The Development of Hospice programme in Hungary Integration of hospice-palliative care

1. Workshopon hospice Brassó-Poljana 26 of Octobre 2011 The Development of Hospice programmein Hungary Integration of hospice-palliative care into theHungarian national health care by the cooperation of Ministry of Health, National Health Insurance Fund Administration and hospice service providers

2. Outline of thepresentation • Overview of the Hungarian Health Insurance System • History and development – from health policy and management perspectives • Capacity and performance data of hospice in Hungary • Future development issues

3. National Health Insurance Fund of Hungary (NHIF)

4. Current challenges in health care systems Ageing  growing number of patients with chronic diseases Consumer needs, demands  service orientation Information society  informed patients Technological development  new, innovative drugs, devices, IT… Cost containment  move to cutback mechanism

5. Links within the health insurance system, 2011 Providers 33 thousands of doctors 6750 GPs 446 outpatient facilities 175 hospitals (71 th. beds) 2620 pharmacies Patients, entitled and insured persons 10 millions in Hun provision 2% employer, 6% employee health insurance contribution + taxrevenues Paymentsystem: capitation, DRGs, German scores, visit fee, daily fee The third party - payer NHIF Administration [OEP, 1993-]

6. Environment of HIF financing ParliamentBudget NHIFA Financing Monitoring Controlling MOHProfessional regulation Government Financial techniques ProfessionalbodiesRegulation Protocols

7. Benefits and services of the Hungarian Health Insurance Fund • Benefits in cash • Pension-type social provisions • Benefits in cash • Accident-related provisions • Benefits in kind: • Curative-preventive provisions: • Primary care • Dental care • Outpatient care • Acute and long-term hospital care • Emergency services • Home health care • Kidney dialysis • Reimbursement of medicines, medical devices, spa services, refunding of travel expenses;

8. Planned structural change of the Hun health care system

9. Restructuring and clearing of profiles at territorial level Small size town hospital Rehabilitation hospital Middle size town hospital Basic professions, emergency care unit Outpatient care, one-day surgery, screening Regional central hospital County hospital Outer site Nursing, chronic care Town hospital Progressive provisions, Emergency centre, central operating block, intensive unit Outer site Primary care, outpatient care, screening

10. ImprovethecostEffectiveness of acutehospitalcare Discharge Hospitalized cases, programmed care Emergency care units Discharge Hazaengedés One-day surgery Serial treatments Day care Policlinics, outpatient care Acute hospital care Rehabilitation Social sphere Chronic care Discharge Nursing Home nursing

11. Opportunities for further reduction of no. of active hospital beds - key fields

12. Strategic purchaser role of the NHIF Administration (OEP)

13. The main roles of the Ministry (Secretariate) of Health • Setting the strategy, the directions of the developments • Operating the accreditation system • Setting the minimal requirements for health care providers • Publishing professional rules, protocols, guidelines • Supervising the national institutes • Coordinating the Professional Colleges Info: www.eum.hu

14. The alternative roles of the NHIFA • Administration role • Controlling the „bills” and paying • Financing role: • A little influence on the origin of bills • Purchasing role • To decide what, from who and how much to „buy” • Real autonomy • Insurance role • risk management • paying fees • loss adjustment

15. Special fields of purchaser role

16. Financial techniques of the main types of provision in Hungary Primary care (GP) Outpatient care Active in-patient care Chronic in-patient care Capitation fee (1992) German score system Full fee for service (1998) Fixed point value: 1,46 Ft/point HBCs (1993) Nation-wide the same base-rate 146.000 Ft/weight Per diem rate 5600Ft/day

17. Risksharingmodel: tendenciesin Europe Fee for service German score (outpatient care) DRGs (Acute care) DRGs with volume control Per diem rate (long term care) Risk adjusted (global) capitation (MCOs) Capitation for GPs Yearly budget Risk at the buyer Risk at the provider side There are two tendencies in Europe: - to introduce DRGs in many countries and - to integrate services and to finance by a risk-adjusted capitation formula

18. History & Development of hospice care in Hungary

19. Brief history of hospice care in Hungary • 1993 - Association • 1996 – Introduction of home health care into the HUN health insurance system • 1993 – 2003 slow development of hospice, 4-5 institutions with appr. 50 beds • 2003 - Professional harmonizing process, conception of the application for the reimbursement from the National Health Insurance Fund

20. Main priorities of the development Aim: development of the complex, integrated system of hospice-palliative care, reaching the nationwide provision, improving the equity in the accessibility for the provision • Integrated approach • Holistic approach: community care = family and social care + health care + volunteers • Psychological, social and spiritual support • Multidisciplinarity – development of multidisciplinary teams • Need-based, direct provision, care-management, equal access • Indicator system, monitoring - later: accreditation • Specific finance to get an effective incentive to develope hospice • Communication between the levels and actors • Networking • Education, training

21. The main elements of the complexdevelopment of hospice care Hospital care development Team works and home care Development of Hospice Professional regulation, protocols quality monitoring Human resource Development – team building Financing at different level

22. Main fields of the development of hospice-palliative care • Volume-capacity • Increase of volume and capacity in order to reach a nationwide extension • Enlargement of education • Improvement of device availability • Quality & HR development • Increasing of the level of education and professional complexity • Development of team work and integrity • Intensive connection with the professional programmes • Enlargement of competencies • Finance • Enlargement of the financed capacity • Elaboration of new types of finance (medical visits, pharmaceutical therapies)

