interquality kick-off meeting warsaw, 18-19 january 2011 work package 6: integrated care christian...

InterQuality Kick-off Meeting Warsaw, 18-19 January 2011

Work Package 6: Integrated CareChristian KrauthVolker AmelungHannover Medical School

InterQuality Kick-off MeetingWarsaw, 18-19 january 2011

General Questions

• What is specific to integrated care

• Which parameters do indicate good performance of integrated care

• How should payment systems be designed

• How can integrated care models be evaluated

• Which contractional designs exist to guarantee longterm effectiveness of integrated care models


The need for integrated Care

Ambulytory Care Acute Hospital Care Rehabilitation

Optimization of interfaces

Care delivery on adequate level

Standar- dization

Cooperation and commu-

nication

Consider deficiencies of existing systems …


Indication-specific IC


A model for population-orientated Integrated Care


Contracting parties• AOK (20.11.2005) and LKK Baden-Wuerttemberg (01.10.2006)

Population and budget • 32000 AOK and LKK-insureds (appr. 50% of insured persons in the

ZIP code area ) • benefit spending appr. € 50 million p.a., Virtual budget of MMG

Contract Scope • total outpatient and inpatient care, all indications except dentistry • Contract duration until 2014

Quelle: Weatherly at al Leuchtturmprojekte 2007

Frames


Integrated Care contracts

Integrated Care in Germany


Sicknessfund A

Sicknessfund B

Sicknessfund C

Sicknessfund D

budget ambulatory

care

budget acute care

99% 99%1% 1%

Contract A

Contract B

Contract C

Contract D

Contract E

pool for integrated services (app. 680

mil. Euro)

Sicknessfund E


Definition

„Pay for performance is not simply a mechanism to

reward those who perform well or to reduce costs.

Its purpose is to align payment incentives to

encourage ongoing improvement in a way that will

ensure high-quality care for all.“

The Institue of Medicine, Rewarding Provider Performance, 2006

Pay-for-Performance


Pay-for-Performance• What is measured - performance factors

- clinical outcomes

- patient satisfaction

- process parameters

- cost efficiency and savings

- utilisation of information technologies

• How will be measured - performance targets

- absolute achievement

- relative performance (compared to other providers)

- improvement

- (combination of perfomance targets)


Performance-orientation in the NHS

Domain

(disease) area Number of Indicators points in

structure process outcomeTotal in

area domainarea domain

Clinical quality

CHD w/ LVD 2 1 12 15 121

550

TIA 1 1 8 10 31

Hypertension 1 2 2 5 105

Diabetes mellitus 1 0 17 18 99

COPD 1 2 5 8 45

Epilepsy 1 0 3 4 16

Hypothyroidism 1 0 1 2 8

Cancer 1 0 1 2 12

Mental health 1 0 4 5 41

Asthma 1 1 5 7 76 72

Practice organisational

Records and information 18 85

184

Patient communication 8 8

Education and training 9 29

Medicines management 10 42

Practice management 10 56 20

PEPatient survey 3 70

100Consultation length 1 4 30

APS

Cervical screening 6 22

36Child health surveillance 1 6

Maternity services 1 6

Contraceptive services 2 10 2

Total 146 870


Performance orientation in the NHS

(disease) area Indicator Description point threshold range(%)

No type

CHD 6 outcome % of patients with CHD, in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less

0-19 25-70

TIA 1 structure The practice can produce a register of patients with stroke and TIA 0-4 >25

Hypertension 5 outcome % of patients with hypertension in whom the last blood pressure (measured in the last 9 months) is 150/90 or less

0-56 25-70

Diabetes mellitus 12 outcome % of patients with diabetes in whom the last blood pressure is 145/85 or less 0-17 25-55

COPD 3 process % of all patients whith COPD where diagnosis has been confirmed by spirometry including reversibility testing

0-5 25-90

Epilepsy 2 outcome % of patients aged over 16 on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months

0-4 25-90

Hypothyroidism 2 outcome % of patients with hypothyroidism with tests recorded in the previous 15 months 0-6 25-90

Cancer 1 structure The practice can produce a register of all cancer patients defined as a ‚register of patients with a diagnosis of cancer excluding non-melatonin skin cancers from 1 April 2003‘

0-6 >25

Mental health 2 outcome % of patients with severe long-term mental health problems with a review recorded in the past 15 months

0-23 25-90

Asthma 3 process % of patients aged over 8 diagnosed as having asthma from 01.04.03 where the diagnosis has been confirmed by spirometry or peak flow measurement

