ACG case-mixand needs-based resource allocation in primary health care Assoc. Professor Anders Halling, Department of Clinical Sciences Malmö General Practice, Lund University Competence Center Blekinge Wämö Center 371 81 Karlskrona firstname.lastname@example.org
Background • What do we do in primary care ? • What results do we achieve with the care we provide ? • In a future with different types of caregivers it is important to be able to monitor results. • How can resources in primary care be allocated on a needs base?
There is a need for analysis of what PHC does and what results are achieved in order to meet the new challanges of an ageing population!
Aim • To briefly describe ACG Case-Mix: a measure of comorbidity. • To briefly describe how health care cost on the individual level can be estimated using activity based costing (ABC-calculation). • To describe how ACG Case-mix and ABC-calculation can be combined to form a needs based primary health care budget.
Changing spectrum of diseases I II III
Where does the patient receive care?-need for coordinated care for patients with comorbidities % 90.9% Primary- and hospital care 48% Primary health care alone 9.3% 1.3% Degree of Comorbidity
To measure comorbidity and towards needs-based resource allocation in primary health care.
Framework of the ACG Case-mix System Diagnosis Codes • Duration • Severity • Diagnostic certainty • Ethiology • Need for specialised care Adjusted Diagnosis Groups (ADGs) JANUARY DECEMBER (ACGs)-Adjusted Clinical Groups
Validation of ACG Case-mix in Swedish PHC • In Sweden health care is funded at the population level, no information on cost at the individual level is available. • In an attempt to validate the ACG Case-mix system we used used Rx as a proxy BMC Public Health 2006, 6:171 • Cost per patient (CPP) calculated using activity based costing (ABC)
Activity based costing Patients Budget Resources Activities
Validation of ACG Case-mix with total primary health care cost calculated with ABC-calculation Age Sex Primary health care district Patients Budget Resources Activities CPP
Mean primary health care cost of for inhabitants in Blekinge county in each resource utilization band (RUB) RUB Year S kr
Mean cost per patient RUB Year Skr
Comorbidity and primary health care cost of in Blekinge county 60.6 % 7.5 % 0.1 7.5 % 9.7 % 1.3 19.9 % 33.6 % 1.7 11.1 % 3.8 42.2 % 5.7 % 8.1 0.7 % 0.1 % 1.4 % 14.0 RUB Year
Modeling comorbidity (ACG Case-mix) and cost (CPP) for primary health care. • Linear regression model • Dependent variable :CPP: ABC calculated cost of primary health care year 2005 of patients listed to county council owned primary health care centres in Blekinge, transformed variable. • Independent variable: • Age,sex, primary health care district • ACG Case-Mix: primary health care year 2005
Model for primary health care cost year 2005 • Constant: 98 kr • Sex: 13 kr • Age: 20-39 år: 1 kr, 40-79 år: 66 kr, 80- år: 1272 kr • Comorbidity: RUB 1: 912kr, RUB 2: 1275kr, RUB 3: 3014 kr, RUB 4: 6626kr, RUB 5: 10774kr. • Primary health care district: 2: -19.36 kr 3: -6.05 kr 4: 0.28 kr 5: -8.40 kr 6: -0.98 kr RUB: resource utilization band
The coefficient of determination R2the proportion of variability in a data set that is accounted for by a statistical model comorbidity 73 % R2 primary health care district age 27 % sex Model
Resource allocation in primary health care Blekinge year 2005 … and adjusted for comorbidity
Resource allocation in primary health care (PHC) Blekinge 2005 PHC district 1 PHC district 2 PHC district 3 PHC district 4 PHC district 5 PHC district 6 0 20 40 60 80 million kr
It does however not tell about… • Which results were achieved? • How large part of the patient´s healthcare need that was fulfilled in primary health care.
Degree of coverage Primary health care ACG Case-mix CPP Hospital care
Background • In a socialised health care system the government has responsibility to provide good quality healthcare that fulfills the population´s health care needs. • The government is also responsible to monitor if the healthcare resources are used cost-efficiently. • The ability of the government´s ability to monitor healthcare provider performance has been limited.
Aim • To study if comorbidity, age and sex is of importance when patient´s decide to relist from a private- to a state owned healthcare center in Blekinge, Sweden.
Method Primary care diagnoses ACG Case-Mix, comorbidity january 2005 december 2005
Method 1-Oct-2005 1-Oct-2006 Privately owned healthcare centre County Council Owned healthcare centre
Metod 1-Oct-2005 4066 480 (12%) 3273 (80%) 1-Oct-2006 County Council Owned healthcare centre Privately owned healthcare centre