Pay-for-Performance Performance (P4P)

Transkript

1 Pay-for-Performance Performance (P4P) Sichern neue Vergütungsbedingungen bessere Ergebnisse? Univ.-Prof. Dr. oec Volker E. Amelung Berlin, Mai

2 Pay-for-Performance 1. P4P - Neue Impulse für das Gesundheitssystem 2. Vergütungssysteme in der Praxis 3. Pay-for-Performance P f Ziele und Grundlagen 4. Meßmethoden und Indikatoren 5. Public Reporting 6. Internationale Erfahrungen 7. Fazit 2

3 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 highquality care for all. The Institue of Medicine, Rewarding Provider Performance, 2006, S.2 3

4 P4P Neue Impulse für das Gesundheitssystem P4P Erfolgsorientierung und Transparenz P4P erfolgsorientierte Vergütung Public Reporting 4

5 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 5

6 Selektives Kontrahieren Stellschrauben für Selektivverträge Die Integrierte t Versorgung nach 140a-d dsgbv Die besondere ambulante ärztliche Versorgung nach 73c SGB V Die ambulante stationäre Versorgung nach 116 SGB V Rabattverträge nach 130a SGB V Wahltarife nach 53 SGB V 6

8 Vergütungssysteme in der Praxis Ziel e eines Vergütungssystems Steuerungs- und Innovations- Akzeptanz, Verteilungsfunktion Anreizfunktion funktion Transparenz, Einfachheit, Vergütungsformen Praktikabilität Gehalt Kopfpauschale Fallpauschale Tagespauschale Leistungskomplex Einzelleistung Erfolgsorientierte Vergütung (Faktor)-Kostenerstattung Vergütungsverfahren Marktsteuerung Kollektivverhandlung Regulierung Einstufiges Verfahren Zweistufiges Verfahren 8

9 Vergütungssysteme in der Praxis Gegenläufige Probleme Gefahr der Überversorgung Gefahr der Unterversorgung FFS DRG FP Capitation 9

10 Vergütungssysteme in der Praxis Vergütungsformen im Vergleich Vergütungsform Erwünschter Effekt Unerwünschter Effekt Gehalt Anreiz zur Gesunderhaltung des Patienten Kopfpauschale Anreiz zur Gesunderhaltung des Patienten Wirtschaftlichkeitsanreize geringe Verwaltungskosten Fallpauschale Ohne Anreiz zur Leistungsausweitung Wirtschaftlichkeitsanreize Keine Wirtschaftlichkeitsanreize Warteschlangen Risikoselektion Kostenverlagerung Qualitätsgefährdung Unterlassen erwünschter Leistungen Upgrading g Kostenverlagerung 10

11 Vergütungssysteme in der Praxis Vergütungsform Erwünschter Effekt Unerwünschter Effekt Tagespauschale Minimierung der Kosten pro Ausdehnung der Tag Verweildauer Leistungskomplex Einzelleistung Erstattung der Faktorkosten Erfolgsorientierte Vergütungsformen kein Anreiz zur Ausweitung von Einzelleistungen Leistungsorientierte Vergütung Produktivitäts- und leistungssteigernd Planungssicherheit für Leistungserbringer Innovationsfördernd Qualitätsverbesserung Arztinteresse und Patienten- interesse sind deckungsgleich Inhalte der Leistungen nur durch Zusatzmaßnahmen gesichert Unerwünschte Leistungs- ausweitung Rosinenpicken, z. B. Bevorzugung von Geräteleistungen Keine wirtschaftlichkeitsanreize, Leistungsausweitung Messprobleme Hohe Kontrollkosten 11

12 Vergütungssysteme in der Praxis Ansätze 1. Zweistufige Vergütungssysteme, d.h. die Kombination verschiedener Anreizausrichtung (z.b. Capitation oder DRG plus erfolgsorientierter Vergütung oder FFS und Capitation 2. Unterschiedliche Vergütungssysteme steme auf den unterschiedlichen Systemebenen(Capitation für das gesamte System, FFS für die einzelnen Leistungserbringer) 3. Die schnelle Veränderung der Vergütungssysteme, t um Anpassungsstrategien zu erschweren(wenn jedes Jahr die Bemessungsgrundlagen und ähnliches verändert werden, werden Anpassungsstrategien ausgesprochen riskant) 4. Ganzheitliche Vergütungssysteme zu entwickeln, bei denen nicht offensichtlich ist, welche einzelnen Aspekte den Erfolg definieren. Hier setzen risk modelling-ansätze an, bei denen die Vergütung an den relativen Veränderungen des Gesundheitsstatus einer Subpopulation gemessen wird. 12

