Caribbean Health Financing Conference Curacao, 31 October 2012 - - PowerPoint PPT Presentation

Caribbean Health Financing Conference

Curacao, 31 October 2012

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Objective: Embark on the train towards value based health care

Aware Interested

• 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

• Investments in integral

chronic care programs

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

• Investments in integral

chronic care programs Aware Interested Willing to try

5

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

• Investments in integral

chronic care programs Aware Interested Willing to try Embark

6

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

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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

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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

9

GDP

(Gross National Product)

National Health Budget

GP Specialist Hospital &intramural Dentist Paramedical Pharmacy Lab Home care Other

Per capita healthcare costs vs. insurance premium Care delivered Morbidity

(Burden of disease)

Burden of disease…

1

Creates demand for care…

2

… care being provided

3

… paid for and administrated

4

… funded by health insurance premiums and gov’t funding

5

…Sourced from National income

5

The care system….

Complex Chronic Acute Urgent Not urgent Elective

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Healthy productive population

GDP

(Gross National Product)

National Health Budget

GP Specialist Hospital &intramural Dentist Paramedical Pharmacy Lab Home care Other

Per capita healthcare costs vs. insurance premium Care delivered Morbidity

(Burden of disease)

Burden of disease…

1

Creates demand for care…

2

… care being provided

3

… paid for and administrated

4

… funded by health insurance premiums and gov’t funding

5

…Sourced from National income

5

The care system….

Complex Chronic Acute Urgent Not urgent Elective

National Health Budget

Population Care products Care providers

Balance between affordability of care and funding for exploitation of care practices and institutes Balance between care needs and quantity and quality of care Balance between what care providers are paid and the care products they deliver

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 VALUE FOR SOCIETY WHY DO WE HAVE TO PAY THAT MUCH? WHAT BURDEN WAS AVOIDED / HOW MUCH VALUE WAS CREATED?

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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

13

Data gathering  information  knowledge is essential

Population Care products Care providers

• A. No complete balance
• B. Balance between costs for society and

income of care providers

– Exploitation costs are covered – Salary cap

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

A B D C

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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

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

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What is the importance of data gathering and analysis?

• Monitor care consumption
• Monitor morbidity and care needs

– How healthy is SXM? – Care needs of the population

• Monitor quality of care

– Process and outcomes

Monitor health risks

0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0

Intramural Pharmacy Specialists GP's Care abroad Lab Other Transport Paramedic Home Care Other private Fatum FZOG Subsidies SVB BZV

Costs of care in 2009, per category* 2,5 22,2 8,6 8,4 5,8 2,1 5,9 5,7 32,9 1,1

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• Monitor morbidity and care needs

– How healthy is SXM? – Care needs of the population

What is the importance of data gathering and analysis?

Monitor health risks

Monitor care consumption

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From Standards of care towards individual care plans

Individual care needs

Diagnosis How ? & Who ? What ? National norm When? & By whom? Individual Patient Client Caregroup District Region

Health problems

Standards of care

Care program Care teams Individual Care plan

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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

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Visualize risk profile

2 4 6 8 10

Smoking Overweight Physical (in)activity Nutrition Alcohol Stress Depression Anxiety Somatisation Cholesterol Blood pressure Nefropathy Glucose Diabetic foot Neuropathy Retinopathy Pulmonary function / dyspnea Exercise tolerance COPD exacerbations

T0 T1

LIFESTYLE PSYCHOLOGICAL COMPLAINTS

VASCULAR RISK

COPD DIABETES MELLITUS

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Make an individual care plan based on assessment

Unhealthy lifestyle General wellbeing Diabetes mellitus Cardiovascular risk-management

Smoking Fhysical activity Alcohol Nutrition Depression Stress Participation Obesity Hypertension Dyslipidemidia Nefropathiy Glucose Retinopathtjy Neuropathy Feet

Sc module 1 Sc module 1 Sc module 1

Health issues Stepped-care modules

Disease specific Disease specific Disease specific Disease specific Sc module 1 Sc module 1 Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Sc module 4 Sc module 4 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 Sc module 1 Sc module 1 Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Sc module 4 Sc module 4 Sc module 1 Sc module 1 Sc module 1 Sc module 1 Sc module 2 Sc module 2 Sc module 2 Sc module 2 Sc module 3 Sc module 3 Sc module 3 Sc module 3 Sc module 4 Sc module 4 Sc module 4 Sc module 4

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Organization individual CVRM: case management

Central care provider

Smoking Cessation therapy Physical therapist Dietician Specialist Pharmacist Psychologist

Patient recruitment Intake Risk and care profiles Individual care plan Follow up Feedback & Benchmark

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Feedback & benchmark every 3 months

Patient recruitment Intake Risk and care profiles Individual care plan Follow up Feedback & Benchmark

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What is the importance of data gathering and analysis?

