Activity Based Funding
Conference
2015 RCSI
Potential of ABF to improve integration of Care
Dr. Orlaith O Reilly,
National Clinical Advisor and Group Programme Lead,
Health & Wellbeing Division
Definitions
• “Integrated Care is a continuum of preventive,
diagnostic, treatment and support services for
patients, appropriate to their needs, across
different parts of the health system”.
• Integrated Care is the full spectrum of care.
• Integrated = joined up.
• HIPE data records conditions that are significant in
terms of treatment, investigation and cost.
• ABF = payment based on activity.
(what you do not who you are)
• ABF is used internationally to incentivise behaviour.
• HIPE and ABF are major systems the HSE resources,
should be used to incentivise the way the system
behaves for the benefit of patients.
Health Service Challenges
• Ageing population (85 years + increasing 4% PA).
• Increased burden of chronic disease ( 20% – 40%
by 2020).
• Multiple chronic diseases.
• Adverse trends in health determinants eg.
obesity, poverty etc.
• Unsustainable increase in cost of care.
• Hospitals over run.
• Need new way to deliver care; Integrated, at
lowest level of complexity.
Full Spectrum of Care
Primary
Prevention
Acute
Episodes
Early
Detection
Chronic Disease
Management
Self
Management
Support
Secondary
Prevention
Rehabilitation
• Full spectrum of care currently takes place in
all settings e.g. Hospital, Primary Care etc.
• Important to capture data on all of it and
incentivise all of it.
CHD mortality fall in Ireland 1985 - 2006 explained by
a) treatments in CHD patients & b) population risk factors
Risk Factors worse +17%
Obesity (increase)
Diabetes (increase)
0
Risk Factors better –66%
-1000
Smoking
-3%
Cholesterol
-24%
Population BP fall
-28%
Physical activity (more) -10%
-2000
-3000
+ 4%
+ 13%
6450
fewer deaths
-4000
1985
2006
Treatments -40%
AMI treatments
Secondary prevention
Heart failure
Angina
Hypertension drugs
Statins 1’ prevention
Reference:
Kabir Z, et al. (2013). Modelling Coronary Heart Disease Mortality declines in the Republic of Ireland, 1985–2006,
International Journal of Cardiology. 168(3):2462-7.
-4%
-12%
-8%
-9%
–3%
-4%
Importance of Prevention and
Self Management Support
• 66% of decrease in CHD mortality due to primary
prevention.
• 12% decrease in CHD mortality due to secondary
prevention.
• 24% reduction due to medication; dependent on
patient self management support.
• 4% reduction due to surgical treatment.
Barriers to Integration
• Don’t record or reward the whole spectrum of
care, including prevention.
• “ Can only manage what you measure”.
• We do record/reward interventions for biological
risk factors e.g. blood pressure management, but
do not for behaviour change interventions – just
as important.
• Don’t record/reward hospital avoidance or early
discharge.
Implications
• Currently don’t share data across spectrum of care.
• Don’t utilise prevention fully.
• Don’t give care at lowest level of complexity.
• Parts of system cost save at the expense of other parts.
• Patients receive disjointed care – little chronic disease
management.
• E.g. 60% of diabetic patients should be managed outside
a hospital.
Solutions
• Prevention is an intervention in each clinical episode.
• Record lifestyle and preventive interventions as we do
other items.
• Share data between Primary and Secondary Care.
• Record data across the full spectrum of care.
• Manage patients at lowest level of complexity.
• Lever the above behaviours by financial incentives.
Examples of ABF incentivising integration of
whole spectrum of care
• Record risk factors and preventive intervention; payment on %
recorded, payment on % intervened.
• Smoking cessation and weight loss programme for patients wait
listed for surgery; incentivise use of DOSA and lifestyle intervention
as well as the surgical intervention.
• Build hospital avoidance programmes into funding.
• Pay for chronic disease management in ambulatory care, including
self management support and secondary prevention.
• Incentivise early discharge programmes.
ABF incentive programmes in Australia
• Chronic disease management programmes set up by the hospital with GP
partners. Saving 1000 – 2000 dollars per patient.
• High ED/admission cohort programme; state funds agreed cohort at
current hospital rates, hospital sets up less costly ambulatory
programmes. Hospital makes a profit, but does not get double paid if
patient admitted.
• Hospital at home programmes; hospital funded to provide this at 85% of
inpatient cost – makes profit.
• Early discharge programmes; supplied by hospital outreach team with
Primary Care partners. Saves 1000 dollars per patient.
