Managing Overseas Care in St. MaartenLessons from Experience

TCI-NHIP/HEU 10th Caribbean Conference on National Health Financing InitiativesTurks & Caicos Islands, 29 October 2015

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NON DISCLOSURE STATEMENT

The information in this document may not to be copied, stored in an electronic database, made publicly available in any way or form, either electronically, mechanically, by means of

photocopying, recording or any other way without the prior written consent of ACSION and SZV

FOR FURTHER INFORMATION

ACSION SZV

AddressVan Engelenweg 21AWillemstadCuraçao,

Sparrow Road 4PhilipsburgSt. Maarten

Phone +(599-9) 737-3595 : +1-721-546-6782

Website www.acsiongroup.com www.szv.sx

eMail Javier.asin@acsiongroup.com

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Agenda

• Overseas Care today– The impact – The Challenges

• Overseas Care in the future– Demand analysis– Expand capabilities and capacity SMMC– New product definitions– Benchmark

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Healthcare expenditures 2013: more than half is spent on hospital careMore is spent on medical referrals abroad than on care in the hospital on St. Maarten

Source: Annual Report SZV 2013

Medical Referrals Abroad

Sint Maarten Medical Center

Pharmaceutical Care

Loss of Wages

Laboratory

Primary Care Physicians

Medical Specialists

Other medical costs

Paramedic Care / Midwives

Home Care

Mental Health

ANG

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Health care expenditures are rising Mainly medical care abroad

Mental Health

Home Care

Paramedic Care / Midwives

Other medical costs

Primary Care Physicians

Laboratory

Loss of Wages

Pharmaceutical Care

Intramural Care

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Data used for the hospital care demand analysisActual data not sufficient – alternative sources for estimates

• Data on actual hospital care delivered– Information on hospitalizations in the SMMC (ICD 9 codes): Vast majority was unspecified– Information on medical referrals abroad: not all referrals recorded accurately plus latent demand

• Indications from additional resources– Demographic profile: age & gender distribution, socio-economic status (STAT 2011 / CIA)– Healthcare survey 2002: self reported health status and morbidity (VSA)– Health expenditures: primary care versus secondary care (SZV)– Reference population in the Netherlands (SMMC/Performation)

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Top 10 countries patients are referred toCuraçao is dominant because of historic ties within the Kingdom

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Musculoskeletal problems prevailTop 20 diagnoses medical referrals abroad and health survey show the same

Top 20 diagnoses NumberHNP (herniated nucleus pulposus, back/neck hernia) 194Gonarthrosis (knee pain) 118Prostate carcinoma (prostate cancer) 76Epilepsy 56Varices (varicose veins) 51Asthma 41PSA (prostate-specific antigen) 33Mamma carcinoma (breast cancer) 31Scoliosis (curvature of the spine) 25RA (rheumatoid arthritis) 24Chronic headache 24Meniscus tear 23Retinal detachment (ablatio retinae) 23Mamma reduction (breast reduction) 22BPH (Benign Prostatic Hyperplasia, prostate enlargement) 22Diabetic Retinopathy (DRP, eye problems) 19Cervical spine (C1 t/m C7) 18Cardiomyopathy (heart muscle disease) 16COPD (Chronic Obstructive Pulmonary Disease) 15Prostatic hypertrophy (prostate enlargement) 14

Prevalence (1 year) of chronic disorders per 100 cases Total (N=754)Chronic back problems 13.2Hypertension 12.6Complaints of the joints* 8.5Migraine & chronic headache 7.9Psychological problems 5.6Dizziness 5.6Diabetes Mellitus 4Chronic non-specific respiratory disease 3.9Stomach/duodenal ulcer 3.6Serious consequences of an accident 2.7Chronic inflammation of the bladder 2.3Heart diseases 2.2Gall stones/inflammation of gallbladder 1.6Glaucoma 1.5Loss of hearing 1.3Blindness 1.2Intestinal disorders 0.9Serious skin disease 0.9Kidney stones 0.9Loss of normal use of limbs 0.9

* Complaints of the joints is a combination of the diseases arthritis and arthrose because respondents cannot always make a distinction between these diseases

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Demographic profile indicates highest care demand in workforceGreying of the population bears high risks with so few young people

