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Pay-for-Performance (P4P)
Sichern neue Vergütungsbedingungen
Pay for Performance (P4P)
bessere Ergebnisse?
Univ.-Prof. Dr. oec Volker E. AmelunggBerlin, Mai 2009
1Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
2Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Definition
„Pay for performance is not simply a mechanism toreward those who perform well or to reduce costs Itsreward those who perform well or to reduce costs. Itspurpose is to align payment incentives to encourageongoing improvement in a way that will ensure high-
quality care for all.“q y
The Institue of Medicine, Rewarding Provider Performance, 2006, S.2
3Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
g
P4P – Neue Impulse für das Gesundheitssystem
P4P – Erfolgsorientierung und Transparenz
P4PP4P
erfolgs-orientierte
erfolgs-orientierte Public Public orientierte Vergütungorientierte Vergütung
Public Reporting
Public Reporting
4Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Selektives Kontrahieren
Es müssen…
Kriterien zur Auswahl von Vertragspartnern gefunden werden,
Kriterien zur Auswahl von Vertragsgegenständen (Leistungsumfang muss definiert werden) und
Erfüllungskriterien (Qualitätskriterien) definiert werden
5Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Selektives Kontrahieren
Di I t i t V h §140 d SGB V
Stellschrauben für Selektivverträge
Die Integrierte Versorgung nach §140a-d SGB V Die besondere ambulante ärztliche Versorgung nach §73c SGB V Die ambulante stationäre Versorgung nach §116 SGB VDie ambulante stationäre Versorgung nach §116 SGB V Rabattverträge nach §130a SGB V Wahltarife nach §53 SGB V
6Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
7Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Vergütungssysteme in der Praxis
Ziel e eines Vergütungssystems
St d Ak tSteuerungs- und Anreizfunktion Verteilungsfunktion Innovations-
funktionAkzeptanz,
Transparenz,Einfachheit,
PraktikabilitätVergütungsformen
Gehalt Kopfpauschale Fallpauschale Tagespauschale
Leist ngskomple Einzelleistung ErfolgsorientierteLeistungskomplex Einzelleistung ErfolgsorientierteVergütung
(Faktor)-Kostenerstattung
Vergütungsverfahren
Marktsteuerung Kollektivverhandlung Regulierung
Einstufiges Zweistufiges
8Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Einstufiges Verfahren
Zweistufiges Verfahren
Vergütungssysteme in der Praxis
Gegenläufige Probleme
Gefahr der Überversorgung Gefahr der Unterversorgung
FFS DRG FP Capitationp
9Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Vergütungssysteme in der Praxis
Vergütungsformen im Vergleich
Vergütungsform Erwünschter Effekt Unerwünschter EffektVergütungsform Erwünschter Effekt Unerwünschter EffektGehalt Anreiz zur Gesunderhaltung
des Patienten Keine Wirtschaftlich-
keitsanreize Warteschlangen
Kopfpauschale Anreiz zur Gesunderhaltung des Patienten
Risikoselektion Kostenverlagerungdes Patienten
Wirtschaftlichkeitsanreize geringe Verwaltungskosten
Kostenverlagerung Qualitätsgefährdung
Fallpauschale Ohne Anreiz zur Leistungsausweitung
Wirtschaftlichkeitsanreize
Unterlassen erwünschter Leistungen
Upgradingpg g Kostenverlagerung
10Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Vergütungssysteme in der Praxis
Vergütungsform Erwünschter Effekt Unerwünschter EffektTagespauschale Minimierung der Kosten pro
Tag Ausdehnung der VerweildauerTag Verweildauer
Leistungskomplex kein Anreiz zur Ausweitung von Einzelleistungen
Inhalte der Leistungen nur durch Zusatzmaßnahmen gesichert
Einzelleistung Leistungsorientierte Vergütung
Unerwünschte Leistungs-ausweitungVergütung
Produktivitäts- und leistungs-steigernd
ausweitung Rosinenpicken, z. B.
