financing within the scope of the integrated disease ...financing within the scope of the integrated...

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Financing within the scope of the

Integrated Disease Management

- Pay for Comprehensive Price -

24th PCSI Working Conference

8th - 11th October, 2008 - Lisbon


An Overview

• The World Health Organization

– A way of preventing and controlling chronic diseases by turning to

a protective and integrated action (WHO, 2005).

• National Health Plan (2004-2010)

– “Within the health sector, the disease management, whether for

infectious or degenerative chronic diseases, is the largest area in

the health sector... By identifying priorities, developing plans and

programmes, creating monitoring and surveillance standards and

systems, it is intended to create a context where it becomes

possible to rationally manage the disease by all those involved.”

(NHP, 2004, p.36)


What we …

…know about the actual model

• Acute

• Hospital centred

• Doctor dependent

• Episodic

• Disintegrated

• Reactive

• Patient as passive recipient

• Low Tech

…wish for a future model

• Long-term conditions

• Embedded in community

• Team based

• Continuous

• Integrated

• Preventive

• Patient as partner

• High Tech


Chronic Disease Management Paradigm

• The first movement

– USA, 1980:

• Focus on care delivery control;

• Costs reduction.

• Other experiments

– Germany and England:

• Focus on primary care and supported self-care



The Portuguese Model


Integrated Disease Management – the strategy

• Use the benefits of the USA chronic disease

management models and the European

experiences;

• Involve all the Departments from the Ministry of

Health;

• Share patient information across the continuum of

care .



Evidence-based decision

Health Gains

Acess Improvement

Health Care Quality

Information

Systems

Clinical

Management

Health Care

Organisation

FinancingStandardization

of clinical

practice

Self-

management

Creation of

public

comparator

Adequacy of

healthcare

delivery levels

Standardization of

Administrative

Procedures

Racionalization of

supply


Clinical Management


Clinical Management

Inputs from the experts at different health care areas:

doctors, nurses, pharmacists, among others, to:

• obtain consensus;

• discuss national and international practices;

• identify strengths and weaknesses characterizing

the current situation of the healthcare delivery.


Clinical Management

Population prevention

Level 1 – Population with chronic

disease (70-80%)

Level 2 – High risk patients (15-20%)

Level 3 – Highly complex patients (5%)

Source: Adapted from Kayser Permanente

Case Management

Specific DiseaseManagement

Supported Self CareManagement


Clinical Management

Significant variations regarding the performance of the health care professionals

Conceptualization of a health care profile as an ideal disease approach and treatment - the clinical procedures, medicines and treatments

It is not compulsory to comply with, the

adherence is voluntary


Health Care Organisation


Heath Care Organisation – What is new?

• Centres of High Differentiation

– units developing clinical and research capabilities, aiming at structuring

the diagnosis approach and the patients’ full treatment;

– act as improvement, effectiveness and efficiency models, positioning

themselves at the top when referring to the existing knowledge;

– capable of effectively responding to the health care needs;

– fundamental for the prevention, diagnosis, treatment, rehabilitation and

monitoring of several conditions, showing the innovation at the

organizations’ support structure.

• Centres of Treatment - with a multidisciplinary and full-time

dedication team


Heath Care Organisation – We want to…

• Make the best use of the resources;

• Ensure that the provision of healthcare takes place

in the appropriate level;

• Use information technology and communication

allowing the healthcare professionals the sharing of

important information about the patient.


Financing

– Pay for Comprehensive Price –


Main characteristic of the organisations and financing

models of the Portuguese Health System:– Pay per act regardless of the results;

– Deficiencies in the cost and activity control;

– Responsibilities of the stakeholders are not well defined;

– Insufficient integration of care with consequences among the

quality of the services delivered;

– Lack of systematic and consistent information at clinical,

economic and financial level.

Sometimes we need more than moral incentives…

Financing


A model which:

• Considers an average per patient for a given period of

time;

• Includes a set of clinical procedures, medicines and

other activities, essential for an adequate provision of

care;

• Depends on the compliance with the quality and safety

parameters of the patient, measured by a set of

outcome indicators.

Pay for Comprehensive Price – What is it?


• Reflects the most appropriate clinical practices

– clinical guidance standards;

– therapeutic protocols;

• Requires the provision of information per patient;

• Establishes a direct relation between financing and compliance

with the patients’ quality and clinical safety parameters;

• Shapes the practices and the organization of care;

• Encourages the risk sharing between the different stakeholders;

• Incorporates auditing and monitoring mechanisms.

Pay for Comprehensive Price


It is not a capitation model:

• Does not distribute a predefined value for a given

population;

• The most appropriate clinical practice and expected

results are defined, which are then valued.



• Prior definition by panels of experts:

– The range of clinical services and consumables required

for the provision of adequate care;

– The organisation of care.

• Definition of evaluating parameters for healthcare

delivery results;

• Valuation of clinical practice resulting in a total value

per patient for a certain period of time;

• Establishment of monitoring ways and mechanisms of

price set managing.

Pay for Comprehensive Price - Calculation


The results focalization is the most important, not minimizing

the importance of the processes, and will contribute to a

greater efficiency of the system:

– Explaining the price components, which become known to all;

– Allows a more rational behaviour from the providers, with the

adoption of the most cost effective innovations and the ongoing

practices;

– Imposition of audit and monitoring mechanisms, such as the

existence of public comparisons ensured by the creation of

Centres of High Differentiation, a support for the corrective

implementation of this model.



Information System


• The information spread by several entities

• Different information systems;

• Data recorded with different criteria depending on

the institution;

• Unrecorded data on electronic support;

• Data not recorded at all.

Information System – What do we have?


The information systems are critical factors of success

when implementing these models, and must ensure:

– The integration of the existing systems;

– The compliance with confidentiality and security

rules;

– The permanent availability of information.

Information System


• Ensure the efficient operation and use of the

information systems;

• Ensure the existence of reliable monitoring

instruments, accepted by all involved;

• Integrate this model within the general framework of

the national health system financing model;

• Test the models’ practical application and ensure

the necessary adjustments.

Integrated Disease Management - Challenges


Filipa MoreiraFinancing and Contracting Operational Unit

[email protected]

Authors:Alexandre Diniz – General-Directorate of Health

Ana Escoval – National School of Public Health

Anabela Candeias – General-Directorate of Health

Fátima Candoso – Central Administration of Health System

Paulo Espiga – Central Administration of Health System

financing within the scope of the integrated disease ...financing within the scope of the integrated...

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