Post on 13-Jan-2016
Forsberg Knezevic EHMA 2008
Stockholm County Council
Reimbursements in psychiatry in Sweden – models and experiences
Birger Carl Forsberg. MD MPH BSc
Milan Knezevic, MBA
Stockholm County Council Administration
Dept of Public Health Sciences
Karolinska Institutet
Stockholm
Sweden
www.sll.se
Forsberg Knezevic EHMA 2008
Stockholm County Council
Reimbursements in psychiatry in Sweden- models and experiences
Stockholms County CouncilRegion Västra Götaland
Region Skåne/Scania
Forsberg Knezevic EHMA 2008
Stockholm County Council
Objective The overall:
– to contribute to the development of psychiatric health services for the overall attainment of good health and client satisfaction
The specific: – to study and understand key characteristics of the
purchaser/provider (PP) models in psychiatric health services and
– to explore the development of reimbursement models in psychiatric care
Forsberg Knezevic EHMA 2008
Stockholm County Council
Methods
Interviews with health care managers
Review of policy and implementation documents
Forsberg Knezevic EHMA 2008
Stockholm County Council
Background
Purchaser-provider models introduced in the early 90es in Sweden
Introduction in phases depending on experience gained and political majority shifts in county councils and at national level
However, gradually purchaser-provider models have been established, particularly in larger county councils
Forsberg Knezevic EHMA 2008
Stockholm County Council
Background
Cost pressures on health services increase the need for cost control
Political developments favoured new systems
Background
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Historical developments
Purchaser-provider models introduced in psychiatry in the mid-nineties
However, traditional historical budget based reimbursement models were used throughout most of the 90es
Performance based reimbursement models were introduced in small scale around 2000 in Stockholm
The first private providers were contracted in 2002 in Region Skåne
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results -Reasons for introduction of purchaser-provider
models in psychiatry
Poor access to services (waiting times, non-availability of staff and treatments)
Poor coordination within services and between psychiatry and other relevant services
Poor flexibility
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Aims
All three regions have developed the same aims:– To increase productivity – To decrease in-patient care– To improve availability of personnel, in particular
psychiatrists– To improve quality– To create a pluralistic supply of services
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
All models contain: – Fixed reimbursement– Performance-based reimbursement– Quality based/target based reimbursement for
delivered patient care In addition, several contracts included specific tasks
that were reimbursed on a lump-sum basis (like special services, training etc.)
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models Region Västra Götaland
– Fixed/performance-based Started 50/50, target now
– 90/10 for in-patient and
– 70/30 for out-patient Actual mix in 2007 52% fixed, performance-based 48%
– Reimbursement based on discharges (IPD) and visits (OPD)
– Classification systems for case-mix tested for a more diversified and truly need-based reimbursement system
– Targets for volumes set – penalty/bonus related – Quality indicators (15) developed - to be implemented 2008 –
basis for 2-3% of total reimbursement
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models Region Skåne
– Out-patient service in two wards through purchasing of private provider: 100% performance based reimbursement Reimbursement based on visits and separated into three categories Geographic area responsibility Financial ceiling set – above that only patient fee Quality indicators (7) developed – not bound to reimbursement but
important for evaluation Clear terms of reference based on a common value ground and clear
targets and expectations
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models Region Skåne
– From 2006 a new reimbursement model for publicly produced
health services 60% fixed and 40% performance based from 100% fixed budget
Performance based reimbursement for inpatient care based on days of
care
Performance based reimbursement for outpatient care based on visits
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models Stockholm County Council 2006-2007
92%
72%
5%
25%
3% 3%
0%
20%
40%
60%
80%
100%
Inpatient care Outpatient care
Quality basedreimbursement
Performancebasedreimbursement
Fixedreimbursement
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models Stockholm County Council
– Performance based reimbursement inpatient care (5%)
– Day 1 SEK 400– Day 2-10 SEK 240– > 11 days SEK 200
outpatient care (25%)– Visit to clinic SEK 350– Home visit SEK 700– Group visit SEK 175– For each patient (individual) SEK 700
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Models
Stockholm County Council 2008– Fixed/performance based 50/50% in both inpatient and
outpatient care– This will be achieved through doubling payment for
visits and increasing reimbursement for inpatient days ten-fold
– A ceiling on volumes will be put on reimbursement. Above the ceiling producers will only get 10% of rates set.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Experience
Increased production Less inpatient care, more outpatient Increased accessibility Improved coordination among care providers and other
actors in Skåne Significant tensions between purchasers and providers Significant time spent on negotiations around quality
indicators (that represent a small part of reimbursement)
Forsberg Knezevic EHMA 2008
Stockholm County Council
Results - Experience
Providers feel purchasers are over-simplifying description of services, emphasizing quantity rather than quality
In Skåne, both providers and purchasers are overall pleased with the cooperation
Purchasers felt that presence of private providers had resulted in increased attention on key issues like productivity in public services
Forsberg Knezevic EHMA 2008
Stockholm County Council
Discussion
All three regions have independent of each other set up strikingly similar targets concerning psychiatric health services, much as a result of facing the same problems.
Emphasis is put on increasing productivity and accessibility and the ambition is to work towards increased quality of care and thereby improved medical outcomes.
Purchasers aim to increase outpatient care and decrease inpatient care. The regions employ the same base reimbursement model, but with
different structures and levels of services, products and prices. The reimbursement models for outpatient care have to a higher extent
performance based reimbursement that inpatient care.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Discussion- Preconditions
Clarity in contracted task and targets are essential Well defined and precise terms of reference is a vital
precondition for a well functioning reimbursement model The contracted task should be based on obligatory tasks
and defined target levels Few but well thought-out quality indicators for
evaluation
Forsberg Knezevic EHMA 2008
Stockholm County Council
Discussion- Problems
Lack of well functioning and generally accepted classification systems.
Preventive and health promoting activities are not rewarded.
Reimbursement models not adapted to individual needs of care.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Conclusion
Performance based reimbursement models in psychiatric care work well given when overall aims are set to increase productivity and structural conditions are similar to those in the regions studied.
Terms of reference and clear definitions of contracted tasks are essential even if they are not specifically linked to payments.
Forsberg Knezevic EHMA 2008
Stockholm County Council
Conclusion
The demand for further development and knowledge concerning the usage and effects of reimbursement models in psychiatric health services is significant.
The knowledge could be used to improve the models for further contribution to reaching the overall aims of services – improved access, client satisfaction and good health.