Transcript PowerPoint-presentation

Forsberg Knezevic EHMA 2008
Stockholm County Council
Reimbursements in psychiatry in Sweden
– models and experiences
Birger Carl Forsberg. MD MPH BSc
Milan Knezevic, MBA
Stockholm County Council Administration
Dept of Public Health Sciences
Karolinska Institutet
Stockholm
Sweden
www.sll.se
Forsberg Knezevic EHMA 2008
Stockholm County Council
Reimbursements in psychiatry in Sweden
- models and experiences
Region Västra Götaland
Region Skåne/Scania
Stockholms County Council
Forsberg Knezevic EHMA 2008
Stockholm County Council
Objective
 The overall:
– to contribute to the development of psychiatric health
services for the overall attainment of good health and client
satisfaction
 The specific:
– to study and understand key characteristics of the
purchaser/provider (PP) models in psychiatric health
services and
– to explore the development of reimbursement models in
psychiatric care
Forsberg Knezevic EHMA 2008
Stockholm County Council
Methods
 Interviews with health care managers
 Review of policy and implementation documents
Forsberg Knezevic EHMA 2008
Stockholm County Council
Background
 Purchaser-provider models introduced in the early 90es in
Sweden
 Introduction in phases depending on experience gained
and political majority shifts in county councils and at
national level
 However, gradually purchaser-provider models have been
established, particularly in larger county councils
Forsberg Knezevic EHMA 2008
Stockholm County Council
Background
Background
 Cost pressures on health services increase the need for
cost control
 Political developments favoured new systems
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Historical developments
 Purchaser-provider models introduced in psychiatry in the
mid-nineties
 However, traditional historical budget based reimbursement
models were used throughout most of the 90es
 Performance based reimbursement models were introduced in
small scale around 2000 in Stockholm
 The first private providers were contracted in 2002 in Region
Skåne
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results Reasons for introduction of purchaser-provider
models in psychiatry
 Poor access to services (waiting times, non-availability of
staff and treatments)
 Poor coordination within services and between psychiatry and
other relevant services
 Poor flexibility
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Aims
 All three regions have developed the same aims:
– To increase productivity
– To decrease in-patient care
– To improve availability of personnel, in particular
psychiatrists
– To improve quality
– To create a pluralistic supply of services
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 All models contain:
– Fixed reimbursement
– Performance-based reimbursement
– Quality based/target based reimbursement for
delivered patient care
 In addition, several contracts included specific tasks
that were reimbursed on a lump-sum basis (like
special services, training etc.)
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 Region Västra Götaland
– Fixed/performance-based
 Started 50/50, target now
– 90/10 for in-patient and
– 70/30 for out-patient
 Actual mix in 2007 52% fixed, performance-based 48%
– Reimbursement based on discharges (IPD) and visits (OPD)
– Classification systems for case-mix tested for a more diversified
and truly need-based reimbursement system
– Targets for volumes set – penalty/bonus related
– Quality indicators (15) developed - to be implemented 2008 –
basis for 2-3% of total reimbursement
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 Region Skåne
– Out-patient service in two wards through purchasing of private
provider:



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100% performance based reimbursement
Reimbursement based on visits and separated into three categories
Geographic area responsibility
Financial ceiling set – above that only patient fee
Quality indicators (7) developed – not bound to reimbursement but
important for evaluation
 Clear terms of reference based on a common value ground and clear
targets and expectations
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 Region Skåne
– From 2006 a new reimbursement model for publicly produced
health services
 60% fixed and 40% performance based from 100% fixed budget
 Performance based reimbursement for inpatient care based on days of
care
 Performance based reimbursement for outpatient care based on visits
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 Stockholm County Council 2006-2007
100%
Inpatient care
Outpatient care
3%
5%
3%
25%
80%
60%
92%
40%
20%
0%
72%
Quality based
reimbursement
Performance
based
reimbursement
Fixed
reimbursement
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 Stockholm County Council
– Performance based reimbursement
 inpatient care (5%)
– Day 1 SEK 400
– Day 2-10 SEK 240
– > 11 days SEK 200
 outpatient care (25%)
– Visit to clinic SEK 350
– Home visit SEK 700
– Group visit SEK 175
– For each patient (individual) SEK 700
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
 Stockholm County Council 2008
– Fixed/performance based 50/50% in both inpatient and
outpatient care
– This will be achieved through doubling payment for
visits and increasing reimbursement for inpatient days
ten-fold
– A ceiling on volumes will be put on reimbursement.
Above the ceiling producers will only get 10% of rates
set.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Experience
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Increased production
Less inpatient care, more outpatient
Increased accessibility
Improved coordination among care providers and other
actors in Skåne
 Significant tensions between purchasers and providers
 Significant time spent on negotiations around quality
indicators (that represent a small part of reimbursement)
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Experience
 Providers feel purchasers are over-simplifying description
of services, emphasizing quantity rather than quality
 In Skåne, both providers and purchasers are overall
pleased with the cooperation
 Purchasers felt that presence of private providers had
resulted in increased attention on key issues like
productivity in public services
Forsberg Knezevic EHMA 2008
Stockholm County Council
Discussion
 All three regions have independent of each other set up strikingly similar
targets concerning psychiatric health services, much as a result of facing
the same problems.
 Emphasis is put on increasing productivity and accessibility and the
ambition is to work towards increased quality of care and thereby
improved medical outcomes.
 Purchasers aim to increase outpatient care and decrease inpatient care.
 The regions employ the same base reimbursement model, but with
different structures and levels of services, products and prices.
 The reimbursement models for outpatient care have to a higher extent
performance based reimbursement that inpatient care.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Discussion- Preconditions
 Clarity in contracted task and targets are essential
 Well defined and precise terms of reference is a vital
precondition for a well functioning reimbursement model
 The contracted task should be based on obligatory tasks
and defined target levels
 Few but well thought-out quality indicators for
evaluation
Forsberg Knezevic EHMA 2008
Stockholm County Council
Discussion- Problems
 Lack of well functioning and generally accepted
classification systems.
 Preventive and health promoting activities are not
rewarded.
 Reimbursement models not adapted to individual needs of
care.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Conclusion
 Performance based reimbursement models in psychiatric
care work well given when overall aims are set to
increase productivity and structural conditions are similar
to those in the regions studied.
 Terms of reference and clear definitions of contracted
tasks are essential even if they are not specifically linked
to payments.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Conclusion
 The demand for further development and knowledge
concerning the usage and effects of reimbursement
models in psychiatric health services is significant.
 The knowledge could be used to improve the models for
further contribution to reaching the overall aims of
services – improved access, client satisfaction and good
health.