Managing Overseas Care in St. Maarten
Lessons from Experience
TCI-NHIP/HEU 10th Caribbean Conference on National Health Financing Initiatives
Turks & Caicos Islands, 29 October 2015
FOR FURTHER INFORMATION
ACSION
SZV
Phone
Van Engelenweg 21A
Willemstad
Curaçao,
+(599-9) 737-3595
Sparrow Road 4
Philipsburg
St. Maarten
: +1-721-546-6782
Website
www.acsiongroup.com
www.szv.sx
eMail
Javier.asin@acsiongroup.com
Address
NON DISCLOSURE STATEMENT
The information in this document may not to be copied, stored in an electronic database, made
publicly available in any way or form, either electronically, mechanically, by means of
photocopying, recording or any other way without the prior written consent of ACSION and SZV
2
Agenda
•
Overseas Care today
– The impact
– The Challenges
•
Overseas Care in the future
–
–
–
–
Demand analysis
Expand capabilities and capacity SMMC
New product definitions
Benchmark
3
Healthcare expenditures 2013: more than half is spent on hospital care
More is spent on medical referrals abroad than on care in the hospital on St. Maarten
ANG
Medical Referrals Abroad
Sint Maarten Medical Center
Pharmaceutical Care
Loss of Wages
Laboratory
Primary Care Physicians
Medical Specialists
Other medical costs
Paramedic Care / Midwives
Home Care
Mental Health
Source: Annual Report SZV 2013
4
Health care expenditures are rising
Mainly medical care abroad
Mental Health
Home Care
Paramedic Care / Midwives
Other medical costs
Primary Care Physicians
Laboratory
Loss of Wages
Pharmaceutical Care
Intramural Care
5
Data used for the hospital care demand analysis
Actual data not sufficient – alternative sources for estimates
•
Data on actual hospital care delivered
– Information on hospitalizations in the SMMC (ICD 9 codes): Vast majority was unspecified
– Information on medical referrals abroad: not all referrals recorded accurately plus latent demand
•
Indications from additional resources
–
–
–
–
Demographic profile: age & gender distribution, socio-economic status (STAT 2011 / CIA)
Healthcare survey 2002: self reported health status and morbidity (VSA)
Health expenditures: primary care versus secondary care (SZV)
Reference population in the Netherlands (SMMC/Performation)
6
Top 10 countries patients are referred to
Curaçao is dominant because of historic ties within the Kingdom
7
Musculoskeletal problems prevail
Top 20 diagnoses medical referrals abroad and health survey show the same
Top 20 diagnoses
Number
HNP (herniated nucleus pulposus, back/neck hernia)
194
Gonarthrosis (knee pain)
118
Prostate carcinoma (prostate cancer)
76
Epilepsy
56
Varices (varicose veins)
51
Asthma
41
PSA (prostate-specific antigen)
33
Mamma carcinoma (breast cancer)
31
Scoliosis (curvature of the spine)
25
RA (rheumatoid arthritis)
24
Chronic headache
24
Meniscus tear
23
Retinal detachment (ablatio retinae)
23
Mamma reduction (breast reduction)
22
BPH (Benign Prostatic Hyperplasia, prostate enlargement)
22
Diabetic Retinopathy (DRP, eye problems)
19
Cervical spine (C1 t/m C7)
18
Cardiomyopathy (heart muscle disease)
16
COPD (Chronic Obstructive Pulmonary Disease)
15
Prostatic hypertrophy (prostate enlargement)
14
Prevalence (1 year) of chronic disorders per 100 cases Total (N=754)
Chronic back problems
13.2
Hypertension
12.6
Complaints of the joints*
8.5
Migraine & chronic headache
7.9
Psychological problems
5.6
Dizziness
5.6
Diabetes Mellitus
4
Chronic non-specific respiratory disease
3.9
Stomach/duodenal ulcer
3.6
Serious consequences of an accident
2.7
Chronic inflammation of the bladder
2.3
Heart diseases
2.2
Gall stones/inflammation of gallbladder
1.6
Glaucoma
1.5
Loss of hearing
1.3
Blindness
1.2
Intestinal disorders
0.9
Serious skin disease
0.9
Kidney stones
0.9
Loss of normal use of limbs
0.9
* Complaints of the joints is a combination of the diseases arthritis and arthrose because
respondents cannot always make a distinction between these diseases
8
Demographic profile indicates highest care demand in workforce
Greying of the population bears high risks with so few young people
9
Per capita income is high and unemployment rates low
However the employed population has mainly physically straining jobs
10
Healthcare spending allows little room for prevention and management of secondary care
Relatively little is spent on primary and home/nursery care
ANG
Medical Referrals Abroad
Sint Maarten Medical Center
Pharmaceutical Care
Loss of Wages
Laboratory
Primary Care Physicians
Medical Specialists
Other medical costs
Paramedic Care / Midwives
Home Care
Mental Health
Source: Annual Report SZV 2013