14 P4P - Entwicklung 1990 Leitlinien Markteinwirkungen Standardisierung des ärztlichen Handelns? GSG QM Kann man Qualität messen? 2000 EBM Wie belastbar ist das GKV medizinische Wissen? Safety Ist die Versorgung sicher? GMG WSG Disclosure Verbessert Transparenz die 2010 und P4P Versorgung? 2010 Quelle: M. Schrappe, SVR 14

15 P4P - Entwicklung Der P4P-Entwiclungsplan Stage 1 Stage 2 Stage Fea atures PCP HEDIS measure PCP + Facility measures, Enhanced data collection, hospital measure Multiple specialities clinical data exchanges, Minimal consumer reporting Balanced Scorecard EB quality and affordability data aggregation Standardized measures + HMO Sortiment Withhold or Bonus based payouts measures All product lines Differential fee schedules outcomes Efficiency Actionable info registries, reminder alerts PHR EHR integration Transparency fits Bene Informational Low impact on cost Preventive care Existing data sets Quelle: G. Baker, Leapfrog 2008 Static consumer report cards Safety and medication errors Provider IT investment Collection of non-claims data (lab values etc.) Enhanced Provider Directories (Provider ratings) Demonstrable ROI Financially Sustainable Member engagement (PHR) Points of care notification 15

16 P4P - Entwicklung Wachstum in P4P-Programmen nach Sponsortyp Quelle: G. Baker, Leapfrog

17 P4P - Grundlagen Bewertungsdimensionen Bewerber unterstützt durch Pay-for- Performance Sponsoren, die spezifische Bewertungsverfahren benutzen, in Prozent, 2003 und 2006 Quelle: Health Affairs, Vol. 26 No. 6 17

18 P4P - Ziele Ziele für das VBP Program Qualität der Kliniken ik erhöhen Probleme von über- und untermäßigem Gebrauch und Missbrauch von Dienstleistungen angehen 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 Behandlungsprozesses systemübergreifend fördern Behandlungsergebnisse transparent und verständlich für den Konsumenten machen Bestehende Missverhältnisse im Gesundheitswesen abbauen und neue vermeiden Quelle: CMS, Option paper on value-based purchasing, April

20 Parameter und Methoden Wie wird gemessen? 1. Die absolute Zielerreichung i (Bonus, wenn x erreicht) 2. Die relative Zielerreichung (Bonus, wenn zu den 10% Besten gehörend) 3. Die Veränderung im Gegensatz zum Vorjahr (20% besser als ) 4. Der Vergleich mit einer Kontrollgruppe 5. Kombinationen aus den drei vorangegangenen 20

21 Parameter und Methoden Type of Performance Target Upside Downside Absolute achievement Clear expectations reduce uncertainty Allow providers to plan Cost-ineffective; most bonuses go to already-high perfomers No incentive to improve beyond the upper-most target Can discourage improvement among poor perfomers Relative performance Can increase competition among Less certainty that compliance high performers efforts will be rewarded Can discourage compliance among poor performers Improvement Combining two or more types of performance targets Encourage low-performers to improve Targeting absolute improvement reduces uncertainty Encourages compliance among all providers Already high-performers have less room for improvement Poor performers could receive larger bonuses than high performers Adds complexity and cost Poor perfomers could receive larger bonuses than high performers Quelle: Cannon, P4P, Yale J HP L E,

22 Parameter und Methoden Example of Hospital Earning Quality Points by Attainment or Improvement Quelle: CMS, Options Paper on value-based purchasing, April

