public healthcare payment systems in catalonia, 1981-2009 · 2011. 4. 19. · public healthcare...

Public healthcarepayment systems in Catalonia, 1981-2009

Historical evolution and future perspectives

Public healthcare payment systems in Catalonia, 1981-2009

© Generalitat de Catalunya Department of Health

Publisher: Catalan Health Service (CatSalut) 1st Edition: Barcelona, December 2009

Graphic design: Ortega i Palau

Chief editors:

Francesc Brosa Services and Quality Department. CatSalut

Enric Agustí GINSA. Grup SAGESSA

Editorial coordination:

Xavier Salvador.Services and Quality Department. CatSalut

Presentation by the Minister 5

Foreword on the Catalan Health Service 7

Introduction 9

Chapter 1 The Catalan healthcare model. Characteristics 13

Chapter 2Payment systems, theoretical bases 29

Chapter 3The UBA model (basic care unit) 45

Chapter 4The activity purchasing model Payment model for hospitals in the XHUP since 1997 57

Chapter 5The pilot plan for purchasing on a capitation basis 81

Chapter 6Evaluation of the capitation test 95

Chapter 7Bases for the definition of a payment model with a territorial base 111

Chapter 8Payment system for all other care lines 119

Chapter 9The evolution of information systems as a support tool for payment systems 129

Authors 143

Bibliography 145

Contents

5

Presentation by the Minister

The commemoration of the 18th anniversary of the creation of the Catalan Health Service, in late 2009, provided a favourable context for reflection and was an excellent pretext for offering a written record of the most recent

and undoubtedly the most innovative part of the history of health services provision in Catalonia.

Our healthcare model is characterised by the existence of a sizeable publicly subsi-dised sector, which includes both administrations and commercial enterprises or or-ganisations historically devoted to healthcare. This specific feature of our system, so often discussed and questioned, is based on an agreement between the main agents involved in providing health services, based on quality, equity and efficiency.

At the same time, the long track record of a model based on separating the func-tions of financing, purchasing and provision, and the improvement of information and communication systems, has allowed us to accumulate broad experience and in-depth knowledge in the sphere of contracting services and the design of payment systems, always in pursuit of optimising expenditure and satisfying the healthcare needs of territories and users.

One result of this valuable learning curve has been the process of reflection which constitutes the book I am introducing now.

Nevertheless, social, technological and care-related changes that we are facing in the early 21st century are forcing our health system towards a transformation necessary to overcome the challenges of an increasingly large, diverse, global and demand-ing society. At this moment in time our health system has to show itself to be more active, both in terms of social and territorial cohesion, and in the essential support that it represents for each individual and for each family. But also with regard to the economic dynamics that contribute greater added value and knowledge.

It is necessary, therefore, to continue professionally and ambitiously managing a healthcare system that generates opportunities and redistributes them, and that remains effective and affective. It is within this reference framework that our cur-rent, capitation-based payment model is implemented, as a form of financing that incentivises expenditure rationalisation and generates improvements in the equity of resources allocation.

I would like to end by thanking the authors for the enormous skill in synthesizing that they have shown and for their efforts as Catalan Health Service professionals to contribute towards documenting the history of healthcare policy in Catalonia.

Marina Geli Catalan Health Minister

7

Foreword on the C

atalan Health Service

For eighteen years, from the creation of the Catalan Health Service to the present time, all its directors and the entire body of professionals who work or have worked in all areas of the organisation, have contributed with their

dedication towards defining, launching and consolidating strategic projects stem-ming from the Catalan Government’s actions in relation to health protection, with ongoing reviews, in order to improve and adapt them to an increasingly changing society. That is what evolution is, changing to ensure better adaptation, and that is what the Catalan Health Service has been doing over this entire period.

Naturally, this has been the case with diverse projects and instruments, and it is es-pecially relevant with those considered key in defining the healthcare model because they are intrinsically related with its global viability. It goes without saying that the payment model is fundamental for any healthcare system’s sustainability. In ours, we have increasingly perfected a tool that allows improved efficiency among the networks of providers, incorporating the Health Plan into contracts as an element for evaluation, consolidating the model of separating the financing function from the provision function, improving information systems and making a prospective acquisition of services that incentivises the development of new product lines.

We have progressed from payment by budget to payment per episode of care, then later we took into account the complexity of the episode and, finally, we reached payment on a population basis.

With payment on a population basis, the aim has been to reach a model of territo-rial allocation that guarantees the comprehensive tackling of the population’s care needs based on the complimentary nature of the territory’s resources, guaranteeing equity and efficiency through coordination between care levels and favouring syner-gies between providers.

With the current payment model we are working towards making the healthcare system fairer and more efficient, given that resources are oriented towards needs and interaction is promoted between providers, which results in an improvement in quality, effectiveness, adaptation, safety and the accessibility of services provided.

All this development has not been sudden. Transitions take a long time, first of all pilot tests need to be done and no system can ever be considered perfect; we will always have to be alert to conceptual imperfections, to problems that may appear in the development of tools and to remedying these.

However, after all this time, we can show with justifiable satisfaction the milestones we have achieved, without overlooking, naturally, everything that still needs im-provement, both in the payments system used by the Catalan Health Service and in the other tools that enable the fulfilment of its mission, which means guaranteeing the provision of healthcare and social health services to the people of Catalonia.

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This is, therefore, the objective of the book currently being presented: to show society the path followed and the evolution of the Catalan Health Service since it was created.

It is rather obvious, but I would like to say all the same, that evolution and im-provement are always the result of teamwork. For that reason and as director of the Catalan Health Service, I would also like to record on these pages our gratitude as an institution to all the people who, with their professionalism, make possible the ongoing adaptation of the healthcare model to the ever-changing needs of our society.

Josep M. Sabaté Director of the Catalan Health Service

9

Introduction

IntroductionThe aim of this book is to give a comprehensive view of the different public health-care payment systems that have been and are being used in Catalonia since the devolution of powers in 1981, and, at the same time, to establish the foundations of systems that will be used in the near future.

These systems link the institutions working in the different healthcare networks in Catalonia with the healthcare Administration. One of the system’s differential characteristics is precisely the breadth and diversity of the networks upon which it is based. The other is the model of separation of functions between financing and the provision of services, since the approval of Health Organisation Act of Catalonia (LOSC) of 1990, which created the Catalan Health Service (SCS) as the institution through which relations between the Healthcare Administration and networks of providers are regulated.

In this environment a model is consolidated that has strengthened the development of purchasing processes, planning, contracting and evaluation of services, and that has contributed in a very prominent way towards configuring an own model distin-guishable from that which exists in the set of autonomous communities that make up Spain. Thus, the process of contracting healthcare services established between the SCS and the different service providers is absolutely key.

Over the course of the different chapters we will review the various payment systems that have existed over the last twenty-five years and the transition towards the current models whose ultimate objective is the integration of providers on a ter-ritorial basis. Before that, however, in Chapter 1 we detail the characteristics of the Catalan model and in Chapter 2 we develop the theoretical bases of the payment systems. It is also important to underline the close relationship that has existed between the definition of the different payment systems developed over the course of the years and the evolution and improvement of information systems. Greater and better knowledge of what is being done and how it is being done has been of major help to buyers in gradually improving their definition of the product that they want to buy, its characteristics and price and, at a later stage, in evaluating how the service has been provided.

Even though the different chapters of this book offer an exhaustive description of all the different payment systems, we will now briefly review the characteristics and conditioning factors that they present.

The model inherited when powers were devolved from the Spanish State, in 1981, was eminently budget-based, with limitations for contracting party and provider alike. We can affirm that the history of payment systems in Catalonia began with the definition and launch of what was an innovative payment system in its day. In

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the year 1986, a new payment model based on stay was defined: the UBA model (Basic Care Unit). This is a prospective model for payment of care episodes that are regulated based on a set of parameters, such as the average stay. The introduction of the UBA model represented a very important qualitative leap because, for the first time, it defined the concept of financing the network based on a clear parameter, the UBA, which was equivalent to a hospital stay. It related the rest of the centre’s products to this unit of measurement, assigning a specific weight to each one. The model took into account the different levels of structural complexity of the hospi-tals and, finally, introduced elements of efficiency (average stay) in the management of services. Broader details of this payment system can be seen in Chapter 3.

Increasingly exhaustive knowledge of the typology and complexity of the activity carried out in the network, as well as the model’s rigid nature, started to spell out a crisis for the UBA. An important contribution to this process was made by the significant growth of hospital costs which was caused, fundamentally, by a combina-tion of different factors:

• Ageing of the population, with the appearance of a significant volume of patients affected by chronic conditions.

• The progress of biomedical knowledge and the appearance of new technologies that were incorporated very quickly into hospitals’ diagnostic and therapeutic arsenals.

• Access to healthcare provision and growth in user expectations.

• Changing expectations of healthcare professionals, due both to demands of pa-tients and technological advances.

It was in this period, in the year 1990, that the minimum basic dataset for hospital discharge (MBDS-HD) was created. This enabled an accurate picture of the volume and content of activity carried out across the entire network to be gained. And based on this increasingly detailed knowledge of the typology and complexity of the activity, the model entered a crisis.

From the perspective of the payment system, this situation resulted in the impossi-bility of transferring this complexity to contracting parameters. To be able to coun-teract these effects, the system was equipped with a series of healthcare programmes whose proliferation was an attempt to cover all these new situations.

Within this context, in the year 1997 a change to a prospective purchasing model for purchasing cases while taking care complexity into account was promoted. This new payment system had the virtue of generating incentives that would significantly boost the network’s productivity and efficiency. The appearance, introduction and development of Major Ambulatory Surgery (MAS) are an example of the impact of the new payment model. The priority objectives of the Health Plan were also incorporated into the contracting process.

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Introduction

The period from 1997 to 2001 represented a very important quantitative and qualitative leap with regard to the improvement of services purchasing tools: it con-tributed clearly towards improving system efficiency; it promoted and consolidated new information systems; it promoted and consolidated the separation of functions between provider and financer, and allowed a prospective purchasing of services, which incentivised the development of new lines of services. The payment per activ-ity model is detailed in Chapter 4 and is currently the payment system applied in those hospitals that are not in capitation allocation zones.

In any event, these payment per activity systems also have negative aspects given that they are models based fundamentally on the existing offer and they prefer-entially measure intermediate results of the care process (discharges, number of appointments, etc.). Furthermore, because a differentiated purchase is made for each service line, there is no stimulation of coordination or collaboration between providers. Finally, evaluation is also considered for each service line, with a lack of a global vision with regard to the population’s health targets.

This diversity of payment systems meant that occasionally conflicts of interests arose between different providers when it came to considering coordinated actions between different lines of service. In this environment, from the year 2002, the SCS promoted a pilot experiment in purchasing services on a population basis with the aim of correcting this set of inefficiencies and promoting a model that would favour coordination and collaboration between the different providers in a territory, as can be seen in Chapter 5.

This model has been piloted since 2002 and currently the bases have been set down to consolidate it and extend it to the entire territory. To achieve this objective, for the last two years the Administration and provider representatives have worked together to consolidate the model for the pilot phase. The evaluation of this experi-ence occupies Chapter 6.

Chapter 7 covers the bases that have to configure a new payment model on a terri-torial basis, which is currently in the phase of discussion and consensus. In fact, the elements described in this chapter include those aspects that the different interlocu-tors have considered vital in the process of evaluation of the capitation experiment. It must always be taken into account that this payment system is still an open proc-ess and liable to incorporate new elements.

To finish, we have incorporated two further chapters, without which this re-view would be incomplete: Chapter 8 summarises the different payment systems that currently govern the remaining care lines, such as primary healthcare, social healthcare and mental healthcare, among others. To end, it was necessary to make reference to healthcare information systems, the true cornerstone of all payment systems. We have detailed these in Chapter 9.

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We complete this volume with a series of bibliographical references, which have served us as support when producing the articles and that may be of use to any reader wishing to study payment systems further. With the aim of avoiding repeti-tions in each chapter of certain bibliographical references that are common to the whole set of articles in this work, we have opted to concentrate them all in a single list at the end of the book.

It is the wish of all the authors that this book will be of use to any reader interested in learning about both the history of healthcare policies in Catalonia and the theory and practice of information systems in general.

Francesc Brosa and Enric Agustí

13

The Catalan healthcare m

odel. Characteristics

Chapter 1

The Catalan healthcare model. CharacteristicsMontse Bustins and Xavier Salvador

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1.1 An overview of the Catalan healthcare model

The Catalan healthcare model was characterized initially by the creation of care networks of providers with civil society playing a very active role, and the ownership of centres was not limited to the health authorities. The creation of the networks was the result of a political decision based on making use of resources that already existed when the Catalan Government took over responsibility for health. The his-torical and legal conditioning factors are detailed in the following section.

The creation of networks, especially the hospital network (Public Hospital Net-work, XHUP), meant the need to establish formal relationships between the financer and the provider of healthcare services. This led the Catalan model to an early incorporation, in comparison with the rest of Spain, of tools for measuring activity to give support to progressively more evolved payment models.

The Catalan healthcare model has evolved over time to respond to new healthcare challenges in an environment of growth in health expenditure. Changes in roles at each care level and new investments to upgrade networks have repercussions on both healthcare and the ownership of the centres that constitute them. In this sense, the role of public companies and consortia alike has grown through the desire to strengthen their autonomy of action, which translates into the transfer to these or-ganisations of buildings owned by the Catalan Government which would otherwise be managed by the Catalan Health Institute (ICS). In parallel, its capacity and its need to equip itself with suitable management resources have grown.

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16 1.2 General legal frameworkThe legal framework of the Catalan healthcare model is governed by the following reference elements, in chronological order:

• The Spanish Constitution of 1978, which guarantees the right to health protection to all citizens (Article 43) as one of the main guiding principles of social policy. It also gives public authorities the powers to organise health education, preventive measures and the provision of services.

• The Statute of Autonomy of Catalonia of 1979, which recognizes the powers of the Catalan Government with regard to basic legislation on healthcare in Catalo-nia (Article 13) and the possibility of organizing health services; high-level inspec-tion is reserved for the State.

• The 1981 Devolution Decree heralded the start of the transfer of services and institutions to the Catalan Government. This gave rise to the deployment of the Health Map (1983), the creation of the Catalan Health Institute (ICS) and the Public Hospital Network (XHUP), and the implementation of the primary healthcare reform (RAP). The hospital reform plan was the driving force behind the redevelopment of a large number of health institutions.

• The Spanish General Health Act (LGS) 1986, which integrates into the National Health system all the public services and envisages the establishment of healthcare services for each autonomous community and the coordination of these through the Inter-regional Council.

• The Healthcare Organisation Act of Catalonia (LOSC) 1990, which establishes the separation of the functions of planning, purchasing and provision of health-care services. Regarding the purchase of services, it provides for the creation of the Catalan Health Service (CatSalut), decentralized into health regions. Regarding the provision of services, it recognizes and promotes provider diversification and management formula within a framework of planned competition.

• The 2003 Act governing Healthcare Cohesion and Quality 2003, which updated the LGS upon completion of the process, initiated in Catalonia in 1981, of devolving powers to all the autonomous communities. In practice, it conditioned the possibilities of additional autonomous developments, especially in the field of information systems.

• The new Statute of 2006 made deeper inroads, in terms of healthcare, in such ar-eas as cost-free status, free choice and right to information, consent and confiden-tiality (Article 23). In particular, the latter points also affected the development of information systems.

• The Decree creating the Territorial Health Authorities (GTS), also from 2006, pro-moted the decentralisation process, envisaged the possibility of sharing management of responsibilities with local governments and promoted the coordination of differ-ent public service providers with the aim of improving the care provided for citizens.

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1.3 The hospital systemIn the development of the Healthcare Map (1983) it was seen that the hospital structures ceded by the National Health Institute (INSALUD), which would form the ICS, were insufficient and furthermore their distribution was too highly con-centrated in the provincial capitals. Moreover, the existence was confirmed of a set of hospitals more widely distributed around the territory that were associated with organisations of varied ownership, mainly non-profits, such as town councils, the Red Cross, the Catholic Church and mutual insurance societies, which if exploited for the provision of publicly financed services would mean tripling the volume of existing beds.

The acceptance of the inclusion of private centres in the public network was a politi-cally accepted decision that led to the creation of the XHUP, which integrated both ICS centres and subsidised centres (which initially represented 72% of XHUP beds). But once the network had been set up with existing hospitals, the Government still had to address three additional points: the lack of facilities in certain parts of the territory (Altebrat, Vall d’Aran, etc.), the existence of obsolete structures requiring urgent replacement (Vilafranca del Penedès, Tempera, Blanes, etc.) and the presence of buildings that were not operative in densely populated areas (Vic, Sabadell and Terrassa), created in the last stages of the National Insurance Institute (NII).

When it came to launching these last three facilities (Hospital General de Vic in September 1986, Hospital del Parc Tauli in Sabadell in October 1986 and Hospital de Terrassa in March 1988), the health administration took a new decision: rather than deciding management via the Catalan Health Institute, it sought a formula to allow two crucial points making up the emerging healthcare model to be achieved:

a) Active participation of local authorities in managing these new facilities to achieve a greater level of connection to the territory.

b) Flexible and autonomous management, with a more business-oriented, less administrative approach. Thus the consortia were born and extended to the new hospitals that were replacing institutions that were previously providing services.

