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Using Costing as a Tool for Advancing Palliative Care in Romania. Daniela Mosoiu, MD, PhD Malina Dumitrescu Hospice Casa Sperantei, Brasov, Romania. www.hospice.ro. Situation Analysis. Understanding the model of the Health Care System History and achievements of palliative care in Romania

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  1. Using Costing as a Tool for Advancing Palliative Care in Romania Daniela Mosoiu, MD, PhD Malina Dumitrescu Hospice Casa Sperantei, Brasov, Romania • www.hospice.ro

  2. Situation Analysis • Understanding the model of the Health Care System • History and achievements of palliative care in Romania • Needs vs. achievements • Funding mechanism for palliative care • www.hospice.ro

  3. Brief review of PC in Romania • Romanian Health care system – Bismarck model • Tax collection (employee + employer) • Population served: insured, special categories, emergencies • Service packages provided • Providers contracted • Annual review of “Frame Contract” and its regulations • Joint roles: Ministry of Health, House of Health Insurances, College of Physicians • www.hospice.ro

  4. History of palliative care in Romania • 1990’s – landmark in PC development in RO • 1992 – Hospice Casa Sperantei founded in Brasov • 1997 – Palliative Care Education Centre in Brasov • 1998 – National Palliative Care Organization • 1999 – P.C. subspecialty acknowledged • 2001 – Oral morphine available for pain control • 2002 – First Inpatient Hospice unit opened in Brasov • 2003 – Hospice Casa Sperantei = Beacon of excellence • 2005 - 2007 – Opioids Law and Norms passed • www.hospice.ro

  5. History of palliative care in Romania • 2005 – P.C. commission set up in the Min.of Health (MoH) • 2005 – Hospice Casa Sperantei = coordinator of the P.C. education as subspecialty in Romania • 2005 – P.C. in inpatient units introduced in the Frame-Contract of the House of Health Insurances (HoHI) • 2007 – First public reimbursement of the HoHI for P.C. admissions in Inpatient Units • 2007-2008 public awareness campaign and national survey • 2007 – First inpatient unit in public hospital • www.hospice.ro

  6. History of palliative care in Romania • 2007 – National Coalition of P.C. providers • 2008 – Partnership between MoH, Hospice and the National Coalition of Cancer Patients Association • 2008 – start of Health Budget Monitoring costing project • 2010 – Home-based Palliative Care services acknowledged • 2009 – curricula for nurses in basic training • 2010 – first Master program in PC (Brasov Medical Faculty) • 2011 – 5 medical faculties in Romania introduce palliative care in the basic studies curricula • www.hospice.ro

  7. PC need in Romania • Estimated need for PC: about 170,000 persons/year • In 2009: 31 PC providers → 46 services: • 21 inpatient units • 15 home-based units • 3 day centres 4003 persons • 4 outpatient clincis received PC • 3 hospital teams • www.hospice.ro

  8. Models of care • Home care: NGO sector15 • In patient units: • Public sector: 8 • Acute hospital wards: 7 • Chronic hospitals: 1 • NGO: 10 • Private sector: 3 • Out patient clinics: 2 • Day centers: 3 • Mobile Hospital teams: 3 • www.hospice.ro

  9. PC need and services • www.hospice.ro

  10. Financing Sources for Palliative Care in Romania Ministry of Health Inpatient Unit Ministry of Finances Home care Ministry of Labour Day centre Min. of Public Admin. Mobile Hospital Team Health Insurance Outpatient Clinic Community Public services Private services External Sources • www.hospice.ro

  11. Why Hospice Casa Sperantei ? • Reference center for country and region • Previous impact at policy level • Partnership with MoH • Success in triggering the new law of opioids • National coordination role in other arias (education program for PC competence, coalition or PC provioders, awareness campaign) • National sustainable development strategy for 60% PC needs coverage by 2020 • www.hospice.ro

  12. Aim of costing project • To facilitate the inclusion of palliative care services in the public funding scheme, by providing research-based cost data • www.hospice.ro

  13. Method • www.hospice.ro

  14. Survey of authorities (FOIA Law 544/2001) • www.hospice.ro

  15. Survey of providers • www.hospice.ro

  16. Results • www.hospice.ro

  17. Expenditure per patient per day • www.hospice.ro

  18. Data pointed out: • Inconsistency of recording • Unclear criteria in allocation • Lack of control of use of public money • Impossibility to base cost calculation on collected data • Consistent contribution of private funds • www.hospice.ro