• In reach to Nursing Home programme; hospital sets up a nurse led nursing
home assessment for acute admission, saves 1000 dollars per head.
• “Keeping kidneys” programme; renal unit sets up an ambulatory care
programme with GPs to provide self management support services and
secondary prevention. Slows down renal failure and demand for dialysis
and transplantation.
Potential for ABF
• ABF is a revolution in funding for health services.
• Need to use it to incentivise the right behaviours.
• Need to use it to incentivise the development of systems to
integrate care.
• Small financial incentives are proven to be very effective.
• Clinical programmes already provide professional
leadership etc.
• Use funding to record, fund and integrate all elements in
the spectrum of care.
Understanding
the Surgical
Workload and
its Funding
Activity Based Funding Conference
28th May 2015
ACTIVITY BASED FUNDING
1. Providers are funded based on the activity they undertake.
2. ‘Casemix funding’ is also used = ‘mix of cases’ that a health service
treats.
3. A health system produces more than treated cases, and includes
maintaining the health of people at home, prevention, teaching,
research etc
4. For this reason, no health system in the world is funded solely on
the basis of its ‘casemix’.
5. Hospital activity is counted by ‘episode of care’- from admission to
discharge
6. The financial incentive is to minimise the cost of each episode of
care
7. Inevitably rewards the shortest length of stay in a hospital bed
8. This raises concerns that patients will be discharged too soon.
9. These concerns can be overcome if patient outcomes are
measured
10. These concerns can be overcome if there is continuity of care
between the hospital and home.
28/05/2015
ACTIVITY BASED FUNDING
16
The ABF Patient
Record Journey
16,708
HIPE
30/admission
6,662
HIPE
20/admission
FUNDING
Encrypted
Who sets the price?
28/05/2015
ACTIVITY BASED FUNDING
17
DRG codes
XnnS
Step 3: Complexity
A = most complex …
D = least complex
(or Z – same price
regardless)split
Step 1: Major Diagnostic
Category (MDC) code
• 23 body systems
• A = complex – Transplant,
prolonged ICU
Step 2: ADRG number
28/05/2015
•
Surgery 00…39;
•
Other 40…59 (eg Echmo, Plasmaphoresis)
•
Medicine 60…99
ACTIVITY BASED FUNDING
698 DRGs in
Ireland
18
28/05/2015
ACTIVITY BASED FUNDING
19
HIPE finalised data file, 2013
DRG / Procedure
MJR SMALL & LARGE BOWEL PR-CCC (G02B)
Right hemicolectomy with anastomosis (3200301)
Limited excision lrg intestine w anstms (3200300)
Resec small intestine w anastomosis (3056600)
Left hemicolectomy with anastomosis (3200600)
Temporary colostomy (3037528)
Extended right hemicolectomy w anstms (3200501)
Total colectomy with ileostomy (3200900)
Abdominal rectopexy (3211700)
Temporary ileostomy (3037529)
Subtotal colectomy w stoma formation (3200400)
Limited exc lrg intestine w stoma frm (3200000)
Reduction rectal mucosa, rectal prolapse (3211100)
Subtotal colectomy w anstms (3200500)
Left hemicolectomy w stoma formation (3200601)
Total colectomy w ileorectal anastomosis (3201200)
Other repair of small intestine (3037519)
Right hemicolectomy w stoma formation (3200001)
Laparoscopy (3039000)
Resec small intestine w formation stoma (3056500)
Other colostomy (3037504)
⁞ ⁞ ACTIVITY BASED FUNDING
# Patients
1,480
403
171
169
93
71
55
49
47
46
42
41
39
26