This dynamic of streamlining management was also applied to public companies. Initially these appeared with the transfer, with a certain number of civil servant staff, from the facilities run by the provincial councils of Lleida, Girona and Tar-ragona. In this case, the best solution was the creation of public companies one hundred percent owned by the Catalan Government.

The creation of the XHUP allowed the activity to be subcontracted to approved subsidised centres, but beforehand required the establishment of structural stand-ards which were specified in the accreditation requirements.

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18 The Catalan accreditation experiment was the first in the whole of Spain. With the accredited centres, contracting mechanisms were put into place for the provision of services.

The development of payment systems drove and was driven by the development of information systems. Particularly important for this process were the orders regard-ing the Compulsory Discharge Report (1986) and Regulation of the Minimum Basic Data Set (MBDS) (1990).

The hospital concept has changed in recent years, progressing from a traditional model of a more closed centre that provides conventional inpatient care, emergen-cies and an outpatient department, to a centre with a greater outpatient focus, with significant roles for ambulatory surgery (major and minor), day hospital and home hospitalisation.

This change was driven by two mechanisms. Firstly, a progressive process of techni-cal improvements, which also drastically reduced the stay of hospitalised patients and the end of which is not yet in sight. Secondly, provided that basic qualitative elements are assured, the move towards outpatient care benefits all involved: it offers better comfort to patients and families, represents a challenge for healthcare professionals, and facilitates improved efficiency for managers and financers that will allow them to spend money on other priorities.

Below is the map with the territorial distribution by GTS and care level of the hos-pitals, with an indication of ownership.

As can be seen, unlike the ICS hospitals, the centres of the entire XHUP are distrib-uted throughout the territory, achieving prioritisation of the health policy that no territory can be over 30 kilometres from a centre. In this sense, the role of the basic general hospitals is crucial.

We must emphasize that for historical and also management reasons, advanced technology is concentrated in centres around the city of Barcelona. This does not represent a breach of equity in conditions of access to health services, the basic pillar of the Catalan and Spanish models, but is due to technical reasons. To contract high technology it is important to meet the demand for efficiency (given the high cost of the technology involved) but also, especially, the demand for the highest profes-sional expertise (that can be consolidated providing that a critical mass is reached linked to the volumes of population and minimum volumes of activity that the lat-ter generates). In spheres such as transplants, optimal levels of care quality can only be reached if sufficient volume of activity is managed to achieve critical mass.

All this leads to changes in information systems and pressures for change in pay-ment systems, as addressed in the corresponding chapters.

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Distribution of XHUP hospitals by GTS, level and ownership

GTS abbreviations

B. L. N. Baix Llobregat NordB. M. Baix MontsenyB. V. Baix VallèsV. Oc. E. Vallès Occidental EstV. Oc. O. Vallès Occidental OestV. Or. Vallès Oriental

Vall d’Aran

Alt Urgell

Tarragonès

Alt Camp -Conca de Barberà

Alta Ribagorça

Cerdanya

Baix Camp

Pallars Jussà -Pallars Sobirà Berguedà

RipollèsAlt Empordà

Baix Empordà

Lleida

Bages-Solsonès

OsonaGironès -Pla de l’Estany -Selva Interior

Alt Maresme -Selva Marítima

Barcelonès Nord -Baix Maresme

BarcelonaBaix Llobregat-Centre-Fontsanta

Baix Llobregat-Delta-LitoralGarraf

B. M.

B. L. N.

Baix Penedès

V. Or.

B. V.

Alt Penedès

V. Oc. E.

V. Oc. O.

Altebrat

Baix Ebre

Montsià

Anoia

Garrotxa

Maresme

Type of hospital

ICS Others

high technology

reference

general basic

isolated general basic

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20 1.4 Primary healthcareThe Catalan model has worked by healthcare lines in which provider networks have been created. The primary healthcare network features four prominent elements:

• Process of primary healthcare reform

The reform process started in 1985 (Decree 84/1985 of 21 March) and ended in 2003. It was born with the aim of revamping the existing healthcare model, es-sentially characterized by an almost absolute predominance of curative care upon demand from the user population, the work of individual healthcare professionals and a lack of orientation of the healthcare offering towards customer service.

The reform led to the gradual implementation of a new model more favourable for primary healthcare developing its role as the first step for healthcare access by the population and becoming a qualitatively different care level, in order to achieve balanced integration of preventive healthcare, curative healthcare, rehabili-tative care and the promotion of community health.

Its basic structural instruments were the delimitation of a territorial framework to allow the operative sectorialisation of the care network, through the creation of basic health areas (ABS) and the gradual introduction of primary care teams (EAPs). The organisational improvements pursued by the implementation of the EAPs focused on establishing working conditions that would facilitate teamwork based on a larger time commitment on the part of professionals. These require-ments largely explain the dragging out over time of the entire process.

• Diversification of the provision of primary healthcare services

The most characteristic element of the distribution of functions made possible in 1990 by the LOSC was the separation between service provision, on the one hand, and the financing, planning and purchasing of these services, on the other. This gave rise to the start of the diversification process in the provision of pri-mary healthcare services with its subsequent permeability towards new forms of management, such as the possibility of management by specialised care provider organisations or direct management by professionals (association-based organisa-tions: EBA). Currently 20% of EAPs are not managed by the ICS.

• Introduction of the contract as part of the relationship

The figure of the primary healthcare services contract responded to the need to have an instrument to articulate the relationship between CatSalut as purchaser of healthcare services and the provider organisations supplying these services. The subcontracting of EAP primary healthcare services began in 1992 with the agreement signed with provider organisation SAGESSA, linked to several local councils and county councils in the healthcare regions of Tarragona and the Terres

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de l’Ebre, in relation with the Primary Healthcare Service of the basic health-care area of Vandellòs and Hospitalet de l’Infant. Following this first agreement, the subcontracting process was progressively extended with the signing of new contracts and agreements over the following years and with the signing, in 1993, of the protocol for mutual collaboration between CatSalut and the ICS, recently renewed with the approval by the CatSalut Management Board, on 23 March 2009, of the CatSalut-ICS programme contract.

The contract is the drive belt in health planning priorities because its clauses set care objectives to enable, for example, definition of how services must be provided and how Health Plan objectives must be made operational. It also allows explicit details for recognition of the portfolio of primary care services and for ensuring compliance. It also puts into operation instruments for sharing responsibility on pharmaceutical expenditure and establishes a maximum acceptable cost (PMA) which can be tolerated while rational medication use is promoted, with medica-tion adapted to the real needs of patients and an efficient selection of medications being made (eg generic drugs).

• Innovation Plan for primary healthcare and community health

Over the past few years new targets have been proposed for primary healthcare. New globalising directions have been taken on board regarding the health concept and along with the ongoing process of cultural, social, technological and scientific changes in our society, this has led to different groups, all involved in one way or another in healthcare, investing continuously in new efforts to progress and improve.

In a context in which the conceptual and organisational bases of the Catalan primary healthcare model are still appropriate for addressing these changes and meeting the new demands of the population, the implementation in coming years of the Innovation Plan for primary healthcare and community health (just approved by the CatSalut Management Board in November 2009) will have to give satisfactory responses to the needs for adaptation and improvement of our primary healthcare services.

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22 1.5 Social healthcareIn the social healthcare sphere advantage has been taken of the consequences of the hospitals reform plan to adapt hospitals that were not part of the XHUP and use them to create a public health network. The Department of Health created the Vida als anys Programme (PVAA) for the care of elderly patients and the chronically ill, via its Order of 29 May 1986. This plan became interdepartmental when, in 1988, the Department of Social Welfare was created.

With the PVAA an important step was taken to tailor services to the care needs of a population with a high rate of ageing, but it also included the promotion of a biopsychosocial model of care with a multidisciplinary approach. The social health-care model advocates the global conception of the individual and the need for a holistic approach, both in needs assessment and in the implementation of treatment programmes. This model is useful for the care of elderly patients, the chronically ill who are dependent and people who are terminally ill and need palliative care.

Social healthcare is regulated by the Decree creating the network of social health-care centres, services and establishments (Decree 92/2002), which establishes the typology and functional conditions of social care centres and services and the rules governing authorisation, and by the Order that regulates the quality standards that must be met. In 1999 the systematic collection of information from the so-called MBDS-SS began, which has allowed longitudinal information to be obtained on social care services.

In the social healthcare sphere, in the field of medical care, Catalonia has three levels of intervention comprising the following facilities:

Hospitalisation servicesLong stay

Medium stay (convalescence and palliative care)

Daily outpatient servicesDay hospitals

Comprehensive outpatient assessment teams

Evaluation and support teamsUFISS

PADES

• In the long-stay hospital services we can differentiate between specific geriatric units (the largest contingent), psycho-geriatric units for people with Alzheimer’s and other dementias and for people with chronic psychiatric disorders; long stay for the severely disabled, for people with tuberculosis and with AIDS.

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• Medium-stay hospitalisation services are composed of different care lines, such as convalescence and subacute care, palliative care or medium stay for Alzheimer’s patients.

• In outpatient day care under the day hospital regime we can distinguish therapeu-tic and rehabilitative aspects, palliative care for patients with Alzheimer’s disease and other dementias or with neurodegenerative diseases and brain damage.

• Ambulatory day care by comprehensive ambulatory evaluation teams (EAIA) ad-dresses geriatric groups, with cognitive disorders or receiving palliative care.

• Home support teams from the Home care support teams programme (PADES) have specialists in neurorehabilitation (for dependent neurological patients with spinal cord injuries or brain damage), AIDS and tuberculosis.

• The in-hospital support teams of interdisciplinary functional social healthcare units (UFISS) are specialized interdisciplinary teams that support the different acute care hospital services in the assessment and monitoring of target patient groups, mainly the elderly and the terminally ill.

Social healthcare problems have been the subject of one of the master plans given priority by the Department of Health1 to implement the policies of the Health Plan, an essential tool used by the Government to set its priorities in health matters. The Social Healthcare Master Plan (PDSS) is the instrument that determines and specifies the guidelines for actions that are to be developed in the healthcare spheres described previously.

1 The Department of Health and Social Security changed its name to the Department of Health in May 2004. Throughout this book reference is made to its current name, the Department of Health.

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24 1.6 Care for mental health and addictions

In this area we will look firstly at psychiatric and mental healthcare, detailing the differences between care for adults and care for children and young people, and fol-lowing this, care for drug dependencies.

The development of psychiatric care in Catalonia has followed a similar process to that of most developed countries. Traditionally, it was not integrated into the Social Security system and depended, in our case, on the provincial councils. It was looked upon more as charitable assistance than healthcare. Psychiatric hospitals, in addition to their strictly health-based function, fulfilled others such as providing asylum, guarding and custody. Individuals declared “socially dangerous” were admitted by court orders. This connection with the legal authorities adds a further degree of complexity to the management of psychiatric institutions.

In the mid seventies in Europe the psychiatric reform movement began which led to the opening of psychiatric hospitals, open regimes for patients admitted there and their reintegration into and treatment in the community. This movement reached Spain with the passing of the General Health Act 14/1986, of 25 April, which established the integration of psychiatric care within the general health system (National Health System). The Catalan health system also presented, in the field of psychiatric care, the characteristic of a relatively smaller public sector in comparison with Spain as a whole. Of all the psychiatric hospitals existing in Catalonia in 1990, only two were owned by the Healthcare Administration.

That same year an agreement was formalized between the Barcelona Provincial Council and the Government of Catalonia, through which the Government took over the management of contracts the Provincial Council had established with dif-ferent organisations to cater for mental health patients in the province of Barcelona. In 1992 the devolution of powers in mental health matters reached the other Cata-lan provincial councils (Tarragona, Lleida and Girona). At the same time, in 1989, a network was launched for the specific care of children and teenagers with mental health problems who suffered exclusion because previous resources were devoted exclusively to the adult population.

In 1999, the Mental Health Network was created through Decree 213/1999 of 3 August. It was composed mainly of a set of private charity and non-profit institu-tions, religious organisations, professional associations and workers’ cooperatives. The Decree established the various facilities making up the mental health network, a truly complex subsystem within the Catalan healthcare system, and differentiated the resources depending on the population catered for (children and young people or adults), organised around three basic levels of care.

25



Specialised outpatient care to support primary healthcare

Mental health centres

Hospital care

Psychiatric emergency services

Acute patients hospitalisation services

Sub-acute patients hospitalisation services

Medium stay psychiatric hospitalisation services

Long stay psychiatric hospitalisation services

Partial hospitalisation services

Treatment in the community services

Multi-purpose units in the community care services

Therapeutic communities

Community psychiatric rehabilitation

Community rehabilitation day centres

Employment integration centres

Regarding the organisation of care for drug dependencies, the development and conceptualisation of the phenomenon determined the changes. Nowadays addic-tive conduct is accepted as a mental disorder by the scientific community, but until recently it was considered to be a moral failing, a lack of willpower, a social/family dysfunction or an act of self-isolation. For this reason, the first services emerged from the social network itself, based on the initiatives of different municipal and private non-profit organisations, closer to the social and charity sphere than the health sphere.

The Network of Care for Drug Addicts in Catalonia (XAD) was founded in a specific and professionalised manner to provide comprehensive care for people with disorders related to psychoactive substance use. It is made up of centres dependent on various agencies (local authorities, NGOs, Catalan Health Institute). Its activi-ties are coordinated by the Specialist Drug Addiction Watchdog (OTD), created in 1986 as one of the key elements in the implementation of the pioneering Law 20/1985, governing prevention and care in matters related to substances that can cause dependency. The OTD works in co-operation with the Department of Wel-fare and Family as regards therapeutic communities and integration programmes. From the functional viewpoint, the XAD structure was divided into four care levels:

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26 • 1st level. Primary health and social care. Early detection and diagnosis of at-risk consumers.

• 2nd level. Care and monitoring centres (CAS) for drug addictions. Specialised treatment on an outpatient basis with multi-disciplinary teams.

• 3rd level. Hospital detoxification units (treatment of withdrawal syndrome), therapeutic communities (long-term treatment in a residential setting oriented towards social rehabilitation of the patient).

• 4th level. Centres and programmes for reintegration into society.

Attention to drug addiction goes beyond care and encompasses other important areas of action such as prevention, harm reduction, rehabilitation, teaching and research and, finally, planning, management and coordination with other depart-ments and agencies.

The actions prioritized by the Department of Health with regard to mental health are reflected in the Master Plan for mental health and addictions, which recognizes the high prevalence of mental disorders (20% of men and 27% of women will be affected at some stage in their life) and the major personal, social and family bur-dens they generate. It emphasizes the promotion and prevention of mental health with the introduction of community-based and multidisciplinary models of care, and ensures adequate attention to individuals with severe mental disorders and also their families.

27



1.7 Other careApart from the aforementioned care lines, there is a group of other additional healthcare services, such as:

• Physiotherapy

• Patient transport

• Oxygen therapy

• Treatment of kidney failure.

Their respective characteristics are addressed in section 8.5, with special reference to the payment system.

Note. The authors would like to thank the co-operation, in different sections, of Carmen Caja, David Magem, Cristina Molina, Ivan Planas and Toni Ponsà.

Chapter 2

Payment systems, theoretical bases Enric Agustí and Xavier Salvador

31

Payment system

s, theoretical bases

2.1 General framework of payment systems

A payment system is a series of instruments used by a financer to reimburse a pro-vider for the provision of services.

The case that concerns us is publicly funded healthcare activity. This is a rather complex environment, due to both the numerous agents involved, whose interests do not always coincide, and the diversity of activities that are eligible for reimburse-ment. But this complexity does not preclude the possibility of breaking down the theoretical bases in a simple way, providing a response to the seven key questions:

Question Concept

Why? What the objectives are that are sought with payment systems.

Who?Description of who pays in a payment system, a role that corresponds to the financer.

Where?Description of who receives payment, and whether each service provider receives it individually or receives it through an integration of providers.

What?Units of measurement of the services provided that are reimbursed by the financer (budgets, care activities, cases attended or payment per capita).

When?Moment in time at which the payment is established (prospectively or retrospectively).

How much? Amounts paid for healthcare (fixed or variable).

How? Details of all the elements of quality related to healthcare.

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32 2.2 Why? The objectives of payment systems

Payment systems are a fundamental tool for achieving healthcare policies, although not the only tool available in an arsenal that includes legislating, organizing and providing financial incentives. To illustrate its importance with an example, the leading recommendation in the health system reforms being considered in the United States is the reform of the payment system.

The objectives of healthcare policies are aimed at achieving a healthcare that meets those requirements demandable of any goods or service, which in the healthcare field can mean:

1. Quality: this has many specific translations in healthcare. For example, ensuring health promotion and disease prevention, reducing readmissions, avoidable com-plications or mortality and ensuring equal access for the entire population.

2. Accessibility: providing incentives to respond to the population’s needs, especially where the priorities of the population do not match strictly health-related priori-ties. We are referring to the comfort associated with reducing waiting lists or providing hospitality elements that compete with private healthcare.

