Work Package 6: Integrated Care

1. InterQuality Kick-off Meeting Warsaw, 18-19 January 2011 Work Package 6: Integrated Care Christian Krauth Volker Amelung Hannover Medical School

2. General Questions • What is specific to integrated care • Which parameters do indicate good performance of integrated care • How should payment systems be designed • How can integrated care models be evaluated • Which contractional designs exist to guarantee longterm effectiveness of integrated care models InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

3. The need for integrated Care Consider deficiencies of existing systems … Optimization of interfaces Care delivery on adequate level Rehabilitation Ambulytory Care Acute Hospital Care Cooperation and commu- nication Standar- dization InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

4. Indication-specific IC InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

5. A model for population-orientated Integrated Care InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

6. Contracting parties AOK (20.11.2005) and LKK Baden-Wuerttemberg (01.10.2006) Population and budget 32000 AOK and LKK-insureds (appr. 50% of insured persons in the ZIP code area ) benefit spending appr. € 50 million p.a., Virtual budget of MMG Contract Scope total outpatient and inpatient care, all indications except dentistry Contract duration until 2014 Frames InterQuality Kick-off Meeting Warsaw, 18-19 january 2011 Quelle: Weatherly at al Leuchtturmprojekte 2007

7. Integrated Care contracts Integrated Care in Germany InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

8. Sickness fund A Sickness fund B Sickness fund C Sickness fund D Sickness fund E budget ambulatory care budget acute care pool for integrated services (app. 680 mil. Euro) 99% 1% 1% 99% Contract A Contract B Contract C Contract D Contract E InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

9. Pay-for-Performance InterQuality Kick-off Meeting Warsaw, 18-19 january 2011 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 high-quality care for all.“ The Institue of Medicine, Rewarding Provider Performance, 2006

10. Pay-for-Performance • What is measured - performance factors - clinical outcomes - patient satisfaction - process parameters - cost efficiency and savings - utilisation of information technologies • How will be measured - performance targets - absolute achievement - relative performance (compared to other providers) - improvement - (combination of perfomance targets) InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

11. InterQuality Kick-off Meeting Warsaw, 18-19 january 2011 Performance-orientation in the NHS

12. InterQuality Kick-off Meeting Warsaw, 18-19 january 2011 Performance orientation in the NHS

13. P4P Measurement Set Evolution InterQuality Kick-off Meeting Warsaw, 18-19 january 2011 Quelle: IHA IHA

14. Pay-for-Performance • (Expected) advantages and disadvantages + improving health care quality + patient and provider interests hamonized - problems measuring performance - high control costs (e.g. avoiding patient selection) • Vital factors - part of a two-stage payment system - valid performance parameters - risk-adjustment to socio-demografic and regional parameters - combined with non-monetary incentives - utilisation of modern information technologies - evaluation and quality assurance InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

15. 6.1 Integrated Care and Pay-for-Performance Objectives • Understand the need for integrated care • Identify central problems in financing integrated care (e.g. motivation problem, problem of measuring performance, specialisation problem) • Find solutions to contractional problems in integrated care • Identify central performance factors for P4P • Highlight vital factors for successful designing and implementing P4P InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

16. 6.1 Integrated Care and Pay-for-Performance Methods • Theoretical analysis of integrated care (new institutional economics) - principal-agent theory (asymmetric information) - transaction cost economics (transaction costs) - property rights theory (incentives) • Identification and assessment of P4P projects in Europe - Review of empirical literature (on P4P projects in Europe) - Expert interviews on success and obstacles of (and satisfaction with) P4P projects in Europe - UK, Germany, Belgium … Deliverables • Review of P4P and integrated care projects in Europe InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

17. Principle-Agent-Theory • Central problem: asymmetric information • Conflicting interests • Opportunistic behaviour InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

18. 6.2 Criteria Development: Risk-Adjustment Objectives • Identification of relevant determinants influencing the performance (besides providers' services) – such as socio-economic parameters, co-morbidities, and regional differences • Developing and testing risk-adjustments (depending on level of influencing determinants) for P4P InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

19. 6.2 Criteria Development: Risk-Adjustment Methods • Literature Review • Evaluation of empirical P4P projects in Europe Deliverables • Analysis of vital performance parameters from provider and payer perspective • Review of guidelines for outcome parameters and risk-adjustment weights vital for quality-oriented payment InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

