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System-wide impact of chronic care payment schemes in Europe: evidence from an empirical analysis

System-wide impact of chronic care payment schemes in Europe: evidence from an empirical analysis. Apostolos Tsiachristas, Carolien Dikkers, Melinde Boland, Maureen P.M.H. Rutten- van Mölken ICIC, Berlin, 11 April 2013 . Content. Background Aim & Methods Results

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System-wide impact of chronic care payment schemes in Europe: evidence from an empirical analysis

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  1. System-wide impact of chronic care payment schemes in Europe: evidence from an empirical analysis Apostolos Tsiachristas, Carolien Dikkers, Melinde Boland, Maureen P.M.H. Rutten- van Mölken ICIC, Berlin, 11 April 2013

  2. Content • Background • Aim & Methods • Results • Discussion & Conclusions

  3. The economic burden of chronic diseases • Chronic diseases are related to (WHO,2007): • 60% of all deaths • 75% of total health care expenditure • Other costs: disability, premature mortality, work absence, reduced productivity, early retirement, informal care • This threat increases due to: • increasing prevalence • multi-morbidity • Chronic diseases account largely for the increasing health care expenditure!

  4. Trends in total health care expenditure (US$ per capita)

  5. Integrated chronic care (ICC) • Chronic diseases: complex, indefinite duration,multiple causes, interaction with many different care providers • Elements of ICC: • collaboration & coordination • care plan • multi-disciplinary professional teams • active role of patient • prevention & risk management • Aim: to increase patients’ QoL and cost savings (in the long run) • Prerequisite: payment scheme that provides adequate financial flows and incentives

  6. Lack of evidence • Overview of payment schemes for ICC in EU • How were implemented • What were the facilitators and barriers • What was the impact on health care expenditure • national level • different categories of expenditure

  7. Content • Background • Aim & Methods • Results • Discussion & Conclusions

  8. Aim Investigate the impact of different payment schemes of chronic care on health care expenditure and Identify facilitators for and barriers to their success

  9. Methods & Data • Literature review to identify payments on national level & countries with such schemes • Interview template (A: semi-open questions, B: rating) • 15 interviews with experts in chronic care (payments) in 6 countries • Empirical policy impact analysis using difference-in-differences (DID) models • Panel data (1996-2010) for 26 European countries from WHO & OECD • Independent variables of interest (payment schemes) • Outcome variables (expenditure categories) • Other covariates (GDP per capita US$PPP, total employment per 1000 inhabitants)

  10. Payment schemes for ICC • Pay-for-coordination (PFC): payment forcoordination of care provided by different care providers (AUS, DEN, FRA) • Pay-for-performance (PFP): payment or financial incentive associated to improvements in the process and outcomes of chronic care (ENG, FRA) • All-inclusive payments including: • Bundled payment for a group of services for a specific diseaseinvolving multiple providers (NL) • Global payment, risk-adjusted payment for the full range of services related to specified group of people (GER)

  11. Why DID • Panel data (FE): • unobserved (time-invariant) effect • First differences: Parallel & Linear !?

  12. DID models • Parallel trends (PT): • Random trends (RT): • Differential trends (DT): • Time lagged models( , , )

  13. Model specifications • Estimation of variance (robust or cluster-robust): • Heteroscedasticity (Breush-Pagan/Cook-Weisberg test) • Autocorrelation (Langram-Multiplier test) • Multicollinearity (VIF) • Select model: • Bayesian information criterion (BIC) • Joint significance • Generalised Hausman test

  14. Content • Background • Aim & Methods • Results • Discussion & Conclusions

  15. Overview of predominant chronic care payment schemes in outpatient care per country by year

  16. Overview of facilitators and barriers per payment scheme

  17. Perceived effects of integrated chronic care payment schemes ++ =strongly agree; +=agree; ?=neutralor unknown; - = disagree; -- = strongly disagree

  18. Model specification tests for different outcomes

  19. Results from the main DID models • * p-value<0.05; **p-value<0.01; ***p-value<0.001; other covariates included in the model were: GDP, total employment in health care; the impact is calculated dividing the respective coefficient by the mean (denoted as μ)of the respective outcome variable

  20. Results from the time lagged DID models • p-value<0.05; **p-value<0.01; ***p-value<0.001; other covariates included in the model were: GDP, total employment in health care; • the impact is calculated dividing the respective coefficient by the mean of the respective outcome variable; ALL: all-inclusive

  21. Linear combined effect of each payment after 4 years of implementation

  22. Content • Background • Aim & Methods • Results • Discussion & Conclusions

  23. Discussion • Complementary value of qualitative and quantitative analysis • Immediate impact (none on total HC expenditure) • PFC: (+) medication & administrative • PFP: (+) medication, (-) hospital & administrative • All-in: (-) medication • Turbulent & long implementation process (incl. reactions) • Within 4 years after implementation • PFC: (+) medication • PFP: (-) hospital & administrative • All-inclusive: (+) total & hospital

  24. Discussion • PFC: • Increased initially administration expenditure, due to overhead costs and GP opposition (?) • Increased medication costs, due to better adherence(?) • Initiated collaborations & was combined with PFP/ALL • PFP: • Most able to tackle HC expenditure growth • Faced with fewer barriers • Concerns about “gaming” and measuring • Failed to promote collaborations • All-inclusive: • Strongest impact on total HC expenditure • Increased hospital expenditure after 2 years, due to “gaming” (?) • Volatile implementation

  25. Conclusions • Payment schemes are powerful tool to stimulate integrated care and influence health care expenditure • Selection based on international experiences & own potentials • Payment reforms designers should: • Fine-tune financial incentives & stimulate cooperation • Impose controls for rogue behavior • Increased expenditure are investments in future cost-savings (?) • Blended payment scheme: global payment including coordination costs that depends (partially) on performance indicators (examples from the US)

  26. Limitations • Limited number of interviewees • No control for the non-payment related policies • No interviews in Portugal, Hungary, Estonia • Distinction between bundled & global payments • No outpatient care expenditure • Other outcomes (e.g. health outcomes)

  27. Thank you for the attention! Questions? tsiachristas@bmg.eur.nl

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