Martine M BELLANGER Tuesday 16 October

1. European comparison of treatment costs of illnesses and their consequences Health benefits and service cost in Europe (HealthBASKET project) Martine M BELLANGER Tuesday 16 October

2. CONTENTS • Context of the research • Cost Methodologies used in the European study • Results • Discussion

3. Context of the research • Changes following the EU Market • Decisions of the European Court of Justice: • e.g. patients’ choice of providers over Europe countries following (Kohll et Decker ; Smits and Peerbooms cases) • Provision of health care services care is no longer at the ‘national’ level • If choices exist, available services and their related costs have to be known by the patients

4. Context of the research • 9 countries participated in the research: • Denmark, England, France, Germany, Hungary, Italy, Netherlands, Poland and Spain. • Common health problems were chosen matching European Community health indicators • Both in and outpatient treatments were studied

5. 10 Vignettes were chosen • Vignette 1 appendectomy; M 14-25; hospital; emergency • Vignette 2 normal delivery; F 25-34; hospital; • Vignette 3 Hip replacement; F 65-75; hospital, planned • Vignette 4 cataract; M 70-75; ambulatory settings • Vignette 5 Stroke; F 60-70; hospital; emergency • Vignette 6 AMI (PCTA) ; M 50-60; hospital, emergency • Vignette 7 Cough M ~2; ambulatory • Vignette 8 colonoscopy; M 55-70; ambulatory • Vignette 9 tooth filling; Child ~12; ambulatory • Vignette 10 knee physiotherapy; H 25-35; ambulatory setting

6. Vignette Appendectomy • A healthy male between 14 and 25 years of age presents at hospital (A&E department), if present; otherwise directly to surgical department). • Start of case vignette: hospital admission. Abdominal palpitation yields typical signs of appendicitis. • End of vignette: Discharge. .

7. Vignette Stroke • Health woman (i.e. without no comorbidities prior to presentation 60 to 70 years with sudden severe hemiparesis (right side) an dependency and with severe aphasia. • Admission to A&E department or directly to neurological unit by ambulance • Start of case: Hospital admission • All interventions, including diagnosis and treatment are delivered in the same hospital which may or not include a stroke unit and early rehabilitation

8. Data collection • Five providers for each vignette • Resources used were collected for the last ten patients concerned by the vignette • Costs were calculated from the provider perspective , (example: cost per case for one hospital • Then, costs were calculated for each provider and per country ( average cost of 5 providers) • Reimbursement tariff = proxy of price

9. Denmark 5 England 6 France 9 Germany 15 Hungary 3 Italy 5 Netherlands 18 Poland 5 Spain 5 Number of hospitals per country

10. Applying methodology • Nurses and physicians were involved as well as financial departments and auditors • All the countries (except Poland) pay for hospitals on the basis of DRGs, nevertheless, different accountancy system are used • Differences of calculation were observed for the running cost and generally for overhead costs

11. Categories of overheads included in total cost • Medical infrastructure: • E.g. laundry, Sterilization, Patient transports (within the hospital) supply of food and drinks. Administrative time of medical and nursing staff • Non medical infrastructure: • E.g. administrative personnel, cleaning, desk officers technical/building maintenance, energy, waste disposal, taxes and insurance & rent related to patient services) • Depreciation: Equipment Buildings • Opportunity costs: Interest on public or private sector capital employed (only included in England) • Large variation of overhead as a proportion of total costs, by vignette & by country (from 75% in Denmark to less than 20% in Spain)

12. Synthesis • For each vignette: • Correlation between prices & costs • Comparison between direct costs and indirect costs (« overheads » in the total costs • Variance analysis for identifying the main cost differences between countries • Explicative analysis of variation factors

13. Result 1: good correlations between costs & prices • Prices= +- costs • Delivery, Stroke, Colonoscopy • Price above costs • Appendectomy, Hip replacement Cataract &AMI • Price lower than costs • Tooth filling • Not enough data for both cough and physiotherapy.

14. Result 2 • For most of the vignettes, total cost is under the average cost for Spain, Hungary and Poland • Differences in personal costs explain cost variation for tooth treatment • Differences in treatment modes are important for both colonoscopy and stroke • % overhead in the total cost vary between countries considerably • 70% Denmark for 5 vignettes • From7 to 21% in all the Spanish vignettes

15. Comparison between countries for stroke treatment • Large differences between countries • Netherlands : higher costs with long Average length of stay (ALOS) • England : High costs too, but important overheads and stroke units , an early rehabilitation included • For stroke, ALOS shows the different treatment process in the different countries: • Example unit strokes and • Specialized units outside hospital for rehabilitative care

20. Comparison between countries for Delivery • Large variations • From € 342 (£228) in Hungary to € 2,107 (1,405£) in France and € 2,365 (£1,530) in Germany • Average €1 260 (£840) • Germany: higher personal costs (physicians) while France higher overheads • ALOS 0.86 for Netherlands & 4.9 France, (England, 1.7 Germany 3.5) • Different organizations: Home care versus hospital based care . • Unit personal costs vary between country

21. Temps de travail et coût horaire du travail pour un accouchement

27. Methodological challenges • Access to data • Variation in sample size • Missing data • Filling in using expert opinion, or national or regional surveys or database • Variation in accounting practice • Time spent by clinicians on administration & indirect care versus direct care • Allocation of overheads to services

28. Conclusions • Cost methodology was feasible (and at low cost) • Vignettes readily transferred between health systems • Mass of valuable information • Concern over treatment of overheads • Starting to understand very large variation in treatments & costs within and between countries

29. Implications • International comparison powerful instrument for improvement • Need for consistent costing rules to facilitate comparison • Quality could be integrated • Processes of care • Outcomes of care • Development of capacity for benchmarking • Implications for construction of DRGs