Caribbean Health Financing Conference. Curacao, 31 October 2012

Transcription

1 Caribbean Health Financing Conference Curacao, 31 October 212

2 Objective: Embark on the train towards value based health care Our business is to create value, not (only) to control costs Episode registration is the cornerstone of our new health system Data is not enough, information and knowledge is what we need Aware Interested Investments in integral chronic care programs 3

3 Objective: Embark on the train towards value based health care Our business is to create value, not (only) to control costs Episode registration is the cornerstone of our new health system Data is not enough, information and knowledge is what we need Aware Interested Willing to try Investments in integral chronic care programs 4

4 Objective: Embark on the train towards value based health care Our business is to create value, not (only) to control costs Episode registration is the cornerstone of our new health system Data is not enough, information and knowledge is what we need Aware Interested Willing to try Embark Investments in integral chronic care programs 5

5 Agenda Factors driving the necessity for value added in health Conceptual framework for focus on value vs cost in health systems Lessons of experience for Caribbean countries Implications of value added focus in health programs 6

6 What is the value of your health? What is most valuable to you? Health? Your family / kids = health Not true Have you ever invested in your health? No there you go Yes why did you stop? To get well is our highest value!! Our priorities are set by our reality 7

7 Agenda Factors driving the necessity for value added in health Conceptual framework for focus on value vs cost in health systems Lessons of experience for Caribbean countries Implications of value added focus in health programs 8

8 The care system. 1 Burden of disease Morbidity (Burden of disease) 2 Creates demand for care Complex Chronic Acute Urgent Not urgent Elective 3 care being provided Care delivered GP Specialist Hospital &intramural Dentist Paramedical Pharmacy Lab Home care Other 4 5 paid for and administrated funded by health insurance premiums and gov t funding Per capita healthcare costs vs. insurance premium National Health Budget 5 Sourced from National income GDP (Gross National Product) 9

9 Healthy productive population The care system. 1 Burden of disease Morbidity (Burden of disease) 2 Creates demand for care Complex Chronic Acute Urgent Not urgent Elective 3 care being provided Care delivered GP Specialist Hospital &intramural Dentist Paramedical Pharmacy Lab Home care Other 4 5 paid for and administrated funded by health insurance premiums and gov t funding Per capita healthcare costs vs. insurance premium National Health Budget 5 Sourced from National income GDP (Gross National Product) 1

10 We have to make sure that the health budget is well spent And is considered an investment rather than cost to society COSTS TO SOCIETY Population VALUE FOR SOCIETY Balance between affordability of care and funding for exploitation of care practices and institutes National Health Budget Balance between care needs and quantity and quality of care WHY DO WE HAVE TO PAY THAT MUCH? Care providers Care products WHAT BURDEN WAS AVOIDED / HOW MUCH VALUE WAS CREATED? Balance between what care providers are paid and the care products they deliver

11 Agenda Factors driving the necessity for value added in health Conceptual framework for focus on value vs cost in health systems Lessons of experience for Caribbean countries Implications of value added focus in health programs 12

12 Data gathering information knowledge is essential A. No complete balance Population B. Balance between costs for society and income of care providers Exploitation costs are covered Salary cap B Care providers A C D Care products BUT: C. No balance between what is paid and what is delivered: Care activities instead of care products D. No match between care needs and the care delivered (quality / quantity): Care needs are not met Too much work for too little payment 13

13 What is the importance of data gathering and analysis? Monitor health risks Infectious diseases (HIV/Aids - STD - Dengue) NCD Lifestyle Monitor care consumption Monitor health risks 14

14 Health budgeting and spending is an ongoing game of balancing the budget From here we drill down to find out : What s the cause / How can we improve balancing the budget