0-15 25-70


P4P Measurement Set Evolution

Quelle: IHA

IHA2003 Measurement Year /2004 Reporting Year

2004 Measurement Year /2005 Reporting Year



Clinical 1. Childhood Immunization w/ 12-month continuous enrollment

2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. LDL Screening (patients w/

cardiac event only

Encounter threshold > 2.7 enc. PMPY

1. Childhood Immunization w/ 24-month continuous enrollment

2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. HbA1c Control7. LDL Screening (patients with

cardiac event and diabetics)8. LDL Control <130

Encounter threshold >3,25 enc. PMPY


2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. HbA1c Control7. LDL Screening 8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for

Children with Upper Respiratory Infection



2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. HbA1c Control7. LDL Screening 8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for

Children with Upper Respiratory Infection

11. Nephropathy Monitoring for Diabetic Patients

12. Obesity Counceling


Weighting 50 % 40 % 50 % 50 %

Patient Experience

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Overall ratings of care

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Overall ratings of care

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Care coordination (CAS

Composite)5. Overall ratings of care

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Care coordination (CAS

Composite)5. Overall ratings of care

Weighting 40 % 40 % 30 % 30 %

Information Technology Investment

1. Integrate clinical electronic data sets at group level for population management

2. Support clinical decision making at point of care through electronic tools

Requires 2 activities, at least one in each Measure, each activity is worth 5 %



Requires 4 activities of which at least 2 are in Measure 2, each activity is worth 5 %

Added more qualifying activities




Added more qualifying activities

1. ntegrate clinical electronic data sets at group level for population management



Weighting 10 % 20 % 20 % 20 %


Pay-for-Performance

• (Expected) advantages and disadvantages

+ improving health care quality

+ patient and provider interests hamonized

- problems measuring performance

- high control costs (e.g. avoiding patient selection)

• Vital factors

- part of a two-stage payment system

- valid performance parameters

- risk-adjustment to socio-demografic and regional parameters

- combined with non-monetary incentives

- utilisation of modern information technologies

- evaluation and quality assurance


6.1 Integrated Care and Pay-for-Performance

Objectives• Understand the need for integrated care• Identify central problems in financing integrated care (e.g.

motivation problem, problem of measuring performance, specialisation problem)

• Find solutions to contractional problems in integrated care• Identify central performance factors for P4P• Highlight vital factors for successful designing and implementing

P4P


6.1 Integrated Care and Pay-for-Performance

Methods• Theoretical analysis of integrated care (new institutional economics)

- principal-agent theory (asymmetric information)

- transaction cost economics (transaction costs)

- property rights theory (incentives)• Identification and assessment of P4P projects in Europe

- Review of empirical literature (on P4P projects in Europe)

- Expert interviews on success and obstacles of (and satisfaction with) P4P projects in Europe

- UK, Germany, Belgium …

Deliverables• Review of P4P and integrated care projects in Europe


Principle-Agent-Theory

• Central problem: asymmetric information• Conflicting interests • Opportunistic behaviour

Pre-contractional Post-contractional

Hidden characteristics Hidden actionHidden information

Asymmetric information

Adverse selection Moral hazard Problem

ScreeningSignallingSelf-selection

MonitoringReportingIncentive systemReputationSpecific investmentsBonding

Soluation


6.2 Criteria Development: Risk-Adjustment

Objectives• Identification of relevant determinants influencing the

performance (besides providers' services) – such as socio-economic parameters, co-morbidities, and regional differences

• Developing and testing risk-adjustments (depending on level of influencing determinants) for P4P


6.2 Criteria Development: Risk-Adjustment

Methods• Literature Review• Evaluation of empirical P4P projects in Europe

Deliverables• Analysis of vital performance parameters from provider and

payer perspective • Review of guidelines for outcome parameters and risk-

adjustment weights vital for quality-oriented payment


6.3 Development of an Evaluation Model

Objectives• Developing a transparent evaluation model for measuring

provider performance and cost-effectiveness of outcome-based payment

• Definition of multiple outcome parameters (e.g. based on IQWiG parameter definitions)

• Definition of health care cost parameters• Testing the model using routine health insurance data


6.3 Development of an Evaluation Model

Methods• Literature Review• Health economic evaluation and decision analysis methods• Empirical analysis of integrated care models based on health

insurance data

- AOK Rheinland/Hamburg (2.8 millions insured)

- AOK Lower Saxony (2.1 millions insured)

Deliverables• Recommended financing models – a model to measure

provider performance for quality-based payment in integrated care


AOK Rheinland: 33 IC contracts in 7 Indication-areas

Populationn-oriented– Palliativmedizin Rheinland– Vollversorgungsverträge SG/WES– Gynäkologische Operationen D/DU/KR

Internal medicine– Beatmungs- und Wachkomapatienten SG/RS– Pflegeheime Rheinland– Diabetischer Fuß D/K/BN/E/A/HH

Neurology– Schlaganfall Rheinland– Multiple Sklerose Rheinland– Chronischer Kopfschmerz/Migräne Rheinland– Chronischer Schwindel Rheinland– Verbesserung der onkologischen Versorgung durch angeleitetes Training Aa/Kr Aa

