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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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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 …
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
Indication-specific IC
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
A model for population-orientated Integrated Care
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
Integrated Care contracts
Integrated Care in Germany
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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)
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
P4P Measurement Set Evolution
Quelle: IHA
IHA2003 Measurement Year /2004 Reporting Year
2004 Measurement Year /2005 Reporting Year
2005 Measurement Year /2006 Reporting Year
2006 Measurement Year /2007 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
1. Childhood Immunization w/ 24-month continuous enrollment
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
Encounter threshold >3,25 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 8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for
Children with Upper Respiratory Infection
11. Nephropathy Monitoring for Diabetic Patients
12. Obesity Counceling
Encounter threshold >3,5 enc. PMPY
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 %
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 4 activities of which at least 2 are in Measure 2, each activity is worth 5 %
Added more qualifying activities
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 4 activities of which at least 2 are in Measure 2, each activity is worth 5 %
Added more qualifying activities
1. ntegrate clinical electronic data sets at group level for population management
2. Support clinical decision making at point of care through electronic tools
Requires 4 activities of which at least 2 are in Measure 2, each activity is worth 5 %
Weighting 10 % 20 % 20 % 20 %
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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)
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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)
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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
InterQuality Kick-off MeetingWarsaw, 18-19 january 2011
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