15 What is the importance of data gathering and analysis? Monitor care consumption 35, Monitor morbidity and care needs 3, 25, How healthy is SXM? Care needs of the population Monitor quality of care 2, 15, 32,9 22,2 Process and outcomes Costs of care in 29, per category* Other private Fatum FZOG Subsidies SVB 1, 8,4 8,6 5,7 5,, Intramural Pharmacy Specialists GP's Care Monitor health risks abroad 5,9 5,8 2,1 BZV 2,5 1,1 Lab Other Transport Paramedic Home Care 16

16 What is the importance of data gathering and analysis? Monitor morbidity and care needs How healthy is SXM? Care needs of the population 35, 32,9 Costs of care in St. Maarten 29, per category* 3, 25, 2, X ANG MLN 15, 22,2 Other private Fatum FZOG Subsidies SVB Monitor health risks 1, 8,4 8,6 5,7 5,, Intramural Farmacy Specialists GP's Care abroad BZV 5,9 5,8 2,1 2,5 1,1 Lab Other Transport ParamedicHome Care Monitor care consumption 17

17 From Standards of care towards individual care plans When? & By whom? Individual Care plan Individual care needs Individual Patient Client How? & Who? Care program Care teams Health problems Caregroup District Region What? Standards of care Diagnosis National norm 18

18 The care standard in the care continuum Identification Risk assessment Risk profile Individual care plan Care modules Coaching patients Smoking Overweight Alcohol Stress Hypertension Cholesterol DM2 Depression 19

19 Visualize risk profile COPD exacerbations Smoking 1 Overweight COPD Exercise tolerance Pulmonary function / dyspnea Retinopathy Physical (in)activity Nutrition Alcohol LIFESTYLE Neuropathy Stress Diabetic foot Depression DIABETES MELLITUS Glucose Nefropathy Blood pressure Anxiety Somatisation Cholesterol PSYCHOLOGICAL COMPLAINTS T T1 VASCULAR RISK 2

20 Make an individual care plan based on assessment Health issues Stepped-care modules Smoking Sc module 1 Sc module 2 Sc module 3 Sc module 4 Disease specific Unhealthy lifestyle Fhysical activity Alcohol Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Disease specific Disease specific Nutrition Sc module 1 Sc module 2 Sc module 3 Sc module 4 Disease specific General wellbeing Depression Stress Participation Sc module 1 Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Sc module 4 Obesity Sc module 1 Sc module 2 Sc module 3 Sc module 4 Cardiovascular risk-management Hypertension Dyslipidemidia Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Nefropathiy Sc module 1 Sc module 2 Sc module 3 Sc module 4 Glucose Sc module 1 Sc module 2 Sc module 3 Sc module 4 Diabetes mellitus Retinopathtjy Neuropathy Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Feet Sc module 1 Sc module 2 Sc module 3 Sc module 4 21

21 Organization individual CVRM: case management Patient recruitment Intake Risk and care profiles Individual care plan Follow up Feedback & Benchmark Smoking Cessation therapy Psychologist Physical therapist Central care provider Pharmacist Dietician Specialist 22

22 Feedback & benchmark every 3 months Patient recruitment Intake Risk and care profiles Individual care plan Follow up Feedback & Benchmark 23

23 What is the importance of data gathering and analysis? Monitor quality of care Process and outcomes BMI Most in patients with included diabetes in CariCare are not controlled 75% Majority of patients of patients have have overweight HbA1c > 9 Number of patients Number of patients HbA1c in patients with DM Costs of care in St. Maarten 29, per category* Smoking Aggregating patient profiles insight into type and volume of care 35, 1 32,9 Nephropathy 8 Overweight 3, 6 Other private 4 25, Fatum 22,2 Hypertension 2 Physical activity FZOG 2, X ANG MLN Subsidies 15, SVB Cholesterol Nutrition BZV 1, 8,4 8,6 5,7 Stress Alcohol 5,9 5,8 5, 2,1 2,5 1,1 1-mrt-9 1-mrt-1, Intramural Farmacy Specialists GP's Care Lab Other Transport ParamedicHome Care abroad Monitor HbA1c < 6.5 Monitor HbA1c care HbA1c Monitor 7.5 -morbidity 9 HbA1c >=9 BMI < 2 BMI BMI BMI health risks consumption and care BMI needs 35-4 BMI >

