Ziekenhuisfinanciering 2.0.
Een visie van een
gezondheidseconoom
Lieven Annemans
Universiteit Gent, VUB
November 2013
Inhoud
I.
II.
III.
IV.
Wat is het probleem?
Hervorming van de gezondheidszorg
Hervorming van de ziekenhuisfinanciering
Finale bedenkingen
2
I. Wat is het probleem?
1. Health expenditure has been growing faster than
the economy
2. Too much unnecessary care and large variability in
care (incl. undertreatment)
3. Lack of coordination: 1st line – 2nd line; preventioncure; ...
4. Increasing problems with equal access to care
source: OECD 2009
3
Probleem! de gezondheidssector groeit(de) sneller dan de
economie
OECD Health Policy Studies. Value for Money in Health
Spending, 2010, 204pp
4
-15.0%
Iceland
Switzerland
Germany
Norway
Hungary
Poland
United States
Austria
Netherlands
Sweden
Canada
Belgium
Finland
France
Denmark
Australia
Spain
United Kingdom
Italy
Czech Republic
Estonia
Portugal
Slovak Republic
-5.0%
Ireland
Greece
 Overal nadruk op besparingen
Jaarlijkse groeicijfers vd gezondheidssector in diverse landen
15.0%
10.0%
5.0%
2001-2009
0.0%
OESO statistieken 2013
2010-2011
-10.0%
5
Maar impact van de vergrijzing &
nieuwe technologie
Vergrijzing
+technologieën
Enkel
vergrijzing
Itinera, 2010, Planbureau 2012
6
“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?
1. Health expenditure has been growing faster than
the economy
2. Too much unnecessary care and large variability
in care (incl. undertreatment)
3. Lack of coordination: 1st line – 2nd line; preventioncure; ...
4. Increasing problems with equal access to care
source: OECD 2009
8
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
9
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%).
10
Bizarre financiering
40%
Budget financiële middelen
Werkingskosten
Verblijfskosten
Verpleegkundigen
Verzorgenden
…
40%
Afhoudingen op
inkomsten van de artsen
Op basis van
betaling per
prestatie
15%
5%
Pharma
Op basis van
afgedwongen
kortingen
11
Inhoud
I.
II.
III.
IV.
Wat is het probleem
Hervorming van de gezondheidszorg
Hervorming van de ziekenhuisfinanciering
Finale bedenkingen
12
5 solutions for a performant health
care system
1.
2.
3.
4.
5.
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
13
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 multimorbidity (supervised by the medical coach)
• “Goal oriented care”
• More telemedicine and –prevention
• Patient responsibility & self-monitoring
• New professions (physician assistants, practice nurses,
nurse-specialists)
• …
15
16
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
….
17
Kost
3. Kosten-effectiviteit
Niet C-Eff
NIEUW
Huidige
aanpak
C-Eff
NIEUW
NIEUW
Dominant
Gezondheidseffect (QALYs)
18
Annemans L. Health economics for non-economists. AcademiaPress, 2008
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
19
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
20
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
• …
21
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 physicianinitiated 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)
23
Inhoud
I.
II.
III.
IV.
Wat is het probleem
Hervorming van de gezondheidszorg
Hervorming van de ziekenhuisfinanciering
Finale bedenkingen
24
Towards pay for quality?
“From Paying to do things To
Paying to do things right
And Paying to do the right things”
25
Evidence on effects
Targets with above 5% positive effect
title
26
27
Cfr. Quality indicators Flanders
http://www.zorg-engezondheid.be/Beleid/Kwaliteit/Basisset2012/#indicatoren
• Moeder en kind
• Oncologie
• Orthopedie
• Cardiologie
• Ziekenhuisbreed domein
28
BUT: some pitfalls of P4Q
1. Poor definition of quality: structure, process and
outcomes indicators
2. Not involving the physicians, lack of communication
3. Size and type of the financial reward/penalty not well
studied
4. Problem with engaging physicians continuously
5. Patient case-mix
29
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
30
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 kosteneffectiviteit
• 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.
31
Vanaf
midden
Februari
2014
32
Ziekenhuisfinanciering 2.0.
Een visie van een
gezondheidseconoom
Lieven Annemans
Universiteit Gent, VUB
November 2013