Bundled payments in the context of Triple Aim and Behavioural economics

1. Bundledpayments  in the context of Triple AimandBehaviouraleconomics Lecture by prof. Guus Schrijvers, health economist and Dr. Jeroen Struijs, principal investigator Bundled Payments in Holland

2. Prognosis health care expenditure in The Netherlands 2010 - 2040

3. Payment systems andintegrated care: a developmental model (1)

4. Background BP model Integrated care for diabetes is introduced in Netherlands since decades. The fragmentary funding hampered the establishment of long-term programs on a national level. In 2007 a bundled payment (BP) approach was introduced in the Netherlands to stimulate integrated care programs.

5. Key elements Dutch BP system for diabetes care Comprehensive funding for one product Content of BP is in conformity with Health Care Standard (HCS) which is comprised to ‘generic’ diabetes care HCS describes activities (the ‘what’, not the ‘who’, ‘where’ and the ‘how’), and is agreed on by all national provider and patients organizations Fees for BP contracts and subcontractors are freely negotiable Not simultaneously with a hospital-based ‘DTC’ ‘uncomplicated diabetes’ Basic assumption BP model: strengthening primary care  less complications  less hospital care  cost containment

6. ‘Outline of BP model’ Insurance companies BP contract based on Health Care Standard Care Group Multidisciplinary protocol GP SPEC LAB DIET PROVIDERi PN

7. Results: health care delivery process • Care providers • Qualityimprovements in patient care process: more structuredandintensived • Reflective information = succes factor! • Risk of task realloction acknowledged • Managers • perceived quality improvements in process of patient care • more transparency (better understanding in individual care needs) • negotiations with preferential and other insurers still difficult • IT hindering factor • Patients • Continued high satisfaction • Insurers • positive about care delivery process and quality of care • increased transparency about quality of care • still too monodisciplinary(mainly GP care)

8. T2 Hba1c <53 mmol/mol 66% Hba1c <53 mmol/mol 66% 24% 27% 32% 33% 15% 18% LDL cholesterol <2.5 mmol/l 54% LDL cholesterol <2.5 mmol/l 49% SBP <140 mmHg 46% SBP <140 mmHg 48% 25% 27% Results: quality of care Compositeoutcome indicator: % of patients below target level on alloutcome indicators (n=5,623) T1 7

9. Results: hospital care use Hospital use of diabetes patients enrolled in a DMP paid via BP (OR; 95% CI) (ref.= care as usual patients) # # adjustedforage (centered), gender, comorbidityand 2008 hospitalutilization 8 8

10. Results: health care expenditures Mean curative health care costs per diabetes patient per payment method and total, 2007-2009 (cross-sectional data) • Dif-in-dif analyses (adjusted for patient characteristics and clustering effect): • about €290 higher increase in costs in BP group as compared to care as usual • Results will be presented in detail during parallel session 1.1 by dr. S.Mohnen • (today at 11.30am). 9

11. Payment systems andintegrated care: a developmental model (1)

12. OutcomeFinancing: a proposalfor Dutch institutesformental health services • 90% based on incomepreviousyears • 93% ifclientexperiencesstay at least the sametobemeasuredby ROM-mingandquestionnairs • 96% ifwaiting time, appointmentterms, number of patientsandotherlogistic indicators stay the same or improve • 100% if professional quality indicators stay the same or improve • 102% ifcostsavinginnovations take place

13. Payment systems andintegrated care: a developmental model (1)

14. Payfor Performance forPatients (P4P4P), someexamples • Healthmiles (savingstamps or debitcardrewards) forhealthyconsumptionandbehaviour (Discovery in South Africa) • Fiscal health policy on tobacco, alcohol, fat, softdrinks, salt • Lowerinsurance premium forchronicpatientswho follow health courses • Co-payments in emergencydepartments • Rewardingpatientsfor smoking cessation (sessions) • Higherinsurance premium forunhealthy living patients • Right on respite care forinformalcarers of frailelderly

15. Payfor Performance forPatients (P4P4P), someexamples • Healthmiles (savingstamps or debitcardrewards) forhealthyconsumptionandbehaviour (Discovery in South Africa) • Fiscal health policy on tobacco, alcohol, fat, softdrinks, salt • Lowerinsurance premium forchronicpatientswho follow health courses • Co-payments in emergencydepartments • Rewardingpatientsfor smoking cessation (sessions) • Higherinsurance premium forunhealthy living patients • Right on respite care forinformalcarers of frailelderly

16. Payment systems andintegrated care: a developmental model (1)

17. Payment systems tobeevaluated on Triple Aims: • Health of the population • Quality of Care • Per capita cost To start on a small scale Aftersimulationexperiments Tobeembedded in behaviouraleconomics

18. Triple Aim: theoryandModel

19. Behaviouraleconomics: • Study of effects of knowledgeandother factors on economicdecisionsanditsconsesquences on resources • Adam Smith’sWealth of Nations versus The theory of the Moral sentiment • Williamson: transaction costtheory • Simon: boundedrationality • Shared decision making • Intelligent incentives versus non-intelligent incentives • B. Douglas Bernheim B. & A. Rangel, Behavioural Public Economics, In: Durlauf SN and LE Blume (eds), The New Palgrave Dictionary of Economics, Second Edition, 2008

20. Three characteristics of Triple Aim • Implementationafterdemonstrationprojects • Open bookrelationbetweenpayerand provider ( playchessdon’tplay bridge) • Keep professionals motivated

21. Leonardo da Vinci (1452 – 1519)

22. At last: • Jeroen and I thankyouforyour attention andwishyou a valuablecongress

23. Contact? Guusschrijvers: • mail@guusschrijvers.nl • www.guusschrijvers.nl • www.twitter.com/GuusSchrijvers Jeroen Struijs • E: Jeroen.struijs@rivm.nl • M: +31 (0)6 4631 2583