The times, they are a' changin': It's more than just "cost"

Adrian Wagg

I have received either directly or indirectly, monies for research, consultancy or speaker honoraria from:

Astellas Pharma

Pfizer Corp

SCA

Conflict of interest

The global aging population

Multimorbidity and aging

Lancet 2012; 380, No. 9836: 37–43

Perry S et al. J Public Health Med 2000; 22(3):427-34 (the Leicestershire MRC incontinence study)

Females

0

5

10

15

20

25

30

35

40-49 50-59 60-69 70-79 80+

Age group (years)

Pre

vale

nce

%

Monthly and slight

Monthly and damp

Monthly and wet

Monthly and soaked

Prevalence and severity of incontinence in women

Prevalence and severity in men

Males

0

5

10

15

20

25

30

35

40-49 50-59 60-69 70-79 80+

Age group (years)

Pre

vale

nce

%

Monthly and slight

Monthly and damp

Monthly and wet

Monthly and soaked Perry S et al. J Public Health Med 2000; 22(3):427-34 (the Leicestershire MRC incontinence study)

Healthcare funding systems vary widely across the globe

Soviet model Beveridge model

Bismarck model

Private health insurer

•Central budget

•Citizenship

•Single scheme

•Public providers

•No demand control

•Focus on care

•Tax funded

•Citizenship

•Single or differentiated schemes

•Mainly public providers

•Strong demand control

•Prevention = care

•Tax funded or social health insurance contribution

•Insured status

•Single or differentiated schemes

•Various providers

•Elements of demand control

•Care > prevention

•Individual savings

•Insured status

•Differentiated schemes

•Mainly private providers

•Strong demand control

•Care > prevention

Who should pay?

Should products be covered, at all?

(Social equity, means testing, personal health care budgets, social consensus, willingness to pay?)

Many payers still see incontinence as a lifestyle limiting or quality of life condition, not a disease entity

WORK TO DO!

Philosophically…

In Europe:

• most countries have provision except for France and Romania

• provision in Hungary is scant

• Variable mechanisms for cost containment

- Number of products /day- Waiting lists for supplies- bureaucracy- Arbitrary assessment of “severity of

incontinence”

Likewise, the provision for continence products within healthcare systems varies

Medicaid coverage varies from state to state. In some states, Medicaid recipients are eligible for complete coverage of absorbent products.

In some states, Medicaid has "preferred vendors“

Medicare does not cover adult diapers or continence products

Veterans Administration coverage varies

In the US, provision varies by State

BC: employment and assistance programme, full coverage

SK: quantity limited, average monthly cost limited

MB: must be on employment and income support, fixed monthly $ amount

ON: must meet both financial and medical need, fixed coverage

QC: either hospitalized, in nursing home or physical or intellectual disability, full coverage

In Canada, provision varies by Province – most systems are “payers of last resort”

NFLD: community dwelling disabled persons, means tested

PEI: LTC residents, >60y

NS: recipients of continuing care only

NB: means tested, “social development clients”, full coverage

Eligibility: daily, non-resolving urinary or bowel incontinence

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Minimum 250mL of urine / stool at each incontinence episode

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Minimum 250mL of urine / stool at each incontinence episode

Must be assessed by: uro / gynae / obstetrician / gastroenterologist / proctologist / NP and certified as intractable – also not amenable to surgery

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Minimum 250mL of urine / stool at each incontinence episode

Must be assessed by: uro / gynae / obstetrician / gastroenterologist / proctologist / NP and certified as intractable – also not amenable to surgery

Severe dementia diagnosis must be certified by neuropsychological testing

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Minimum 250mL of urine / stool at each incontinence episode

Must be assessed by: uro / gynae / obstetrician / gastroenterologist / proctologist / NP and certified as intractable – also not amenable to surgery

Severe dementia diagnosis must be certified by neuropsychological testing

Cannot have diagnosis of stress urinary incontinence or urgency urinary incontinence (unless severely demented)

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Minimum 250mL of urine / stool at each incontinence episode

Must be assessed by: uro / gynae / obstetrician / gastroenterologist / proctologist / NP and certified as intractable – also not amenable to surgery

Severe dementia diagnosis must be certified by neuropsychological testing

Cannot have diagnosis of stress urinary incontinence or urgency urinary incontinence (unless severely demented)

Cannot have only nocturnal enuresis

Many systems use a variety of “rules” for regulating eligibility, for example:

Eligibility: daily, non-resolving urinary or bowel incontinence

All possible interventions tried – for a minimum of three months (except palliative care / severe dementia)

