Shifting accountability - An international comparison of payment reforms. Jeroen N. Struijs

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1 Shifting accountability - An international comparison of payment reforms Jeroen N. Struijs Financiering Eerstelijnszorg Jan van Es instituut Almere,10/09/2015

2 2 END OF PART 1

3 Verzekeraar Zorginkoopmarkt Zorgverzekeringsmarkt Zorgaanbieders Zorgverleningsmarkt Patient/ consument 3

4 Ref: unknown

5 5 Juridische entiteit Per verrichting (FFS) Integrale Bekostiging Shared Savings Uitkomst Bekostiging Bron: Averill et al., 2010, bewerkt voor Nederlandse bekostigingsmodellen

6 Background FFS: flexible and easy maximizing patient visits (volume?) No incentive to deliver efficient care or prevent unnecessary care No accountability across setting and multiple providers Financial risk for payer

7 Background Capitation: flexible and easy Minimizing patient visits (incentive to deliver efficient care or prevent unnecessary care Stinting on care? Financial partly for provider and provider (salary)

8 Background Alternative models: Pay for coordination Pay for reporting Pay for Performance Bundled payment Shared savings Global payment Combination of above

9 Centrale vragen 1. Hoe bekostigingshervormingen in verschillende landen vormgegeven? 2. Hoe kunnen zorginkoopcontracten bijdragen aan kwaliteitsverbeteringen en kostenreducties in de zorg? (lessen van de AQC voor NL) Casussen: - Zorggroepen / Integrale bekostiging (NL) - Alternative Quality Contract (AQC) (US) - MSSP ACOs (US) - Clinical Commissioning Groups (England) Methode: semi-gestructureerde interviews en literatuur

10 Dutch payment reform Insurers Bundled Payment contracts (multiple single-disease care program contracts) Care Group capitation capitation capitation capitation FFS GP PROVIDER i PROVIDER i PROVIDER i PROVIDER i 10

11 National monitor Pioneer sites Shift from BP towards Population Management 9 regions selected as pioneer sites of population management Pioneer sites are enrolled in the National Monitor of Population Management All aiming to improve the TA 11

12 Where are we? Thema s Thema s & Thema s updates & Themes updates & updates & updates Follow-up report: Process and outcomes Drewes et al. Samen werken aan duurzame zorg. urzame_zorg_landelijke_monitor_proeftuinen 12

13 Objectives National Monitor PM 4 overall research questions: 1. How is population management designed? 2. What are the barriers and facilitators in PM? 3. How is health, quality of care and costs developed over time? 4. What is the association between these outcome measures? Mixed methods 13

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16 Organisation: involved actors Schools/ Sports Employer GGD Municipality Home care Youth care Mental care GPs Long term care Hospitals Others Patient representatives Health care insurers A say Co-produce Advice Consult/ inform 16

17 Current Interventions Prevention Lifestyle interventions Selfmanagement Awareness Selfmanagement capacity Integrated care Frailty Maternity care Mental care Diabetes COPD VRM Others Substitution Farmacy 1,5 care Concentration&specialisation Diagnostics Precondition Teamclimate Community involvement Data-infrastructure Transition towards population management 26 maart

18 Population Rest NL Population Sexe (% male) 48,5 49,8 49,5 49,3 48, ,1 50,2 51,6 49,1 Age (% 65+) 23,6 23,2 27,6 25,2 18,4 21,4 23,1 22,8 23,2 20,8 Education (% low) 8 7,3 11 9,4 6,6 6,4 5,2 6,7 8,7 8 Income (% high ) 20,9 16,7 24, ,8 23,5 26, ,4 24,9 Employed (%) 57,3 60,8 59,8 55,4 65,4 62, ,4 62,7 63,2 Disablled to work (% totally disabled) 5,8 3,2 4,5 6,9 2,2 4,8 4,6 4 3,2 3,9 Transition towards population management 26 maart

19 Population health Blauwe Zorg Friesland Voorop Goed Leven Mijn Zorg PZF Rijnland Pelgrim SSiZ SmZ Vitaal Vechtdal Rest NL Experienced health (% more or less-bad ) Disabilities (% 1 or more) Chronic conditions (% at least 1) 26,2 19,2 26,7 32, ,7 22,4 24,5 21,9 23,6 14,8 12,4 17,5 18,9 11,2 13,8 11,9 15,5 14,9 14,9 62, ,1 69, ,5 57,3 57,9 57,1 60,4 Anxiety and depression (% high risk) 6 3,9 5,2 7,7 4,7 6,4 4,3 5,8 4 5,7 BMI (% overgewicht) 46,5 47,4 53,5 54,4 42,1 48,1 45,1 48,4 51,3 48,3 Mortality (per ) *red = significant unhealthier; green= significant healthier compared to other regions **Not standardized results. Transition towards population management 26 maart