24 Identify population needs by aggregation of Individual Care Plans Aggregating patient profiles insight into type and volume of care 25

25 Number of patients What is the importance of data gathering and analysis? Monitor patterns of care Process and outcomes 35, 3, 25, 2, X ANG MLN 15, 1, 5, 32,9 22,2 8,4 Costs of care in St. Maarten 29, per category* 8,6 5,7 5,9 5,8 2,1 Other private Fatum FZOG Subsidies SVB BZV 2,5 1,1 Smoking 1 Nephropathy 8 Overweight 6 4 Hypertension 2 Physical activity Cholesterol Nutrition Stress Alcohol 1-mrt-9 1-mrt-1 Aggregating patient profiles insight into type and volume of care Most patients with diabetes are not controlled Majority of patients have HbA1c > 9 HbA1c in patients with DM2 HbA1c < 6.5 HbA1c HbA1c HbA1c >=9, Monitor health risks Intramural Farmacy Specialists GP's Care abroad Lab Other Transport ParamedicHome Care Monitor care consumption Monitor morbidity and care needs Monitor Quality of care 26

26 What is an episode? An episode of care is a health problem from its first presentation to a health care provider until (and including) the last encounter for it : an individual patient s problem followed over time Three key components : Reason for 1 2 Diagnosis 3 Process Encounter Coded in ICPC-2 / ICD-1 1 st I m feeling the patient s Reason(s) for Encounter (RFEs): Tiredness Encounter should be recognizable by the patient as an acceptable description of his/her demand for care 2 nd the GP s diagnosis: Encounter tired A4 what s the test result? A6 gives the name to the episode of care qualified as new what s or the old, and certain or uncertain 3 rd Encounter test result? process: the interventions D6 that occur A4 iron deficiency Anemia B8 Ca Colon D75 Hb A34 Colonoscopy D4 Referral D67 Advice D45 27

27 Information we need from the most important care episodes For example: New episodes uncomplicated hypertension (K86) Duration of episode Activity pattern % yr 64% > 1 year 5% > 2 years Cum % of episodes / duration duration 4 yr or more 19% 23% 1% 1% 1% 1% 6% 49% Med exam/health evalua/partial Medication/prescript/injection Advice/health education Other blood test Electrical tracings Provid init episode new/ongoing Diagnostic radiology/imaging Other Encounters? ~6 times per annum Median: 1 per 55 days Average: 1 per 65 days Prescription pattern 9% 3% 2% 1% 1% 7% 28% Beta-blocking agents, plain, selective Angiotensin system blocking agents Thiazides and combinations N Interval of encounters 6 months 13% 18% 2% Calcium channel blockers Combinations with potassium sparing diuretics Angiotensin II blocking agents High-ceiling (loop) diuretics Source: international data on episodes in family practice, Transitieproject 28

28 We have to make sure that the health budget is well spent Additional value when care needs and care delivery are transparent COSTS TO SOCIETY Plain cost cutting Care providers Population National Health Budget Care products VALUE FOR SOCIETY Source more funds from organizations who perceive value added Pool risks, care capacity and competencies based on the care needs Prevent avoidable complications and costs Overproduction / Fraud / too high tariffs CARE NEEDS AND CARE DELIVERED TRANSPARANT Unnecessary procedures

29 Agenda Factors driving the necessity for value added in health Conceptual framework for focus on value vs cost in health systems Lessons of experience for Caribbean countries Implications of value added focus in health programs 3

30 Patient centered information gathering Morbidity and mortality data (Epi info) Care quality Health risks Care professionals have access to all relevant information they have to see Nobody has access to information they are not allowed to see Automatic COV Automatic declaration process Automatic payments Cost / fraud monitoring & Control Health budget Capacity needs Investments needs 31