3. Efficiency: the growth of public money has structural constraints and, moreover, we are in an environment of technical progress in which new care alternatives constantly appear, often at a high price. Everything that encourages efficiency and helps limit spending growth allows the sustainability of the system to be ensured.

These three elements are the measures that we will apply to the different theoreti-cal systems. As in the case of any other goods or services, achieving a product that simultaneously meets all requirements is extraordinarily difficult, but the ultimate goal of any system.

Some of the more specific technical objectives that must be evaluated to get closer to the overall goal are:

• The relationship between the quality levels provided and health expenditure, on the one hand, and the relationship between quality and costs of providers, on the other, to see if they are optimal or not. The latter comparison requires information systems on provider costs and the associated calculation methodology to be able to assess it accurately.

• Other factors that prevent the provider from reaching optimal levels (eg, defensive medicine or the capture of patients at inadequate care levels), taking into account their autonomy, negotiating skills and the level of competition among providers.

33

Payment system


• The regulations set by existing legislation, in particular the functioning of pay-ment mechanisms and characteristics of the financer, to ensure that they do not prevent optimum levels of quality and efficiency being reached. Policy changes in the structure of payment systems may have the potential to increase the quality and/or reduce (or at least control) the costs of health systems.

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34 2.3 Who? The financer of the systemDifferent institutional systems have different definitions of who pays and what the limits of their liability are. A universally accessible healthcare system financed by taxes is different from a system of rights based on national insurance contributions. Moreover, a universal system can be channelled through a single financer or numer-ous competing insurers.

In the Catalan model there is a single financer, with the functions of providing services and health planning separated. So in this model the financer is not limited by ownership of the organisations that provide public healthcare, provided that the regulatory definitions that ensure quality standards in the care provided are met.

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Payment system


2.4 Where and what? Where payment is charged and in what units payment is made

Service providers are those who charge for providing healthcare. Providers tend nec-essarily to maximize profits, but there is no reason for their benefits to be exclusively monetary. Depending on provider structure, conditioned by the payment system in force, social elements can also be part of this maximisation.

It is especially interesting to know whether the providers of each care line receive payment individually or if it is received by an agency that integrates different care levels. This is a key element in ascertaining to what point social benefits can be internalised into their operation and knowing which items can be reimbursed.

When each provider is paid individually, inefficiencies may arise related to competi-tion in capturing activity that lies at the intersection of areas where the product or service to be provided by each provider is difficult to define. For this reason, health systems today tend towards models where the integration of healthcare services is financed based on the services of different providers that converge around a project or a territory. This leads some systems to steer contracting towards the improvement of the community’s health.

Below is a list of different items that can be reimbursed according to integration level and, in the case of individual providers, the items are exemplified in the spe-cific cases of primary healthcare and hospital care:

Item reimbursedIndividual providers

Integrated providersOutpatients Hospitalisation

Budgets Budget Budget Budget

Care eventsAppointments/contacts

Days stay

—Weighted caseload attended

Episodes Discharges

Payment per capita Capita — Capita

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36 It must be kept in mind that the financer may contract different service lines with different payment systems, which may create a conflict of interests between provid-ers as they seek to maximize profits. For example, payment per capita in primary healthcare clashes with the payment per case of hospital care. These conflicts must be resolved by the financer. Conflicts may also arise within providers: payment per case at a hospital clashes with payments to fixed salary professionals at the same hos-pital, as this does not encourage the practitioner to produce more.

Below we detail the models individually:

• Payment by budget

Providers receive an agreed amount during a given period. The amount is inde-pendent of the number of patients receiving care or the volume of services provided.

• Payment per event

In this system the provider is remunerated for each event, whether an appointment or a stay. A portfolio of services is agreed between provider and financer, which may be more or less exhaustive according to the level of information and the profits envisaged. Those activities not included in the portfolio are not remunerated.

• Payment per case

In this system centres are paid for the number of cases attended according to the complexity that these present. The complexity is evaluated using case mix grouping tools, which we detail in Chapter 9.

• Payment by capitation

In this system providers receive an agreed sum for each person that is in their charge, with different weightings according to the propensity towards consuming resources of the respective reference population.

37

Payment system


2.5 When and how much?The amount and the moment at which this is determined are detailed below:

Time of payment Fixed amounts Variable amounts

Prospective Pure prospective model ... with retrospective adjustments

Retrospective — Retrospective model

Two pure models exist:

• Models where the amounts that must be paid are established beforehand (prospective). In principle these are associated with fixed sums.

• Models where amounts that must be paid are established afterwards (retrospective). These are always associated with variable sums.

But while the retrospective payment is always variable (there is no logic in making a retrospective payment of fixed sums!), it is very difficult for a prospective payment to be purely fixed. There are different elements that, in practice, mean that prospec-tive models should receive retrospective adjustments. For example, to respond to in-creased costs associated with catastrophic conditions that appear randomly. Or, for example, to give a quick response to the emergence of new therapies that increase costs but are demanded professionally and socially.

In a prospective system, parameters and budgets are determined ex-ante. In these systems it is important that a close relationship exists between providers and financers, especially as regards the relationship between costs and payment, both in ordinary contracting and marginal reimbursements, which should match the expected marginal costs. These systems have greater incentives to stimulate effi-ciency and many attractions for the financer because of their high potential for cost containment. The risk that they pose is that, in pursuit of efficiency, the provider makes savings at the expense of the quantity and / or quality of care provided. For example, by pressuring for early discharges, with the consequent risk of complica-tions and readmissions.

Fixed systems have repercussions on the prospective payment. From the viewpoint of providers they involve receiving a fixed sum ex-ante and, therefore, there are incentives to reduce marginal costs because the marginal profits are negligible. The number and intensity of activities will tend to reduce with a potential deterioration of quality. From the viewpoint of the financer they are very useful at times of cost containment, since the expenditure is determined ex ante.

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38 In principle, therefore, prospective payment is a fixed payment. But on certain occasions the assigned budgets may end up being exceeded, forcing the financer to establish corrective measures to neutralize the excess spending (this may be in the same accounting period or the following one). This will depend on financial capacity and information systems (whether or not they allow any deviations to be revealed quickly). For this reason, prospective models often end up associated with some variable element or with agreements on increases in activity for future years.

In a retrospective system, the costs of the providers are reimbursed ex-post in full (or partially in some systems). As the reimbursement is based on real costs, provid-ers have no incentive to contain costs. They may even have incentives to increase them, thus growing their income. It is a system which, obviously, in principle does not encourage technical efficiency.

Variable systems imply that providers will produce until marginal income equals marginal costs. Production, therefore, depends on marginal income (prices) with relation to the marginal cost of production. If prices are high this may lead to an increase in production that is not always desired. For the financer, this system repre-sents an initial budget that is virtually unlimited and, therefore, unlikely to contain costs. For this reason existing systems that finance a certain number of activities (with the risk of overproduction) tend to incorporate maximum budget “ceilings” into the activity and transfer the risk from the financer to the provider. The aim is to avoid infra / overproduction, by keeping within the assigned budget.

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2.6 What, when and how much!The relationship between payment models and units is presented below:

Item reimbursed Prospective model with adjustments Pure retrospective model

BudgetsBudget (with retrospective adjustments)

—

Care events Payment by events (with regula-tions)

Payment by events

Weighted caseload attended

Payment linked to evaluation (weighted) of caseload attended

Payment linked to evaluation (weighted) of caseload attended

Payment per capita

Payment per capita (with retrospective adjustments)

—

Following the reasoning of the previous section, when we evaluate the different con-cepts that can be reimbursed, we find that, as a general rule, quantities and costs go in opposite directions:

• Reimbursable units that help to control costs, but that in the attempt tend to limit volumes of activity:

Payments by budget, in principle, control expenditure very well but may fall into the trap of cutbacks in activity that automatically generate a profit. The risk of carrying out less activity may be corrected if accompanied by retrospective adjust-ment production incentives. There is a margin for improving efficiency if internal processes are improved, but it depends on the will to cooperate.

Payments per capita generate incentives to reduce costs by maximising profits. Unlike payment per case, no incentive exists to increase activity: the provider has certain resources assured and all the cuts in costs that it achieves are transformed into profit. Therefore, it is necessary to ensure that the cut in costs is not extended to cutting back on activity carried out as this gives rise to weakening of the quality of the healthcare provided. The system does not work if not complemented with evaluation based on qualitative indicators.

• Units that do not limit activity and, therefore, do not help to control costs:

Payments per event are clearly inflationist, since the more services the more re-muneration. Therefore, unless a final global budget is delimited, induced demand processes may arise, as providers will tend to maximise profits with the same cost. Therefore, with this model it is very difficult to achieve control of spending if not accompanied by limiting measures (reimbursement ceilings, marginality).

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40 Payment per case also carries the same risk as payment per event. It increases activity, but at the same time it improves productivity, leaving the question of whether or not induced demand is ultimately generated. But when payment per case is made weighted according to the assignation of each case to an isocost group, a certain restraint is introduced. Anyway, except when a total monetary amount is agreed, this system may greatly increase the costs expected by the financer.

After considering the various adjustments, as well as the relevant regulations and weightings, we find the following models:

• Prospective payment by budget (with retrospective adjustments)

Payments by budget are always fixed and known beforehand by the financer and the provider. The problem with this type of payments, from the financer’s view-point, is correctly adjusting the budget to the expenditure, as the eventual devia-tions must be corrected by the financer. Thus, although the expenditure is known ex-ante, it is not surprising that ex-post adjustments are needed that mean that the system ends up having retrospective elements.

• Payment per event (with regulations)

This is a variable payment system that may have a prospective or a retrospective base. Normally the systems based on stays are inefficient as they tend to increase invoiceable or invoiced events or, in the case of hospitals, the average stay. For this reason it is necessary to include regulations, such as, for example, a maximum average reimbursable stay.

• Payment per weighted case

This is a generally prospective system where the payment per case does not neces-sarily take into account the real costs of the patients, if not backed by a good costs information system, with agreed cost allocation methodologies.

The risk of this system is the tendency to treat relatively healthier patients (adverse selection) to try and maximise profits. In extreme cases, the maximisation of profits would lead to economising on complementary tests or the forcing of early discharges. It also creates the risk of coding patients incorrectly with the aim of increasing the apparent relative cost. Therefore, these systems should always be accompanied by coding audits.

• Payment by capitation

This is a prospective system that gives the possibility of stimulating the promotion of health and the prevention of disease. In theory it is more profitable and avoids unnecessary admissions. In this sense, it tends towards a reduction in costs as it has to eliminate unnecessary treatments.

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Payment system


Consequently, from the viewpoint of the financer it allows improvements to be instated in population health elements and from the financial viewpoint it allows the expected expenditure in the period to be known ex-ante. But it has evident risks, such as catastrophic conditions that cause the expenditure of certain patients to exceed manifold the reimbursement expected (forcing the financer to respond jointly and severally). Or the selection of people according to the expected risk, trying to ensure that only healthy people (who will not cause expenditure) remain in its capita.

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42 2.7 How? Care qualityThe qualitative element of care emerges in any of the model alternatives. Salient points for assessing the level are:

• Availability of information systems on activity quality, used to calculate indicators in relation to the care provided.

• Availability of information systems on quality costs, which reveal spending ef-ficiency.

• Explicit inclusion of indicators in care purchasing contracts (and the level of im-pact caused by their inclusion on provider’s decisions).

With regard to qualitative indicators, many definitions exist, but most fall into the following areas:

• Prevention of disease: the formats of these indicators are rates of hospitalisation for conditions sensitive to better control on the part of primary healthcare, such as hypertension, diabetes or COPD, for example. All this with the relevant statistical adjustments, particularly for the population’s age structure.

• Care provided (in the hospital setting): mortality rates adjusted for certain pathol-ogies with empirically observed variability and not explainable by conventional statistical adjustments (gastrointestinal hemorrhage, craniotomy, etc.); assess-ment of the achievement of critical mass in certain proceedings with a significant survival gradient depending on the volume of practical interventions (pancreas resection or PTCA).

• Patient safety: this is related basically with treatment complications and the ap-pearance of iatrogenic pathologies.

• Appropriateness of care: adjusted activity rates for diseases with high discretional-ity between areas (not explained by prevention) that may highlight inefficient practices; rates of readmission due to complications (mainly in per case payment systems, but not in per event, by budget or per capita payments).

• Access to services: rates of activity and previous time on waiting lists for basic con-ditions where there should be no significant differences after adjusting for those explanatory variables that are necessary.

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2.8 SummaryAchieving a perfect model is a utopia. Any model that comes close to perfection will gradually consolidate “perversions” over time, due to the interests of agents involved and to incidental changes that take place in healthcare. Therefore, in practice, the systems require fine-tuning. Several payment systems are often used at the same time, as combining them allows potentially maximising strengths and minimizing any adverse effects.

One way or another, health policies, regardless of the payment system used, should ensure that at all times quality standards are maintained while facilitating the mechanisms necessary for proper integration of services within the health system framework overall. This can be done through the coordination of providers or by putting the patient at the heart of the system.

It is also essential to develop quality information systems, both relating to the care provided (Chapter 9, Evolution of information systems as a support tool for pay-ment systems) and to the costs incurred in providing that care.

Chapter 3

The UBA model (basic care unit)Carme Casas and Montse Llavayol

47

The UBA

model (basic care unit)

3.1 The XHUP and the contractAs detailed in Chapter 1, following the devolution of health matters to the Catalan Government, in 1981, a scenario was set up for the provision of specialised care for acute patients made up of devolved public ownership centres and a set of centres under differing ownership which complement the provision of hospital services necessary for public healthcare.

This peculiarity of the Catalan system with its coexistence of centres under different ownership made necessary the creation of the public hospital network (XHUP). On 15 July 1985 Decree 202/1985 was passed, creating the XHUP, with the funda-mental aim of achieving a hospital organisation that allowed adequate homogenisa-tion of care services and the optimal utilisation of human and material resources .

The XHUP was the instrument that most helped improve geographic and treat-ment equity for patients in Catalonia. Its creation led to all hospitals being integrat-ed into a single healthcare network, regardless of their legal ownership. The network initially consisted of 64 centres providing a total of 15,500 beds.

Due to the varying ownership of the XHUP member centres, their structural diver-sity and the differential nature of the health services they provided, it was necessary to establish a contracting system that would identify those services to be bought and establish a system of financial consideration. With this new contracting system the aim was to change the existing relationship between the provider and the financer of healthcare services.

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48 3.2 The basis of the payment systemAt first the activity of the hospitals was quantified and it became quite apparent that there was a need to adopt new measures to regulate the agreements for the provision of healthcare services, which until then was regulated by the Order of 20 November 1981. This was the reason behind the passing of the Order of 25 April 1986, on con-tracted healthcare, whose main objective was the establishment of contracts for the delivery of healthcare services with public or private organisations owning hospitals, centres or services deemed necessary to complement health and care provisions not met by the centres and services owned by the Catalan Health Institute (ICS).

The payment system of hospital contracts aimed to improve hospital efficiency while maintaining quality of care. The unit of payment of the contracts mentioned was determined based on each patient treated in hospitalisation and outpatient modalities.

With the aim discussed above, in 1986 a prospective payment system was defined whose essential pillars were:

- To establish a unit of equivalence, the basic care unit (UBA).

- To define the structural levels of the hospitals.

Due to the great weight that the hospitalisation concept had in the model of the time, the hospital stay was used as starting point with its equivalence being the UBA.

The UBA was an indicator that included the global activity of the hospitals and its aim was to translate the different measures of hospital activity into a single measure-ment unit. These measurements made reference to:

- average stay

- occupancy rate

- rotation rate

- number of consultations

- ratio of first appointments and subsequent appointments

- urgent appointments

- number of interventions

- average intervention duration

Stays were modulated by an indirect efficiency factor, the average stay, without tak-ing into account the case mix of the patients treated.

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3.3 Details of the invoicing systemHospitalisation was invoiced based on the number of stays effected by the patient at the hospital, meaning the whole overnight stay and corresponding time for the sup-ply of a main meal (lunch or dinner). At the time this unit was established, hospital was basically a facility for admission. Therefore, the UBA amounted to one stay and all the other care events took the UBA as the reference unit.

Outpatient activity was quantified according to the following criteria:

• First appointment: 40% of the fee per stay. The first visit included the first con-tact, indication and performance of examinations and the visit for verification of these explorations.

• Subsequent appointment: 20% of the fee per stay. The subsequent appointment was considered to be that in which the patient was monitored based on the results of the first appointment.

• Emergency: 50% of the fee per stay. Emergency was considered to be urgent outpatient care only. Emergency care lasting 12 hours or more could be accredited as a stay in substitution of the outpatient emergency. A stay and an outpatient emergency could not be accredited simultaneously.

• Outpatient intervention: 75% of the fee per stay. An outpatient intervention was one requiring at least a local anaesthetic which did not generate a hospital stay.

• Day hospitalisation: 75% of the fee per stay. Day hospitalisation was understood as applicable only to patients included in intravenous fluid therapy and chemo-therapy programmes or others that could be approved with a minimum stay of four hours and a maximum of 12 hours.