23 Ergebnisindikatoren Clinical Domain Measures to be collected, reported and recommended for payment Clinical PO encounter threshold for reporting Clinical Weighting Quelle: IHA MY 2009 P4P Measurement Set Year 6 Measures: 2008 Measurement Year / 2009 Reporting Year 1. Childhood Immunization Status w/ 24/-month continuous enrollment 2. Appropriate Threatment for Children with Upper Respiratory Infection 3. Breast Cancer Screening 4. Cervical Cancer Screening 5. Chlamydia Screening in Women 6. Use of Appropriate Medication for People with Asthma 7. Cholesterol Management LDL Screening (includes Pts. w/ Cardiovascular Conditions) 8. Cholesterol Managements LDL Control <100 (includes Pts. w/ Cardiovascular Conditions 9. Colorectal Cancer Screening 10. Appropriate Testing for Children with Pharnyngitis 11. Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis 12. Use of Imaging Studies for Low Back Pain 13. Medication Monitoring (ACE/ARBs, digexin, diuretics 3.75 Encounters per member per year(using Encounter Rate by Service Type Specs) 40 % 40 % Year 7 Measures: 2009 Measurement Year / 2010 Reporting Year 1. Childhood Immunization Status w/ 24/-month continuous enrollment 2. Appropriate Threatment for Children with Upper Respiratory Infection 3. Breast Cancer Screening 4. Cervical Cancer Screening 5. Chlamydia Screening in Women 6. Use of Appropriate Medication for People with Asthma 7. Cholesterol Management LDL Screening (includes Pts. w/ Cardiovascular Conditions) 8. Cholesterol Managements LDL Control <100 (includes Pts. w/ Cardiovascular Conditions 9. Colorectal Cancer Screening 10. Appropriate Testing for Children with Pharnyngitis 11. Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis 12. Use of Imaging Studies for Low Back Pain 13. Medication Monitoring (ACE/ARBs, digexin, diuretics 14. Asthma Medication Ratio 15. Evidence-based Cervical Cancer Screening 4.0 Encounters per members per year (using Encounter Rate by Service Type specs) 23

24 Struktur- und Prozessindikatoren IT-Measure 1 Description Eligible Qualifying Activities (Group must demonstrate capability and actual use by physicians as of 12/31/04) Examples of Eligible Qualifying Activities Measure 1 Integrate Population management independent of patient clinical contacts. electronic data Rewards group-level sets for integration of relevant populationbased electronic data sets, including only*: management Visits/claims Lab results or claims Prescribtions Inpatient stays or ER visits Radiology findings or claims Clinical findings: blood pressure, BMI, tobacco use, substance abuse or other findings relevant to clinical guidelines and the ability to report at the patient level to practice sites or individual physicians. i *Note: Eligibility lists do not count as a relevant data set the use of eligibility data is assumed. 1) Use of electronic diesease regitstry or data Credit for one acitivity (each) warehouse or other electronic data capability to A list of patients diagnosed with CHF by produce any of the following on all eligible patients, practice site (visits) showing hospitalizations for all practice sites, updated at least twice and ER visits in the past year (inpatient or annually: ER records) - actionable reports on patients at the physicians or A list of each physicians diabetic patients practice site level, or production of a query list for (visits and/or pharmacy data) with HbA1c physicians or practice sites, which integrate at least above 95(labresults) 9.5(lab 2 of the data sets at left Electronic query list for a practice site of - registries of patients at the physicians or practice children who visited the ER for asthma and site level that integrate at least 2 of the data sets at had no follow-up visit to PCP(ER records left plus visit data) Any of the 4 specific HEDIS measures that 2) Internally and electronically generated include lab results or clinical findings in numerator and denominator results for any of the 4 numerator specific HEDIS measures that include lab results or A list of eligible patients (visit data to find clinical findings in numerator. Those measures patients with contraindications) missing include only the following*: BCS(radiology findings or claims) or CCS - Cholesterol Management LDL Control (laboratory findings or claims) - Comprehensive Diabetes Care HbA1c control Electronic query list or report for a practice - Comprehensive Diabetes Care LDL control site of each physician s patients with - Controlling High Blood pressure. diabetes(visits and/or pharmacy data), and [Therefore, any group self-reporting either of the their clinical lab results, most recent visit(s) first two control measures, which are also in the and most recent pharmacy fills(1 condition, 3 clinical i l measure set for Year 2, gets credit for an IT datasets) t Investment activity also] Electronic query list or report for a practice site, of all patients most recent lab results *Note: HEDIS measures of the presence of and office visits screening or testing, such as HbA1c testing or A list covering all a practice s patients with cervical cancer screening, do not count. hypertension(visits) and their last three blood pressure readings (clinical findings) 24