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Per capita income is high and unemployment rates low However the employed population has mainly physically straining jobs

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Healthcare spending allows little room for prevention and management of secondary careRelatively little is spent on primary and home/nursery care

Source: Annual Report SZV 2013

Medical Referrals Abroad

Sint Maarten Medical Center

Pharmaceutical Care

Loss of Wages

Laboratory

Primary Care Physicians

Medical Specialists

Other medical costs

Paramedic Care / Midwives

Home Care

Mental Health

ANG

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Challenges with current medical referrals abroadNeed for change given the impact of referrals on patients, costs and outcomes

• No continuity of care– No shared protocols– Transfer of information is incomplete and sometimes even absent– Direct contact between medical specialists is ‘forbidden’ by agencies

• Logistics– Visa requirements– Patients are often not used to traveling and/or do not comply with the advise given– Bureaucracy often causes delays in urgent cases

• Lack of information about the care demand and cost drivers– Hospital diagnoses are not registered with sufficient accuracy / detail– Reasons for referral abroad, diagnoses, costs and outcomes are not registered structurally– No system in place to assess and monitor integral quality and efficiency

Given the impact of medical referrals on patients, costs and health outcomes,it is clear that optimization is not an option but a must

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Conclusions and recommendations

• Proper registration is a prerequisite to analyze the care needs and the demand for care– Episode registration with ICPC2 / ICD 10 codes in primary and secondary care

• Accurate data registration in the medical referral process is necessary

• It seems that permanent availability of an orthopedic surgeon, urologist, neurologist, cardiologist and ophthalmologist is necessary– Could be financed from the avoided referrals abroad since the vast majority is linked to these specialisms

• Expanding available services to lower medical referrals abroad is not the only solution – Perhaps even more important is to invest in measures to prevent avoidable hospital care with

• Adequate labor laws• Fighting obesity and cardiovascular risk management• Adequate procedures and processes for medical referrals

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Agenda

• Overseas Care today– The impact – The Challenges

• Overseas Care in the future– Demand analysis– Expand capabilities and capacity SMMC– New product definitions– Benchmark

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Our approachFrom a shared vision to the strategy for hospital care

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Elements of the vision for intramural care St. Maarten

• Demand driven

• Minimal norms for quality and safety

• On St. Maarten or the best alternative if needed

• Affordable and sustainable

• Integrated care: cooperation and coordination

• Safeguard patient rights

• St. Maarten stakeholders always in charge

• Transparency

Shared vision for intramural care Build strategy clockwise in the 3 balance model

HOSPITAL CARE REMAINS AFFORDABLE

THE NECESSARY HOSPITAL CARE CAN BE DELIVERED PREFERRABLY LOCALLY AND IN A SUSTAINABLE MANNER

THE NECESSARY AMOUNT AND QUALITY OF CARE IS AVAILABLE

POPULATION COUNTS ON AVAILABILITY AND ACCESS TOHOSPITAL CARE THEY NEED (QUANTITY AND QUALITY)

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The strategic frameworkTranslation of Vision and Objectives to a Strategy to be operationalized

Demand driven• Care demand analysis• Care episode registration• Care product definition

Optimal Quantity and Quality of care

• Norms for quality and safety

• Benchmark

Viable healthcare infrastructure

• Continuous development of the National Hospital

• Medical coordination on St. Maarten

• Procurement processAdequate financing

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SCM will be described for the most important care products High volume, high costs and/or referrals abroad necessary

Top 20 diagnoses NumberHNP (herniated nucleus pulposus, back/neck hernia) 194Gonarthrosis (knee pain) 118Prostate carcinoma (prostate cancer) 76Epilepsy 56Varices (varicose veins) 51Asthma 41PSA (prostate-specific antigen) 33Mamma carcinoma (breast cancer) 31Scoliosis (curvature of the spine) 25RA (rheumatoid arthritis) 24Chronic headache 24Meniscus tear 23Retinal detachment (ablatio retinae) 23Mamma reduction (breast reduction) 22BPH (Benign Prostatic Hyperplasia, prostate enlargement) 22Diabetic Retinopathy (DRP, eye problems) 19Cervical spine (C1 t/m C7) 18Cardiomyopathy (heart muscle disease) 16COPD (Chronic Obstructive Pulmonary Disease) 15Prostatic hypertrophy (prostate enlargement) 14

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Based on international guidelines

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Care product definition consist of an algorithm and SCMs Example: HNP diagnosis and treatment

• SCM1a: conservative treatment for 12 weeks• SCM 1b: conservative treatment for 12 weeks with

assessment by neurologist after 6-8 weeks

• SCM 2: Intensive conservative treatment for another 8 weeks

• SCM 3: Operation

• SCM 4: Reassessment after SCM 3 was not successful

Urgent referral indications?