19
18
18
17
16
16
14
⁞⁞
AvLOS
11.28
9.86
9.70
12.51
9.83
12.18
11.67
15.18
7.23
12.17
21.33
11.73
4.31
12.42
16.53
11.11
8.06
14.82
17.38
21.44
11.57
⁞⁞
Avg Rel
Cmplxty
7.27
8.14
6.80
4.97
8.14
6.47
8.14
11.43
6.47
6.02
8.59
8.59
5.58
11.43
8.14
11.43
5.58
8.14
4.24
6.02
6.47
⁞⁞
DRGS ARE FOR FUNDING AND NOT FOR
CLINICIANS MEASURING THEIR ACTIVITY
THIS IS DONE BY HIPE
28/05/2015
20
NCPS Mapping of
Surgical Procedures
Our analysis:
• By patient episode, by primary
procedure
• Procedures* (mainly PRIMARY)
drive surgical DRGs and ABF
• Procedures > 20 in any one year in
all surgery (2010, 2011, 2012, 2013)
Excluding procedures < 10 in 2013
ACTIVITY BASED FUNDING
28/05/2015
>98%
21
Patients who had an Above Knee Amputation (4436700) during a single admissions in 2012
PRIMARY
28/05/2015
ACTIVITY BASED FUNDING
22
Multiple
Procedure
Example
HIPE CAN COLLECT
UPTO 30 DIAGNOSES
& 20 PROCEDURES
28/05/2015
ACTIVITY BASED FUNDING
23
NQAIS
Surgery
Web enabled
interactive
reporting tool
Using your own
hospital’s HIPE data
28/05/2015
ACTIVITY BASED FUNDING
24
HOW ABF WILL DRIVE CLINICAL PRACTICE
1. BY IMPROVING EFFICIENCY AND QUALITY OF CARE BY SETTING
APPROPRIATE TARIFFS
2. BY CORRECTING PERVERSE INCENTIVES - DAY v INPATIENT ACTIVITY
3. BY FUNDING CARE IN CORRECT SETTING - AMBULATORY CARE
4. BY INCENTIVISING SHORTENED AVLOS
5. BY INCENTIVISING BETTER CARE
6. BY MANAGING INAPPPROPRIATE GEOGRAPHIC VARIATION
7. BY LIMITING OVER INVESTIGATION AND OVER TREATMENT
28/05/2015
ACTIVITY BASED FUNDING
25
LAP CHOLECYSTECTOMY-CDE-CSCC (H08B)
National target 60%
€4,826 PerCase
€4,896 PerCase
€3,429 PerCase
€3,226 PerCase
Elective
HIPE data
2013
We need to
incentivise
move to
Day Case
28/05/2015
ACTIVITY BASED FUNDING
26
BY FUNDING CARE IN CORRECT SETTING - AMBULATORY CARE
€5539/week
€12,798 /week
Expense
28/05/2015
ACTIVITY BASED FUNDING
27
Examining 2012 Surgical Day Case Activity
Day Surgical
Procedures
85,140
39%
GI
Endoscopes
51,456
23%
Out Patient
Day Procedures
Minor
Opp
Proctrue Day
(not
Surgery)
42,863 68,40029,537
19%
38% 13%
28/05/2015
Valid
Day
Case
ACTIVITY BASED FUNDING
N= 208,996
OUT PATIENTS
Examination of the Eye
Nasoendoscopy
Aspiration of breast
Fine needle biopsy of breast
Rigid sigmoidoscopy
Sclerotherapy for haemorrhoids
Ear toilet, unilateral
Papanicolaou smear study
Micro injections of venular flares
MINOR OPS – SIDE ROOM
Removal of toenail or in-growing toenail
Biopsy of skin & subcutaneous tissue
Excision of lesion(s) SSCT, foot
Biopsy of tongue
Biopsy of oral cavity
Removal of wart
Should be done as Day Cases. Funding should reflect the correct site
28
BY INCENTIVISING BETTER CARE - Hip Fracture
KPI – Surgery within 48 Hours
Transfers – Acute Hip fracture operations in receiving hospital
Transferred from Acute Hospital / HIPE hospital list or from non-Acute Hospital (Admit source 3 or 4)
HIPE 2013 data
Admitted direct
Transfer from other Hospital
Operating Hospital
AMNCH Tallaght
BEAUMONT HOSPITAL, DUBLIN
CONNOLLY HOSPITAL, BLANCHARDSTOWN
CORK UNIVERSITY HOSPITAL
KERRY GENERAL HOSPITAL
LETTERKENNY GENERAL
MATER MISERICORDIAE, DUBLIN
MAYO GENERAL HOSPITAL
MIDLAND REGIONAL HOSPITAL, TULLAMORE
OUR LADY OF LOURDES, DROGHEDA
REGIONAL (UCHG), GALWAY
REGIONAL, (DOORADOYLE) LIMERIC
SLIGO GENERAL HOSPITAL
ST. JAMES'S HOSPITAL, DUBLIN
ST. VINCENTS UNIVERSITY HOSPITAL
TEMPLE ST. CHILDREN, DUBLIN