1 UBA = 1 STAY

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50

The value of the payment units for the services provided by centres was established with a rate for each level, so it was necessary to classify centres by levels. Each hospi-tal level was assigned a price per stay.

The Order of April 23, 1986, established the following levels of the centres includ-ed in the XHUP:

• Level A: basic general hospitals. The allocation of hospitals to this level had to be adequate to cover about four fifths of the demand for hospitals of a reference population.

• Level B: reference hospitals. There had to be one hospital at this level for each area with a reference population of 400,000 inhabitants. For reasons of centre access or capacity, there could be a hospital of this level in an area with a larger or smaller population.

• Level C: reference hospitals with high-technology services and equipment. These centres were always general hospitals with specialities and equipment that, due to high cost or complexity or low usage frequency, were classified as high technology centres. Across the entire XHUP there was one level C hospital for every million and a half inhabitants.

Exceptionally, a speciality or high-tech equipment could be housed at a B-level hospital when, due to demand criteria, this was justified.

The legislation sought a more rational distribution of beds, which were overly con-centrated in Level C. Thus it was established that the maximum number of beds in Level C hospitals would be 25% of the total beds in centres making up the XHUP,

Hospital stay

Day hospitalisation

Outpatient intervention

Emergency

First appointment

Subsequent appointment

1

0.75

0.75

0.5

0.4

0.2

0 1

Graph 1. Equivalences of care events

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instead of the pre-existing 34.7%. With respect to Level B, a maximum value of 35% was set, slightly above the previous 32%. This change would allow Level A to increase from the existing 33.3% to a minimum of 40%.

Having defined the basic unit and hospital levels, the factors modulating or regulat-ing the activities contracted were determined:

• In the case of hospitalisation, activity was modulated by length of stay.

• In the case of outpatient activity, this was established as a percentage of the total activity.

At the same, a payment distribution was established, with part fixed, giving the centres financial stability, and part variable, depending on the activity carried out, which was adjusted at the year end.

Basic general

Reference

High technology

Graph 2. Percentage of distribution of XHUP beds by hospital level

Previous

Target

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52 3.4 Impact of care changes on the modelThe change of hospital care model, characterized by the increasing importance of outpatient activity, the development of alternatives to conventional hospitalisation and the emergence of new techniques and technologies of high complexity, made a readjustment of the UBA system necessary to allow better recognition of differen-tial activities and structures. For this reason later, and due to financial insufficiency among the organisations, five levels of tariffs were defined (level A, level A / B, level B, level B / C and level C) and a number of special programmes were incorporated (in 1992 there were about 70 programmes growing to nearly 140 after four years) valued in terms of activity or budget. Over time these two factors, mainly, eventu-ally led to a distortion of the UBA system.

UB

A

Graph 3. Evolution of the UBAs 1988-1996

6,000,000

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

0

Years

1988 1989 1990 1991 1992 1993 1994 1995 1996

Hospital UBAs Outpatient UBAs Programme UBAs

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The improvement in information systems, with the systematic collection of the Minimum Basic Dataset for Hospital Discharge (MBDS-HD) in acute hospitals, was another factor that accelerated the implementation of a new payment model.

Graph 4. Percentage evolution of the UBAs 1986-1996

Outpatient UBAsHospital UBAs Programme UBAs

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%198819871986 1989 1990 1991 1992 1993 1994 1995 1996

Note: the data from the years 1986-87 do not include information from the ICS hospitals.

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54 3.5 Need for changesThe evolution of the UBA system was caused by several factors:

Firstly, the change in model that occurred in hospital care meant that the UBA equivalence was exceeded in areas such as:

• a decrease in stays based on a concept of efficiency through reduction of the average stay,

• the development of new outpatient techniques such as better defined day hospital or major ambulatory surgery,

• the integration of specialised activity into primary healthcare, leading to an increase in the volume of ambulatory activity,

• the consolidation of emergency care as a line with its own personality and well-defined activity,

• the increasing complexity of certain procedures (which were paid at a price that did not recognize this complexity), among others.

Secondly, the progressive limitation of the tariff by levels system triggered:

• a disproportionate increase in situations that required a differentiated payment that could not be assumed by the Cartesian logic of the UBA, given that it was very difficult to integrate new medical and technological advances that appeared in non-pure admission to hospitalisation processes, and

• changes in structural levels due more to financing needs than to planning criteria.

The third factor was that improved information systems opened up new possibili-ties. The systematic collection of the Minimum Basic Dataset for Hospital Dis-charge (MBDS-HD) in acute hospitals enabled the implementation of a qualitative information system on the activity carried out. There was an information unit defined by the MBDS-HD on each patient discharged enabling knowledge of the type of patients treated in hospitalisation units and the grouping and comparing, using the appropriate tools, of performance parameters on an intra-hospital basis and for all centres in sector. This is dealt with in detail in Chapter 9.

The fourth and final factor was that the sector was calling for a change in model to be able to apply new methods of diagnosis and treatment not directly related to conventional hospitalisation and which resulted in increased organisational ef-ficiency. The development of new medical techniques, the concept of short-term hospitalisation and the recognition of research and training, at undergraduate and post-graduate levels, helped shape a new hospital model, more based on service lines that were homogeneous as far as products were concerned.

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The UBA


3.6 Strong points of the UBA system worth maintaining

However, the UBA system had a set of strong points that should not be forgotten and that any later modification would have to preserve.

1. Prospective contracting of the activity represented two main advantages: firstly, the possibility of adapting the activity at each of the centres to the needs detected in the population, with the possibility of modulating growth or reduction ac-cording to changes in the environment. Secondly, it allowed control of expendi-ture assigned to hospital care.

2. The system was based on the activity to be undertaken by each of the provider centres. These were parameters that, while not strictly clinical, could be under-stood by the sector and were not strange to it. Thus, the discharge, first appoint-ment or urgent event formed a part of the hospital’s intrinsic vocabulary.

3. The creation of a conversion unit, the UBA, was a facilitator of dialogue between different agents in the system, regardless of origins, and encouraged a culture of relations.

4. The “level of care” concept allowed the recognition of different types of hospital according to the structure or role they exercised in the public system. Moreover, the variation in fees by levels allowed the modulation of selective purchasing parameters for determined centres and / or care lines within the XHUP.

5. The system allowed comparability, albeit somewhat imprecise, between different establishments. The use of the average stay as an indicator made for a clear case.

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56 3.7 Objectives for the next modelDespite the strong points of the UBA system, the aforementioned factors made it necessary to change the payment system with the aim of:

• Incorporating the information obtained in prior periods so that contracting and the payment system more accurately recognised the real situation of each of the centres.

• Designing a system that recognised the intrinsic importance of each of the hospi-tal products.

• Creating a system that would introduce incentives and disincentives for each of the centres’ activities to support the prospective purchase.

• Having a system able to directly incorporate the provision of services with guaran-teed quality, equity and efficiency.

Chapter 4

The activity purchasing modelPayment model for hospitals in the XHUP since 1997Enric Agustí

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The activity purchasing model

4.1 General principles of a new payment model

In the early 1990s it was clear that the payment system using the basic care unit (UBA) required in-depth reform, since a series of circumstances had made it in-creasingly necessary to incorporate previously marginal elements in order to achieve the most modern contract possible.

Once the need to amend the payment model was accepted, the general principles were established. In 1994, one of the conclusions of the 2nd XHUP Conference was the need to change the payment model. Therefore, at the proposal of the direc-tor of the Catalan Health Service, an advisory committee was established that was to develop a consensus proposal for a future payment model.

This committee consisted of representatives of CatSalut, the Catalan Hospitals Union, the Hospital Consortium of Catalonia, the Catalan Health Institute and the major city hospitals in Barcelona not attached to the ICS, advised by professional experts from the universities of Catalonia. After two years of discussions a new pay-ment model was designed and then approved by the CatSalut Steering Committee and published in the Catalan Government’s Official Gazette (DOGC) on 20 July 1997, applicable from 1997 onwards.

The payment model presented by CatSalut was defined by a series of basic lines:

• The global budget

Basically, the budget allocated to hospital care would be treated as a whole. The distribution would be effected based on the purchasing of services. The purchasing contract would be the instrument that served to guarantee the population’s health-care services.

The global budget was used to give priority to certain healthcare actions over oth-ers, always in line with previously established healthcare policy parameters.

• The prospective purchasing of services

The care provided had to meet healthcare objectives and respond to identified needs; it was absolutely essential to maintain the prospective purchasing of services as the main contracting instrument.

To successfully complete this purchase, in line with healthcare policy, the Health Department already had different tools to help it determine the state of health of the population and the actions that it deemed most appropriate and priorities for improving it. The most useful tools for knowing the population’s needs were the Catalan Health Plan and the associated health plans from the healthcare regions.

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60 With respect to quantitative and qualitative indicators, there was sufficient histori-cal data on hospital attendance rates, both for hospitalisation and outpatient serv-ices, emergency, types of patients who were admitted to hospitals, mortality rates, readmissions etc.

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4.2 General payment model outlineIn general terms, the payment model recognized two large blocks, completely dif-ferentiated from each other, which we call activity and programmes.

The activity block covers differentiated valuation of activities undertaken at hospi-tals in four product lines that have clear clinical significance: inpatient, outpatient, emergency and techniques, and specific treatments and procedures.

The programmes block includes Department of Health special interest pro-grammes, teaching and research.

Fixed prostheses and osteosynthesis material, diagnostic support and therapeutic tests carried out on patients referred from primary care and medication for hospital outpatient dispensing, as well as that destined for specific groups, were contracted as with the previous payment model (Table 1).

Annually, the Health Department determines the programmes that, in line with healthcare policy and the Health Plan, are of special healthcare interest and, therefore, require differentiated treatment. The teaching and research line includes postgraduate training and basic research, as shown in the following diagram:

Table 1. Diagram of the XHUP hospitals payment model

In the following sections details are given on:

Fixed prosthetics

Tests aiding diagnosis

Special Medication

Payment model

Activity Programmes

Product lines

Hospitalisation Techniques, treatments and specific procedures

Department of Health

Teaching and research

Outpatient appointments

Emergencies

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62 • The definition, parameters for contracting and payment model for inpatient, outpatient, emergency and techniques and treatments and procedures.

• Programmes that, according to healthcare policy and the Health Plan, are of special healthcare interest and that, therefore, require a different treatment to the ordinary buying of activity.

• Finally, parameters are described that allow the identification of those centres that must be acknowledged both in the line of basic research and that of undergradu-ate and postgraduate teaching.

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4.3 Contracting of the hospitalisation line

• Purchasing parameters

With the aim of establishing volume according to the needs identified, CatSalut contracts a determined number of discharges which include the following:

Concepts included in the hospitalisation line of payment

a) Conventional discharge: set of activities and procedures that are performed on a pa-tient admitted for a continuous period greater than or equal to one stay, provided that this set of activities and procedures is not included in other lines of activity due to the complexity or specificity that they present (such as those included in a line of specific techniques, treatments and procedures), or alternatively because it is recognised as a programme of special healthcare interest by the Department of Health. We define the stay as including one night and the time corresponding to the supply of one main meal (lunch or dinner).

In general, for contracting purposes, in this group equal status and equal treat-ment are afforded to episodes that after the period of conventional hospitalisation and the corresponding administrative discharge have a period of home care until the final medical discharge, not being considered, therefore, as independent processes.

b) Major ambulatory surgery: medium or high complexity surgical procedure per-formed under anaesthetic, that although not requiring conventional hospitalisa-tion does need a period of non-intensive, short-term observation and control and which, in some cases, may require home monitoring and control.

The concept of hospital discharge includes all medical procedures, diagnostic tests, complementary examinations, therapeutic procedures and medications needed for adequate treatment whenever appropriate to the care level, regardless of whether provided at the centre or by other providers. It also includes all types of material used and prostheses for cataract surgeries. It only excludes other non-recoverable fixed prostheses and osteosynthesis material.

• Payment model

The care process is determined above all by these two factors:

- the organisation and structure of the hospital, and- the inherent characteristics of the patient and of the disorder obliging the patient

to seek hospital treatment.

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64 With this in mind, it is considered necessary to continue using mixed payment systems, so that the system recognizes the two factors when considering a payment per process. We analyse them separately and below show how they are inter-related in payment per discharge.

1. Hospital structure

The hospital structure directly influences centre costs and therefore, the design of the payment models to be applied. There is no uniformity among the different XHUP centres, mainly due to their geographic location, area of influence, decision-making capacity, teaching possibilities and the complexity of research studies carried out there.

Traditionally, payment models have recognized the different structures by applying discrete scales of hospital levels, so that each level corresponded to a different pay rate. The discrete rating scale used was too exclusionary, both when we started to compare several centres and when, sometimes, the different structural levels had no purely technical explanation.

Previous studies conducted in other countries were used along with any personal ex-perience taking as a basis the application of fuzzy sets to health and social sciences. A classification model was applied in line with the continuous scale. The theory is based on the statistical application of a form of multivariate analysis, the so-called grade of membership. Briefly, the principles of analysis are as follows: all the XHUP hospitals are studied according to various structural and organisational parameters. The application of the analysis of grades of membership configures a series of groups (“pure types”) that have statistically similar characteristics. Each hospital is compared with these “pure types” and then the grade of membership of each of the “pure types” is calculated.

The structural features of a hospital can resemble totally or partially one or more “pure type” hospitals. For example, we may find that one classification of hospitals has five “pure types”:

- Hospital X resembles a type 1 hospital.- Hospital Y resembles 30% a type 1 hospital and 70% a type 2 hospital.- Hospital Z resembles 25% each of the types 2, 3, 4 and 5.

This continuous classification presents properties that must be known: the pure types, although numbered from 1 to n, do not express gradation. A type 2 pure hos-pital is no more than one of type 1. All we know is that it is different. The assigna-tion is only statistical: a hospital that presents a certain physical and organisational structure resembles in a variable proportion a pure group.

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How was the structure installed determined?

At the outset, a survey was sent to all provider centres for them to quantify the most relevant parameters of their structures. The items used to define groups of hospitals are based on both their physical structural elements (total beds, beds per service, number of outpatient appointments, etc.) and on the presence of certain technol-ogy, organisation and equipment (see Annex 1).

The statistical information was contrasted with matching information from Cat-Salut to corroborate the practical reliability of the method and the efficient ap-plication of the levels. Value was given to the purchase of services at centres being adapted to the structural capacity actually used for CatSalut funded care.

Speciality hospitals deserve separate treatment. Because most hospitals in the XHUP were and are of the general type, introduction into the classification system of a number of centres that have very different characteristics compared to the rest forced a pragmatic adaptation of the structure to levels that would be considered equivalent.

Practical application of purchase by structure. The Relative Structure Index (RSI)

When the centres were located within the continuous classification of hospitals, this classification had to be related with the purchase of hospital activity. The determi-nation of the price per discharge for centres is the result of applying the regression between the hospital purchase and hospital levels to obtain a discharge price per process.2 By knowing what the theoretical prices are per average discharge of the entire XHUP, it is possible to know the discharge prices of each centre.

In order to unify the purchase parameters an indicator was designed which would be called the Relative Structure Index (RSI), which would be unique for each hospi-tal and would enable the relationship to be known between the price per discharge by structure and the average discharge price in the XHUP. For example, if the aver-age discharge price for patients treated at XHUP centres is 2,000 euros, and it cor-responds to a centre to charge 2,350 euros per discharge, the centre would have an RSI 2,350/2,000 = 1.175 with respect to the average discharge price of the XHUP.

Naturally, there were imbalances when it came to applying the continuous hospitals classification since previously the payment was based on a discrete classification. It took an adjustment parameter that allowed modulation of the assignation of pur-chasing to the centres. The adjustment of the RSI allowed the payment model to be implemented.

2 Since we do not have access to costs per process in our environment, we have opted, in the first phase, to use for the entire XHUP the relative costs that have as parameters those corresponding to the Medicare payment system in the USA.

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66 The adjustment of the complexity through new surveys to find out the changes that had taken place in XHUP centres was carried out every five years with the aim of letting a reasonable time pass between one survey and another, mainly due to the risk of creating an inflationary system with relation to the variables, with a clear significance in the structure.

The centre case mix

The systematic gathering of the minimum basic hospital discharge dataset (MBDS-HD) in acute hospitals enabled the implementation of a system of qualitative in-formation about the activity carried out. Thanks to the systematic collection of this information, episodes of hospitalisation of patients can be classified in homogene-ous groups, allowing aspects of hospital activity to be known that favour the study of patients attended, both from the viewpoint of a single hospital and comparisons between centres.

Adoption of the patient classification system

Once the discharge was encoded according to the International Classification of Diseases (ICD-9-CM), diagnosis-related groups (DRG) were chosen as the group consolidator. Once we know the case mix of patients from one hospital we can find out the relative importance of the centre complexity and, by extension, the relative importance of the hospitals in the XHUP.

Each entry is assigned to a DRG, each DRG has a relative weight. As a result of the composition of the discharges treated, the average relative weight of the hospital is ob-tained, which is the measurement of the relative weights of the discharges effected dur-ing a certain period. The relative weight of the XHUP set is obtained in a similar way.