Bevorzugung von GeräteleistungenGeräteleistungen
Erstattung der Faktorkosten
Planungssicherheit fürLeistungserbringer
Keine wirtschaftlich-keitsanreize,
Innovationsfördernd Leistungsausweitung
Erfolgsorientierte Vergütungsformen
Qualitätsverbesserung Arztinteresse und Patienten-
Messprobleme Hohe Kontrollkosten
11Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Vergütungsformen Arztinteresse und Patienteninteresse sind deckungsgleich
Hohe Kontrollkosten
Vergütungssysteme in der Praxis
1 Zweistufige Vergütungssysteme d h die Kombination
Ansätze
1. Zweistufige Vergütungssysteme, d.h. die Kombination verschiedener Anreizausrichtung (z.B. Capitation oder DRG plus erfolgsorientierter Vergütung oder FFS und Capitation
2 Unterschiedliche Vergüt ngss steme a f den nterschiedlichen2. Unterschiedliche Vergütungssysteme auf den unterschiedlichen Systemebenen(Capitation für das gesamte System, FFS für die einzelnen Leistungserbringer)
3 Di h ll V ä d d V üt t3. Die schnelle Veränderung der Vergütungssysteme, um Anpassungsstrategien zu erschweren(wenn jedes Jahr die Bemessungsgrundlagen und ähnliches verändert werden, werden Anpassungsstrategien ausgesprochen riskant)Anpassungsstrategien ausgesprochen riskant)
4. Ganzheitliche Vergütungssysteme zu entwickeln, bei denen nicht offensichtlich ist, welche einzelnen Aspekte den Erfolg definieren. Hi t i k d lli A ät b i d di V ütHier setzen risk modelling-Ansätze an, bei denen die Vergütung an den relativen Veränderungen des Gesundheitsstatus einer Subpopulation gemessen wird.
12Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
13Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
P4P - Entwicklung
Markteinwirkungen1990 Leitlinien Standardisierung des ärztlichen
1995 QM
1993GSGHandelns?
1995 QMKann man Qualität messen?
2000 EBM 2000GKV2000Wie belastbar ist das medizinische Wissen?
20052007
Safety2004
2007
GMG
WSGIst die Versorgung sicher?
2010Disclosure
2010Verbessert Transparenz die
14Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: M. Schrappe, SVR
2010 und P4P 2010Versorgung?
P4P - Entwicklung
Der P4P-EntwiclungsplanStage 1 Stage 2 Stage 3Stage 1
1996‐2004
Stage 2
2004‐2006
Stage 3
2007‐2010
PCP HEDIS measure PCP + Facility measures Enhanced data collection PCP HEDIS measure hospital measure Minimal consumer
reporting HMO Sortimentat
ures
PCP + Facility measures, Multiple specialities
Balanced Scorecard EB quality and affordability
measures
Enhanced data collection, clinical data exchanges, data aggregation
Standardized measures + outcomes HMO Sortiment
Withhold or Bonus based payoutsFe
a measures All product lines Differential fee schedules
outcomes Efficiency Actionable info – registries,
reminder alerts PHR EHR integration
Informational Low impact on costfit
s
Static consumer report cards
PHR – EHR integration Transparency
Enhanced Provider Directories (Provider ratings) Low impact on cost
Preventive care Existing data sets
Ben
e cards Safety and medication
errors Provider IT investment Collection of non claims
(Provider ratings) Demonstrable ROI Financially Sustainable Member engagement (PHR) Points of care notification
15Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: G. Baker, Leapfrog 2008
Collection of non-claims data (lab values etc.)
Points of care notification
P4P - Entwicklung
Wachstum in P4P-Programmen nach Sponsortyp
16Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: G. Baker, Leapfrog 2008
P4P - Grundlagen
Bewertungsdimensionen
Bewerber unterstützt durch Pay-for- Performance Sponsoren, die spezifische
17Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: Health Affairs, Vol. 26 No. 6
y p , pBewertungsverfahren benutzen, in Prozent, 2003 und 2006
P4P - Ziele
Q lität d Kli ik höh
Ziele für das VBP Program
Qualität der Kliniken erhöhen Probleme von über- und untermäßigem Gebrauch und Missbrauch
von Dienstleistungen angeheng g Auf den Patienten zentrierte Behandlung fördern Patientensicherheit erhöhen und negative Einflüsse reduzieren Unnötige Kosten in der Behandlung vermeiden Investitionen in strukturelle Komponente und in den
innerbetrieblichen Strukturwandel des Behandlungsprozessesinnerbetrieblichen Strukturwandel des Behandlungsprozesses systemübergreifend fördern
Behandlungsergebnisse transparent und verständlich für den Konsumenten machenKonsumenten machen
Bestehende Missverhältnisse im Gesundheitswesen abbauen und neue vermeiden
18Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: CMS, Option paper on value-based purchasing, April 2007
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
19Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Parameter und Methoden
1 Di b l t Zi l i h (B i ht)
Wie wird gemessen?