WATERFORD REGIONAL (ARDKEEN)
Grand Total
28/05/2015
# Patients
133
189
58
280
138
105
132
84
115
152
101
188
80
64
328
2
258
2,407
BDU
2,955
5,693
1,915
4,034
1,786
1,722
3,731
2,017
1,647
2,816
1,900
2,069
1,078
3,071
8,626
8
4,635
49,703
AvLOS
22.2
30.1
33.0
14.4
12.9
16.4
28.3
24.0
14.3
18.5
18.8
11.0
13.5
48.0
26.3
4.0
18.0
20.6
# Patients
26
4
0
5
0
1
2
0
6
65
4
10
0
1
1
0
142
267
BDU
502
154
0
71
0
129
26
0
57
1,240
56
63
0
9
6
0
2,512
4,825
ACTIVITY BASED FUNDING
AvLOS
19.3
38.5
0.0
14.2
0.0
129.0
13.0
0.0
9.5
19.1
14.0
6.3
0.0
9.0
6.0
0.0
17.7
18.1
Total
# Patients
159
193
58
285
138
106
134
84
121
217
105
198
80
65
329
2
400
2,674
BDU
3,457
5,847
1,915
4,105
1,786
1,851
3,757
2,017
1,704
4,056
1,956
2,132
1,078
3,080
8,632
8
7,147
54,528
AvLOS
% Transfer
from Hsptl
21.7
30.3
33.0
14.4
12.9
17.5
28.0
24.0
14.1
18.7
18.6
10.8
13.5
47.4
26.2
4.0
17.9
20.4
16.4%
2.1%
0.0%
1.8%
0.0%
0.9%
1.5%
0.0%
5.0%
30.0%
3.8%
5.1%
0.0%
1.5%
0.3%
0.0%
35.5%
10.0%
29
BY MANAGING INAPPPROPRIATE GEOGRAPHIC VARIATION
Extraction of Cataract w or
wo implant Lens procedures (C16Z)
Elective 2013
Cases Per
Discharged to 000's Pop
City / County 01
9.21
City / County 02
3.96
City / County 03
3.96
City / County 04
3.30
City / County 05
2.92
City / County 06
2.82
City / County 07
2.56
⁞
City / County 21
1.78
City / County 22
1.78
City / County 23
1.52
City / County 24
1.45
City / County 25
1.45
City / County 26
1.42
City / County 27
1.40
City / County 28
1.21
City / County 29
1.17
City / County 30
0.99
City / County 31
0.88
Ireland Total
1.98
HIPE 2013 data
4.7 times
national avg
Tonsillectomy without
adenoidectomy TONSILLECTOMY,
ADENOIDECTOMY (D11Z)
Elective 2013
Cases Per
Discharged to
000's Pop
City / County 01
0.82
City / County 02
0.80
City / County 03
0.77
City / County 04
0.59
City / County 05
0.57
City / County 06
0.51
City / County 07
0.46
⁞
City / County 20
0.26
City / County 21
0.26
City / County 22
0.21
City / County 23
0.20
City / County 24
0.20
City / County 25
0.20
City / County 26
0.20
City / County 27
0.20
City / County 28
0.19
City / County 29
0.16
City / County 30
0.13
City / County 31
0.03
Ireland Total
0.31
HIPE 2013 data
for Adults only (16 & Over)
2.6 times
national avg
BY LIMITING OVER INVESTIGATION AND OVER TREATMENT
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
28/05/2015
ACTIVITY BASED FUNDING
31
CCPs arose from HSE/RCPI/RCSI
collaboration 2010
Opportunities
New Minister
New Secretary General
New HSE Directorate Structure (5)
New National Clinical Leads (5)
New Presidents RCPI and RCSI
New Hospital Groups
Money Follows The Patient/ABF
New GP Contract
Economic upswing
Leo the Pirate
Change (Reform)
“All change is difficult,
even from worse to better!
Richard Hooker
Want to make enemies?
Try changing something!
Pres. Woodrow Wilson
Clinical Care Programmes
• National Acute Medicine Programme
(50% of all bed days used)
• Older persons, Surgery, Emergency
Medicine, Critical Care programmes
and Primary Care - all vital partners
in integrated care delivery
• IHRP/SDU – assist with performance
management & redesign of care
processes
National Acute Medicine Programme
Described new model of care with 4
intervention areas
1). Ambulatory Care (AEC, AUC, SDEC)
2). Short Stay Units (< 2/7)
3). Inpatient wards (3-14/7)
4). Complex discharges (> 14/7)
National Acute Medicine Programme
– (contd.)