25 Patientenzufriedenheit Messung der Patientenzufriedenheit (MY 2003) Domain 1: Comumunication with MD Proposed Item Weighting Individual Item Weighting Doctor Patient Communication Composite Domain 2: Overall Ratings Ratings of personal doctor or nurse question item Ratings of all health care question items Domain 3: Speciality Care Listen carefully to you 3,34 % Explain things in way you could understand 3,33 % Providers spend enoungh time with you 3,33 % Proposed Item Weighting Your rating of your personal doctor or nurse 5,00 % Your rating of all health care from providers 5,00 % Proposed Item Weighting 10 % Individual Item Weighting 10% Individual Item Weighting Problem seeing specialist question item How much of a problem was it to see a specialist that you needed to see? 5,00 % Rating of specialist question item Your rating of the specialist you saw most often 5,00 % 10% Domain 4: Timely Access to Care Timely Care and Service Proposed Item Weighting How often did you get an appointment as soon as wanted? 2,00 % 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 200% 2,00 appointment time? Individual Item Weighting 10 % Quelle: Nach Emmert, P4P,

27 Public Reporting IHA Public Reporting: 2006 data reported in

28 Public Reporting MN Community Measurement Provider Group Profile 28

29 Beispiel 29

31 IHA Gewichtung der Maßgrößen Klinisch 50 % 40 % 50 % 50 % Patienten- 40 % 40 % 30 % 30 % zufriedenheit IT- Investitionen 10 % 20 % 20 % 20 % Individuelles Ärzte- Feedback Programm X X Quelle: IHA 31

32 IHA 2003 Measurement Year / 2004 Reporting Year P4P Measurement Set Evolution 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-month continuous enrollment continuous enrollment continuous enrollment continuous enrollment 2. Cervical Cancer Screening 2. Cervical Cancer Screening 2. Cervical Cancer Screening 2. Cervical Cancer Screening 3. Breast Cancer Screening 3. Breast Cancer Screening 3. Breast Cancer Screening 3. Breast Cancer Screening 4. Asthma Mgmt. 4. Asthma Mgmt. 4. Asthma Mgmt. 4. Asthma Mgmt. 5. HbA1c Screening 5. HbA1c Screening 5. HbA1c Screening 5. HbA1c Screening 6. LDL Screening (patients w/ cardiac 6. HbA1c Control 6. HbA1c Control 6. HbA1c Control event only 7. LDL Screening (patients with cardiac 7. LDL Screening 7. LDL Screening event and diabetics) 8. LDL Control < LDL Control <130 Encounter threshold > 2.7 enc. PMPY 8. LDL Control <130 Encounter threshold >3,25 enc. PMPY 9. Chlamydia Screening 10. Appropriate Treatment for Children with Upper Respiratory Infection Encounter threshold >3,25 enc. PMPY 9. Chlamydia Screening 10. 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 Care 2. Timely acces to care 3. Doctor-patient-communication 4. Overall ratings of care 1. Speciality Care 2. Timely acces to care 3. Doctor-patient-communication 4. Overall ratings of care 1. Speciality Care 2. Timely acces to care 3. Doctor-patient-communication 4. Care coordination (CAS Composite) 1. Speciality Care 2. Timely acces to care 3. Doctor-patient-communication 4. Care coordination (CAS Composite) 5. Overall ratings of care 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 1. Integrate clinical electronic data sets at group level for population management 2. Support clinical decision making at point of care through electronic tools 1. Integrate clinical electronic data sets at group level for population management 2. Support clinical decision making at point of care through electronic tools 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 2 activities, at least one in each Measure, each activity is worth 5 % Requires 4 activities of which at least 2 are in Measure 2, each activity is worth 5 % Added more qualifying activities Requires 4 activities of which at least 2 are in Measure 2, each activity is worth 5 % Added more qualifying activities Requires 4 activities of which at least 2 are in Measure 2, each activity is worth 5 % Weighting 10 % 20 % 20 % 20 % Quelle: IHA 32