20 Population health corrected for age and sexe (100=NL average) Blauwe Zorg Friesland Voorop Goed Leven Mijn Zorg PZF Rijnland Pelgrim SSiZ SmZ Vitaal Vechtdal Experienced health (% more or less-bad ) Disabilities (% 1 or more) Chronic conditions (% at least 1) Anxiety and depression (% high risk) BMI (% overgewicht) *100= equal to expected health based on age and sexe red = significant unhealthier; green= significant healthier compared to other regions 20

21 Background US health care system

22 Affordable Care Act / Obamacare Why the ACA? What is in it?

23 US Health Care System age 65 US population

24 US Health Care System age 65 US population

25 age 65 Employment based insurance Veterans Health Administration, 1930 subsidized excluded from taxable income US population

26 US Health Care System age 65 Indian Health Services 1955 Employment based insurance subsidized excluded from taxable income Veterans Health Administration, 1930 US population

27 US Health Care System age 65 Indian Health Services 1955 Employment based insurance subsidized excluded from taxable income Veterans Health Administration, 1930 Medicaid 1965 US population

28 US Health Care System age Traditional Medicare Fee-for-service payment Indian Health Services 1955 Employment based insurance subsidized excluded from taxable income Veterans Health Administration, 1930 Medicaid 1965 US population

29 US Health Care System age Traditional Medicare Fee-for-service payment Indian Health Services 1955 Employment based insurance subsidized excluded from taxable income Veterans Health Administration, 1930 Medicaid 1965 US population Children Health Insurance Program 1997

30 US Health Care System age Traditional Medicare Fee-for-service payment Indian Health Services 1955 Employment based insurance subsidized excluded from taxable income Veterans Health Administration, 1930 Medicaid 1965 US population Children Health Insurance Program 1997

31 US Health Care System age Traditional Medicare Fee-for-service payment Indian Health Services 1955 Employment based insurance subsidized excluded from taxable income Veterans Health Administration, 1930 Medicaid 1965 Children Health Insurance Program 1997 Uninsured (small firms, individuals, 2012) US population Uninsured Health Insurance Exchanges

32 In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Insured all year, not underinsured^ 54% 100 million Uninsured during the year* 30% 55 million Insured all year, underinsured^ 16% 30 million 184 million adults ages Note: Numbers may not sum to indicated total because of rounding. * Combines Uninsured now and Insured now, time uninsured in past year. ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012).

33 Why the ACA?

34 U.S. Health in International Perspective: Shorter Lives, Poorer Health Americans live shorter lives and are in poorer health at any age Poor outcomes cannot be fully explained by poverty or lack of insurance White, insured, college-educated, and upper income Americans are in poorer health than their counterparts in other countries

35 International Comparison of Spending on Health, Average spending on health per capita ($US PPP) US SWIZ NOR NETH GER CAN FRA SWE AUS UK NZ $8,745 $3, Total expenditures on health as percent of GDP AUS NOR UK SWE NZ CAN SWIZ GER FRA NETH US % 8.9% Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, November 2013). US data from National Health Expenditure Accounts, adjusted to match OECD definitions.

36 Cumulative Increases in Health Insurance Premiums, Workers Contributions to Premiums, Inflation, and Workers Earnings, % 200% 150% 100% Health Insurance Premiums Workers' Contribution to Premiums Workers' Earnings Overall Inflation 196% 182% 117% 119% 50% 0% 56% 57% 50% 34% 14% 40% 29% 11% SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), ; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April).

37 The ACA: What s in it?

38 ACA Made Simple Hundreds of provisions in two big buckets: Coverage expansion Delivery system reform

39 Coverage Expansion Cover the uninsured (26 million*): Medicaid expansions (about half) Subsidies to buy private insurance (about half) Regulate private markets: Insurance mandate Children to 26 No discrimination against sick Health insurance marketplaces * Latest CBO estimate (April 2014).

40 Delivery System Reform Reduced Payments for Avoidable Complications Value Based Purchasing Medicare Advantage Plan Bonuses Accountable Care Organizations Bundled Payments Hospital Inpatient Quality Reporting Physician Quality Reporting System Medical Homes Meaningful Use

41 Delivery System Reform: Three Buckets Payment reforms: pay for performance Hospital and physician quality Medicare readmissions Hospital acquired conditions Organizational reforms Accountable care organizations Patient centered medical homes Increased training and payment for primary care Information availability Comparative effectiveness research ($500 million/year) Health information technology

42 Cross-nation comparison of payment reforms

43 Dutch payment reform Insurers Bundled Payment contracts (multiple single-disease care program contracts) Care Group capitation capitation capitation capitation FFS GP PROVIDER i PROVIDER i PROVIDER i PROVIDER i 43

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45 Medicare Shared Savings Program ACOs Medicare Shared savings contract ACO FFS FFS FFS Multiple Multiple PROVIDER i PROVIDER i PROVIDER i PROVIDER i PROVIDER i FFS = Fee For Service 45