The global relative weight obtained for each hospital refers to the mean relative weight of the entire XHUP. This gives a centred indicator that we call relative re-sources intensity (RRI) of the hospital. The RRI factor represents the position that each centre occupies with respect to the global position of the XHUP with respect to the illness treated. For example, the hospital x represents a mean relative weight of 1.072, and across the entire XHUP in the same period it is 0.887, therefore the hospital x’s relative resources intensity is 1.072 / 0.887 = 1.208.

The mean relative weight of reference for each year, for each hospital, and for the whole of the XHUP is the result of the discharges attended during the first previous annual period.

• Establishment of unit prices for discharges from the XHUP

The purchasing parameter of the hospitalisation line establishes a dual modulation mechanism: recognition of the structure and complexity of the pathology treated by each hospital.

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The total hospital discharges of each centre modulated by the factors of the respec-tive centres constitute the hospital discharges modulated by complexity.

The total hospital discharges of each centre modulated by the factors of the respec-tive centres constitute the hospital discharges modulated by structure.

To determine the unit price of the hospital discharge modulated by structure and of the hospital discharge modulated by complexity of each of the centres of the XHUP, the procedure is as follows:

(AltesH1 x IRRH1) + (AltesH2 x IRRH2) + ... + (AltesHn x IRRHn) =

= Sumatori altes modulades complexitatXHUP

(AltesH1 x IRRH1) + (AltesH2 x IRRH2) + ... + (AltesHn x IRRHn) =

= Sumatori altes modulades estructuraXHUP

Global budget per hospitalisation=

Price discharge complexityXSum discharges modulated by complexityXHUP

Global budget per hospitalisation=

Price discharge structureXSum discharges modulated by structureXHUP

After the prices for discharge by structure and by complexity of all the XHUP are known, the percentages to be applied to hospital discharge modulated by structure and hospital discharge modulated by complexity are determined. All these factors allow the unit price of the hospital discharge to be established.

Establishment of the discharge price for each XHUP centre

The calculation of the amount corresponding to the price of the discharge contracted with each hospital is as follows:

[(% complexity x RRIH1 x Price discharge complexityXHUP)+

(% structure x RSIH1 x Price discharge structureXHUP)] = Price dischargeH1

Currently, the structure percentage is 65% and the complexity percentage 35%, justified by a certain relationship with fixed and variable costs, respectively.

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68 And, consequently, the total sum of payment for hospitalisation is:

Total dischargesH1 x Price dischargeX1 = Total sum hospitalisationH1

Each centre has a discharge price resulting from the operations indicated, which is what allows the hospitalisation line to be contracted.

• Marginalities

One of the factors taken into account when implementing the payment system was to introduce the concept of marginality.

It is considered that if a centre attends one patient over the agreed amount, that discharge must be paid at a percentage of the contracted discharge price. With this the payment system did not become a closed system of purchase by activity but it allowed firstly, the Administration to give coverage to more patients in areas where necessary, and secondly, from the viewpoint of providers, being able to charge high marginals allowed them to optimise costs with the aim of introducing marginal profits with respect to the marginal cost.

Marginal discharges were payed initially at 35% of the contracted discharge price and they have been adjusted up to now in that the payment of the marginal admis-sion depends largely on the expected attendance in the hospital’s area of influence. This avoids the possible induced demand that might be generated.

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4.4 Contracting of ambulatory activityin outpatient appointments

Currently payment per process is still not possible in this product line, above all due to the lack of information. Definitions were given of what was considered to be a first appointment and what was considered to be the reiteration rate.

• Purchasing parameter

The purchase of ambulatory activity services in outpatient appointments is based on the contracting of first appointments, modulated according to the needs of the hospital catchment area.

Definition of purchasing parameters

The definitions of the parameters for purchasing outpatient appointments tend towards a rather clinical concept taking into account the following concepts:

- As a general rule, all outpatient consultation procedures (contacts between the patient and the hospital) generate at least a first appointment.

- The clinical discharge, and not a bureaucratic regulation, is the parameter that determines the end of the outpatient process. Any subsequent outpatient care has to be considered as a first appointment.

- The payment model also introduces two important concepts: the interconsul-tation, which lets changed responsibilities be established and the preoperative anaesthetic first appointment.

First appointment

A first appointment is the event carried out in outpatient consultations that com-plies with one of the following criteria:

- First contact between the user and the hospital which is effected in an outpatient and programmed setting. The users comes from:

· Another hospital.· A primary healthcare team (EAP) and/or specialists from Primary Healthcare (APS).

· Social healthcare service.· Mental health service.

If it is not the first contact between the patient and the hospital, the visit must present one of the following characteristics:

- Although previous episodes exist at the hospital related with the process for which there is an outpatient appointment, it is considered a first appointment when at least one year has passed since any previous appointment for the same process.

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70 - If the patient has gone to Accident and Emergency and later monitoring is carried out at outpatient appointments, the first event is considered as a first appointment.

- If the patient, as a consequence of going to Accident and Emergency, has been admit-ted for hospitalisation, and the later monitoring takes place at outpatient appoint-ments, the first appointment would be the first contact following discharge. It is important to differentiate, therefore, the process that, having begun at an outpatient consultation, leads to admission and later to outpatient monitoring. In this case the second outpatient period is not a first appointment, but a subsequent appointment.

- If a patient attended to at outpatient consultations requires surgery, the transfer of responsibilities from one department to another is considered a first appoint-ment if the second department takes on responsibility for the patient’s care; if the responsibility continues to lie with the first department, it is considered a subse-quent appointment.

- Preoperative anaesthesia is considered a first appointment. This first preoperative visit is paid as a single visit.

Subsequent appointment

This is a programmed outpatient event generated by a first appointment. We distin-guish the following types:

- Subsequent appointment: that which is generated after a first appointment. The appointment takes place subsequently in the same department. This is the usual subsequent visit.

- Interconsultation: any subsequent appointment and for diagnostic needs for a differ-ent service than that where the first appointment took place. The ultimate responsi-bility for the patient lies with the first department, although the events produced by and deriving from this interconsultation are the responsibility of the second.

- Subsequent appointment after admission: that occurring following hospital dis-charge provided that there is a first outpatient appointment for the same process prior to hospitalisation.

• Payment model

This takes into account two important factors: firstly the criteria for reimbursement of the activity and secondly, the volume of appointments to be contracted:

Determination of care levels

Each centre has unique characteristics; certain processes (in a very variable propor-tion according to pathologies and care facilities) do not have to be fully resolved at all hospitals, resulting in a flow of patients between some centres and others. How-ever, certain outpatient appointments need differentiated technological support according to the degree of care required, which leads us to a differentiation of costs.

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Since we have a level of more detailed information, four levels of hospitals are identi-fied in accordance with a discontinuous classification. The four levels correspond to:

- Level 1: hospital isolated from a geographical standpoint or that belongs to the complementary network.

- Level 2: basic general hospital.

- Level 3: reference hospital.

- Level 4: high technology hospital.

The price per appointment is different at each care level.

Contracting mechanism

The steps followed in the contracting of outpatient consultation appointments in hospitals are as follows:

- The number of appointments are contracted according to the needs of the hospital catchment area.

- The centre’s recurrence rate is applied, according to the composition of the first appointments by speciality, obtaining the number of subsequent visits it is neces-sary to contract from the hospital.

- The amount of appointments to be contracted from the hospital is totalled.

- Appointments are weighted by the price per hospital visit.

Total appointments to be contracted = Number of first appointments ++ (Recurrence rate x Number of first appointments)

This figure includes all appointments, whatever their historical origin (activity pro-ceeding from the integration of specialties, from primary healthcare, ie a primary healthcare centre (CAP II), or hospital outpatient service).

Consequently, the budget for the purchase of outpatient activity for a given hospital is:

(Number of first appointments of centre + subsequent appointments of centre)x Price of appointment for hospital level = Budget for outpatient consultations at centre

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72 4.5 Contracting of emergencies activityIn this product line two clearly differentiated and mutually exclusive modes of pay-ment are established:

a) Firstly, a unit price per emergency is determined. As in the case of payment for outpatient consultation activity, four groups of hospitals are identified according to their care structure, with the exclusion from classification of isolated basic general hospitals.

b) It is considered that, because of equal access policies, certain hospitals situated in geographically isolated and / or sparsely populated areas must be treated differently in the payment model. These centres (a total of six) share such common features as small care volumes and similar costs to maintain the infrastructure of the Emergen-cies department with optimal quality parameters. In these cases, with this type of hospital a payment is decided equivalent to the cost of emergency services regardless of the number of emergencies attended.

• Payment model

The total amount contracted at each centre for this line is calculated:

a) For all XHUP centres, except isolated basic general hospitals, the emergency price corresponding to the centre’s structural complexity group is applied to the total emergencies contracted.

Total emergenciesCENTRE x Price per emergencyGROUP = Total sum emergenciesCENTRE

b) For isolated basic general hospitals there is a sole assignation amount directly des-tined to cover the functioning of minimum emergencies services and the volume of emergencies attended is not counted.

Sole assignation maintenance minimum emergency services = Total sum emergenciesCENTRE

3 An emergency is understood as a care event carried out in the accident or emergency area of the hospital; all emergencies attended are included, whether admitted or treated as outpatients. The price of the emergency includes the costs of all the care events necessary to provide correct healthcare assistance.

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4.6 Contracting of the line of specific techniques, treatments and procedures

Specific techniques, treatments and procedures define a set of individualised activi-ties not included in other product lines whose provision is linked to specific care facilities regardless of the complexity of the procedure and the need for patient hospitalisation.

We include the following concepts:

- Minor outpatient surgery. Minor surgery without anaesthetic or with local anaesthetic.

- Day hospital. Application of certain reiterative therapeutic procedures, without hospitalisation. Paradigmatic examples include outpatient oncological treatments, outpatient treatments for patients with AIDS, etc.

- Treatments and diagnostic tests of high complexity. All need special units or facili-ties, which for the main part are located in high technology hospitals. Currently these include:- Radiotherapy treatments.- Stereotactic radiosurgery and neuro-radiology treatments.- Treatments of high complexity:

· Cardiac catheterisms.· Hepatic catheterisms.· Urological high technology.

• Payment model

The purchasing parameter in this payment line is the case treated, regardless of which of the aforementioned processes are involved.

In patients treated with minor ambulatory surgical procedures and day hospital a price is established per intervention or stay weighted by the hospital level. It is agreed that the hospital levels are the same as those established in the outpatient consultation purchasing line.

For other procedures stipulated rates are established per case.

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74 4.7 Specific contracting of certain services

The payment model reserves the possibility of specifically financing certain services or facilities having predetermined characteristics:

- Projects that allow the viability of special facilities of recognised need, that would otherwise be totally unfeasible or would represent an unsustainable cost to the provider company of whom the service is demanded.

- Selective activities that have to be incentivised or regulated, in line with health policy criteria.

- Start of different facilities to reach the productive dimension necessary (new hospitals).

Recognition of the university teaching role at undergraduate and graduate level:

the payment model incorporates in a specific line recognition of direct and indirect costs that are generated at hospitals with postgraduate teaching programmes (MIR, FIR, etc.).

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4.8 Consequences of the application of the model for purchasing hospital activity

The introduction of the payment per activity mechanism led to a number of conse-quences, especially regarding hospital activity. It is worth noting the qualitative and quantitative consequences that occurred as they are an example of the adaptation of the financer and providers to the application of the payment system.

The introduction of the RRI is an improvement on the coding of discharges:

• The discharges with main diagnoses left blank imply a relative weight of 0, which reduces the relative weight of the hospital. Figure 5 shows the reduction in main diagnoses left blank from 5.2% in 1993 to almost 0% in 1999.

Graph 5. Percentage of main diagnoses left blank

• The number of diagnoses per discharge for hospitals, a very important factor when ascertaining the centre’s relative weight, grew from 1.7 to nearly 2.5 during the same period (Graph 6).

0.060

0.045

0.030

0.015

01993 1994 1995 1996 1997 1998 1999

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76 Graph 6. Number of diagnoses per discharge

• An indirect indicator of the quality of hospital coding was the percentage of DRG with complications and / or comorbidity, as shown in Graph 7.

Graph 7. Percentage of DRG with or without complication and / or comorbidity

• As a consequence of the factors mentioned above, the average complexity weight for the totality of the XHUP hospitals increased from 0.8 to 1.01, as can be ob-served in graph 8.

2.500

2.313

2.125

1.938

1.750

1993 1994 1995 1996 1997 1998 1999

100 %

75 %

50 %

25 %

0 %

1993 1994 1995 1996 1997 1998 1999

with c/cwithout c/c

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Graph 8. Evolution of the average weight of the XHUP

Payment per discharge made possible the introduction of a series of efficiency meas-ures such as, for example, reducing average stay. New treatment techniques were applied such as major ambulatory surgery and intrahospital processes reengineering.

The evolution of XHUP discharges was as follows: the total number of discharges between 1993 and 1999 grew from 504,783 to 662,963, but at the expense of such a determining factor as the growth in discharges for stays of between 0 and 2 days. As shown in Graph No. 9.

Graph 9. Evolution of discharges of patients attended in the XHUP

1.100

0.917

0.733

0.550

0.367

0.183

0

1992 1993 1994 19941995

19951996

1995 1996 19961997

1997 19971998

1998 19981999

19992000

1999

700,000

525,000

350,000

175,000

01993 1994 1995 1996 1997 1998 1999

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78 However, more important was the introduction of major ambulatory surgery, increasing from one hospital with MAS (Viladecans Hospital) to 49 hospitals in the public network in 1999. See graph 10.

Graph 10. Hospitals with MAS

Consequently, patients treated via MAS increased from 3,741 to 60,033 between 1993 and 1999, as shown in graph 11.

Graph 11. Patients treated via MAS

50.0

37.5

25.0

12.5

0

1992 1993 1994 1995 1996 1997 1998 1998

70,000

52,500

35,000

17,500

0

1993 1994 1995 1996 1997 1998 1999

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4.9 Consequences of purchasing by activity

As with any payment system with years of evolution, a series of pending issues ex-ist that deserve to be reconsidered. Thus, the “discharges” product line should be reviewed in three areas:

• The hospital structure: the concept of levels of structure according to a continuous classification of hospitals is correct, but it may pose methodological problems in the adaptation of theoretical structures to reality, which deserves in-depth reflection.

• The case mix. Currently the relative weight of the cost of hospital discharges is considered without bearing in mind that many procedures are performed on an outpatient basis and involve lower costs. The case mix should be divided into pay-ment per outpatient discharge and payment per admission, which would allow us to better adjust the relationship between cost (relative weight) and price.

• The classification systems for inpatients. It would be useful to be able to study the implementation of isocost groupings being used in countries with a healthcare system similar to ours, ie the patients grouping being used in Australia, the UK or Germany, for example.

• New payment methods. In 2006 a payment by processes form of payment started to be used in English-speaking countries, the P4P (pay for performance), which it would be worth studying, since in our environment there is a series of experiences related to continuity of care.

In relation to the line of outpatient appointments, little progress has been made with respect to the initial data, but the computerisation of medical records is now a reality in most hospitals in Catalonia. Consideration should be given to an out-patient payment system based on Ambulatory care groups (ACG), Ambulatory patient groups (APG) or similar, and the applicability of these payment systems in our environment verified.

With respect to emergencies, pilot schemes are being applied similar to those used for outpatient consultations.

New lines for updating

• Subacute care: it should be currently taken into account that, in fact, subacute care units have already been created when we refer to palliative care units, but the payment system would have to be extended to early discharges of acute patients, who would require more intensive care and attention. We must study the applica-tion of payment mechanisms based on the complexity of care and its application in our setting.

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80 • Day hospitals: with respect to this line of action, it is necessary to define the types of problems treated and the relationship with home care from other care lines.

Finally, the big unresolved issue in the payment system was, in its day, studying hospital costs, as the close relationship between costs and prices is well known.

Now that it is known that there is a clear improvement of computer systems with regard to hospital costs, it would be important to re-start studies on costs, espe-cially on the analytical costs of admission, outpatient, emergency and other lines to reach costs per end product (discharges, consultations, emergencies) with a uniform methodology that can be extrapolated.

Annex. Structural parameters of the different hospitals used to define the grade of membership

Total number of beds available for public use for admitting acute patients.

- Beds commonly used for medical conditions.

- Beds commonly used for surgical pathologies.

- Beds commonly used for gynecology and obstetrics.

- Beds commonly used for pediatric services.

- Beds used for intensive care or coronary care units.

- Beds used for treatment of major burns.

- Places for neonatal care.

- Other beds used for acute care patients.

- Consulting rooms for outpatient activity. Hourly usage.

- Examination rooms. Hourly usage.

- Medical-surgical day hospital places.

- Diagnosis and treatment bays for emergency care.

- Places for emergency observation.

- General and specific radio-diagnosis rooms. Hourly usage.

- Operating theatres and resuscitation spaces. Hourly usage.

- Labour rooms and delivery rooms.

- Doctors in postgraduate training for MIR system.

- Transplant activity and types.

- Undergraduate teaching.

- Equipment for radiotherapy. Hourly usage.

- Tertiary cardiology activity. Extracorporeal surgery.

- Other high-technology equipment. Hourly usage.