1. Die absolute Zielerreichung (Bonus, wenn x erreicht)2. Die relative Zielerreichung (Bonus, wenn zu den 10% Besten
gehörend)g )3. Die Veränderung im Gegensatz zum Vorjahr (20% besser als…)4. Der Vergleich mit einer Kontrollgruppe55. Kombinationen aus den drei vorangegangenen
20Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Parameter und Methoden
Type of Performance Target Upside Downside
Absolute achievement Clear expectations reduceuncertainty
Cost-ineffective; most bonuses goto already high perfomersuncertainty
Allow providers to planto already-high perfomersNo incentive to improve beyond theupper-most targetCan discourage improvementamong poor perfomersg p p
Relative performance Can increase competition among Less certainty that compliancehigh performers efforts will be rewarded
Can discourage compliance amongpoor performers
Improvement Encourage low-performers toimproveTargeting absolute improvementreduces uncertainty
Already high-performers have lessroom for improvementPoor performers could receivelarger bonuses than highperformersperformers
Combining two or more types ofperformance targets
Encourages compliance among all providers
Adds complexity and costPoor perfomers could receive larger bonuses than high performers
21Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: Cannon, P4P, Yale J HP L E, 2006
bonuses than high performers
Parameter und Methoden
Example of Hospital Earning Quality Points by Attainment or Improvement
22Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: CMS, Options Paper on value-based purchasing, April 2007
Ergebnisindikatoren
MY 2009 P4P Measurement SetYear 6 Measures:2008 Measurement Year / 2009 Reporting Year
Year 7 Measures:2009 Measurement Year / 2010 Reporting Year
Clinical Domain
Measures tobe collected,
1. Childhood Immunization Status w/ 24/-monthcontinuous enrollment
2. Appropriate Threatment for Children with UpperRespiratory Infection
3. Breast Cancer Screening
1. Childhood Immunization Status w/ 24/-monthcontinuous enrollment
2. Appropriate Threatment for Children with UpperRespiratory Infection
3. Breast Cancer Screeningbe collected, reported andrecommendedfor payment
3. Breast Cancer Screening4. Cervical Cancer Screening5. Chlamydia Screening in Women6. Use of Appropriate Medication for People with Asthma7. Cholesterol Management LDL Screening (includes
Pts. w/ Cardiovascular Conditions)
3. Breast Cancer Screening4. Cervical Cancer Screening5. Chlamydia Screening in Women6. Use of Appropriate Medication for People with Asthma7. Cholesterol Management LDL Screening (includes
Pts. w/ Cardiovascular Conditions))8. Cholesterol Managements LDL Control <100
(includes Pts. w/ Cardiovascular Conditions9. Colorectal Cancer Screening10. Appropriate Testing for Children with Pharnyngitis11. Avoidance of Antibiotic Treatment of Adults with Acute
)8. Cholesterol Managements LDL Control <100
(includes Pts. w/ Cardiovascular Conditions9. Colorectal Cancer Screening10. Appropriate Testing for Children with Pharnyngitis11. Avoidance of Antibiotic Treatment of Adults with Acute
Bronchitis12. Use of Imaging Studies for Low Back Pain13. Medication Monitoring (ACE/ARBs, digexin, diuretics
Bronchitis12. Use of Imaging Studies for Low Back Pain13. Medication Monitoring (ACE/ARBs, digexin, diuretics14. Asthma Medication Ratio15. Evidence-based Cervical Cancer Screening
Clinical PO encounterthreshold forreporting
3.75 Encounters per member per year(using Encounter Rate by Service Type Specs)
4.0 Encounters per members per year (using EncounterRate by Service Type specs)
23Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: IHA
Clinical Weighting
40 % 40 %
Struktur- und ProzessindikatorenIT-Measure 1 Description Eligible Qualifying Activities (Group must
demonstrate capability and actual use byphysicians as of 12/31/04)
Examples of Eligible Qualifying Activities
Measure 1 –Integrate
Population managementindependent of patient
1) Use of electronic diesease regitstry or datawarehouse or other electronic data capability to
Credit for one acitivity (each) A list of patients diagnosed with CHF byg
clinicalelectronic datasets forpopulation-basedmanagement
p pcontacts.Rewards group-levelintegration of relevant electronic data sets, including only*: Visits/claims