11
Challenges with current medical referrals abroad
Need for change given the impact of referrals on patients, costs and outcomes
•
No continuity of care
– No shared protocols
– Transfer of information is incomplete and sometimes even absent
– Direct contact between medical specialists is ‘forbidden’ by agencies
•
Logistics
– Visa requirements
– Patients are often not used to traveling and/or do not comply with the advise given
– Bureaucracy often causes delays in urgent cases
•
Lack of information about the care demand and cost drivers
– Hospital diagnoses are not registered with sufficient accuracy / detail
– Reasons for referral abroad, diagnoses, costs and outcomes are not registered structurally
– No system in place to assess and monitor integral quality and efficiency
Given the impact of medical referrals on patients, costs and health outcomes,
it is clear that optimization is not an option but a must
12
Conclusions and recommendations
• Proper registration is a prerequisite to analyze the care needs and the demand for care
– Episode registration with ICPC2 / ICD 10 codes in primary and secondary care
• Accurate data registration in the medical referral process is necessary
• It seems that permanent availability of an orthopedic surgeon, urologist, neurologist, cardiologist
and ophthalmologist is necessary
– Could be financed from the avoided referrals abroad since the vast majority is linked to these specialisms
• Expanding available services to lower medical referrals abroad is not the only solution
– Perhaps even more important is to invest in measures to prevent avoidable hospital care with
• Adequate labor laws
• Fighting obesity and cardiovascular risk management
• Adequate procedures and processes for medical referrals
13
Agenda
•
Overseas Care today
– The impact
– The Challenges
•
Overseas Care in the future
–
–
–
–
Demand analysis
Expand capabilities and capacity SMMC
New product definitions
Benchmark
14
Our approach
From a shared vision to the strategy for hospital care
15
Elements of the vision for intramural care St. Maarten
•
Demand driven
•
Minimal norms for quality and safety
•
On St. Maarten or the best alternative if needed
•
Affordable and sustainable
•
Integrated care: cooperation and coordination
•
Safeguard patient rights
•
St. Maarten stakeholders always in charge
•
Transparency
16
Shared vision for intramural care
Build strategy clockwise in the 3 balance model
HOSPITAL CARE REMAINS AFFORDABLE
THE NECESSARY HOSPITAL CARE CAN BE
DELIVERED PREFERRABLY LOCALLY AND
IN A SUSTAINABLE MANNER
POPULATION COUNTS ON AVAILABILITY AND ACCESS TO
HOSPITAL CARE THEY NEED (QUANTITY AND QUALITY)
THE NECESSARY AMOUNT AND QUALITY OF CARE
IS AVAILABLE
The strategic framework
Translation of Vision and Objectives to a Strategy to be operationalized
Demand
driven
• Care demand analysis
• Care episode registration
• Care product definition
Optimal
Quantity and
Quality of care
• Norms for quality and safety
• Benchmark
Viable
healthcare
infrastructure
• Continuous development of the
National Hospital
• Medical coordination on St. Maarten
• Procurement process
Adequate
financing
• Financial balance
• Value based
reimbursement system
18
SCM will be described for the most important care products
High volume, high costs and/or referrals abroad necessary
Top 20 diagnoses
Number
HNP (herniated nucleus pulposus, back/neck hernia)
194
Gonarthrosis (knee pain)
118
Prostate carcinoma (prostate cancer)
76
Epilepsy
56
Varices (varicose veins)
51
Asthma
41
PSA (prostate-specific antigen)
33
Mamma carcinoma (breast cancer)
31
Scoliosis (curvature of the spine)
25
RA (rheumatoid arthritis)
24
Chronic headache
24
Meniscus tear
23
Retinal detachment (ablatio retinae)
23
Mamma reduction (breast reduction)
22
BPH (Benign Prostatic Hyperplasia, prostate enlargement)
22
Diabetic Retinopathy (DRP, eye problems)
19
Cervical spine (C1 t/m C7)
18
Cardiomyopathy (heart muscle disease)
16
COPD (Chronic Obstructive Pulmonary Disease)
15
Prostatic hypertrophy (prostate enlargement)
14
19
Based on international guidelines
20
Care product definition consist of an algorithm and SCMs
Example: HNP diagnosis and treatment
•
•
SCM1a: conservative treatment for 12 weeks
SCM 1b: conservative treatment for 12 weeks with
assessment by neurologist after 6-8 weeks
•
SCM 2: Intensive conservative treatment for another 8
weeks
SCM 1a
•
SCM 3: Operation
SCM 1b
•
SCM 4: Reassessment after SCM 3 was not successful
Diagnosis Lumbosacral
Radicular Syndrome (LRS)
Urgent referral
indications?