  19. Standards for PC • www.hospice.ro

  20. Physicians (1,5 full-time equivalent per 10 beds) • Nurses and nurse assistants (14-18 full-time equivalent per 10 beds, 1 nurse per 3-5 beds and 1 nurse assistant per 5-7 beds, all per 8 hours shift) • Psychologist (0,5 full-time equivalent per 10 beds) • Other specialized personnel (4 full-time equivalent, including part-time for social worker, therapist, cleric, pharmacist, pharmacist assistant and others) • Auxiliary personnel (1 full-time medical secretary)

  21. Unit Cost • www.hospice.ro

  22. Costing frameworks • International expert • Tested/adjusted local economist • Comprising • Running costs • Sett up costs • For home care and inpatient services • www.hospice.ro

  23. Use of costing frameworks • www.hospice.ro

  24. The costs structure • www.hospice.ro

  25. Costing process • www.hospice.ro

  26. Costing: Home-based PC • www.hospice.ro

  27. MonthlyStaff Costs/patientHomecare • www.hospice.ro

  28. Costing: PC inpatient units • www.hospice.ro

  29. Monthly Staff Costs/patientIn-patient Unit • www.hospice.ro

  30. Comparative cost analysis 448 € vs 1500 € • www.hospice.ro

  31. Start-upcostsfor Inpatientvs HC • www.hospice.ro

  32. Preapring advocacy Costs Benefits CURE ≠ CARE Difference: • OUTCOMES • Life saving, • Disease curing • Quality in • End-of-Life Care • www.hospice.ro

  33. Preapring advocacy • HOW to convince? • “Why spend on a new service?” • “NO money is cheaper than SOME money” • “They are dying anyway” • PERSONAL EXPERIENCE (… feelings…) • COST EFFECTIVENESS (… financials…) • What is cost-effectiveness”? • NOT: to spend less get best quality • YES: to spend wisely for as many beneficiaries… • with existing resources • www.hospice.ro

  34. Advocacy methods • 1. Creating networks of direct supporters • Involved PC coalition: send letters to local HoHI and MPs • Letter from local HoHI in Brasov to the National HoHI to support the change • PC commission in the MS contacted national HoHI • Contact MPs from all parties for support • Supporter beneficiar IP in CNAS ??? • 2. Proving service and education • replication model • supporters who know from inside what PC means • www.hospice.ro

  35. Advocacy methods Direct communication • Conference at the Parliament • Meeting at the National HoHI to present results of costing 3. Public awareness • Press conference • Results presented in conferences and • Materials provided to Local Health Boards and local HoHI and to providers • www.hospice.ro

  36. Advocating for a change • Short term results: • Developing funding mechanisms for existing services • Base reimbursement on realistic costs • Medium/long term expected results: • Influence general legal framework to include PC in the public health system • Improved funding for PC services • Provide annual budgetary allocation for PC services • Increased coverage with PC services • www.hospice.ro

  37. Advocating for a change • 2. Medium/long term results • Influence general legal framework to include PC in the public health system • Amendments submitted to the Parliament for Health Law No.95/2006 in June 2010 (resolution pending) • Amendments to ministerial Orders submitted in 2009: • Authorization of service providers • Staff ratio for PC in Inpatient units • Human resources education (pre- and post-graduate) • Evaluation and monitoring of quality in PC services • www.hospice.ro

  38. New challenges: • Home-based PC (= preferred setting for patients): • Restrictive and bureaucratic procedure to access home care • Resticttive access by type of disease (only cancer and HIV/AIDS) • Restrictied access of providers to contract services (insufficient legal regulations for providers’ authorization • Insufficient funding dedicated to Home-based PC • Inpatient PC services: • Lowest qualification of PC inpatient units, resulting in poor funding • www.hospice.ro

  39. New challenges: • Outpatient PC: • Define outpatient services for PC • Evaluate costs in outpatient PC services • Hospital Mobile PC teams: • Evaluate costs after a 2-year pilot project • Define hospital teams input • Submit results and advocate to include hospital teams • www.hospice.ro

  40. Conclusions • Identify barriers and opportunities • Act collectively rather that individually • Monitor the change • Share the experience • www.hospice.ro

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