Evaluation of Patient Choice Systems in Stockholm County

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Evaluation of Patient Choice Systems in Stockholm County

4 October 2013

Michael Högberg

Stockholm County Council

[email protected]

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Evaluation of Patient Choice Systems in Stockholm County

Agenda:

Patient choice in Stockholm county

Impressions of patient choice in Sweden

Reimbursement models

Cost containment

Innovation – New projects

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Utvecklingsavdelningen

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2014

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What distinguish patient choice in Stockholm?Medical centres/general practitioners

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2008 2009 2010 2011 2012Child welfare clinics Hip and knee

arthroplastyObstetric care Vaccination Spec. gynecology

Antenatal care Cataract extraction

Obstetric ultrasound

Primary hearing rehab

Spec. dermatology out-patient care

Chiroprody Vaccination pandemia(ended 2010)

Planned spec. rehabilitation for neurology, onchology and lymphoma

Spec. eye out-patient care

Spec. physiotherapy

Medical centers/family doctors and home care

Fundus photo-graphy for diabetics (incl. in spec. eye out-patient care from 2012)

Specialist dental care for children and youth

General dental care for children and youth

Spec. ear-nose-throat out-patient care

Physicians in residential homes for elderly

Dental surgery for children and youth

Speech therapy Primary care rehab

SCC: Implemented patient choice programs


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Vårdval Stockholm: Objectives and measures

Improved access Choices and multiple provider structure Competion (”neutrality btw public and private

GPs”)

Payment:– Ca 40% capitation based on age (no socio-economic indicators) – Remaining payment: per visit per type of visit, extra payment for

home-visits, interpreter, and some geographical areas.– Patient fees are kept by providers, but reduced from payment from

the county council, the ”high-cost protection” is paid by the county council

– Ceiling for reimbursement, reduced after 1,9 visits per listed (average), after 4 visits/listed – only patient fee.

– Some medical services is included in the reimbursement


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Evaluation of the Patient Choice Reform- Health Economics perspective(Karolinska institutet)

Cost containment

Efficiency/productivity

Distribution and Equity

Quality/Patient satisfaction

Ownership and contracts


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The development of costs in GP services, Stockholm county council, 2006-2010

§) Korrigerat med LPI


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Productivity (cost per contact), 2006-2010


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Cumulative share of population

(ranking from poorest to richest)

Cu

mu

lativ

e s

hare

of

perfo

rman

ce 20%

40%

60%

80%

100%

20% 40% 60% 80% 100%

O

B

C

The Lorenz-curve – distribution of utilization per income area


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The distribution of doctor’s visit per income quartile (geogr areas)

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The distribution of visits to doctors, nurses and costs across low and high income areas

* = A positive value(+) indicates a higher utilization in rich geographical areas, and a negative value (-) indicates a higher utilization in poor areas.


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SCC:Private and public share of total costs in 2007

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SCC: Private and public share of total costs in 2008

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Ownership distribution

SLSO = public providers


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Conclusions

Cost containment achieved

Improved access to GP service

Increase in productivity (first year – extra-ordinary)

Some improvement in patient satisfaction

No conflict productivity and patient satisfaction

Larger increase of utilization in poor areas

Increase of supply – private providers >50% of the

market

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Share of patients that could visit the GP within 7 days in private and public care in Sweden (Source: Nat. waiting time database)

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The Counties’ purchase of services 2006-2012 per type of provider, private and public, million SEK and share of total net cost (Source: SALAR)

Share of net cost

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Impressions of patient choice in Sweden – sources:

National Board of Health and Welfare

Swedish Agency for Health and Care Services Analysis

Karolinska Institutet

Swedish association of Local Authorities and Regions

Reports from several counties

Other

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Impressions of patient choice in Sweden - results

The patients value freedom of choice – those who made active choices were more satisfied

Patient satisfaction seems to have increased (with increased freedom of choice)

The patients choice of provider were based on short distance and reputation – not medical results

Cost controlled during implementation of patient choice in PC

No signs of cost-shifting But all of the population have increased the use of care in a larger extent than

individuals with great need of care Co-operation between PC and other care (incl social services) more difficult due

to versatility of providers Patient choice contracts more flexible than procurement

Potential for improvement– knowledge of structure for decisisons– information to citizens of patient choice and informed decisions – follow-up (reporting of statistics, implementing validated goals for quality )– stimulate co-operation between providers across administrative boarders

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Reimbursement models for patient choice (vårdval) in primary care (Source: Anell & SALAR)

Capitation - Fixed reimbursement per listed individual. Age wheight.