33 IHA Year 6 Measures 2008 Measurement Year/ 2009 Reporting Year Year 7 Measures 2009 Measurement Year/ 2010 Reporting Year Efficiency Domain 1. Generic Prescribing See appropriate resource use domain below Efficiency Weighting Separate from quality incentivepool Separate from quality incentivepool Appropriate Resource Use Domain Appropriate resource use weighting Gain-sharing arrangement in development 1. Inpatient utilization acute care discharges 2. Inpatient utilization Bed 3. Outpatient surgeries utilization 4. Emergency department visits 5. Inpatient readmissions withing 30 Days 6. Generic Prescribing Gain-sharing arrangement in development Transition measures Clinical: i l 1. Blood pressure control in diabetics Measures to be collected 1. Asthma Medication Ratio 2. Optimal diabetes care but not publicly reported or 2. Evidence-based cervical cancer screening 3. Adolescent immunizations (Tdap, recommended for payment. These measures have been Appropriate resource use measures (will be used to establish a baseline): meningococcal, HPV) tested and approved for addition to the P4P measure set in the following year. 1. Inpatient utilization acute care discharges 2. Inpatient utilization Bed 3. Outpatient surgeries utilization 4. Emergency department visits 5. Inpatient readmissions withing 30 Days 6. Generic Prescribing Quelle: IHA 33

34 IHA Neue Vergütungsformen: Point-of-Care Technologie Quelle: IHA 34

35 Leistungsorientierung im britischen NHS (disease) area Number of Indicators points in Domain structure process outcome area Total in domain area domain CHD w/ LVD TIA Hypertension Diabetes mellitus COPD Clinical quality 550 Epilepsy Hypothyroidism Cancer Mental health Asthma Records and information Practice organisational PE APS Patient communication 8 8 Education and training 9 29 Medicines management Practice management Patient survey 3 70 Consultation length Cervical screening 6 22 Child health surveillance 1 6 Maternity services 1 6 Contraceptive ti services Total

36 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 (measured in the last 15 months) is 150/90 or less 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 Diabetes mellitus 12 outcome % of patients with diabetes in whom the last blood pressure is 145/85 or less COPD 3 process % of all patients whith COPD where diagnosis has been confirmed by spirometry including reversibility testing 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 Hypothyroidism 2 outcome % of patients with hypothyroidism with tests recorded in the previous 15 months 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 Mental health 2 outcome % of patients with severe long-term mental health problems with a review recorded in the past 15 months Asthma 3 process % of patients aged over 8 diagnosed as having asthma from where the diagnosisi has been confirmed by spirometry or peak flow measurement 0-6 >

37 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 es wurde kürzlich eine Erkrankung festgestellt Der Patient bekommt die max. vertragbare Medikamentendosis, aber 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 möglich Quelle: Doran et all

39 Fazit Ergebnisse durch P4P aus Versicherungssicht Es berichten 38 % von einer Steigerung der Qualität 42 % von Mixed Effects 20 % von keine Veränderungen Quelle: Rosenthal

40 Erfolgsfaktoren und Hemmnisse Folgende Aspekte müssen ausführlich betrachtet werden: Valide Messparameter Einbeziehung der Anwender Berücksichtigung lokaler l Unterschiede und adäquate Risikoadjustierung Einsatz moderner Informationstechnologie Ausreichende finanzielle Auswirkungen Einzel- und Gruppenmotivation Kombination mit nicht-monetären Anreizen Umfassende Evaluation 40

41 Erfolgsfaktoren und Hemmnisse Hemmnisse Auswirkungen auf nicht berücksichtigte Kriterien Zu starke Prozessorientierung Fragmentierung Selektionseffekte Bürokratie und Einbindung kleinerer Leistungserbringer Motivation von Leistungsschwächeren Kontinuierliche Motivation von leistungsstarken Anbietern Aufbau von Versorgungsbarrieren und Vergrößerung der Versorgungsunterschiede 41

42 Herzlichen Dank für die Aufmerksamkeit! Univ.-Prof. Dr. Volker Amelung Medizinische Hochschule Hannover Abteilung Epidemiologie, Sozialmedizin und Gesundheitssystemforschung OE 5410 Carl-Neuberg-Str Hannover Tel.: amelung.volker@mh-hannover.de 42