• Monitor quality of care

– Process and outcomes

Monitor health risks

Monitor care consumption

Monitor morbidity and care needs

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Most patients with diabetes are not controlled Majority of patients have HbA1c > 9

50 100 150 200 250

HbA1c < 6.5 HbA1c 6.5 - 7.4 HbA1c 7.5 - 9 HbA1c >=9 HbA1c in patients with DM2

Number of patients

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BMI in patients included in CariCare 75% of patients have overweight

50 100 150 200 250 BMI < 20 BMI 20 - 24.9 BMI 25 - 29.9 BMI 30 - 34.9 BMI 35 - 40 BMI > 40

Number of patients

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Identify population needs by aggregation of Individual Care Plans

Aggregating patient profiles… …insight into type and volume of care

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What is the importance of data gathering and analysis?

• Monitor patterns of care

– Process and outcomes

Monitor health risks

Monitor care consumption

Monitor morbidity and care needs Monitor Quality of care

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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

Reason for Encounter Diagnosis 1 2 Process 3

Three key components :

Coded in ICPC-2 / ICD-10

• the patient’s Reason(s) for Encounter (RFEs):
• should be recognizable by the patient as an acceptable description of

his/her demand for care

• the GP’s diagnosis:
• gives the name to the episode of care
• qualified as new or old, and certain or uncertain
• process: the interventions that occur

Hb A34 ‘I’m feeling tired’ A04 Tiredness A04

1st Encounter

Colonoscopy D40 ‘what’s the test result?’ A60 iron deficiency Anemia B80

2nd Encounter

Referral D67 Advice D45 ‘what’s the test result?’ D60 Ca Colon D75

3rd Encounter

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Information we need from the most important care episodes For example: New episodes uncomplicated hypertension (K86)

Prescription pattern Activity pattern Duration of episode

64% > 1 year 50% > 2 years ?

Encounters

~6 times per annum Median: 1 per 55 days Average: 1 per 65 days

4 yr or more 1 yr

Cum % of episodes / duration

6 months

Interval of encounters %

N

duration

49% 23% 19% 6% 1% 1% 1% 1% 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 28% 20% 18% 13% 9% 7% 3% 2% 1% 1%

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 25 50 75 100 50 100 150 200

Source: international data on episodes in family practice, Transitieproject

National Health Budget

Population Care products Care providers

CARE NEEDS AND CARE DELIVERED TRANSPARANT

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 VALUE FOR SOCIETY  Plain cost cutting  Overproduction / Fraud / too high tariffs  Source more funds from

• rganizations who

perceive value added  Pool risks, care capacity and competencies based on the care needs  Prevent avoidable complications and costs  Unnecessary procedures

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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

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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

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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

• f 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

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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

http://en.wikipedia.org/wiki/Continuity_of_Care_Record

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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

http://en.wikipedia.org/wiki/Continuity_of_Care_Record

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What do we need for data gathering and analysis?

Monitor health risks

Reason for Encounter Diagnosis 1 2 Process 3 Hb A34 ‘I’m feeling tired’ A04 Tiredness A04

1st Encounter

Colonoscopy D40 ‘what’s the test result?’ A60 iron deficiency Anemia B80

2nd Encounter

Referral D67 Advice D45 ‘what’s the test result?’ D60 Ca Colon D75

3rd Encounter

GP system

Monitor care consumption

Monitor morbidity and care needs

Blood pressure in patients with hypertension Most patients are not controlled

Monitor Quality of care Monitor Patterns of care

Current systems

NHI Insurance System NHI Database PAHO EpiInfo Monitoring System EpiInfo Database Hospital Systems Hospital Database Pharmacy Systems RX Database Laboratory Systems ??? Database Specialists Systems ??? Database Census Office Census Database

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What do we need for data gathering and analysis?

Monitor health risks

Reason for Encounter Diagnosis 1 2 Process 3 Hb A34 ‘I’m feeling tired’ A04 Tiredness A04

1st Encounter

Colonoscopy D40 ‘what’s the test result?’ A60 iron deficiency Anemia B80

2nd Encounter

Referral D67 Advice D45 ‘what’s the test result?’ D60 Ca Colon D75

3rd Encounter

GP system

Monitor care consumption

Monitor morbidity and care needs

Blood pressure in patients with hypertension Most patients are not controlled

Monitor Quality of care Monitor Patterns of care

SZV Insurance System SZV Database PAHO EpiInfo Monitoring System EpiInfo Database SMMC Systems SMMC Database Pharmacy Systems RX Database Laboratory Systems ??? Database Specialists Systems ??? Database Bevolkingsregister Systeem SedulaDatabase

Current systems

Health Information Broker (fully automated with rules who gets what)

Health Information REPository (HIREP)

Encrypted Data (secure non readable)

CVRM program

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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!

39

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

• Investments in integral

chronic care programs Aware Interested Willing to try Embark