23. Introduction and development of health insurance reimbursement of hospice-palliative care • Professional harmonizing, conception of the application for the reimbursement from the National Health Insurance Fund, preparation and authorization of the announcement / from September 2003/ Invitation to tender for the complex development of the home and institutional hospice-palliative care • Inviting applications: 7th May 2004; EvaluationContracting: from 1st September 2004 • New capacity tender: 31st October 2004 Invitation to tender for the enlargement of the home hospice-palliative care • Inviting applications: 30th June 2005, EvaluationContracting: from 1st November 2005 • Further capacity development: • In home hospice – titled to availability, equity • In inpatient care – under restructuring of hospital system – development of chronic care by switching of acute care beds • by EU development tenders – outpatient care units, rehabilitation

24. Financial background since 2004 • In Hungary the home care/home special nursing is financed according to the number of visits, one visit costs for the NHIFA 3200 HUF (~12 EUR). • The base of the reimbursement of the hospice-palliative home care is the so called hospice-day which is the 120% of the basic home care visit costs (~14 EUR/day). • In case of hospital care the hospice-palliative care is a kind of chronic provision. In Hungary the chronic provisions are financed according to daily fees (5600 HUF~20 EUR/day), and the special chronic provisions (e.g. different types of rehabilitation) have additional multipliers. • It means for the providers accepted on the tender a 1,7 multiplier (35 EUR/day). • Mobil team – there is not special reimbursement

25. Afterthefirst tender, 2004 Yellow: home hospice care Green: Institutional and home hospice care

26. Extension of home care hospicein2007 Hospice care in Budapest and in counties of Hungary

27. …and nowadays (2009* supplemented) Total: 81 service providers Home care: 63 providers Other: 4 instutitions (nursing homes) Hospital care: 9+3 units Mobil teams: 3 units

28. Capacities and performace data

29. Capacities and performaces: home hospice care - 2004-2009*

30. Performance in home hospice careX. 2004. – II. 2011.

31. Capacities and performaces:ininpatient hospice careunits - 2004-2011* 7 units with 1,7 multiplier +2 units (under other professional code)

32. Performacesininpatient hospice careunits - 2004-2010

33. Defficiencies of thecurrentsystem • Lack of accredetedprofessional curriculum onhospice-palliativecareoranyformalpostgraduateprogrammeforphysicians • There is no department of hospice-palliativecareinanyofthe 4 MedicalUniversities – to be professionalleader of theprogramme • Weakcommunicationbetweendifferent service providers, stillfragmentedhealthcaresystem: gapbetweenprimary – secondary and tertiarycare Lack of continuoumofcareinthemajorityofthe country

34. Future development issues

35. Actualities Development of rehabilitation services (EU tender) Regional, integrateddevelopment of rehabilitationservices development of infrastructure, equipments In 4 regions – aimed to the development of long term care In-patient hospice-palliative care units – for the palliative care of terminally ill patients Max.10% from the whole subsidization (from 250-800 million HUF / sites) confirmedbyprofessionalconcepts, protocols; horizontal and verticalcooperations; education Deadline of theRehabilitation tender: 2011.11.30 Strategicplan of severalHungarianhospitalsinclude the establishment of new hospice unit or increasethecapacities of currentones

36. Indicators investigated during the two-year monitoring period Admission form Stadium of decubitus Social needs (form and extent of the needed social care – family support, nutrition, day care, others; and the care giver person – family, social worker, civil helper) Monthly report of performance Number, extension and stadium of decubitus Average VAS Date of the last visit (in home care), number of performed visits, time spent by the patient

37. Main directions of theintermediatetermdevelopmentprogramme According to the WHO recommendations • To disseminate hospice-palliative care in residential homes for elderly • To improve day care for patients • To develop palliative mobil teams in the framework of hospitals, university clinics • To extend hospice-paliative care to other indications (further group of patients: COPD, hearth fealiure) • To develop management of care • between different service levels and • among service providers

38. Conclusions • We’ve managed to reach a breakthrough by the 2003-2004 programme (tenders and the increase of public funding) • Every programme element is to be developed and held on simultaneously for the success of the programme • Continuous quality-monitoring and feedback in regulation, education and reimbursement are necessary • Continuous development is also essential so much as the governmental intention for the support of plus resources

39. Thank you for your attention ! Contact us: csaba.dozsa@invitel.hu

40. What to do? – experiments v. experiences • Because of the comprehensive financing dataset the indicator lists determined in the application have lost their significance (the dataset must be sent by the providers consists these indicators or they can be calculated from the data). Lesson learned: Indicators must be determined after considering the financing dataset. • The over-dimensioning of nursing activities comes up at the expense of the mentality of hospice. The „nursing at all hazards” is still typical, instead of complementary activities (social organization, determination and supervision of medication). • The low level of financing was indicated also by the lack of additional sources. The costs of provision are not completely covered by the health insurance reimbursement. • Inequality in territorial availability -  • The provision is not well known by the GPs -  • The inequality in capacities (because of the low starting number of applicants) needs to be corrected timely - 