p yproduce any of the following on all eligible patients, for all practice sites, updated at least twiceannually:- actionable reports on patients at the physicians orpractice site level, or production of a query list forphysicians or practice sites which integrate at least
p g ypractice site (visits) showing hospitalizationsand ER visits in the past year (inpatient orER records)
A list of each physicians diabetic patients(visits and/or pharmacy data) with HbA1c above 9 5(lab results)management Visits/claims
Lab results or claims Prescribtions Inpatient stays or ER
visits Radiology findings or
physicians or practice sites, which integrate at least 2 of the data sets at left- registries of patients at the physicians or practicesite level that integrate at least 2 of the data sets atleft
above 9.5(lab results) Electronic query list for a practice site of
children who visited the ER for asthma andhad no follow-up visit to PCP(ER recordsplus visit data)
Any of the 4 specific HEDIS measures thatclaims
Clinical findings: bloodpressure, BMI, tobaccouse, substance abuseor other findingsrelevant to clinical
2) Internally – and electronically – generatednumerator and denominator results for any of the 4 specific HEDIS measures that include lab results orclinical findings in numerator. Those measuresinclude only the following*:- Cholesterol Management – LDL Control
include lab results or clinical findings in numerator
A list of eligible patients (visit data to find patients with contraindications) missingBCS(radiology findings or claims) or CCS (laboratory findings or claims)relevant to clinical
guidelines
and the ability to report atthe patient level to practicesites or individual
h i i
Cholesterol Management LDL Control- Comprehensive Diabetes Care – HbA1c control- Comprehensive Diabetes Care – LDL control- Controlling High Blood pressure.[Therefore, any group self-reporting either of thefirst two control measures, which are also in theli i l t f Y 2 t dit f IT
(laboratory findings or claims) Electronic query list or report for a practice
site of each physician‘s patients withdiabetes(visits and/or pharmacy data), andtheir clinical lab results, most recent visit(s) and most recent pharmacy fills(1 condition, 3 d t t )physicians.
*Note: Eligibility lists do notcount as a relevant data set– the use of eligibility data isassumed.
clinical measure set for Year 2, gets credit for an IT Investment activity also]
*Note: HEDIS measures of the presence ofscreening or testing, such as HbA1c testing orcervical cancer screening, do not count.
data sets) Electronic query list or report for a practice
site, of all patients most recent lab resultsand office visits
A list covering all a practice‘s patients withhypertension(visits) and their last three blood
24Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
g yp ( )pressure readings (clinical findings)
Patientenzufriedenheit
Messung der Patientenzufriedenheit (MY 2003)Domain 1: Comumunication with MD Proposed Item
WeightingIndividual ItemWeighting
Doctor – Patient Communication Composite
Listen carefully to you 3,34 %
10 %Explain things in way you could understand 3,33 %
Providers spend enoungh time with you 3,33 %
Domain 2: Overall Ratings Proposed Item Weighting
Individual ItemWeightingWeighting Weighting
Ratings of personal doctor ornurse question item
Your rating of your personal doctor or nurse 5,00 %
10%Ratings of all health care questionitems
Your rating of all health care from providers 5,00 %
Domain 3: Speciality Care Proposed Item Weighting
Individual ItemWeighting
Problem seeing specialistquestion item
How much of a problem was it to see a specialist that you needed to see? 5,00 %
10%Rating of specialist question item Your rating of the specialist you saw most often 5,00 %
Domain 4: Timely Access to Care Proposed Item Weighting
Individual ItemWeighting
How often did you get an appointment as soon as wanted? 2,00 %
Timely Care and Service
y g pp
10 %
When called during regular office hours, how often did you get advice/help? 2,00 %
When needed care right away, how often did you get care as soon as wanted? 2,00 %
When needed after hours care, how often did you get care/help needed? 2,00 %
How often did you see the person you came to see within 15 minutes of your 2 00 %
25Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
How often did you see the person you came to see within 15 minutes of yourappointment time?