Cauda Equina
Syndrome
Yes
No
Direct referral to
neurologist
Yes
Serious paresis /
malignancy in history?
Referral to neurologist
1-3 days
Yes
No
Suspect rare or
serious cause?
No
Yes
Referral to neurologist
Yes
Serious pain despite
adequate pain
medication?
No
No
No
Insufficient reduction
of pain and/or loss of
function after 6-8
weeks
No
Patient prefers
operaton?
No
Neurologist
advisies operation?
Yes
Yes
Insufficient reduction
of pain and/or loss of
function after 12
weeks
No
Indication or
preference for
operation?
No
Yes
SCM 2
SCM 3
No
Sufficient reduction of
complaints after SCM
1-3?
No
Geopereerd?
Yes
SCM 1: Conservative treatment for 12
weeks
SCM 4
75% SCM 1a/1b
15%
SCM 2
10%
SCM 3
21
SCMs for diagnosis, treatment and rehabilitation HNP
Assessment / Diagnosis
GP
SMMC
SCM 1A
History / Phys
examination
SCM 1b
SCM 1a
Assessment
neurologist
SCM 2
SCM 1
2 Assessment
neurologist
SCM 3
SCM 1 / 2
Pre-operative
radiology
SCM 4
SCM 4 is on top of SCM 3
Treatment / interventions
Abroad
Pre-operative
radiology
Postoperative
reassessment
GP
SMMC
Pain medication /
careful exercise
(12 weeks)
Pain medication /
careful exercise
(12 weeks)
Pain medication /
careful exercise
(20 weeks)
Pain medication /
careful exercise
(8 – 20 weeks)
SCM 4 is on top of SCM 3
Rehabilitation
Abroad
GP
Abroad
SMMC
After Care
Assessment
neurologist
Additional
treatment
After Care
Assessment
neurologist
After Care
Assessment
neurologist
After Care
Assessment
neurologist
Post-operative
check-up
SCM 4 is on top of SCM 3
22
Items to be described in SCM
INSTRUCTIONS
• Description of the SCM including the objectives and a summary of the care to be delivered
• Advise for patient: explanation of the care to be delivered as well as self management instructions
• Instructions for nurse / physician: the objectives, procedures, schedule and data to be registered
INTERVENTIONS (incl. minimal competencies)
• Diagnostic procedures: lab, imaging, function tests
• Combined lifestyle interventions/ paramedic care: smoking cessation, nutrition, exercise, addiction care
• Psychosocial support: to cope with the disease/treatment/life issues or to support lifestyle interventions
• Medical (specialist) interventions: pharmaceutical, surgical or radiological interventions
MONITORING
• Monitoring frequency: schedule for monitoring visits
DATA REGISTRATION
• Parameters to be registered for care continuum, logistics and integral quality management / benchmark
23
Benchmark for procurement and Shared Decisionmaking with patient
•
Country level
–
–
–
–
•
Hospital level
–
–
–
–
•
Accessibility (travel / Visa)
Language
Costs
Agencies
Capacity / Scale / Experience
Functions
Quality system / Accreditation
Outcomes and complications
Medical specialists
– Specialties
– Process and outcome indicators
•
Treatment / SCM
– Experience and Outcomes
– Willingness to cooperate in SCM
– Costs
24
Summary
•
Medical referrals abroad have an enormous impact on health(care) St. Maarten
– However at the moment very limited instruments to manage costs and outcomes
•
Change #1: Standardized data registration
– Care demand analysis
– Capability as well as capacity planning
– Integral quality management
•
Change #2: expand capabilities and capacity SMMC
– To accommodate more treatment as well as pre-treatment and rehabilitation capabilities
•
Change #3: SCMs as the new product definitions
– Continuity of care with joined protocols and multidisciplinary sharing of patient data
– Procurement of parts of the SCMs rather than the complete care tracks
•
Change #4: Procurement with benchmarks
25