PERFORMANCE BASED SUPPLEMENTARY PAYMENT SYSTEM

IN PUBLIC HOSPITALS:EVIDENCE FROM TURKEY

Prof. Dr. Sabahattin AYDINMinistry Of Health, TURKEY

17. Nov. 2008Washington DC

• Shortfalls in supply of health personnel• Overcrowding in public hospitals • Long waiting times • Low provider satisfaction• Low patient satisfaction• Lack of capacity• Long patient queues• Low salaries• Doctors prefering private sector.

Problems requiring new reforms

Hospital Reforms in Turkey

• The hospital reforms carried out to date:

– Granting hospital managers more autonomy and flexibility over the management of revolving funds, as well as procurement and investment decisions

– Implementation of hospital quality and efficiency audits.

– Outsourcing of hospital clinical services (diagnostics) to the private sector (public-private partnerships),

– Upgraded health information systems,

– Implementation of a performance based supplementary payment system

Performance Based Supplementary Payment System

Objective

The main objective of the PBSP system was to

encourage job motivation and productivity among public sector health personnel.

Development and implementation of the model

• First introduced in 2004.

• Initially pilot has been realized for ten hospitals &

• Subsequently expanded to all MoH Health Facilities.

• Developed by strictly monitoring the changes and evaluating the feed backs.

• Currently all 850 MoH hospitals have in place within the PBSP system.

2003

2004

2005

2006

2008

PPIILOT LOT STUDYSTUDY

Development and implementation of the modelDevelopment and implementation of the model

INDIVIDUALINDIVIDUAL

MANMANAAGERGERIALIAL

INSTITUTIONALINSTITUTIONAL

CLINIC INDICATOR CLINIC INDICATOR SPECIFICATIONSPECIFICATION

What is the PBSP system?

• An additional payment in addition to regular salaries.

• Base salary from line item budget.

• Performance-based payment from hospital earnings

• Bonus payments linked to performance of health personnel.

• Standardized and transparent process.

Payment to health personnelPayment to health personnel

• Each personnel earns a fixed salary

+• A bonus

related to their own performance and the performance of the hospital

Line-item

budgetHospital

Revenues

Salary + PBSP

Fixed

Individual performance

Institutional performance

Individual performance Individual performance measurementmeasurement

• Each service is rated with a point

• Each clinician collects points from his/her tasks (load of service)

2005 HASTANE

KO DU

BUT 2005

KO DUİŞLEM ADI PUANI

510.121Dahili branşlardaki servislerde günde en az iki kez yapılan hasta başı vizit (günlük her hasta için)

21

520.010 Konsültasyon ücretleri (her bir hekim için) 10520.020 Acil poliklinik muayene ücreti 21520.030 Normal poliklinik muayene ücretleri 21

520.031 Sevki yapılan muayene 5520.032 İçapcı nöbetinde yapılan muayene 30

520.033Psikiyatri Muayenesi (ilk 10 hasta için 30 puan sonraki hastalar 21 puan)

30

530.020 Apse veya hematom drenajı, derin 150530.100 Elektrokardiyogram 0530.140 IM enjeksiyon 0530.150 IV enjeksiyon 0

530.581 Ria takılması 40550.130 Anestezi A1 grubu (Özellikli ameliyatlar ve girişimler) 1.200

550.131Anestezi A1 grubu (Özellikli ameliyatlar ve girişimler),uzman ve anestezi teknisyeni birlikte

400

604.660 Valvotomi, mitral kapak, kapalı 1.280

604.910Koroner arter by-pass, karotid endarterektomi + patch plasti

2.500

607.980 Splenektomi, total 500610.130 Appendektomi 420619.910 Müdahaleli doğum 143619.920 Normal doğum 143

619.921 Ebe eşliğinde yapılan doğum 36619.930 Sezeryan 143801.690 Akciğer grafisi (iki yön) 4804.190 MR, beyin 20901.500 Glukoz 0

All procedures made by the mentioned units are billed and priced according to tariff (SUT)

There are some awarding and punishment elements which result in increasing or decreasing the net performance scores of the personnel

Hospital managers have, but limited filexibility in rewarding and punishing

+ / - bonuses+ / - bonuses+ / - bonuses+ / - bonuses

How does PBSP system work ?How does PBSP system work ?

How does it work?

Factors which determine how much health personnel will receive as performance-based payments:

– The total amount capped at 40% of revenues.

– This total (capped) amount is subsequently adjusted based on institutional performance of the hospital (0-1).

– An individual level performance score is calculated for each staff member.