20. 6.3 Development of an Evaluation Model Objectives • Developing a transparent evaluation model for measuring provider performance and cost-effectiveness of outcome-based payment • Definition of multiple outcome parameters (e.g. based on IQWiG parameter definitions) • Definition of health care cost parameters • Testing the model using routine health insurance data InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

21. 6.3 Development of an Evaluation Model Methods • Literature Review • Health economic evaluation and decision analysis methods • Empirical analysis of integrated care models based on health insurance data - AOK Rheinland/Hamburg (2.8 millions insured) - AOK Lower Saxony (2.1 millions insured) Deliverables • Recommended financing models – a model to measure provider performance for quality-based payment in integrated care InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

22. Populationn-oriented Palliativmedizin Rheinland Vollversorgungsverträge SG/WES Gynäkologische Operationen D/DU/KR Internal medicine Beatmungs- und Wachkomapatienten SG/RS PflegeheimeRheinland Diabetischer Fuß D/K/BN/E/A/HH Neurology Schlaganfall Rheinland Multiple Sklerose Rheinland Chronischer Kopfschmerz/MigräneRheinland Chronischer SchwindelRheinland Verbesserung der onkologischen Versorgung durch angeleitetes Training Aa/Kr Aa Oncology Familiäre Belastung - Brust-/Ovarial CA Rheinland Maligne Lymphome Rheinland CIO – Integrierte Onkologie K Ovarial-CA BN/D/KR/LEV/K Psychiatry Seelische Gesundheit Depression AA/DÜ/HS SchizophrenieK/AA Krisenintervention DemenzRheinland Cardiology Akuter HerzinfarktRheinland Herzinsuffizienz/TelemedizinK/E/HH Kardiologie/Diabetes HH AOK Rheinland: 33 IC contracts in 7 Indication-areas • Orthopaedics • OsteoporoseRheinland • Paediatrics • AD(H)S bei Kindern und JugendlichenRheinland • Adipöse KinderRheinland • Asthma bei KleinkindernRheinland • Auf die BeineK • Mukoviszidose (CF-Cystic Fibrosis) Rheinland • Kinder und Jugendliche mit NeurodermitisRheinland • Übergewichtige Kinder und JugendlicheAa/Kr.A • Willkommen im Leben(Start 1. Halbjahr 2011) Rheinland InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

23. Which data are available for evaluation? Inscription Patient satisfaction Process quality BQS IC quality data Report für das Netz Routine data Cost and health care services! KV-No IC cost data Ambulante Daten H&H Daten Stationäre Daten Reha Daten InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

24. 6.4 Longterm Contract Design Objectives • Idenfication of population-based and healthcare service related longterm risks of providers and payers • Analysis of strategies in longterm contracts (ex post opportunistic behaviour to exploit specific investments of the contract partner) • Determining a longterm framework for contracts in integrated care (relational contract) InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

25. Longterm contracts (Hold-up) Problem • Changing environment • Incomplete contracts • Prohibitive transaction costs • ex-post opportunistic behaviour (hold-up) exploitation of contract-specific investments Solutions • Vertical integration • Specific investments • Transfer payments as security • Gain- and risk-sharing InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

26. 6.4 Contract Design Methods • Theoretical analysis based on contract theory • Review of empirical literature • Evaluation of the identified P4P projects in Europe Deliverables • Recommended framework for longterm relational contracts InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

27. 6.5 Effectiveness of Patient Education Programs Objectives • Evaluation of patient education programs considering - quality, - efficiency, and - access to programs • Examples of diabetes and depression • Comparative evaluation of selected metropolitan areas (London, Warsaw, Berlin) InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

28. 6.5 Effectiveness of Patient Education Programs Methods • Literature Review • Expert interviews • Evaluation of patient education programs in three metropolitan areas: Warsaw, London, and Berlin Deliverables • Analysis of effectiveness of patient education programs under everyday conditions InterQuality Kick-off Meeting Warsaw, 18-19 january 2011

29. Thank you for your attention! PD Dr. Christian Krauth Institute of Epidemiology, Social Medicine, and Health System Research Hannover Medical School D-30625 Hannover Germany krauth.christian@mh-hannover.de www.mh-hannover.de/epi.html InterQuality Kick-off Meeting Warsaw, 18-19 january 2011