Adjusted Clinical Groups (ACG). Adjustment for diagnose classification – Case-mix

Care Need Index (CNI) socioeconomic wheight, describes the expected risk of illness.

Reimbursement per visit – GP, nurse etc.

Goal related reimbursement – Variable reimbursement based on

result.

Geography – Adjustment for localization of medical centre.

Coverage – Adjustment according to listed persons visits in PC in

relation to total number of out-patient visits.

Responsibility for cost for visiting other providers, drugs, medical

service etc.

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Patient choice and reimbursement models in primary care (Source: Anell & SALAR)

Principles of reimbursement: (fixed/variable, visit/procedure-related

and goal-related reimbursement)

Fixed reimbursement varies from 40 to 80% of total– 13 counties adjust for age, 8 for ACG (5 kombinerar)– 16 counties adjust for difference in socioeconomy (CNI etc.)– 14 counties adjust for localization of medical centre– 15 counties adjust for coverage (definitions varies!)

Stockholm CC and Uppsala CC – highest share of reimbursement per visit

All counties except one use goal-related reimbursement (2-5%)

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Cost containment (Source: Anell & SALAR)

Rationing demandUnspecified problems Specified problems

Responsibility for remittance and

cost

Assessment of need/illness

Differentiated patient fees Guidelines against indication creep

Rationing supply

Low reimbursement for ”PC-visits”

Episode of care/bundle price if

possible

Episode of care/bundle price/

/capitation

Retroactively reduced price Retroactively reduced price

Maximum procedure per patient (or

provider)

Maximum procedure per patient (or

provider)

Guidelines/standardization Guidelines/standardization

Need for complementary management and follow-up!

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Additional objectives with patient choice system in PC and specialized care

Stimulate innovation and new ways to organize

the care

Get a larger variety of providers

Stimulate coherent chains of care

– (elderly – PC – hospital care, etc.)

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New projects with reimbursement models- Valuebased healthcare & episodes of disease (bundled payment)- Patient centered & health related outcomes- Case management & disease management- Integrated care- DRG outpatient care

Hip/knee arthroplasty (complication guarantee)

Spine & neck surgery (10% health outcome based)

Rheumatoid Arthritis (chronic care, valuebased, patient

centered, disease episode, e-Health, drug cost, DRG)

COPD (care chain, episode, guidelines, incentives, DRG)

”Aktiv Hälso Styrning (AHS)” (case & disease management)

- coaching: Multicontacts emergency hospitals, CHF, COPD

New Karolinska university hospital

& future healthcare system


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Base reimbursement

Known additional costs

Potentially Avoidable Complications

Outcome reimbursement Retrospective

Expected additional costs

Prospective

Prometheus model (US)

1.1. Base reimbursementBase reimbursement

2.2. Reimbursement additional costsReimbursement additional costs

3.3. Reimbursement for PACReimbursement for PAC

4.4. Reimbursement for outcomeReimbursement for outcome

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2

3

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FirstvisitFirstvisit OperationOperation Rehabilita-

tionRehabilita-

tionRevisit

1 monthRevisit

1 month

> Lump-sum reimbursement> Lump-sum reimbursement > Outcome reimbursement> Outcome reimbursement > Provider warranty> Provider warranty> Patient informed provider > Patient informed provider

choicechoice> Freedom of establishment> Freedom of establishment

Value basedValue basedcompetitioncompetition Value = Value =

Health OutcomesHealth Outcomes

Cost of treatmentCost of treatment

Bundled payment model

Sick patientSick patient Healthy Healthy patientpatient

complicationcomplication

Bundled price = X SEK + outcomebased reimbursement

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Spine surgery

+10% of X SEK

for health outcome

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Value-based reimbursement – rheumatoid arthritis (RA)

Research questions

Which outcome measures concerning patients and cost

can be used to operationalize value?

What in the healthcare is experienced as value by the

patient with RA?

How are incentives for continuous innovation created in

the care to increase value for the patient?

