Using Payment by Results to commission better quality clinical care

Eileen RobertsonPayment by Results (PbR) Development Team

Pay

men

t by

Res

ults

2

Outline

What is Payment by Results?

Using PbR to commission better quality care

Supporting best practice: Fragility hip fractures

Pay

men

t by

Res

ults

3

What is Payment by Results?

The aim of PbR is to provide a transparent rules-based system for paying providers in England

a system in which PCTs pay hospitals for the number and complexity of patients treated, using a price list – the national tariff – for all activity within the scope of PbR

covers admitted patients, outpatients and A&E

new way of funding NHS activity introduced in 2003-04

replaced block contracts based on historic costs

part of a group of payment systems known internationally as casemix funding

Pay

men

t by

Res

ults

4

At a basic level the tariff is…

Tariff

A fixed price

Priced at national average cost

Paid per patient

At spell levelPer HRG

Published annually

Pay

men

t by

Res

ults

5

Using PbR to commission better quality care

PbR focuses negotiations between commissioners and providers away from price and towards quality

Introduction of best practice tariff to better support improved quality

Is better quality clinical care more efficient? Reduce length of stay

Reduce re-admissions

Improved outcomes

Wider health and social care impact

Pay

men

t by

Res

ults

6

Supporting better quality care: Fragility Hip Fracture

High Quality Care for All (HQCFA) report

High volume service area

Significant variation in clinical practice

Improve both quality and value

Excellent source of clinical data (NHFD)

Support existing work on fragility hip fracture care

From April 2010 PbR will be introducing a “Best Practice Tariff” for fragility hip fractures.

Pay

men

t by

Res

ults

7

The best practice tariff aims to…

Reduce unexplained variation in quality and universalise best practice.

Characteristics are best practice – they go beyond the standard

Key clinical characteristics:

Surgery within 36

hours

Involvement of an (ortho)-geriatrician

AND

Pay

men

t by

Res

ults

8

Definition of characteristics

1. Time to surgery Arrival in A&E or diagnosis if an inpatient to start of anaesthesia

2. Involvement of an (ortho)-geriatrician: All 4 required

a) Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon

b) Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia

c) Assessed by a Geriatrician * in the perioperative period **

* Geriatrician defined as Consultant, NCCG, or ST3+

** Perioperative period defined as within 72 hours of admission

d) Postoperative Geriatrician-directed:

Multiprofessional rehabilitation team

Fracture prevention assessments (falls and bone health)

Pay

men

t by

Res

ults

9

Best practice care costs less…

“Looking after hip fracture patients well is a lot cheaper than looking after them badly.”

The ‘Blue Book’ (p. 10)

invest

save

time

unit cost

Cost profile of meeting best practice

Tariff to reflect this

profile over time

Pay

men

t by

Res

ults

10

The tariff will be paid in two-parts…

Reduction in base tariff for national compliance rate

Additional payment for best practice

Base tariff for each HRG

Payment per

patient

National average

cost

National Hip Fracture Database captures compliance with clinical practice

PCTs to monitor and make additional payments quarterly

Pay

men

t by

Res

ults

11

Summary of best practice tariff

Aim is to universalise best practice around two key characteristics with hip fracture care

Payment to be a 2-part tariff with compliance to be monitored through NHFD

Additional funding to providers of best practice care

PCTs reap financial benefits through savings in super-spell and future reductions in tariff

2010/11 is an opportunity to change practice