Ziekenhuisfinanciering 2.0. Een visie van een gezondheidseconoom Lieven Annemans Universiteit Gent, VUB November 2013

Inhoud Wat is het probleem? Hervorming van de gezondheidszorg Hervorming van de ziekenhuisfinanciering Finale bedenkingen

I. Wat is het probleem? Health expenditure has been growing faster than the economy Too much unnecessary care and large variability in care (incl. undertreatment) Lack of coordination: 1st line – 2nd line; prevention-cure; ... Increasing problems with equal access to care source: OECD 2009

Probleem! de gezondheidssector groeit(de) sneller dan de economie OECD Health Policy Studies. Value for Money in Health Spending, 2010, 204pp

 Overal nadruk op besparingen Jaarlijkse groeicijfers vd gezondheidssector in diverse landen OESO statistieken 2013

Maar impact van de vergrijzing & nieuwe technologie gieën Enkel vergrijzing Itinera, 2010, Planbureau 2012

“Health is a value in itself “Health is a value in itself. It is also a precondition for economic prosperity. People’s health influences economic outcomes in terms of productivity, labour supply, human capital and public spending.”

I. Wat is het probleem? Health expenditure has been growing faster than the economy Too much unnecessary care and large variability in care (incl. undertreatment) Lack of coordination: 1st line – 2nd line; prevention-cure; ... Increasing problems with equal access to care source: OECD 2009

Recent study in Belgian hospitals 34 hospitals (IMS database) MCD and Financial information for all stays 2 substudies: Readmissions for same reason as index stay within 1-3 months Hospital acquired infections

Results re-admissions 2.1% readmissions (n = 27,000) within 3 months after original hospitalisation total cost to the health insurance = € 280 Mln Wide variability between hospitals (1.17 - 6.40%) Results HAI 5.9% of the hospital stays associated with a HAI (+/- 75,000 cases of HAIs). Total cost of HAI in Belgium is estimated at € 533 Mln Variability between hospitals (3.77-9.78%).

Afhoudingen op inkomsten van de artsen Bizarre financiering 40% 40% 15% 5% Afhoudingen op inkomsten van de artsen Budget financiële middelen Pharma Werkingskosten Verblijfskosten Verpleegkundigen Verzorgenden … Op basis van betaling per prestatie Op basis van afgedwongen kortingen

Inhoud Wat is het probleem Hervorming van de gezondheidszorg Hervorming van de ziekenhuisfinanciering Finale bedenkingen

5 solutions for a performant health care system Setting goals and targets Revising structures and processes Search for cost-effectiveness in all what we do Invest in a perfect ICT system Revising the way healthcare providers are paid

1. The primary goal of health care policies 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. Report of the Belgian EU Presidency, endorsed by the EU Council of Ministers of Health in Dec 2010 Must be translated in concrete SMART objectives 14

2. Change the structures & processes A mandatory GP (medical coach) for everyone Integrated care networks and case managers for multi-morbidity (supervised by the medical coach) “Goal oriented care” More telemedicine and –prevention Patient responsibility & self-monitoring New professions (physician assistants, practice nurses, nurse-specialists) …

The benefits of primary care oriented health systems Less hospital admissions Less emergency visits* Less non-evidence based surgery Less readmissions Better self reported health More prevention …. Een vaste huisarts voor IEDEREEN

Gezondheidseffect (QALYs) 3. Kosten-effectiviteit C-Eff Niet C-Eff Threshold (+/- 40.000/QALY) Kost NIEUW Huidige aanpak NIEUW NIEUW Dominant Gezondheidseffect (QALYs) Annemans L. Health economics for non-economists. AcademiaPress, 2008

all information for all the patients , all the time 4. Perfect health information system “ If you do not have all information for all the patients , all the time you are wasting your money ”                             George Halvorson, CEO,Kaiser Permanente intreview http://vimeo.com/4039344

Improving quality and reducing costs - Is it possible ? Latest news from Kaiser Permanente Cut Serious heart attacks by 62% in 10 years Cut Heart attacks by 24 % in 10 years Cut fractures in osteoporotic patients by 37% Cut hospitalization in patients with co-morbidity by 70 %!!! 25% lower medical costs 10 % lower insurance primes Investing in IT: € 30 per member/year

5. Change the way we pay “Fee for Service” Overconsumption (supplier induced demand) Prospective payments (Pay per stay) “ALL-IN” Cost shifting Risk selection Quality  Unbundling Outliers problems …

Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation (due to reduced cost sharing) indicate limited evidence for moral hazard. 22

More “Capitation”? Fixed amount per patient per time period + decreased risk for overconsumption + improved access + more focus on prevention + patient empowerment undertreatment? attractivity of young healthy patients? cost shifts? Not shown by KCE (KCE rapport , 2009)

Inhoud Wat is het probleem Hervorming van de gezondheidszorg Hervorming van de ziekenhuisfinanciering Finale bedenkingen

Towards pay for quality? “From Paying to do things To Paying to do things right And Paying to do the right things”

Evidence on effects Targets with above 5% positive effect title

Cfr. Quality indicators Flanders http://www.zorg-en-gezondheid.be/Beleid/Kwaliteit/Basisset-2012/#indicatoren Moeder en kind Oncologie Orthopedie Cardiologie Ziekenhuisbreed domein

BUT: some pitfalls of P4Q Poor definition of quality: structure, process and outcomes indicators Not involving the physicians, lack of communication Size and type of the financial reward/penalty not well studied Problem with engaging physicians continuously Patient case-mix

Opties voor ziekenhuisfinanciering Forfait per APRDRG per verblijf incl. 1 maand post P4Q Idem maar excl. artsen forfait voor intellectuele prestatie artsen P4Q Idem maar excl. artsen FFS voor intellectuele prestatie artsen P4Q ! Geen afhoudingen meer

IV. Final thoughts Economisch denken in de zorg moet ten dienste staan en niet ten koste gaan van kwaliteit. Eeen systeem met perverse financiële prikkels kan nooit performant zijn Er is nog veel ruimte voor verbetering inzake kosten-effectiviteit In de toekomst zal fee for service geleidelijk aan plaatsmaken voor “capitation” en P4Q De toekomstige ziekenhuissector zal relatief kleiner en financieel gezonder moeten zijn Een visie 2025 is nodig voor de ganse gezondheidssector.

Vanaf midden Februari 2014

Ziekenhuisfinanciering 2.0. Een visie van een gezondheidseconoom Lieven Annemans Universiteit Gent, VUB November 2013