Established Hospital Models 1, 2, 3, 4, (5)
Flow/reverse flow
GP/Hospital Liaison Committees
Move from horizontal to vertical care
(‘pit stops’)
National Early Warning Score (NEWS)
MFTP/ABF/VBF
Abolish perverse incentives
Support virtuous incentives/VFM
Fund Ambulatory Care, focused on older
patients (Elderly Frail Units) and chronic
disease care in the Community
Must be transparent, accountable, make
financial sense and work for the patient
Facilitates rationale future service planning
Gets CEOs’ attention!
ABF
• Streamlines flow to and from primary and
secondary and tertiary care
• Identifies and removes delay, duplication and
cost by peer reviewed comparative analyses
• Builds confidence and interdisciplinary
cooperation between GPs and hospitals and
within and between hospitals
• Should cross all care interfaces
• Reduces variation and risk and improves
clinical outcomes for patients
• Ensures costs/rewards are fairly apportioned
between GPs/Community/Hospitals
‘every
system is perfectly
designed to get the results it
gets’
10
8
% of attendees
Arrivals
6
4
Departures
2
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour
% all Medical patients on AMAU
Pathway
Year
% AMAU Pathway
2012
21%
2013
29%
2014
32%
Current % across all hospitals ranges from 16% (lots of
trolleys/terrible PETs) to 74% (few trolleys/great PETS)
2015 Target = 40%
2016 Target = 50%
Needs 7/7 working
Me dical AvLOS for 2009, 2010, 2011, 2012, 2013
9
8.8
8.6
8.4
AvLOS (days)
8.2
8
7.8
7.6
7.4
7.2
7
Jan
10
Jan
11
Jan
12
Time Period
Jan13
Data Source: HIPE, ESRI
© A cute Medicine Programme HSE Ireland
Why AMAUs work
•
•
•
•
•
•
•
•
•
•
•
•
Multidisciplinary Team working
Clearly defined roles/responsibilities
Mindsets of staff (can do attitude)
Investigate to discharge, NOT admit to investigate
Ability to change ‘tempo’ in response to unit demands
Coordinated/organized
Older patient focused
Systems set up for Safety
& Quality
& Speed
Reduce LOS
Improve PET
Model of Care (NAMP)
Respiratory
Unit
Stroke Unit
GastroIntestinal
Unit
GP
Decision
to admit
Acute Bed Pool
Acute Elderly
Care Unit
2 nights
Metabolic
Unit
ED
Critical
care
Cardiac
Unit
Hospital C : % of Inpatient Discharges by Length of Stay
Category for Acute Medicine
Combined Emergency and Elective Admissions
>14 Days
15%
0 Days
12%
10-14 Days
10%
1-2 Days
24%
6-9 Days
17%
3-5 Days
22%
Hospital C : % of BDU by Length of Stay Category for Acute
Medicine Combined Emergency and Elective Admissions
0 Days
1%
>14 Days
54%
1-2 Days
4%
3-5 Days
11%
6-9 Days
16%
10-14 Days
14%
Health Reform and the Quality
Agenda
• Includes all groups:
DOH/Government
HSE
GPs
Community
Hospitals
ICT/Analysis/Governance/ABF
Patient groups
has significant start up costs and quality has a price!
(recouped later in efficiency gains and risk reduction)
ABF encourages competition!
Conclusion - we need to:
Re-engineer healthcare systems based on
cooperation, interdisciplinary working and flow
modelling
Achieve highest quality of safe, efficient care with
lower mortality and length of stay with improved
patient outcomes and increased staff satisfaction
Develop Acute Physicians who can manage
complex, co-morbid illnesses, leading
multidisciplinary teams and who embrace
performance improvement skills as core
competencies
Absolute need for:
• New thinking, communication and
collaboration
• Clinical/Financial Management Systems
(ICT) to administer ABF fairly and
transparently
• National Quality Improvement
Programmes (e.g. NQAIS Medicine)
• Realistic health budget
• Clinical, Managerial, Political Leadership
• Media engagement
New approach
•
•
•
•
•
•
•
Invest-return cycle
Business Cases
Never get discouraged, never give up!
Set goals – something to aspire to
Celebrate success
Don’t founder on cherished outcomes
Relentless focus on opportunities
• Oh, did I mention BRAVERY?
That €10K could come in handy...
ABF
Thanks for listening –
Now go out and just do it!
Eilish Croke,
Programme Manager
Garry Courtney
Clinical Lead