Minimum 250mL of urine / stool at each incontinence episode

Must be assessed by: uro / gynae / obstetrician / gastroenterologist / proctologist / NP and certified as intractable – also not amenable to surgery

Severe dementia diagnosis must be certified by neuropsychological testing

Cannot have diagnosis of stress urinary incontinence or urgency urinary incontinence (unless severely demented)

Cannot have only nocturnal enuresis

Can only have 1 category of product

Many systems use a variety of “rules” for regulating eligibility, for example:

2013-14 annual spend for continence supplies in AB was

For

10,767 recipients of diapers, liners and underpads, 2,500 underpads only

4,400 recipients of catheters and catheter supplies

Administrative cost not included!

Despite controls:

Category Funding (CAN$)

Diapers and liners 9,888,024

underpads 141,099

Catheters and catheter supplies 1,903,170

Total 11,932,293

Many health care systems deal with the increase and overspending of the health care budget by

• allocating more budget • limiting the spending by limiting reimbursement to citizens • limiting quality or choice.

None of these options are sustainable and will lead in the end to limited access to health care for a major part of the citizens

Trends

For example:

Absorbent products, hand held urinals and toileting aids should not be considered as a treatment for UI. Use them only as:

• a coping strategy pending definitive treatment

• an adjunct to ongoing therapy

• long-term management of UI only after treatment options have been explored.

Many National and International Continence Guidelines recommend where in the treatment pathway products should be used:

Urinary incontinence in women: the management of urinary incontinence in women CG 171 NICE UK 2013

Recommendations for service organization in order to deliver guideline compliant care exist

2

1

3Case co-ordination3

Enabling technologies

Community-based

support

Containment products

4

Case detection

Initial assessment

and treatment

Specialist assessment

and treatment

PLoS One. 2014 Aug 14;9(8):e104129. doi: 10.1371/journal.pone.0104129.

Use a comprehensive standardised assessment of user, product, and usage-related factors to assess needs with regards to containment products

• Use standardised assessment of following factors as per international standard (ISO 15621: 2011):User –related factors; Product-related factors; Usage-related factors

• Needs of each patient must be reassesed periodically

For payers: in order to provide the highest quality continence care, ensure care standards are incentivised

Transparency on outcome indicators can motivate improved performance

Financial incentives linked to outcomes can also motivate powerfully

Operational performance measures can indicate level of efficiency

Recommendation 6

Recommendation 8

Outcome-orientated standard

April 15, 2023 25Outlook 2014

Using recommendations from the optimum continence service specification

• placing a fully qualified NP in primary care in the Netherlands

• applying this model for continence care to older people with multimorbidity (4 co-existing conditions or more)

Can a call for investment in integrated continence services save money?

Outcomes, costs and QALYs per patient per 3 years

The majority of any cost saving comes from a reduction in social care need for this section of the

population

Budget impact over a period of 3 years

Implementing the optimum continence service specification in the Netherlands by having a continence nurse practitioner in the GP practice is likely to:reduce the level of incontinence

improve quality of life

reduce costs - from a payer’s perspective as well as from the patient’s and carer’s perspective

Savings total €29 million in health cost and €117 million in social costs over 3 years

Outcomes from incontinence products

Product

Function

Outcome

Materials

Quality of life

Courtesy of SCA

Functional description of care insured in laws and regulation:

to what care people are entitled

products provided, that best fit patients /caregiver needs:

Insurers/ providers look for a system in which prescribers prescribe based on functional characteristics to achive best possible outcome

Prerequisite is objective assessment of care-need to make the best possible match between care needs and medical device solutions available.

Functional prescribing

Netherlands: In December 2008, Ministry of Health, Welfare and Sport (VWS), decided the client is entitled to the "most appropriate functional solution.

search for the perfect match between what a person wants, can and may (in terms of objective function) and what tool (medical devices) can be offered.

That means that in providing tools (medical devices) not the device, but the performance of the client will be central – person centred care

Function-claim

Courtesy of SCA

Functional prescription cycle

Detect Problem

Formulate care need

Define care direction

Programof demands

Select samples, try and decide

Deliveryand instruction

Use Evaluate

Care plan

Courtesy of SCA

Acquisition cost is a poor indicator of “cost”

Products are soft targets for cost cutting in times of financial hardship

Limiting either choice, availability or quality may not give the desired impact

The major savings in improving continence care come from a reduction in societal costs

Integrated continence services, providing incentivized, guideline adherent care result in savings

Principle driven eligibility should be the norm

Standardised assessment with person centred provision is desirable

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