Chapter 5

The pilot plan for purchasing on a capitation basisFrancesc Brosa

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The pilot plan for purchasing on a capitation basis

5.1 BackgroundIn the late nineties a large array of payment models was reached based on the con-tract per service line and provider.

This type of contracting maximizes the objectives and specific products of each line, often hindering the establishment of cooperation policies between different provid-ers, whether of the same service line or different care levels (Table 1).

Table 1. Payment systems of the different service lines

Acute care Social healthcare

Mental health

Primary healthcare Others

Activity

StaysResource

use groups (RUG)

Hospitalisation

Discharges

Modulated by

complexity and structure

Other lines

Outpatient appts,

emergencies, day hospital

Budget PADESUFISS Programmes

CapitaAccording to age, sex

and rurality

Pilot plan

For this reason, in 2002 CatSalut promoted a pilot experiment of purchasing services on a population basis, with the aim of establishing a coordinated action of all provider organisations in order to achieve a comprehensive provision of services putting the citizen at the heart of the system and integrating health promotion, prevention and treatment of illness.

Considering the peculiarity and particularity of the Catalan healthcare model, which separates the functions of financing from those of the provision of services, it was decided to define a capitation allocation to some pilot areas, with the following objectives:

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84 - Promote equity of access to healthcare services.

- Improve system efficiency by encouraging the coordinated management of health-care services and continuity of care.

- Improve the quality of health services so that patients receive adequate healthcare for their needs at the most appropriate care level.

- Stimulate integration between providers.

- Spread responsibility among all system agents, sharing part of the management risk with the providers.

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5.2 MethodologyTo make the pilot test effective, specific legislation was passed based fundamentally on determining the capitation allocation in a territory.

The first step was to calculate the capita of Catalonia and the average allocation of net current healthcare expenditure per inhabitant. This was established as the basic parameter of reference for the calculation of the capita to be applied to each area of the pilot test. The capita of Catalonia is the result of the division of the budget as-signed annually to health among the officially recognised resident population.

To define the budget assigned, a series of entries were taken from the global budget of the Department of Health, such as those destined to the Department’s central services. To ensure more equal distribution, also removed were entries designed to guarantee territorial equity among territories, as well as those destined to the care of tertiary pathology (these items were later allocated to territories that needed it). Finally, entries related to certain centralized programmes of the Department of Health were eliminated (Table 2).

Table 2. Method of calculation of the net expenditure per inhabitant of Catalonia

Numerator: budget of the SCS/ICS, except:• Expenditure of central services: staff costs, running costs and costs

of goods and services• Expenditure on teaching and research• Fund for intra-community and immigrant territorial imbalances• Healthcare policy for balance: - Tertiary pathologies - Departmental Special Interest Programmes - Isolation

Denominator: reference populationUntil 2003, the reference for the calculation of this parameter was the register of inhabit-ants. From 2004 the reference became the Central Register of insured persons (RCA)

To determine the reference population, throughout the pilot tests phase two indica-tors were used. Until 2003 the census register information was used and from 2004, the population residing in the territory according to the database annually drawn up by the Catalan Health Service for each year.

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86 Table 3 shows the evolution of the net expenditure per inhabitant in Catalonia from 2002 to date, published annually by resolution of the Regional Minister for Health and Social Security

Table 3. Evolution of net healthcare expenditure per inhabitant

Year Average capita of Catalonia Annual increase (%)

2002 984.08

2003 724.45 5.90

2004 855.54 18.10

2005 913.11 6.73

2006 987.54 8.15

2007 1061.51 7.49

2008 1094.06 3.07

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5.3 Assignment of pilot zonesInitially five geographical areas were established as capitation allocation zones dur-ing the course of the pilot test. The five areas were chosen as structures with well differentiated offerings to be able to offer the model later in other areas. The charac-teristics of the existing offering in each area are described in Table 4

Table 4. Areas, population and healthcare services of the pilot test zones

Zone Basic health

areas

Acute care hospitals

Social healthcare

centres

Mental health

centres

Number of provider

organisations

Population

Osona 10 1 2 2 8 128,927

Altebrat 4 1 2 2 2 41,199

Alt Maresme-Selva Marítima

8 2 4 2 2 160,462

Cerdanya 1 1 1 2 1 13,350

Baix Empordà

5 1 1 3 2 100,567

Total 28 6 10 11 15 444,505

The project population represents 70% of Catalonia’s population

To formulate the model it was necessary to know the healthcare expenditure in the areas mentioned, and for this an exhaustive analysis of the cost of the various lines of care was conducted, also covering pharmaceutical costs, healthcare transportation (emergency and scheduled) and orthoprosthetic services. Subtracted from the cost allocation of all patients resident in the capitation area were those who had been treated in acute hospitals outside the pilot area. It was assumed that other lines of care were being attended to within the capitation area.

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88 5.4 Risk adjustmentsOnce the historical allocation was known, the final allocation of the capitation zones was made through risk adjustment. Risk adjustment is the process whereby it is attempted to adjust the allocation to the healthcare characteristics of each person. An attempt is made to estimate what the health expenditures of an individual for a specified period would be, if this individual were to behave like the average of people with similar health needs. In the pilot experiment, risk adjustment was based on two factors: pharmaceutical expenditure and costs of hospitalisation of acute patients according to complexity, both weighted by age and sex structure, as shown in Graph 12.

Graph 12. Risk by age groups

Initially no other risk adjustment factor was taken into account due to the lack of exhaustive information that can be extrapolated, although the integration of other elements that could adjust the risk was planned, mainly morbidity data in primary healthcare and socioeconomic variables.

7.00

6.00

5.00

4.00

3.00

2.00

1.00

0

1-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 90-94<1 5-9 15-19 25-29 35-39 45-49 55-59 65-69 75-79 85-89 95 i +

FemalesMales

Factors

< 1 year 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44

Males 3.89 0.60 0.37 0.30 0.31 0.36 0.38 0.43 0.49 0.59

Females 3.41 0.45 0.30 0.26 0.30 0.39 0.58 0.66 0.58 0.58

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 i +

Males 0.70 0.97 1.26 1.40 2.83 3.37 4.38 3.89 4.32 4.26 6.43

Females 0.63 0.80 0.92 0.91 2.08 2.42 2.96 3.03 3.46 3.63 4.10

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The end result is the distribution, to each capitation pilot zone, of an amount that will be the result of multiplying the number of inhabitants of the area by the aver-age expenditure per inhabitant by a correction factor that takes into account the different related factors, as reflected in the following formula:

Allocation based on the population of a territory =Capita per inhabitant in Catalonia x Correction factor x Population of the territory

After defining the allocated resources per capita, the amounts are incorporated into each area that had initially been subtracted from the budget allocation for the whole of Catalonia with reference, for example, to the increased allocation for increased demand in summer periods, isolation programmes, etc.

For some expenditure items, such as pharmaceutical costs or orthoprosthetic services, agreements are reached with the provider organisations of the territory on a maximum expenditure ceiling for a certain time period (usually one year). If this maximum expenditure is not reached, or is exceeded, the deviations are divided between the SCS and provider organisations according to the risk percentage that has been assumed and agreed at the beginning of the period.

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90 5.5 Pilot test operationThe launch of the pilot test was regulated via an order (Order SSS/172/2002, of 17 May), which established the following aspects:

- Geographical sphere

- Population attended

- Annual establishment of a coordination agreement between the SCS and the pro-vider organisations in which care targets are set, as well as the calculated capitation allocation and the risk percentage for those items to which a maximum expendi-ture is assigned.

- Subsequent settlements at the year-end.

- Setting up of a monitoring committee composed of eight members: one from the Department of Economics and Finance, three representatives of provider associa-tions (Hospital Consortium of Catalonia, Catalan Institute of Health and Catalan Hospitals Union) and four from the SCS. Furthermore a committee was formed to monitor the project in each zone, consisting of members of the SCS and the providers in the area.

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5.6 Evolution of the pilot testThe pilot test launched in 2002 has been extended each year until 2008, gradu-ally expanding its area of influence to a total of 25 zones, with a population of 3,437,567 people representing 45.82% of the population of Catalonia. Table 5 shows those territories where the experiment has been implemented to date.

Table 5. Zones that currently form part of the project

Year of incorporation Population (year 2008) Territory

2002 522,081 Altebrat


Baix Empordà

Osona

Cerdanya

2005 991,358 Alt Penedès

Garraf

Maresme

Barcelonès Nord

Montsià

2006 1.924,128 Alt Urgell

Pallars Jussà-Pallars Sobirà

Alt Camp-Conca de Barberà

Baix Camp

Baix Ebre

Gironès-Pla de l’Estany-Selva Interior

Alt Empordà

Garrotxa

Ripollès

Bages-Solsonès

Berguedà

Baix Montseny

Granollers

Baix Vallès

Vallès Occidental Oest

Total 3,437,567 Total

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92In table 7, the evolution of the capita of each area can be observed from the mo-ment of its entry into the pilot experiment until the year 2008.

Table 6. Evolution of the territorial capita

Territory Year 2002

Year 2003

Year 2004

Year 2005

Year 2006

Year 2007

Year 2008

Altebrat 810.22 864.34 951.70 988.26 1077.70 1169.68 1224.36


610.27 623.46 665.77 675.79 712.61 752.82 807.31

Baix Empordà 626.96 645.77 698.81 697.43 724.76 767.37 777.77

Osona 681.34 723.29 733.28 744.92 801.09 872.88 924.37

Cerdanya 749.82 748.94 928.43 954.84 1001.34 1104.71 1238.88

Alt Penedès 782.17 845.73 896.02 925.36

Garraf 692.14 765.74 802.82 824.81

Maresme 756.15 768.58 855.05 841.00

Barcelonès Nord 1002.96 1056.37 1133.59 1179.94

Montsià 812.67

Alt Urgell 981.02 1131.15 1288.69

Pallars Jussà-Pallars Sobirà 1166.28 1283.37 1487.05

Alt Camp-Conca de Barberà

864.00 921.39 939.58

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Territory Year 2002

Year 2003

Year 2004

Year 2005

Year 2006

Year 2007

Year 2008

Baix Camp 980.23 1033.80 1077.65

Baix Ebre 1060.22 1193.14 1281.36

Gironès-Pla de l’Estany-Selva Interior

960.68 1017.03 1059.82

Alt Empordà 704.21 705.69 716.06

Garrotxa 784.60 799.10 818.69

Ripollès 1012.82 1054.93 1094.28

Bages- Solsonès 995.84 1048.88 1079.95

Berguedà 1129.35 1161.19 1190.77

Baix Montseny 622.55 703.57 720.55

Granollers 709.35 780.85 816.83

Baix Vallès 679.53 737.75 774.92

Vallès Occidental Oest

784.11 837.11 882.03

Chapter 6

Evaluation of the captitation testJosep Maria Argimon

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Evaluation of the capitation test

6.1 IntroductionAs discussed in the previous chapter, in 2002 a new population-based payment sys-tem was launched with the aim of improving integrated care for users, by promot-ing coordination among providers and encouraging, among other things, equity of access to health services for the population.

The introduction of a new population-based purchasing model aims to overcome the problems caused by purchasing that is fragmented into service lines and progress to-wards an integrated purchasing of health services, through allocation of a per capita budget to the providers operating in a territory. This new purchase model also re-quires a new way of evaluating, more focused on assessing the global results obtained by the care process than the activity carried out by each provider (Figure 1).

Figure 1. Evolution of the purchase of services and evaluation objectives

In 2006 an evaluation was made of the pilot from different aspects:

• Evaluation of health indicators. In order to monitor the experience, the evalua-tion was carried out annually of a set of health indicators grouped by dimensions: accessibility, resolution, efficiency and satisfaction.

• Qualitative assessment. In 2005, a qualitative study was conducted to identify the factors that had helped and hindered the implementation of the population-based purchasing system. To obtain this information, interviews were held with key people involved in the process, from both provider organisations and the Catalan Health Service, with different documents being analysed.

Structure

Activity

Results

What do we have?

What do we do?

How do we do it? What do we achieve?

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98 6.2 Analysis of health indicators A set of indicators that, as far as possible, met the ideal characteristics of an indica-tor, were selected and defined. It was decided that they should reflect important aspects of the care process as close as possible to final health outcomes. This deci-sion was based on the fact that process measurements are more sensitive to detect-ing differences in care quality, easier to interpret and can be directly attributed to the performance of the healthcare services, unlike the final measurements of health outcomes, which depend on many factors.

Some of the indicators analyzed are presented in Table 7. The indicators fall into the dimensions of accessibility, resolution/effectiveness (including safety), efficiency and citizen satisfaction, following a conceptual framework similar to that of other countries. In addition, attendance for various healthcare services was monitored.

The specific questions formulated during the evaluation process were as follows: did the geographic areas participating in the pilot test show different results to those of similar areas that maintained the current contracting system? Did pilot areas im-prove their results with respect to the previous year? Did pilot areas obtain satisfac-tory results with respect to a standard value?

Along the same lines, and in order to make the necessary comparisons, certain con-trol areas were selected using multivariate cluster analysis according to the ageing of the population, geographical density, household disposable income and the area’s resolution capability. Moreover, the results of the pilot area were compared with those obtained the previous year and with those of the whole of Catalonia.

Table 8 shows an example of how the results were presented. In order to establish a system that would allow evaluation of the average quality level of the pharmaceuti-cal service in each pilot area with respect to the average level of Catalonia, a syn-thetic indicator was used where Catalonia had the value 1. Values above 1 implied a higher quality than the average for Catalonia, and values below 1 a lower quality. This indicator was a synthesis of the following prescription indicators: high intrinsic value, selection indicators, new therapeutic products and generic drugs. In general, it can be seen that almost all the pilot areas had higher levels than the control areas and the average for Catalonia. As can be verified, the evolution of the indicator was practically stable over the previous period. In order to ensure that the interpreta-tion of results was agile, quick and direct, a scale was applied following the criteria shown in Table 8.

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Table 7. Main health indicators analysed in the pilot test

Accessibility

• Percentage of population aged 75 and older assigned to the EAP served by the home care programme (ATDOM).

• Patients on hospital surgery waiting list: patients ratio per 1000 people.

• Patients on hospital surgery waiting list and resolution time in months.

• Participation in the Programme for early detection of breast cancer.

• Coverage of the Programme for early detection of breast cancer.

Resolution/effectiveness

• Influenza vaccination coverage among the assigned population aged 60 or over.

• Tetanus immunisation coverage in the assigned adult population attended to.

• Discharges avoidable with suitable hospital admission.

• Percentage of caesarean sections.

• Radical breast surgery as a proportion of total breast cancer surgery.

• Discretionality (excluding discharges avoidable with suitable hospital admission and additional purchase).

• Discharges avoidable with suitable hospital admission.

• High intrinsic value of pharmaceutical prescription.

Efficiency

• Percentage of major ambulatory surgery (MAS), funded by CatSalut as a proportion of scheduled surgical activity.

• Pharmaceutical prescription of selection indicators (SI).

• Pharmaceutical prescription of new therapeutic products (NT).

• Prescription of generic drugs.

• Global synthetic index of pharmacological prescriptions.

Satisfaction

• Primary care: degree of user satisfaction in general (0 to 10).

• Primary care: percentage of patients who would return to this primary healthcare centre.

• Hospital care: degree of user satisfaction in general (0 to 10).

• Hospital care: percentage of patients who would return to this hospital.

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Pilot zone Value

Comparison with:

control value Catalonia (1.00)

previous period

Altebrat 1.10 0.86 1.12 34

Baix Empordà 1.28 0.83 1.27 34

Alt Maresme- Selva Marítima 1.10 83 1.12 34

Osona 1.13 1.03 1.08 4

Cerdanya 0.63 — — 666 0.59 4

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6.3 Evaluation of health indicators by dimensions

In the accessibility dimension, a broadly favourable trend was observed when comparing pilot capitation zones with control zones. With relation to the indicator of the population aged 75 and older assigned to the EAP and attended under the ATDOM programme, the percentage was higher in capitation areas than in control areas.

With respect to waiting lists, the results also were better in all capitation areas with respect to the average of Catalonia. As regards population coverage and participa-tion in screening for breast cancer, all pilot capitation areas were above the control areas with very significant differences. With respect to the average of Catalonia, all capitation areas were higher than the average, except the Cerdanya, which was slightly lower.

In general, in capitation areas the results of the indicators of the efficiency dimen-sion stood out favorably when compared with control areas and the whole of Catalonia. It must be remembered that what was being measured was the favour-able relationship between the economic cost of human and material resources used by the healthcare services and outcomes achieved in the care process. In this regard, the endeavour made by the different hospitals in the capitation areas to devote more effort to ambulatory surgery as a proportion of total scheduled surgery must be un-derlined. Also highlighted was the low percentage of pharmaceutical prescription of drugs for new therapeutic areas in comparison to the control areas and the average for Catalonia.

In the dimension of resolution / effectiveness, no definite trend was observed, as the results were highly heterogeneous. Among the positive highlights, the capitation zones scored higher in aspects such as coverage of anti-influenza vaccination, with percentages between 65.6% and 75.5% in pilot capitation areas and anti-tetanus, with percentages higher than those of Catalonia and the control areas. The pilot capitation areas also stood out favorably in general in the indicator of the intrinsic value of pharmaceutical prescriptions.