Serious pain despite adequate pain medication?

Insufficient reduction of pain and/or loss of

function after 6-8 weeks

Direct referral to neurologist

Referral to neurologist

No

Yes

Yes

Diagnosis Lumbosacral Radicular Syndrome (LRS)

Patient prefers operaton?

Yes

No

Insufficient reduction of pain and/or loss of

function after 12 weeks

SCM 3Yes

Cauda Equina Syndrome

Referral to neurologist 1-3 days

Yes

Serious paresis / malignancy in history?

Yes

No

No

No SCM 1a

Suspect rare or serious cause?

No

Yes

No Neurologist advisies operation?

Yes

SCM 1bNo

NoIndication or

preference for operation?

No SCM 2

Sufficient reduction of complaints after SCM

1-3?No SCM 4Geopereerd? Yes

No

SCM 1: Conservative treatment for 12 weeks

75% SCM 1a/1b 15% SCM 2

10% SCM 3

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Assessment / Diagnosis

GP SMMC Abroad

Treatment / interventions

GP SMMC Abroad

Rehabilitation

GP SMMC Abroad

SCMs for diagnosis, treatment and rehabilitation HNP

History / Phys examination

Pain medication / careful exercise

(12 weeks)SCM 1A After Care

SCM 1a Assessment neurologist

Pain medication / careful exercise

(12 weeks)SCM 1b After Care Assessment

neurologist

SCM 1 2 Assessment neurologist

Pain medication / careful exercise

(20 weeks)SCM 2 After Care Assessment

neurologist

SCM 1 / 2 Pre-operative radiology

Pre-operative radiology

Pain medication / careful exercise(8 – 20 weeks)

Assessment neurologistSCM 3 After Care Assessment

neurologistPost-operative

check-up

SCM 4 is on top of SCM 3 Postoperative reassessment SCM 4 is on top of SCM 3 Additional

treatmentSCM 4 SCM 4 is on top of SCM 3

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Items to be described in SCM

INSTRUCTIONS• Description of the SCM including the objectives and a summary of the care to be delivered• Advise for patient: explanation of the care to be delivered as well as self management instructions• Instructions for nurse / physician: the objectives, procedures, schedule and data to be registered

INTERVENTIONS (incl. minimal competencies)• Diagnostic procedures: lab, imaging, function tests• Combined lifestyle interventions/ paramedic care: smoking cessation, nutrition, exercise, addiction care• Psychosocial support: to cope with the disease/treatment/life issues or to support lifestyle interventions• Medical (specialist) interventions: pharmaceutical, surgical or radiological interventions

MONITORING• Monitoring frequency: schedule for monitoring visits

DATA REGISTRATION• Parameters to be registered for care continuum, logistics and integral quality management / benchmark

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Benchmark for procurement and Shared Decisionmaking with patient

• Country level– Accessibility (travel / Visa)– Language– Costs– Agencies

• Hospital level– Capacity / Scale / Experience– Functions– Quality system / Accreditation– Outcomes and complications

• Medical specialists– Specialties– Process and outcome indicators

• Treatment / SCM– Experience and Outcomes– Willingness to cooperate in SCM– Costs

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Summary

• Medical referrals abroad have an enormous impact on health(care) St. Maarten– However at the moment very limited instruments to manage costs and outcomes

• Change #1: Standardized data registration – Care demand analysis– Capability as well as capacity planning– Integral quality management

• Change #2: expand capabilities and capacity SMMC– To accommodate more treatment as well as pre-treatment and rehabilitation capabilities

• Change #3: SCMs as the new product definitions– Continuity of care with joined protocols and multidisciplinary sharing of patient data– Procurement of parts of the SCMs rather than the complete care tracks

• Change #4: Procurement with benchmarks