementing and Monitoring Incentives for Quality 24

25 Define/operationalize & measure Quality Define/operationalize Incentives Communicating Implementing Evaluation Payer characteristics Provider characteristics Patient characteristics Health care system characteristics 25

26 Options for hospital financing Bundled per APRDRG per stay incl. 1 month post P4Q Idem but excl. physicians Bundled for intellectual acts physicians P4Q Idem but excl. physicians FFS for intellectual acts physicians P4Q! No more deductions! 26

27 Main problems tackled Inequity in health and health care more and more people cannot pay their health bills increasing health inequalities Overconsumption & overtreatment unneccesarry care overuse, misuse over medicalizing Undertreatment insufficient care early discharge waiting lists Lack of coordination fragmentation of care mistakes due to poor communication Changing epidemiology demographic changes chronic disease & multimorbidity mental diseases Continuous technology push expensive technologies & medicines expectations by citizens 27

28 Discussion 1. Today we are not much progressed with P4Q in Belgium We have a cook book but policy makers don t want to cook with it (yet). They prefer a kroket uit de muur 2. The planned hospital reforms (Federal) and quality initiatives (Flanders) are an ideal opportunity for a revival 3. Need for a GP based pilot program fully according to the MIMIQ model. 4. Evaluation should also focus on fragmentation, inequity, cost effectiveness, 28

29 Available as from Feb 19 29