Oncology– Familiäre Belastung - Brust-/Ovarial CA Rheinland– Maligne Lymphome Rheinland– CIO – Integrierte Onkologie K– Ovarial-CA BN/D/KR/LEV/K

Psychiatry– Seelische Gesundheit Depression AA/DÜ/HS– Schizophrenie K/AA– Krisenintervention Demenz Rheinland

Cardiology– Akuter Herzinfarkt Rheinland– Herzinsuffizienz/Telemedizin K/E/HH – Kardiologie/Diabetes HH

Orthopaedics Osteoporose Rheinland

Paediatrics AD(H)S bei Kindern und Jugendlichen Rheinland Adipöse Kinder Rheinland Asthma bei Kleinkindern Rheinland Auf die Beine K Mukoviszidose (CF-Cystic Fibrosis) Rheinland Kinder und Jugendliche mit Neurodermitis Rheinland Übergewichtige Kinder und Jugendliche Aa/Kr.A Willkommen im Leben (Start 1. Halbjahr 2011)

RheinlandEntwicklung der IV-Teilnehmer

2005-2010

32.882

20.312

12.471

6.051

1.427

43.596

744 1.0871.799 2.077 2.901 4.211

2005 2006 2007 2008 2009 2010

Versicherte Leistungserbringer


Aufnahme Orthopädie

PatientHausarzt Oththopäde Facharzt

HilfsmittelAmbulanz

Ambulante Versorgung Stationäre Versorgung

Orthopädie Stationäre Reha

Rehabilitation

Ambulante Reha

Patient hat Beschwerden

Diagnostik und Aufnah-megespräch

Diagnostik und

Überweisung Orthopäde

Diagnostik

ÜberweisungKrankenhaus

Weitere Behandlung

außerhalb der IGV

j

n

OPj

n

OP

Entlassung

Stationäre Reha

j

n

DurchführungStat. Reha

AmbulanteReha

j

n

DurchführungAmbul. Reha

Post-Reha Abschluß-

untersuchungNachsorge-

untersuchung (nach 3, 6 u. 9

Monaten)

AmbulanteReha

j

n

Abschlußuntersuchung (nach 18 Monaten) und

Ausschreibung IGV

Einschrei-bung

SF 12

E1

E2

NN Prozeß-qualität

E6

BQS

E3

SF 12(3 Monate)

E2

Aufklärungs-gespräch

(6 Monate)

E4

Abschlußun-tersuchung (9 Monate)

E5

NN Prozeß-qualität

E6

?

IGV

Rh

ein

lan

dN

etz:

En

do

pro

thet

ik N

ied

errh

ein

Version 1.0 – 19. Januar 2005

Routine dataCost and health care services!

KV-No

AmbulanteDaten

H&HDaten

StationäreDaten

RehaDaten

Inscription

Patient satisfaction

Process quality

BQS

IC quality data

IC cost data

Which data are available for evaluation?

Report für das Netz


6.4 Longterm Contract Design

Objectives• Idenfication of population-based and healthcare service

related longterm risks of providers and payers• Analysis of strategies in longterm contracts (ex post

opportunistic behaviour to exploit specific investments of the contract partner)

• Determining a longterm framework for contracts in integrated care (relational contract)


Longterm contracts (Hold-up)

Problem• Changing environment• Incomplete contracts• Prohibitive transaction costs• ex-post opportunistic behaviour (hold-up)

exploitation of contract-specific investments

Solutions• Vertical integration• Specific investments• Transfer payments as security• Gain- and risk-sharing


6.4 Contract Design

Methods• Theoretical analysis based on contract theory• Review of empirical literature• Evaluation of the identified P4P projects in Europe

Deliverables• Recommended framework for longterm relational contracts


6.5 Effectiveness of Patient Education Programs

Objectives• Evaluation of patient education programs considering

- quality,

- efficiency, and

- access to programs• Examples of diabetes and depression• Comparative evaluation of selected metropolitan areas

(London, Warsaw, Berlin)


6.5 Effectiveness of Patient Education Programs

Methods• Literature Review• Expert interviews• Evaluation of patient education programs in three

metropolitan areas: Warsaw, London, and Berlin

Deliverables• Analysis of effectiveness of patient education programs

under everyday conditions


Thank you for your attention!

PD Dr. Christian Krauth

Institute of Epidemiology, SocialMedicine, and Health System ResearchHannover Medical SchoolD-30625 HannoverGermany

[email protected]/epi.html

interquality kick-off meeting warsaw, 18-19 january 2011 work package 6: integrated care christian...

Documents

integrated care contracts

integrated services

inpatient care

highquality care

provider performance

payment systems

dentistry contract duration

lkkinsureds appr