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Using Costing as a Tool for Advancing Palliative Care in Romania. Daniela Mosoiu, MD, PhD Malina Dumitrescu Hospice Casa Sperantei, Brasov, Romania. www.hospice.ro. Situation Analysis. Understanding the model of the Health Care System History and achievements of palliative care in Romania - PowerPoint PPT PresentationTRANSCRIPT
–www.hospice.ro
Using Costing as a Tool for Advancing Palliative Care in Romania
Daniela Mosoiu, MD, PhD
Malina Dumitrescu
Hospice Casa Sperantei, Brasov, Romania
–www.hospice.ro
Situation Analysis
• Understanding the model of the Health Care System
• History and achievements of palliative care in Romania
• Needs vs. achievements• Funding mechanism for palliative care
Brief review of PC in Romania
Romanian Health care system – Bismarck model Tax collection (employee + employer) Population served: insured, special categories,
emergencies Service packages provided Providers contracted Annual review of “Frame Contract” and its regulations Joint roles: Ministry of Health, House of Health
Insurances, College of Physicians
–www.hospice.ro
–www.hospice.ro
History of palliative care in Romania
• 1990’s – landmark in PC development in RO• 1992 – Hospice Casa Sperantei founded in Brasov• 1997 – Palliative Care Education Centre in Brasov• 1998 – National Palliative Care Organization• 1999 – P.C. subspecialty acknowledged• 2001 – Oral morphine available for pain control• 2002 – First Inpatient Hospice unit opened in Brasov• 2003 – Hospice Casa Sperantei = Beacon of excellence • 2005 - 2007 – Opioids Law and Norms passed
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• 2005 – P.C. commission set up in the Min.of Health
(MoH)• 2005 – Hospice Casa Sperantei = coordinator of the P.C.
education as subspecialty in Romania• 2005 – P.C. in inpatient units introduced in the Frame-
Contract of the House of Health Insurances (HoHI)• 2007 – First public reimbursement of the HoHI for P.C.
admissions in Inpatient Units• 2007-2008 public awareness campaign and national
survey• 2007 – First inpatient unit in public hospital
History of palliative care in Romania
–www.hospice.ro
• 2007 – National Coalition of P.C. providers • 2008 – Partnership between MoH, Hospice and the
National Coalition of Cancer Patients Association• 2008 – start of Health Budget Monitoring costing project• 2010 – Home-based Palliative Care services acknowledged• 2009 – curricula for nurses in basic training• 2010 – first Master program in PC (Brasov Medical Faculty)• 2011 – 5 medical faculties in Romania introduce palliative
care in the basic studies curricula
History of palliative care in Romania
PC need in Romania
Estimated need for PC: about 170,000 persons/year In 2009: 31 PC providers → 46 services:
–21 inpatient units–15 home-based units–3 day centres 4003 persons–4 outpatient clincis received PC–3 hospital teams
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–www.hospice.ro
Models of care
• Home care: NGO sector 15• In patient units:• Public sector: 8• Acute hospital wards: 7• Chronic hospitals: 1
• NGO: 10• Private sector: 3
• Out patient clinics: 2• Day centers: 3• Mobile Hospital teams: 3
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Financing Sources for Palliative Care in Romania
Ministry of Finances
Community
External Sources
Ministry of Health
Ministry of Labour
Min. of Public Admin.
Health Insurance
Inpatient Unit
Home care
Mobile Hospital Team
Outpatient Clinic
Private services
Public services
Day centre
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Why Hospice Casa Sperantei ? • Reference center for country and region• Previous impact at policy level– Partnership with MoH– Success in triggering the new law of opioids
• National coordination role in other arias (education program for PC competence, coalition or PC provioders, awareness campaign)
• National sustainable development strategy for 60% PC needs coverage by 2020
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Aim of costing project
To facilitate the inclusion of palliative care services in the public funding scheme, by providing research-based cost data
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Data pointed out:
• Inconsistency of recording• Unclear criteria in allocation• Lack of control of use of public money• Impossibility to base cost calculation on
collected data• Consistent contribution of private funds
• Physicians (1,5 full-time equivalent per 10 beds)• Nurses and nurse assistants (14-18 full-time equivalent per
10 beds, 1 nurse per 3-5 beds and 1 nurse assistant per 5-7 beds, all per 8 hours shift)
• Psychologist (0,5 full-time equivalent per 10 beds)• Other specialized personnel (4 full-time equivalent, including
part-time for social worker, therapist, cleric, pharmacist, pharmacist assistant and others)
• Auxiliary personnel (1 full-time medical secretary)
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Costing frameworks
• International expert• Tested/adjusted local economist• Comprising – Running costs– Sett up costs
• For home care and inpatient services
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Monthly Staff Costs/patient In-patient Unit
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Comparative cost analysis
448 €vs1500 €
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Start-up costs for Inpatient vs HC
Preapring advocacy
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CURE ≠ CAREDifference: CostsBenefits
–OUTCOMES
–Life saving,–Disease curing
–Quality in –End-of-Life Care
HOW to convince?“Why spend on a new service?”“NO money is cheaper than SOME money”“They are dying anyway”
→ PERSONAL EXPERIENCE (… feelings…)→ COST EFFECTIVENESS (… financials…)What is cost-effectiveness”?
NOT: to spend less get best qualityYES: to spend wisely for as many beneficiaries…
with existing resources–www.hospice.ro
Preapring advocacy
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Advocacy methods
1. Creating networks of direct supporters• Involved PC coalition: send letters to local HoHI and MPs• Letter from local HoHI in Brasov to the National HoHI to
support the change• PC commission in the MS contacted national HoHI• Contact MPs from all parties for support• Supporter beneficiar IP in CNAS ???2. Proving service and education
replication model supporters who know from inside what PC means
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Direct communication• Conference at the Parliament• Meeting at the National HoHI to present results of
costing3. Public awareness• Press conference• Results presented in conferences and • Materials provided to Local Health Boards and local
HoHI and to providers
Advocacy methods
Advocating for a change
Short term results: Developing funding mechanisms for existing services Base reimbursement on realistic costs
Medium/long term expected results: Influence general legal framework to include PC in the
public health system Improved funding for PC services Provide annual budgetary allocation for PC services Increased coverage with PC services
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–Advocating for a change
2. Medium/long term results Influence general legal framework to include PC in the
public health system Amendments submitted to the Parliament for Health Law
No.95/2006 in June 2010 (resolution pending) Amendments to ministerial Orders submitted in 2009:
Authorization of service providers Staff ratio for PC in Inpatient units Human resources education (pre- and post-graduate) Evaluation and monitoring of quality in PC services
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–New challenges:
Home-based PC (= preferred setting for patients): Restrictive and bureaucratic procedure to access home care Resticttive access by type of disease (only cancer and HIV/AIDS) Restrictied access of providers to contract services (insufficient legal regulations for providers’ authorization Insufficient funding dedicated to Home-based PCInpatient PC services: Lowest qualification of PC inpatient units, resulting in poor funding
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–New challenges:
Outpatient PC: Define outpatient services for PC Evaluate costs in outpatient PC servicesHospital Mobile PC teams: Evaluate costs after a 2-year pilot project Define hospital teams input Submit results and advocate to include hospital teams
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–Conclusions
Identify barriers and opportunities
Act collectively rather that individually
Monitor the change
Share the experience
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