2,00 %
Quelle: Nach Emmert, P4P, 2008
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
26Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Public Reporting
IHA Public Reporting: 2006 data reported in 2007
27Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Public Reporting
MN Community Measurement Provider Group Profile
28Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Beispiel
29Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
30Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
IHA
Gewichtung der Maßgrößen2003 2005 2005 2006
Klinisch 50 % 40 % 50 % 50 %
Patienten- 40 % 40 % 30 % 30 %Patientenzufriedenheit
40 % 40 % 30 % 30 %
IT-Investitionen
10 % 20 % 20 % 20 %
Individuelles Ärzte
X XÄrzte-FeedbackProgramm
31Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: IHA
IHA
P4P Measurement Set Evolution2003 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 1 Childhood Immunization w/ 24-month 1 Childhood Immunization w/ 24-month 1 Childhood Immunization w/ 24-monthClinical 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
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)
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 <130
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 <130
Encounter threshold > 2.7 enc. PMPYevent and diabetics)
8. LDL Control <130
Encounter threshold >3,25 enc. PMPY
8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for Children
with Upper Respiratory Infection
Encounter threshold >3,25 enc. PMPY
8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for Children
with Upper Respiratory Infection11. Nephropathy Monitoring for Diabetic
Patients12. Obesity Counceling
Encounter threshold >3 5 enc PMPYEncounter 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)
1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Care coordination (CAS Composite)
5. Overall ratings of care 5. Overall ratings of care
Weighting 40 % 40 % 30 % 30 %
Information TechnologyInvestment
1. Integrate clinical electronic data setsat group level for populationmanagement
2. Support clinical decision making at
1. Integrate clinical electronic data setsat group level for populationmanagement
2. Support clinical decision making at
1. Integrate clinical electronic data setsat group level for populationmanagement
2. Support clinical decision making at
1. ntegrate clinical electronic data sets atgroup level for populationmanagement
2. Support clinical decision making atpoint of care through electronic tools
Requires 2 activities, at least one in each Measure, each activity is worth 5 %
point of care through electronic tools
Requires 4 activities of which at least 2 arein Measure 2, each activity is worth 5 %
Added more qualifying activities
point of care through electronic tools
Requires 4 activities of which at least 2 arein Measure 2, each activity is worth 5 %
Added more qualifying activities
point of care through electronic tools
Requires 4 activities of which at least 2 arein Measure 2, each activity is worth 5 %
32Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: IHA
Weighting 10 % 20 % 20 % 20 %
IHAYear 6 Measures2008 Measurement Year/2009 Reporting Year
Year 7 Measures2009 Measurement Year/2010 Reporting Year
Efficiency Domain 1. Generic Prescribing See appropriate resource use domainb lbelow
Efficiency Weighting Separate from quality incentivepool Separate from quality incentivepool
Appropriate Resource UseDomain
1. Inpatient utilization – acute caredischargesg
2. Inpatient utilization – Bed3. Outpatient surgeries utilization4. Emergency department visits5. Inpatient readmissions withing 30
DaysDays6. Generic Prescribing
Appropriate resource useweighting
Gain-sharing arrangement in development Gain-sharing arrangement in development
T iti Cli i l 1 Bl d t l i di b tiTransition measuresMeasures to be collectedbut not publicly reported orrecommended for payment. These measures have been
Clinical:1. Asthma Medication Ratio2. Evidence-based cervical cancer screeningAppropriate resource use measures(will be used to establish a baseline):
1. Blood pressure control in diabetics2. Optimal diabetes care3. Adolescent immunizations (Tdap,
meningococcal, HPV)
tested and approved foraddition to the P4P measureset in the following year.