In contrast, the capitation areas did not present such favourable values in areas re-lated with inadequate procedures, such as the high number of avoidable discharges (hospital admissions that could be prevented by some procedures specific to the first care level, including prevention of the occurrence of the health problem, early diagnosis and the treatment of acute episodes of illness, and / or the control and monitoring of disorders with chronic evolution), the percentage of Caesarean sec-tions or the number of radical mastectomies.

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102 Regarding the satisfaction measurement, the results of the satisfaction surveys plan of CatSalut cover holders, with respect to primary and hospital care, were more favourable in capitation areas than in control areas.

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6.4 Qualitative evaluationAs noted above, the main purpose of the qualitative evaluation was to identify factors that could favour or impede the implementation of a population-based purchasing system in Catalonia.

For the study, a theoretical sampling of documents and respondents was carried out, including documents that could provide information on strategic and organi-sational changes to improve the coordination of care that had been developed after the introduction of the test (Table 9).

Table 9. Sample of documents analysed in line with the capitation evaluation zones

Documents Altebrat Osona Baix Empordà

Alt Maresme -Selva M.

Cerdanya

CatSalut and providers cooperation agreement, annexes I and II 2001-2005

4 4 4 3 4

Annex II assessment 2 2 3 3 1

Reports on the healthcare region 2000-2005 5 5 5 5 5

Providers’ reports 2001-2005 3 3 3 3 3

Cooperation agreement between providers 1 1 1 1 a

Agreement on the formalisation of partnerships

a 0 a a a

Cooperation agreement documents a 6 2 a a

Strategic plans or other strategic documents 2001-2005

a 1 2 a a

Minutes of capitation meetings 1 165 1 1 a

Annual allocations per capita 0 0 3 3 0

Other documents released 7 10 20 0 0

a = has not been developed in the territory.

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a) Directors of providers (territorial and multiterritorial at central, regional and local level).

b) Health professionals.

c) Directors of the buyer (central and regional services).

The sample was restricted to persons who had contact with the test due to igno-rance of the same by the respondents who had no contact with it. A link was sought in each region to identify the respondents according to the defined profiles.

Tabla 10. Composition of the samples of respondents according to the capitation evaluation zones

Type of respondent Altebrat Baix

Empordà CerdanyaAlt

Maresme -Selva M.

Osona Central Level Total

Managers territorial providers

— 2 2 1 6 — 11

Managers multiterritorial providers central *

— — — — — 4 4

Managers multiterritorial providers regional *

1 1 1 1 1 — 5

Managers multiterritorial * providers territory

3 -— — 1 2 — 6

Managers central buyers — — — — — 4 4

Managers buyers health regions

1 2** 1*** 3** 1*** — 5

Professionals 3 4 3 3 3 — 16

* Multiterritory organisation: manages health services in several areas of Catalonia.** Two respondents covering the two areas.*** The respondent is the same in the two areas.

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Methods used for the collection of information were, firstly, the analysis of docu-ments to find information on the processes developed in the pilot regions in order to improve coordination of care and, secondly, semi-structured individual interviews were held to obtain the perspectives and opinions of respondents about changes in the coordination of care within their territories. An interview guide was developed, with a common part and a specific part according to the group of re-spondents. The interviews, lasting 60-90 minutes each, were taped and transcribed verbatim.

A narrative analysis was carried out of the information content using the software Atles-ti, segmenting data from the interviews by group of respondents and issues, and documentary information by areas and issues. Categories for analysis were generated in a mixed form, from the interview guides and those emerging from the data (Table 11). To ensure data quality, information was triangulated by compar-ing several sources of information, techniques, and groups of respondents. Three analysts with different training and a good knowledge of the context took part in the analysis.

Table 11. Analysis categories

Analysis categories Analysis subcategories

Partnerships intro-duced in the capitation evaluation zones

Partnerships between providers in the territory

Opinions on the implementation of partnerships

Test tool: joint agreement between providers and buyer

Changes introduced among territory providers

Strategic dimension

Organisational Structure

Coordination mechanisms between providers - Test monitoring - Pooled risk management - Care coordination

Awareness and dissemination of the test

Test objectives

Allocation form

Global test strategies

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Analysis categories Analysis subcategories

Opinions of key players

Pilot test in general - Contributions of the test - Difficulties in the methodological development - Objectives of the pilot test - Enablers of the evolution of the pilot test - Inhibitors of the evolution of the pilot test

Test elements - Criteria of choice of the territories - Formula for the calculation of the capita - Risk management - Objectives set by the buyer - Invoicing system

Collaboration in the territory - Enablers and inhibitors of collaboration in general - With providers with presence in different territories

Buyer’s role - Factors that facilitate and inhibit the efficacy

of the implementation

Proposed changes Partnerships in the territories

Objectives set by the buyer

Formula for calculating the capita

Risk management

Buyer’s role

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6.5 Results of the qualitative evaluationBelow are the main results of the qualitative study and the strategies that were used to obtain the results.

Only in one area had the providers involved established a formal partnership. Re-spondents identified as potential hindering factors the fear of losing the identity of each organisation, the legal personalities and managers’ level of interest in partici-pating. Other factors that appeared to influence the establishment of partnerships were the number and size of providers in the territory and prior experiences.

In terms of changes in providers in relation to the strategic dimension, the organi-sational structure and coordination mechanisms had been limited. In fact, in most territories no common strategic dimension had been developed, nor had organisa-tional changes been made. However, in all territories some mechanisms had been introduced for coordination between providers, mainly for monitoring the test (standing committees) and for pooled management of risks, or for the control of pharmaceutical costs (pharmacological guides, objectives for professionals, training in the use of drugs). Instead, the joint development and implementation of mecha-nisms for improving coordination of care had been variable. According to respond-ents, although communication had improved, the perception of temporality of the test had limited more extensive development of the same.

Knowledge of the theoretical aspects of the test and the joint actions developed were only found in the discourse of managers, while dissemination to the professionals of the institutions had generally been poor.

Respondents agreed to consider the capitation-based payment system as a good alternative to the current system and felt that, overall, the test had initiated a para-digm shift, had provided a stimulus for dialogue and had managed to direct provid-ers towards the territory and collaboration. Confidence and transparency among providers had also improved. However, numerous weaknesses were identified.

The interviewees shared the view that the pilot had been implemented with weak methodological foundations that had hindered its development. The willingness to cooperate and good relationship among people who represented the provider organisations was the main facilitator. Hindering factors were identified related to the context (incomplete reform of primary care, characteristics of the health system with multiple providers and a segmented care model, the concomitance of other programmes and the change in government), to providers (dissemination limited to professionals, capitated territories mismatched with the territorial limits of any provider, different institutional cultures, impossibility of transferring resources and professionals, etc.) and to the buyer (changes in health regions and territories belonging to two regions, etc.).

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108 The buyer and provider agreed to stress the willingness to participate as a criterion for selection of the territory, but while the buyer added the characteristics of the ter-ritory provider, the latter mentioned the good relationship with the buyer.

Regarding the formula for calculating the capita, the buyer and providers agreed on considering a feasible formula, based on the historical budget, which penalized the more efficient territories. The providers also thought that it was not sufficiently transparent nor sensitive to population changes.

On the pooled risk management, there were divergent views. While the buyer thought risk was shared on everything manageable, providers felt that some of the items were not really risk (outpatient dispensing of hospital medication, catastroph-ic risks). Both groups of respondents agreed on the limitations for the management of items relating to transport and its users, as well as difficulties in implementing corrective measures due to not having the information necessary in time. Among the limits to pooled risk management, they identified interference from local politi-cians, the limited ability to affect the results in some of the institutions participating and difficulties in the assigning of users to organisations.

The interviewees shared the view that collaboration between the providers of the territories, facilitated by the specific characteristics of individuals, was good. They attributed some of the difficulties encountered to the weak management capacity and co-responsibility of the territorial operating units of multiterritory providers, relations with the central levels, political interference in the governing bodies and limited knowledge of the test of the professionals involved in the care activity.

Those interviewed offered some recommendations on the main problems identi-fied: more promotion of partnerships, improvement of objectives with the focus on results, negotiated and linked to the variable part of the contract; improved calcu-lation formula with the inclusion of variables of need and sensitive to changes in population; elimination of pooled management of the risks of unmanageable items; adaptation of information systems to be able to access information with adequate time; more support from the buyer and greater involvement of providers in meth-odological development and adaptation of the territories.

In conclusion, the qualitative assessment from the viewpoint of those involved showed that the implementation of the pilot test had obtained limited results, geo-graphically and temporally, with respect to the processes of integration of care in the territories, and indicated that CatSalut should develop, in addition to purchasing, effective policies to improve coordination and exercise its regulatory function with the aim of eliminating the structural barriers that hindered collaboration.

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6.6 Elements of the futureIn general, the outcome of the evaluation of the pilot test shows that the popula-tion-based financing instrument has proved useful for generating changes in the organisation of providers and to guide towards a more integrated model that places the citizen at the heart of the system.

From the result of the experience it can be concluded that it is necessary to improve the allocation mechanism, introducing new factors that enable better risk adjust-ment. It can also be concluded that incentives must be created that strengthen cross-cutting actions in order to promote prevention, care, treatment and rehabilita-tion wherever it is more efficient.

When the pilot test reaches the metropolitan environment, it highlights the need to address the management of patient flows between territories. It so happens that the five territories of the pilot test are outside the metropolitan area and their level of interaction is quantitatively much smaller.

Per capita payment implies the establishment of inter-invoicing mechanisms between the different capitated areas. However, this system generates the need to create a powerful organisational structure and that consumes staffing resources (especially inappropriate in a limited budget environment). Apart from this, inter-invoicing would formally set up mechanisms of competition between territories.

Some additional steps must be taken therefore, and we will discuss these in the next chapter.

Chapter 7

Bases for the definition of a payment model with a territorial baseFrancesc Brosa and Josep Jiménez

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Bases for the definition of a payment m

odel with a territorial base

7.1 IntroductionIn this chapter we will define the bases that should inspire the definition of a terri-torial-based payment model, building on the experience accumulated over nearly eight years of the population-based purchasing of services pilot experiment.

In developed countries, factors such as ageing, changes in the epidemiological pat-terns of health problems, the emergence of new diagnostic and therapeutic technol-ogies and increased expectations in relation to health services, both for citizens and for health professionals, mean that there is a mismatch arising between the increas-ing demand for healthcare and the limitations posed by available resources.

Given this situation, health services must respond and adapt to this new context, without compromising the sustainability of the system. Thus, the report Crossing the Quality Chasm (Institute of Medicine, 2001) proposes changes on four levels of the U.S. health system, changes that could spread to Europe:

1. Large scale changes related to the country’s health policy, including reforms in payment systems, accreditation, professional training, etc.

2. Changes in organisations and institutions that provide health services, so as to develop information systems that provide safer and more efficient medical care, which encourages professional development through continuing education, and to increase teamwork and cooperation with other organisations.

3. Changes on a micro-management scale (primary care teams, hospital services, etc.) designed to ensure that doctors, who are the ones that assign the largest part of resources of the systems, have the knowledge, skills and attitudes necessary to make decisions that are cost effective.

4. Introduction of a culture of transparency and accountability at all levels of the health system.

The ultimate goal of this adjustment is to achieve a patient-focused healthcare system that guarantees equity, effectiveness and efficiency of the services provided. With this perspective, the Catalan healthcare model is considering a shift from a system organized on the basis of levels of care (primary care, specialized care, social healthcare, mental healthcare, etc.) to a model based on the integration of services .

Given that these organisational changes must be accompanied by changes and / or adjustments to compensation instruments to align incentives with targets, in 2002 CatSalut promoted a project to test a population-based services purchasing model for the comprehensive contracting of services in several areas of Catalonia. In paral-lel, the administration chose a model based on decentralisation, with participation of local government, which has resulted in the creation of regional health govern-ments (GTS). These GTS need to have an allocation of resources to ensure equal

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114 access to a portfolio of homogeneous services throughout the territory, continuum of care and system efficiency, and based on transparent criteria that stimulate the goal of services integration.

As mentioned in the previous chapter, the pilot testing showed that the model tested could be a useful tool in this process, but also highlighted the need to adapt the design methodology to be able to extend it across the region.

To make this possible, the Catalan Health Service has been working since early 2008 with the associations of providers (Catalan Hospitals Union, Hospital Con-sortium of Catalonia, Catalan Health Institute and Association of Health Centres, ACES) to analyze the results of the population-based services purchasing pilot test and to adapt the calculation methodology to current requirements, in line with the evaluation of the experiment.

This chapter presents the methodological bases and the criteria used for the de-velopment of the new population-based territorial allocation model for Catalonia, whose implementation is currently in the work and consensus phase.

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7.2 Objectives of the modelThe aim is to define a model of resource allocation to the territory that encourages the networking of providers in relation to the needs of patients and to guarantee equity, effectiveness and efficiency.

Specific objectives:

• Encourage the development of integrated health systems to meet the care needs of the population:

- Placing the citizen at the heart of the system.- Facilitating cooperation rather than competition among different providers

and care levels.

• Improve efficiency through a more coordinated management of the healthcare system:

- Defining procurement systems that favour the coordinated management of resources, continuity of care and collaboration among providers.

- Seeking substitution effects between lines.- Eliminating duplications.- Orienting the organisation towards the end product: the health of citizens.

• Eliminate competition between areas by incorporating compensation between territories due to population shifts to the model’s calculation.

• Stimulate improvement in the quality of healthcare by situating care at the most appropriate level.

• Incorporate prevention, promotion and protection of health.

• Share responsibility for the different levels of care by transferring part of the risk to providers.

The bases on which work has been done to formulate the model have taken into account the following basic principles:

• Resource allocation is made on territorial basis.

• The model must be based on the needs of the population.

• The model must be understandable, objective, transparent, stable over time, cred-ible and based on reliable data.

• Based on the monetary value of the capita represented by current financing, the model must allow establishment of which horizon each territory must reach.

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116 • The term must be defined for the current situation and the timing of this change to evolve towards the theoretical situation defined by the model with viability criteria.

• Contracting will still be carried out through the purchase of services from differ-ent providers individually.

• Contracting has to incorporate the capacity for incentives, in accordance with the achievement of explicitly defined objectives.

• The objectives of accessibility and resolution defined have to promote the inte-gration and coordination of services between different providers and care lines, and should be reflected in the coordination agreement for the population-based services purchasing system and the contracts established with different organisa-tions in the region.

• The evaluation of the model must take into account, furthermore, the results in terms of health and satisfaction of users.

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7.3 Methodological basesThe model proposed envisages that the resources that reach a territory be defined based on the sum of three concepts:

1. Basic capita: amount corresponding to the core portfolio common to all territories. This amount is allocated territorially based on three parameters:- Population of the territory- Average capita of Catalonia- Territorial correction factor

The formula for calculating the allocation to the territory is a key element in pro-viding the model with consistency and credibility. To achieve this, it is important that the formula incorporates, besides the strictly population-based criterion, other variables such as demography, population dispersion, income level, cover-age, etc., allowing the inclusion of characteristics typical of each territory as well as the care needs of their population, so that the allocation of resources is as fair and adequate as possible.

The evolution that is taking place regarding the implementation of information systems, especially the progressive introduction of the MBDS for primary care and others, will allow refinement of the analysis of morbidity treated and prob-ably will spark a qualitative leap for the territorial allocation system.

2. Tertiary and high complexity procedures: the amount corresponding to the payment for reference activities aimed at attending to a broader population than that residing in the territory where these activities are located, so that such activi-ties are not evenly distributed in the territory. The amount would be allocated through payment per case.The evaluation of high complexity is based on a detailed analysis of care flows between GTS, based on MBDS data.

The list is reviewed critically with input from industry experts and aims to be re-newed periodically to incorporate new high-complexity care features and remove from the list those activities that have entered the entire network.

3. Programmes of special interest for the Department of Health (PEIDS): amount corresponding to the financing of these programmes.In this way, the model allows the theoretical allocation to be determined for each territory on the basis of:

Allocation (euros) = Basic capita + High complexity + PEIDS

Eventually other factors could be taken into account that are related with the activ-ity and would avoid the risk of hypoactivity.

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118 7.4 ImplementationAs we mentioned at the beginning, this chapter does not intend to describe the pay-ment model exhaustively, but to introduce the concepts and theoretical foundations being worked on currently to be able to formulate it.

As stated in the objectives of the model, it is necessary to develop a payment system that puts the patient at the heart of the system, guaranteeing equity, effectiveness and efficiency:

• Equity will be guaranteed to the extent that the territorial allocation incorporates elements to allow the identification of the real needs of the population of each ter-ritory, which is key to bringing resources to those who need them.

• Effectiveness will be guaranteed because it will require the adopting of a compre-hensive view of the population’s health problems and this perspective will enhance health-promoting and disease prevention actions, as well as the allocation of atten-tion to the most appropriate level of care.

• Efficiency will be guaranteed because this is a model that eliminates incentives to stimulate demand.

In short, this is to facilitate the work of providers in the territory from the aspect of complementarity and coordination of their operations in order to achieve the com-mon goal.