Can a value-based reimbursement act as incentive to

increase the value for patients with RA?


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8.4.1. Genomsnittlig förändring av sjukdomsaktivitet (DAS28) med konfidensintervall över tre år, vid alla månadskontrolltillfällen (MK1-MK36) för RA patienter. Visar att den initiala förbättringen tre månader efter inklusion i kvalitetsregistret tenderar att kvarstå.

Example: RA - phases and targets for value improvement8.4.1. Genomsnittlig förändring av sjukdomsaktivitet (DAS28) med konfidensintervall över tre år, vid alla månadskontrolltillfällen (MK1-MK36) för RA patienter. Visar att den initiala förbättringen tre månader efter inklusion i kvalitetsregistret tenderar att kvarstå.

Diagram för långtidsuppföljning från SRQ Årsrapport 2009.

Prephase•Short duration of illness

•Access to reum. clinic

•Coherent pathway

PC – reum. clinic

8.4.1. Genomsnittlig förändring av sjukdomsaktivitet (DAS28) med konfidensintervall över tre år, vid alla månadskontrolltillfällen (MK1-MK36) för RA patienter. Visar att den initiala förbättringen tre månader efter inklusion i kvalitetsregistret tenderar att kvarstå.

Phase 1, response

Aim phase 1• Quick response

• Treatment to reach

low or no disease

activity

• Preserved function

Prephase,early

detection

Aim phase 2• Good QoL and function

• Remission

• Low level of disease-

activity

• Physical excercise

• Smoking cessation

Phase 2, keep down

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COPD: Incentives for better health outcome and resource use

Objective:

To use register data to describe the chain of care

for COPD-patients

Calculate the cost of the chain of care

Analyze the correlation between registered

procedures and effects

Compare with existing guidelines for care of COPD-

patients

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COPD: Incentives for better health outcome and resource use

Cost

Course of disease

Investment in PC

Incentives for early detection, evidence-based treatment & collaboration

Avoiding unnecessary acute contacts, visits and in-hospital care

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Case management and Disease management: A small part of the population accounts for a large part of healthcare expenditures

Source: National Registry of Health Care Quality (SALAR), National Registry of Atshma, Health Economics of Depression - Sobocki (2006), National registry of Diabetes, National registry of CHF, National Registry of Stroke, Swedish National Institute of Public Health, Health Navigator analysis

80%

10-15%

5-10%

Case ManagementMost healthcare intensive

patient groups

Disease ManagementMost healthcare intensive

diseases

Population Health Management Risk groups in the

population

In the County of Stockholm 1 % of adults account for 30

% of total health care spending and 25% of all emergency admissions

1,5 million Swedes suffer from asthma, depression,

diabetes, CHF or stroke

In Sweden there are:

•Approx 1,8 million smokers

•Approx 2,7 million overweight

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The case management intervention

1. Motivational conversations2. Self-care support3. Patient education4. Coordination of social and

medical services

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The result for all patients included during the last 12 months RCT’s evaluating case management models in the County of Stockholm

CHF**

800 ind

Compared with a control group – Patients receiving nurse support have . . .

Frequent ER*

visitors

4 459 ind

• 14 % less in hospital days and slightly increased outpatient care

• - 9 % or 1 600 Euro per patient in reduced health care cost

• 35 % less in hospital days and slightly increased outpatient care


COPD***

1 204 ind

• 20 % less in hospital days and a slightly increased outpatient care


* ER = emergency room; ** CHF = Congestive Heart Failure; *** COPD = Chronic Obstructive Pulmonary Disease

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Challenges

Reimbursement models based on the value for the individual patient

– More variables concerning the patient’s situation incl patient safety & health outcome

– Adaptation to law concerning secrecy and integrity

– Coherent pathways – episode-based models

– Bundled payment

Quality deficiency – never-events – cost containment

Use and development of existing registers – nat. quality registers, etc.

Comparability via common validated, standardized data

– Providers, patients, public

Informatics, standardized solutions for compatibility

Support for implementing guidelines and evidence-based care

Open mind, cooperation between counties & central – regional – local levels

Innovations – try out & secure evidence

– Stimulate research - implementation


Health & Medicine

Evaluation of Patient Choice Systems in Stockholm County