1. Inpatient utilization – acute care discharges2. Inpatient utilization – Bed3. Outpatient surgeries utilization4. Emergency department visits5 Inpatient readmissions withing 30 Days
33Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: IHA
5. Inpatient readmissions withing 30 Days6. Generic Prescribing
IHA
Neue Vergütungsformen: Point-of-Care Technologie
34Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: IHA
Leistungsorientierung im britischen NHS(disease) area N b f I di t i t i
Domain
(disease) area Number of Indicators points in
structure process outcomeTotal in
area domainarea domain
CHD w/ LVD 2 1 12 15 121
Clinical quality 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 45Clinical quality 550
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 29organisational g
Medicines management 10 42
Practice management 10 56 20
PEPatient survey 3 70
100Consultation length 1 4 30Consultation length 1 4 30
APS
Cervical screening 6 22
36Child health surveillance 1 6
Maternity services 1 6
C t ti i 2 10 2
35Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Contraceptive services 2 10 2
Total 146 870
Leistungsorientierung im britischen NHS(disease) area Indicator Description point threshold
range(%)No type
CHD 6 outcome % of patients with CHD in whom the last blood pressure reading 0-19 25-70CHD 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 0-56 25-70Hypertension 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 orless
0-17 25-55
COPD 3 process % of all patients whith COPD where diagnosis has been confirmed by 0-5 25-90COPD 3 process % of all patients whith COPD where diagnosis has been confirmed byspirometry 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-melatoninki f 1 A il 2003‘
0-6 >25
skin cancers from 1 April 2003‘
Mental health 2 outcome % of patients with severe long-term mental health problems with a reviewrecorded 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 h th di i h b fi d b i t k fl
0-15 25-70
36Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
where the diagnosis has been confirmed by spirometry or peak flowmeasurement
Leistungsorientierung im britischen NHS
Gründe für Hausärzte, Patienten vom Pay-for-Performance Programm auszuschließen
Der Patient hat min. drei Aufforderungen zu einer Untersuchung in den letzten 12 Monaten erhalten, ist aber nicht erschienen
Der Patient hat sich erst kürzlich in der Praxis registriert oder esDer Patient hat sich erst kürzlich in der Praxis registriert oder es wurde kürzlich eine Erkrankung festgestellt
Der Patient bekommt die max. vertragbare Medikamentendosis, aber die Wirkung bleibt suboptimalaber die Wirkung bleibt suboptimal
Der Patient hat eine Allergie, verspürt Nebenwirkungen oder Gegenanzeigen gegen verabreichte Medikamente
Der Patient stimmt einer Untersuchung oder Behandlung nicht zu Eine vorgeschriebene Untersuchungsmöglichkeit ist für den
Hausarzt nicht möglichHausarzt nicht möglich
37Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: Doran et all 2206
Pay-for-Performance
1. P4P - Neue Impulse für das Gesundheitssystem
2. Vergütungssysteme in der Praxis
3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen
4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren
5. Public Reporting5 ub c epo t g
6. Internationale Erfahrungen
7. Fazit
38Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Fazit
E b i ht
Ergebnisse durch P4P aus Versicherungssicht
Es berichten 38 % von einer Steigerung der Qualität 42 % von „Mixed Effects“42 % von „Mixed Effects 20 % von keine Veränderungen
39Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric AmelungQuelle: Rosenthal 2008
Erfolgsfaktoren und Hemmnisse
Folgende Aspekte müssen ausführlich betrachtet werden:
Valide Messparameter Einbeziehung der Anwender
B ü k i hti l k l U t hi d d dä t Berücksichtigung lokaler Unterschiede und adäquate Risikoadjustierung
Einsatz moderner Informationstechnologieg Ausreichende finanzielle Auswirkungen Einzel- und Gruppenmotivation Kombination mit nicht-monetären Anreizen Umfassende Evaluation
40Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Erfolgsfaktoren und Hemmnisse
Hemmnisse
Auswirkungen auf nicht berücksichtigte Kriterien Zu starke Prozessorientierung
F ti Fragmentierung Selektionseffekte Bürokratie und Einbindung kleinerer LeistungserbringerBürokratie und Einbindung kleinerer Leistungserbringer Motivation von Leistungsschwächeren Kontinuierliche Motivation von leistungsstarken Anbietern Aufbau von Versorgungsbarrieren und Vergrößerung der
Versorgungsunterschiede
41Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
Herzlichen Dank für die Aufmerksamkeit!
Univ -Prof Dr Volker AmelungUniv.-Prof. Dr. Volker Amelung
Medizinische Hochschule HannoverAbteilung Epidemiologie Sozialmedizin undAbteilung Epidemiologie, Sozialmedizin undGesundheitssystemforschung OE 5410Carl-Neuberg-Str. 130625 Hannover
Tel.: 0511 – 532 [email protected]
42Pay-for-Performance (P4P)
Univ.-Prof. Dr. Volker Eric Amelung
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