31 Short term registration strategy: Reporting for reimbursement and to build new tariff structure Registration strategy R r + r To support care delivery and continuity of care International standards for health record keeping Continuity of Care Record (CCR) / Continuity of Care Document (CCD) Reporting mandatory + information for further development of funding system Data to monitor care consumption linked to diagnoses (DIS) Reporting mandatory for reimbursement Short term solution 32

32 Continuity of Care Record What is it? Core data set of the most relevant and timely facts about a patient s healthcare. Organized and transportable. Prepared by a practitioner at the conclusion of a healthcare encounter. To enable the next practitioner to readily access such information. May be prepared, displayed, and transmitted on paper or electronically. Completely based on XML 33

33 Core Data Set (CCR) 17 items: Demographics Encounters Problems / diagnoses Health Care Providers Payers Immunizations Allergies and alerts Family History Social History Procedures Medical Devices Functional status Vital Signs (Lab)results Advanced Directives Medication Plan of Care 34

34 From here we drill down to find out : What s the cause / How can we improve balancing the budget 35, 3, 25, 2, X ANG MLN 15, 1, 5,, 32,9 22,2 8,4 Intramural Farmacy Specialists GP's Care abroad Costs of care in St. Maarten 29, per category* 8,6 5,7 5,9 5,8 2,1 Other private Fatum FZOG Subsidies SVB BZV 2,5 1,1 Lab Other Transport ParamedicHome Care Duration of episode Encounters? % N 1 yr 64% > 1 year 5% > 2 years Cum % of episodes / duration duration ~6 times per annum Median: 1 per 55 days Average: 1 per 65 days Interval of encounters 4 yr or more 6 months Activity pattern Prescription pattern 19% 23% 9% 13% 6% 3% 2% 1% 1% Source: international data on episodes in family practice, Transitieproject 7% 18% 49% 28% 2% Medication/prescript/injection Advice/health education Other blood test Electrical tracings Provid init episode new/ongoing Diagnostic radiology/imaging Other Beta-blocking agents, plain, selective Angiotensin system blocking agents Thiazides and combinations Calcium channel blockers Combinations with potassium sparing diuretics Angiotensin II blocking agents High-ceiling (loop) diuretics 16 What do we need for data gathering and analysis? 1 st Encounter 1 Reason for 2 Diagnosis 3 Process Encounter I m feeling Tiredness Hb tired A34 A4 A4 NHI Insurance System PAHO EpiInfo Monitoring System Pharmacy Systems 2 nd Encounter what s the test result? A6 iron deficiency Anemia B8 Colonoscopy D4 NHI Database EpiInfo Database RX Database 3 rd Encounter what s the test result? D6 Ca Colon D75 Referral D67 Advice D45 Census Office GP system Census Database Current systems Laboratory Systems Specialists Systems Hospital Systems??? Database??? Database Hospital Database From promised care, we budgetted our spendings and bought care Health budgetting and spending is an ongoing game of balancing the budget Nephropathy Smoking Overweight Aggregating patient profiles insight into type and volume of care Blood pressure in patients with hypertension Most patients are not controlled Number of patients 18 Information we need from the most important care episodes For example: New episodes uncomplicated hypertension (K86) Monitor health risks Monitor care consumption Hypertension Cholesterol 4 2 Stress 1-mrt-9 Physical activity Nutrition Alcohol 1-mrt-1 Monitor morbidity and care needs S < 12, D <= 8 S 12-14, D <= 8 S 12-14, D 8-1 S 14-16, D 8-1 S 14-16, D > 1 S > 16, D > 1 (normal) (slight systolic) (slight systolic and (moderate systolic / (moderate systolic & (severe hypertension) diastolic) slight diastolic) diastolic) 31 Monitor Quality of care 1% 1%1% 1% Med exam/health evalua/partial Monitor 36 Patterns of care