– Total points score for a physician is adjusted by a job title coefficient

Distribution of Hospital RevenuesDistribution of Hospital Revenues

Hospital Revenues

15 % Treasury Share

0 – 40 %

PBSP Budget

45 – 85 %

Regular Hospital

Expenditures

Management Board

the total amount that health facilities can allocate to performance-based payments to health personnel is capped at 40% of revenues

40 %

capped amount

0.8

institutional performance adjustment*

> 40% of hospital revenue

0 - 1

x=

32 %

devoted to staff bonuses

Effect of institutional performance on the amount to be transferred to the staff

Healthcare institution’s revenues

Individual performance Individual performance measurementmeasurement

• Each service was rated with a score

• Each clinician collects scores from his/her tasks (load of service)

Example for medical procedures and grading for clinicans

Example for medical procedures billed but not scored

• Individual scores and • Hospital average

100021

300

1030 1000

21

300

1030

10 21

300

1030

21 2121

21300

13.000 7.00015.000 5.000 17.000 ++++

Dr 1 Dr 2 Dr 3 Dr 4 Dr 5

57.000 /5

11.400

Σx1...xn /n

Indirect performance score estimationfor those who do not have scores of medical procedures

xBIOCHEM. SPEC.

xAUX.

xCIV. SER.

xNURSE

xANES.TEC

xMANAGER

=2.5x

=.25x

=.25x

=.4x

=.5x

=1x

OTHER

xHEAD PHYSICIAN =4.5x

Adjustments

• The total points score for a physician is adjusted by,

– a job title coefficient: to measure workload aside from providing clinical care (i.e. administrative duties, teaching etc.)

– the number of days the person has worked in that month.

– depending on whether the person is doing private practice or not (0.4/1.0).

Institutional Performance Component

40 %

capped amount

0.8

institutional performance adjustment*

> 40% of hospital revenue

0 - 1

x=

32 %

devoted to staff bonuses

categories of indicators for institutional performance

Institutional Performance

0 - 1

Access to examination

Infrastructure and process

Patient satisfaction

Institutional productivity

Institutional targets

N1 + N2 + N3 + N4 ∑: N1 -N4 / 4

Check PointsCheck Points

Hospital Revenues

PBSP Budget

Social Security Institution

MEDULA

Examination Comisson

Invoicing / Recording has 2 check points

Hospital Revenue Blling /

Recording

Electronic &

manual controll

Service Delivery

Types of upper cap restrictions in the system:

–Cap for distributing hospital revenues (40 %)

–Control of fluid cash (Managerial Board)

–Multiplier of basic salary for profession

Upper Cap Restrictions

CCaps for bonuses as multiplier of basic aps for bonuses as multiplier of basic salarysalary

   CoefficientCoefficient

Full timeFull time clinic chiefs and associate chiefs clinic chiefs and associate chiefs 88

Full time Full time specialist physicians, specialist dentistsspecialist physicians, specialist dentists 77

Ful time Ful time practitioners and dentistspractitioners and dentists 55

CClinic chief, associate chiefs, specialist physicians, specialist dentistslinic chief, associate chiefs, specialist physicians, specialist dentists doing doing private practice (part time)private practice (part time) 3,53,5

PPractitioners and dentists ractitioners and dentists doing private practice (part time) doing private practice (part time) and hospital and hospital managers and pharmacistsmanagers and pharmacists 2,52,5

Head nurses and the Head nurses and the staffstaff working in specific services such as ICU working in specific services such as ICU (Intensive Care Unit)(Intensive Care Unit), delivery, newborn, nursing infant, burn, , delivery, newborn, nursing infant, burn, dialysis, surgery, bone marrow transplantation unit, ER, mental dialysis, surgery, bone marrow transplantation unit, ER, mental health and the psychiatry services in the hospitalshealth and the psychiatry services in the hospitals 22

The other The other staffstaff 1,51,5

Individual bonuses for staff are capped at a certain multiplier of basic salary.

Differences in other settingsDifferences in other settings• PHC facilities

• Some preventive healthcare service indicators are used for scoring.

• Adjustments are made according to the characteristics of the region where the personnel is working.

• Training Hospitals• Additional scores are given for;

– Training activities and – Scientific publications

What has changed after PBSPS ?What has changed after PBSPS ?

Ratio of full time and part time working doctors

Number of patient visits by years

There has been a large increase in physician productivity in public hospitals

Number of people examined in public hospitals in 2006 has increased by 75 % when compared to 2002.

In the same period, the number of patients per physician has decreased by 25 %.

Number of examination in public hospitals

Note: the figure for 2002 covers SSK hospitals.

Number of examination rooms in public hospitals

Number of examination rooms in public hospitals has increased by 145 %.

Idle capacity has started to be used with the principle of “an examination room for each physician”.

Referral rate from public hospital to a senior institution(%)

•Highly organized and improved digital recording system for invoice producing is constituted. Almost all of the public hospitals have HIS now. Informal procedures and alike are decreased.Thus contribution is made to the reliable data collection to run the health financing more accurate.

•As the working time in hospitals became longer, surgery, lab, imaging services are given for a longer period of time. Waiting periods for imaging and pathology labs became shorter.

Income-expenditure balances of the healthcare institutions are started to be followed sensitively as if they work on totally professional health sector enterprises.

As all hospital personnel gained the awareness that they become like the partners of the institution, they started to question actions, to develop, to adapt the capacity and quality building steps, to support and to get tasks.

Other improvements

People “satisfied” with health center services People “satisfied” with health center services (%)(%)

People “satisfied” with public hospital services People “satisfied” with public hospital services (%)(%)

Ratio of the out-of-pocket health expenditureRatio of the out-of-pocket health expenditure (%) (%)

People generally satisfied with healthcare People generally satisfied with healthcare services services (%)(%)

Source: TUİK

TUİK Life Satisfaction Survey