46 Alternative Quality Contract (AQC) BlueCross BlueShield AQC contract AQC group FFS FFS FFS Multiple Mutliple PROVIDER i PROVIDER i PROVIDER i PRIMARY CARE PHYSICIAN PROVIDER i FFS = Fee For Service

47 The AQC explained Source: Blue Cross Blue Shields

48 England s payment reform NHS England Resource allocation formula + quality premium CCG contract contract contract contract contract contract SPECIALIZED CARE GP PROVIDER i PROVIDER i PROVIDER i PROVIDER i CCG: Clinical Commissioning Group 48

49 Results (I) Primary care providers role is strengthened in all models: Rostering patients within primary care practice seems to be a key element (AQC, CG, CCG) Up-scaling the organizational structures of primary care But applied to different markets: ACO + AQC: price-sensitive referral system delivery market England + The Netherlands: use of clinical knowledge purchasing market Under ACOs, AQCs and CCG no real transformation of the way providers are paid, while CGs made some steps towards capitated fees Quality improvement tied to payment incentive in most models (CCG, ACOs, AQC) 49

50 Results (II) Different approach to shift providers financial risks across services: The Netherlands: narrow services package but full financial risks Other models: Broad services package but no / moderate financial risks Huge impact of contextual factors: Data information for providers Local market structure: diversity in AQC contracts Voluntary (CGs, ACOs and AQC) vs. mandatory (England) health care is local 50

51 Financial risk across services 100% Financial risk Up side 0% Down side ACO (one sided) AQC services 100% CG 51

52 Policy Implications General Joy of the workforce is neglected within payment reforms How to evaluate payment reforms? United States How ACOs incentivize their providers which still are paid on Fee For Service is unclear The Netherlands How to tie quality improvement to payment model? 52

53 Lessen van de AQC AQC Key drivers Transferable Lessons - Shared savings contract (twee zijdig) - FFS omgeving - Shared saving afhankelijk van resultaat indicatoren Succesfactoren Randvoorwaarden (context afhankelijk en context onafhankelijk) Bron: Ruwaard, et al. Transferring key drivers in provider-payer contracts: Lessons from the AQC (in preparation)

54 Succesfactoren Het AQC geeft de aanbieder een prikkel en de mogelijkheid om patiënten te sturen naar hoog-kwaliteit en betaalbare aanbieders Prikkel om te sturen: (1) Vormgeving bekostigingsmodel Mogelijkheid om te sturen: (2) Verplichte verwijzing van vaste huisarts (3) Data Inzet van verzekeraar Maar, - Het vervullen van deze 3 criteria in een andere setting hoeft niet automatisch tot soortgelijke succesen te leiden - Daarnaast zijn deze 3 criteria niet per se de enige manier om aanbieders een prikkel en de mogelijkheid te geven om te sturen

55 Lessen voor het buitenland : context-onafhankelijk 1. Het bekostigingsmodel werkt het beste op grote schaal: het succes van de hervorming neemt toe naarmate aanbieders soortgelijke prikkels ervaren 2. Haal eerst de grote spelers binnen: deze aanbieders (1) kunnen het risico het makkelijkst dragen, (2) spelen een belangrijke rol in het reduceren van kosten, (3) en kunnen het moeilijkst zijn om te overtuigen 3. Start met genereuze en lange-termijn contracten: aanbieders moeten de middelen en tijd hebben om de hervorming door te voeren 4. Vooraf afgebakende populatie: Het ex ante definiëren van een populatie geeft een verhoogde prikkel om juist deze populatie proactief te managen

56 Lessen voor het buitenland: context-afhankelijk 5. Stel verwijzing verplicht: Als het niet mogelijk is om patiënten aan een vaste huisarts te koppelen, dan kan het verplicht stellen van een verwijzing van een huisarts een alternatieve oplossing bieden 6. De marktstructuur moet sturen toelaten: De structuur van de aanbiedersmarkt moet zo georganiseerd zijn dat er voldoende concurrerende aanbieders zijn die eenzelfde geografische markt delen 7. Beleid, wet- en regelgeving: regelgeving mag het introduceren van het bekostigingsmodel niet belemmeren

57 Discussie Een soortgelijk bekostigingsmodel kan in andere settingen geïntroduceerd worden zolang aanbieders een prikkel en de mogelijkheid hebben om te sturen Contextuele lessen: Voldoet Nederland aan de randvoorwaarden? Hoe sturen juridische entiteiten hun downstream providers? Hoe duurzaam zijn de AQC resultaten? Arbeidssatisfactie van zorgaanbieders onderbelicht

58 Conclusie Juridische entiteiten die financiele risico s op zich gaan nemen staan nog steeds in de kinderschoenen maar sterk in ontwikkeling In alle modellen een beperkt risico voor zorgaanbieders maar bevatten wel prikkels om zinnige en gepaste zorg te bieden Uitkomstbekostiging nog ver weg 58