35 From here we drill down to find out : What s the cause / How can we improve balancing the budget 35, 3, 25, 2, X ANG MLN 15, 1, 5,, 32,9 22,2 8,4 Intramural Farmacy Specialists GP's Care abroad Costs of care in St. Maarten 29, per category* 8,6 5,7 5,9 5,8 2,1 Other private Fatum FZOG Subsidies SVB BZV 2,5 1,1 Lab Other Transport ParamedicHome Care Duration of episode Encounters? % N 1 yr 64% > 1 year 5% > 2 years Cum % of episodes / duration duration ~6 times per annum Median: 1 per 55 days Average: 1 per 65 days Interval of encounters 4 yr or more 6 months Activity pattern Prescription pattern 19% 23% 9% 13% 6% 3% 2% 1% 1% Source: international data on episodes in family practice, Transitieproject 7% 18% 49% 28% 2% Medication/prescript/injection Advice/health education Other blood test Electrical tracings Provid init episode new/ongoing Diagnostic radiology/imaging Other Beta-blocking agents, plain, selective Angiotensin system blocking agents Thiazides and combinations Calcium channel blockers Combinations with potassium sparing diuretics Angiotensin II blocking agents High-ceiling (loop) diuretics 16 What do we need for data gathering and analysis? 1 Reason for 2 Diagnosis 3 Process Encounter SZV Insurance System PAHO EpiInfo Monitoring System Pharmacy Systems SZV Database EpiInfo Database RX Database 1 st Encounter I m feeling tired A4 Tiredness A4 Hb A34 Bevolkingsregister Systeem 2 nd Encounter what s the test result? A6 iron deficiency Anemia B8 Colonoscopy D4 Sedula Database Laboratory Systems Specialists Systems SMMC Systems 3 rd Encounter what s the test result? D6 Ca Colon D75 Referral D67 Advice D45??? Database??? Database SMMC Database GP system Current systems CVRM program Health Information REPository (HIREP) Encrypted Data (secure non readable) Health Information Broker (fully automated with rules who gets what) From promised care, we budgetted our spendings and bought care Health budgetting and spending is an ongoing game of balancing the budget Nephropathy Smoking Overweight Aggregating patient profiles insight into type and volume of care Blood pressure in patients with hypertension Most patients are not controlled Number of patients 18 Information we need from the most important care episodes For example: New episodes uncomplicated hypertension (K86) Monitor health risks Monitor care consumption Hypertension Cholesterol 4 2 Stress 1-mrt-9 Physical activity Nutrition Alcohol 1-mrt-1 Monitor morbidity and care needs S < 12, D <= 8 S 12-14, D <= 8 S 12-14, D 8-1 S 14-16, D 8-1 S 14-16, D > 1 S > 16, D > 1 (normal) (slight systolic) (slight systolic and (moderate systolic / (moderate systolic & (severe hypertension) diastolic) slight diastolic) diastolic) 31 Monitor Quality of care 1% 1%1% 1% Med exam/health evalua/partial Monitor 37 Patterns of care

36 Take away messages Healthcare spending have to be considered an investment in health and productivity rather than costs for society Balances on 3 levels necessary in the optimal healthcare system Balance between affordability for society and income for care providers Balance between amount paid and care provided in return Balance between quality and quantity of care delivered and the care needs in the population Data gathering essential to build the optimal healthcare system What has to be in place? National care data registration strategy: specify types and standards for data to be gathered Implementation and coupling of care information and administration systems Healthcare Management Information System Data Information Knowledge! Investments in integral chronic care programs for at least CVRM and Diabetes Willingness to act! 38

37 Result: Ready to embark on the train? Our business is to create value, not (only) to control costs Episode registration is the cornerstone of our new health system Data is not enough, information and knowledge is what we need Aware Interested Willing to try Embark Investments in integral chronic care programs 39