Introduction to the Disease

Management Funding

approach

Jacob Hofdijk

EFMI president

Ministry of Health – Integrated Funding Team

Care continuum with silo’s

Reasons for Reform in 1994

• Two contra productive business models

• Hospital tries to keep within the budget

• Physician on fee for service

• Involvement of Government too restrictive

• Growing costs, but no metrics of the outcome

• 1994 Biesheuvel Report Modernising Curative

Care

• The start of Paradigm Shift from supply to

demand orientation

Performance based hospital funding

• Demand orientation Health issue patient

• Combine diagnostics and treatment

• Payment of Hospital / Medical specialist

• Requires data collection by patient by health

issue

• New dimension in health information systems

• System designed by major stakeholders

• After preparation introduction for funding 2005

Health Insurance Act 2006

• Mandatory Insurance scheme for all

• After 30 years of political discussion !

• Competing private insurance companies

• Insurance company contracts health

providers of choice

• Central role for Insurance companies

• Focus on Quality Improvement

• Sustainable health care system

Impact contracted careproducts

The Dutch DBC Funding results

More market and transparency

Patients can choose

Process of CHANGE !

DBC-systems works

7

The 2030 Long Term Care Crisisgrowth of chronic diseases since 2005

0

10

20

30

40

50

60

70

80

90

Diabe

tes

Diab+

BM

I

Har

tinfa

rct

Ber

oerte (C

VA)

Har

tfalen

Col

onka

nker

Lon

gkan

ker

Bor

stka

nker

Astm

a

COPD

Osteo

poro

se

%

Mannen

Vrouwen

Chronic Disease Costs > 70%

Major Causes of Chronic

Diseases

Diabetes Care Standard

11

Care Standard is Special

• Developed by Care Providers and Patients

• Based on Guidelines / Protocols / Lifestyle

• Defines what Good Chronic Care is for patiënt

• Not who should perform

• Combines Prevention and Care

• Defines Quality Performance Indicators

• Base for Task substitution

• Involvement Patient

2005 National Diabetes taskforce

• Diabetes Care is growing

• The system will not be able to cope

• The NDF Diabetes Care Standard • Agreed by professionals and patient organisation

• Only applied to 40 % of the patients

ACTION is needed

13

2006 Diabetes funding Experiment

• Performance based funding for Diabetes

• Based on the Care Product Approach

• Contracting by Insurance Companies

• With Multidisciplinary Care Team

• Represented by a Care Group, a legal entity

• Reporting of Process and Outcome

• Care based on the NDF Care standard

• First step to Integrated Care Delivery

• Experiment with 10 groups

The Dutch Chronic Care Funding Model

Carestandard for

Good Diabetes Care

Process

Outcome

Patient CQ

Caregroup InsurerContract

15

PatientPatientCare

Providers

• Care group responsible for outcome

• Focus on education and continuous learning

• Documentation of care process and outcome

• IT support still in its infancy, but good examples

• Quality improvement process stimulated

• The contracting process is new for all

Result Experiment

In Green en White areas with

lower then expected foot

amputations a disease mgt

approach was applied.

The black and red areas have

Higher then expected

amputations

First indications of result

Next Step

Integrated Care Funding

introduction for chronic diseases

Preparation started in 2009

18

Integrated Care Funding 2010

• Integrated Funding for chronic conditions1. Diabetes2. Cardio Vascular Risk Management3. COPD

• Based on Authorized Care Standards• Contract on Price / Performance Indicators• Free pricing• Transparency by Reporting Chronic Dataset• Focus on Prevention • Patient part of the team – Lifestyle changes

19

Integrated Care in and exclusions

Integrated Care Product

Incidental Medical

Specialist Care

Physiotherapy

program

Indication

Indication

Ex

clusion

In

clusion

Integrated care & care standard

21

Care StandardMedical

Specialists

PATIENT

Dietist

Physiotherapies

Podotherapist

GP Pharmasists

Laboratory

Imaging Dept

Home Care

A meta standard for care standards

• Care standard development was hot

• National Platform for care standards

• Develop a model for care standards

• Define what care should be provided

• Care standard base for individualised care

• Define Obligate Parameters

• Process and outcome measures

• Implementation aspects

22

Focus Care Standard

Healthy

At R

isk

Dia

gnosis

Chro

nic

ally

Ill

23

Care Standard Model

Indexed

PreventionCare related

Prevention & treatment

IT requirements

• Multidisciplinary team of primary (GP’s, Nurses

, paramedical specialist) and secundary care (

medical specialist)

• Patiënt is part of the care team

• Individual Proactive Treatment plan

• Semantic Interoperable Data

• Cross institutional solution

• Annual Reporting Dataset by patient

Documentation Parameters (DCM)

Each submodule has a number of Obligate Parameters

Document these in a Detailed Clinical Model DCM

The DCM is the base for registration , Exchange of Data and

Reporting

DCM are part of the care standard

DCM will be maintained nationally

DCM have two dimensions

Modeling clinical content to clinical datamodel

Translating Clinical datamodel to implementation standards

Care Standard Model +

Indexed

PreventionCare related

Prevention & treatment

Specification

Parameters DCM

Implementation Dimensions

Reporting

Datasets

eHealthRequirements

I

N

T

E

G

R

A

T

E

D

Result

• Care standard

Care Process

Interventions

Quality Indicators

• Annex to the Care Standard

• Funding arrangement

• Contracting

• Documentation

• Specification Clinical Parameters

• Reporting dataset

• ICT requirement

Website to support

New health delivery model –

phase 1

Integrated DBC funding

Diabetes

CardioVascularRisc Management

Take Home Message

• Active involvement of Patient, individual

treatment plan based on

• Care standards ( Clinicians Consumer Patients)

with integrated eHealth standards

• Interlinking of prevention and care

• New business model focused on quality

• Reorientation Health Delivery System

substitution

• Challenges providers and insurers

• European Approach seems needed !

Healthy

At R

isk

Dia

gn

osis

Ch

ron

ica

lly Ill

34

Find the Motivation