Financing Healthcare and Managing Chronic Diseases
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Financing Healthcare and Managing Chronic Diseases. Setting up the scene. Multiple health providers Primary care by GPs or Health centers Hospitals as referral institution Multiple providers for social care Specific providers for old age population Multiple health financers

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Setting up the scene
Setting up the scene

  • Multiple health providers

    • Primary care by GPs or Health centers

    • Hospitals as referral institution

    • Multiple providers for social care

    • Specific providers for old age population

  • Multiple health financers

    • Variety of origin of funds according to countries

    • Level of coverage varying with case mix

    • Coverage in relation to nature of provision of care

Setting up the scene1
Setting up the scene

  • Evolving Health care

    • Continuum of care  patient centered care

    • Specialization versus holistic approach

    • Promises of technologies: e-health

      • Electronic medical record

      • Tele-medecine

      • M-health

  • Payment system reform to increase performance

    • Key element of health care reform

    • Hospitals at the center of the reforms

    • Limited links with other system reforms

Financing healthcare and managing chronic diseases

A review of payment systems

Source: WBI Flagship course on health system

Payment system
Payment System

Fee for service for health workers
Fee for Service for Health workers

  • Definition: a payment based on a tariff scheme set by the government or Insurance

  • Behavior: incentives to increase volume of service

  • For NCD patients :

    • No incentive for handing over patient

    • Need specific payment for coordination of activities

    • Asymmetric relation patient-provider: excessive care

Salary bonus for health workers
Salary (+Bonus) for Health workers

  • Definition: an annual amount for serving patient (+ a bonus that is paid if some performance target is reached)

  • Behavior: incentive toserve as few patients as possible, leave work early, (+ achievethe targeted service)

  • For NCD patients:

    • Importance of Assessment of work performed

      • If volume is favored: poor patient follow up expected

      • If health outcome favored: good incentive for follow up

  • If bonus related to individual care  ++

  • If no bonus: poor incentive for following up patients

Capitation for health workers
Capitation for Health workers

  • Definition: Provider receives a fix amount per patient enrolled.

  • Behavior: Incentive to limit services, sacrifice of quality, cream skimming

  • For NCD patients:

    • Positive for comprehensive care with more prevention

    • Risk of discharge of heavy patients: referral is over loaded

    • Positive for long term relation

The risk for who
The risk for who ?

For NCD Patients:

Fee for service is not appropriate if no payment of prevention/follow up

Salary is OK if assessment and bonus relevant for NCD treatments

Capitation is OK if limits on discharge to referral care

Per diem or day for hospital
Per Diem or Day for Hospital

  • Definition: Amount paid to a facility per day of patient care, with or without an adjustment for case mix

  • Behavior: Incentives to increase in-patient stay and any activity paid against a fee

  • For NCD patients:

    • Preference on volume not quality

    • Poor prevention if not under fee scheme

    • Risk of useless medical acts

Global budget for hospital
Global Budget for Hospital

  • Definition: A fixed given amount to a facility for provision of agreed services

  • Behavior: if funds run out,incentive toundersupply or cut quality; no direct incentives for efficiency; in public sector no clear limitation on services

  • For NCD patients:

    • Allows comprehensive care but limits quality

    • Risk of transfer to other facility of heavy patients

Case or per episode for hospitals
Case or Per Episode for Hospitals

  • Definition: hospital paid a set amount to treat a case or a full episode of care, often classified with a ‘diagnostic related group’ (DRG)

  • Behavior: incentive to improve efficiency per case but try to classify or treat patients in more expensive DRG categories = ‘DRG drift’

  • For NCD patients:

    • Not very effective for comprehensive care including outpatient services

    • Risk of inpatient treatments to get payment when no capping on volume of activities

Capitation for hospital
Capitation for Hospital

  • Definition: Amount paid to a facility per patient registered

  • Behavior: Incentives to cream skim and to limit cost on patients (investigations)

  • For NCD patients:

    • Allows support for prevention

    • Longer term relation with provider

    • Limits use of Primary Care

The risk for who1
The risk for who ?

Managing payment systems
Managing Payment systems

Enabling environment
Enabling Environment

Current trends
Current trends

  • Combining payment systems

    • Capping of expenditure

    • Paying on activities

    • Using per episode mechanisms

  • Paying for results: outcomes instead of outputs

    • Relies on very effective information systems

    • Choice of indicators is problematic

    • Limits social mission of health providers

Www ihf fih org

Thank You