The implementation of this model will represent a leap with respect to the current model and will allow, firstly, the incorporation of the proposals and recommenda-tions put forward by the different experts consulted during the evaluation tests of the pilot test to the resources allocation model. And, secondly, the incorporation of the objectives arising from the various strategic plans, master plans, Primary Health-care Innovative Plan, etc., which have been developed in recent years by the Depart-ment of Health.

Chapter 8

Payment system for all other care linesCarme Casas and Montse Llavayol

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for all other care lines

8.1 Relative conditioning factorsThe payment system for the remaining lines of care has not evolved at the same rate as that of hospital care, mainly due to the difficulty of developing a sound and reliable information system. This process is detailed in the following chapter. Other care lines have peculiarities that make their quantification or parameterisation dif-ficult.

For example, in the field of mental healthcare, apart from the activity of hospitalisa-tion, outpatient appointments and emergencies, due to the interest of the Depart-ment of Health a large number of projects aimed at specific groups or different sectors of the population have been promoted and have generated countless well-differentiated programmes.

In the field of social healthcare, the parameterisation is more difficult because the intensity of care is variable during the patient’s stay, since it is difficult to compare the profiles of the different patients (patients receiving palliative care and convales-cent patients, for example).

And in the field of primary healthcare, the ratio between the time needed to gener-ate care information and the time spent on care in the true sense is disproportion-ately high. As professional functions are incorporated or expanded, this difference becomes even more apparent.

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122 8.2 Primary healthcareThe payment system for primary care is determined according to:

a) The population assigned to each primary care team according to the Central Reg-istry of Insured Persons (RCA), weighted by demographic variables, of dispersion and continuous care, based on which the theoretical resources needed for each team, human resources and operating resources alike, are defined.

The standard cost of the team is modified based on the classification of each basic health area (ABS) determined based on certain specific characteristics of each area:• Population characteristics (assigned population and percentage of people aged

over 65 years).• Dispersion of the population (distance between population centres that exist

in the sphere of the ABS, degree of isolation, population density, number of surgeries).

• Socio-economic characteristics of the population.• Teaching.• Coordination (according to the coordination tasks inherent to each EAP).

b) Intermediate product: according to the population assigned to each primary care team weighted by age (below 64 years and over 64 years) and the floating popu-lation covered by each team.

c) Test Strips: according to the population assigned to each primary care team aged over 14 years.

d) Services, facilities and specific programmes of recognised needs and/or activities – derived from the Health Plan of Catalonia and other healthcare policy criteria – that it is necessary to implement.

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8.3 Social healthcareThe payment system for social healthcare incorporates, in general, the following aspects:

a) Hospitalisation: this includes all activities and procedures to patients cared for following admission, whether total or partial, and including long and medium-stay hospitalisation and day hospital.

b) Activities of the support teams for primary healthcare and hospital centres (PADES and UFISS), which are performed through specific facilities, regardless of the complexity and the need for hospitalisation of the individual patient.

c) Activities of comprehensive outpatient assessment in geriatrics, palliative care and cognitive disorders, including the consultation for the evaluation and monitor-ing of the individual patient and the multidisciplinary assessment carried out by specialised teams to provide support to both the individual patient and their relatives.

d) Services, facilities and specific programmes of recognized need and / or activi-ties that need to be implemented arising from the Catalan Health Plan and from other health policy criteria.

The parameters for each of the aspects defined are:

a) Hospitalisation. The parameter consists of the stay, in each of the different modes of hospitalisation.

The activity of long stay and day hospital is financed by the Department of Health and the Department of Welfare and Family. The latter takes charge of the module called social support.

In the healthcare field a unit price will be established for each subtype of activity, which can be modulated, where appropriate, according to the disorders treated.

For long stay activity, depending on the degree of dependence, the disorders and the therapeutic complexity, three modulating factors of complexity are estab-lished that, by resolution of the person in charge at the Department of Health, will be assigned each year to the different centres. The social support module will be the same, regardless of the complexity modulating factor assigned.

b) Activity of support teams for primary care and hospitals: the payment is structur-al and in this mode includes home care programmes (PADES) and the interdisci-plinary social healthcare functional units (UFISS).

PADES: a maximum annual compensation is established based on the number of professionals, the degree of implementation of primary healthcare reform and the geographical catchment area and team performance.

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124 UFISS: a minimum and maximum compensation is established for each type of UFISS (geriatric, palliative care, mixed and assessment of cognitive and behavio-ral disorders) based on the number of professionals, the centre where it is located, the activity carried out and the time in operation.

c) Activity of comprehensive outpatient assessment in geriatric care, palliative care and cognitive disorders: in the consultation for assessment and monitoring, the parameter is constituted by the appointment, while in the multidisciplinary as-sessment the parameter is the process.

A unit price is established for the consultation appointment for assessment and monitoring and for each type of multidisciplinary assessment (geriatric, palliative care or cognitive disorders).

The payment system for hospitalisation services (long stay and medium stay) must include a variable payment, of a maximum of 3% of the financial compen-sation, according to the compliance of the actions with relation to the Health Plan, information systems and specific programmes.

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8.4 Psychiatric and mental healthcareThe payment system for psychiatric and mental healthcare includes, in general, the following aspects:

a) Hospitalisation: includes all activities and procedures that are performed on patients treated as inpatients.

b) Outpatient appointments and specialised primary care services: this includes the care of patients in an outpatient setting, consisting of the first appointment, subsequent appointments and diagnostic and therapeutic tests performed during this care process.

c) Emergencies: this includes care for patients reaching the centre by their own initiative or from other services, using the alternative circuit to programming, as a consequence of objective or subjective need for immediate treatment and independently of whether the patient’s final destination includes admission at the centre or not.

The payment system for psychiatric and mental healthcare, when necessary and apart from the aspects referred to in the above section, will incorporate the follow-ing specific services:

a) Specific services, facilities and programmes of recognised need. b) Activities that have to be implemented derived from the Catalan Health Plan and

other health policy criteria.c) Teaching and research functions.

For each of the aspects defined, in relation to psychiatric and mental healthcare, the following specific parameters of compensation are established:

a) Hospitalisation (including the subtypologies of hospitalisation of acute cases, hospitalisation of subacute cases, medium and long stay hospitalisation and day hospital): the parameter is composed of the stays, modulated by an average stay.

A unit price is established for each hospitalisation subtypology.

b) Primary Care Services specializing in mental health, both for the adult popula-tion and for children and young people: the parameter is composed of total appointments, setting a unique global allocation designed to meet the costs of maintaining this structure so that it works properly.

c) Rehabilitation Services (includes subtypologies of adults and children and young people): for the adults subtypology the parameter consists of the case treated and, for rehabilitation services for children and young people, it consists of the place contracted.

The unit price is determined for each of the subtypologies.

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126 8.5 Payment of other healthcare servicesWithin this group of “other healthcare services” the following services are included:

• Rehabilitation. Currently the healthcare provision of rehabilitation care occurs in both the hospital and the outpatient setting. The existing services include outpa-tient rehabilitation, home rehabilitation and speech therapy.

Depending on complexity, intensity of use of necessary resources and require-ments of individualised attention to achieve the therapeutic goals established, the processes are grouped into four different levels of complexity in outpatient care, five levels of complexity in home care and four levels of complexity in speech therapy.

In home care, to differentiate the difficulty in accessing the home, there are also four tariff types distinguished (A, B, C, D), according to the area where the activ-ity takes place according to the following parameters:

- Geographic and demographic characteristics of the area where the service is provided.- Dispersion of the population, distance between centres, number of inhabitants

and age structure.- Accessibility of the road network, ease of travel between different centres and

availability and characteristics of public transport.

The contracting procedure is by processes and the payment system is 100% vari-able. If the activity contracted is exceeded, additional activity is paid at 50% of the tariff.

• Transport. The organisation of medical transport in Catalonia includes the emer-gency transport and programmed transport aspects. A service is defined as the journey between the patient’s collection point and destination point. In the case of programmed medical transport, this can be individual or collective. The payment is per service provided and must be justified according to what is determined in the specific procedure for medical transport invoicing.

As for urgent medical transport, the payment system by structure envisages a fixed payment and a variable payment based on the activity carried out. The parameters that this service includes are:

- Primary services- Adult interhospital transfer- Pediatric interhospital transfer- Coordination centre- Medical transport facilities- Coordination and extraordinary referrals (coronary and non-coronary patients)- Sanitat Respon helpline

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- Continual home care- Repatriations

With respect to the first four parameters, the payment system is based on the number of services or acts performed and, for the last five parameters, the pay-ment is based on a specific-purpose budget.

• Oxygen therapy. Home-based respiratory therapy techniques aim to maintain correct ventilatory status, improve quality of life and life expectancy, improve social integration and reduce hospital stays of patients with chronic respiratory illness. Its aim is to practice respiratory therapy techniques in the home of patients affected by respiratory diseases and to tailor specific treatments according to each disorder, offering the possibility to prescribe all treatments that exist, using the lat-est equipment , to minimize damage and give patients a better quality of life. This healthcare service is based on the parameter of the day of treatment completed. The payment system is based on the number of sessions and the requirements of the tender governing it.

• Treatment of kidney failure. With respect to public cover for nephrological care from the Catalan Health Service, three levels of care are defined:

Level I nephrology units (equivalent to what was formerly called nephrology services). These are units that provide highly self-sufficient nephrological care in accordance with their care level (reference or high technology hospital). They are responsible for nephrology care for the reference population in their geographic sphere with regard to prevention, diagnosis and treatment of kidney diseases and the prescription of substitution treatment.

Level II nephrology units. These are units that provide non-self-sufficient nephro-logical care according to their care level; they can prescribe substitution treatment in coordination with the Level I nephrology unit of their locality sphere. At the same time they provide renal replacement therapy through dialysis.

Dialysis centres and units. They provide renal replacement therapy through he-modialysis.

The payment system is based on the item concept of the dialysis session.

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128 8.6 Future viewImprovements in the information systems of these care lines, which are addressed in the next chapter, will gradually allow more in-depth comprehensive analysis of mor-bidity treated. The possibility of integrating all healthcare information for a single person (preserving confidentiality) and aggregating this information at the regional level should allow significant advances in the evaluation of the delivery of care. It also has potential use in relation to the territory-based payment model addressed in the previous chapter.

Chapter 9

The evolution of information systems as a support tool for payment systemsMontse Bustins and Xavier Salvador

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The evolution of information system

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9.1 Healthcare information systems and payment systems

We can not finish this book without detailing the information systems that have allowed the evolution of the payment systems described in the previous chapters.

After a brief summary of the theory concerning information systems and their practical application in the health sector, the procedure is detailed that allows the process to move from: 1) the documentation of basic care (discharge reports) to 2) the systematic collection through the minimum basic datasets (MBDS) and from this, to 3) the classification of the data available into clinically homogeneous groups that present a similar distribution of costs (case mix groupers) and, finally, to 4) as-sessment of the complexity / cost of care provided.

In the process of identifying clinical homogeneity and isocosts, the case mix groupers have differentiated attributes depending on the setting to which they are to be applied. For example, in the field of hospital care, the operating theatre is an essential element that needs to be considered, as is the intensity of rehabilitation in the social healthcare setting, which places special emphasis on the needs for support in everyday activities. But in the primary care setting, and also in the capitated en-vironment, the most important thing is to identify the patterns of chronic multip-athological combinations.

The final sections of the chapter are devoted to detailing the hospitalisation groupers, the groupers of the other lines, and the groupers to be applied based on capitation.

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132 9.2 Theory on the uses and limitations of information systems

An information system is a mechanism which guarantees the systematic collection of data related to an area of interest, so that it can provide useful information for decision making. Therefore, when developing an information system there are two basic elements to consider:

• The reason for creating it. Or put another way: what questions are expected to be answered with the data obtained. It is clear that no information system can be developed properly if there is no expectation of obtaining benefits from it.

• Assessing the quality of the data. The great risk of information systems is the use of data whose quality is unchecked to make decisions. The process of obtain-ing data quality is never as fast as future users would like and the temptation to use the first data available is great. But first it is necessary to follow a process that ensures both the completeness of the information collected and the internal con-sistency of the data (internal validity) and its faithfulness to the phenomenon we want to illustrate (external validity).

If we apply these to the healthcare sector, we find that the development of health-care information systems is always linked to the expectation of using them, initially, for planning services. Quality requirements in relation to planning are, generally, easier to meet because they do not require a level of extreme detail. Once these minimum validity requirements are met, their use as support for payment systems can be considered. However, the requirements for the purchasing of services are greater and years can pass before the information system reaches the point of ma-turity. This explains the time lapses between the creation of an information system and the effective use of it for the intended objective.

The first references to the activity provided focus on the hospital environment, which will always be the spearhead of healthcare information systems due to the proportional importance it reaches in budgets and because it has structural ele-ments that facilitate the collection of information and that other lines of care do not have:

• For hospitals it is easier to arrange the collection and delivery of information due to a simple question of volume of available human resources in admissions and filing services.

• The discharge as a unit of analysis has a more manageable volume of cases, for ex-ample, than contacts with primary healthcare, mental health outpatient treatment or non-admitted emergencies.

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• The hospital discharge has a simpler definition in terms of variables to be collected and reporting timetable than, for example, assessments of patients admitted to the social healthcare centres.

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134 9.3 Treatment reportsAs discussed, the basis of any healthcare information system is the treatment report written by professionals, without which the clinical details of the treatment pro-vided cannot be known.

Hospital activity data started to be systematically collected on a limited basis in 1951, while defining the morbidity survey, which was modified in 1977. The information collected was expanded in 1973 with the establishment by ministerial decree of the Statistics of hospitalisation regimes in healthcare (EESRI). The obliga-tion to keep a register came with a decree of 1976 and the discharge report became compulsory with a ministerial decree of 1984.

In Catalonia, the regulation is implicitly contained in the accreditation rules of 1983 and explicitly regulated by the Order of 7 November 1986, compulsory medi-cal discharge report. Here the minimum information required in relation to the medical centre, the patient and the care process, is regulated.

The regulation of care reports has three purposes:

• complying with the right to information and allowing the patient to know their clinical progress,

• allowing the patient’s general physician to be informed of the patient’s progress, thus maintaining continuity of care,

• nurturing the Aministration’s activity system, an essential step towards developing an information system such as the MBDS, which we address below.

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9.4 Minimum basic datasetsThe discharge report data are the basis of the creation of what has been called the hospital discharge Minimum Basic Dataset (MBDS), which in Catalonia began with the Order of 23 November 1990, regulating the sending of the minimum basic data set in Catalonia, although in 1989 there was already a first pilot trial with 29 centres.

But the process to get to this point began in 1973, in the United States, where the National Committee on Vital and Health Statistics proposed the Uniform hospital discharge data set. This process reached Europe in 1982, when the Committee for Information and Documentation in Science and Technology defined the European minimum basic data set (MBDS), and Spain in 1987, when the Interterritorial Council Plenary Meeting approved the hospital discharge MBDS.

On this base the different autonomous communities developed their respective MBDS, with some variations in relation to contents and speed of development. The Catalan MBDS was amended twice to respond to changes and opportunities:

- In 1996 it was extended to respond to organisational changes associated with the boom in ambulatory activity for treatments previously requiring conventional admission. The definitions of the MBDS were adapted, allowing the inclusion of major ambulatory surgery (MAS) and also of the day hospital.

- In 2003 structural modification was carried out to integrate the MBDS into the CatSalut systems plan. This integration responded to the requirements of the law for protecting data confidentiality, a particularly necessary issue for linking the MBDS, through the Systems Plan, with the Central Registry of Insured Persons (RCA). This link provided the MBDS with more accurate sociodemographic information. The integration also changed the environment for sending the infor-mation, which acquired greater security and speed. The modification also served to broaden the clinical variables collected.

The other care lines have gradually incorporated the MBDS, with specific difficul-ties in each case:

• The mental health network has two distinct MBDS: one for hospitalisation in specialist psychiatric hospitals (which has a structure similar to that of other acute hospitals) and one for mental healthcare on an outpatient basis (which collects quarterly counts of activity per patient).

• The social healthcare network also has an MBDS. In this case, it includes the dif-ferent dependency assessments practiced on patients with the frequency required for each facility type separately.

• With respect to primary healthcare, in 2008, a pilot trial began to collect infor-mation from all contacts, which represents a considerable volume of records.

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136 In terms of the exhaustive collection of all patient care activities, at present, only hospital outpatient consultations lack an MBDS, since a pilot was launched in 2009 to test the hospital emergencies MBDS.

The development of all these MBDS allows the consideration of comprehensive evaluations of the care provided to citizens, regardless of the facility, and opens the way to the use of capitation-oriented case mix groupers.

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9.5 International Classification of Diseases

An essential element of the MBDS is the translation of literal clinical information from the care reports to a language that can allow statistical use to be made of them, since without a standard codified tool, the great wealth of literal information cannot be analyzed in aggregate.

This language is fundamentally the International Classification of Diseases (ICD). The ICD is a tool that maintains its usefulness on the basis of an ongoing revision process to reflect the changes observed in the health sphere, with one of the ele-ments for updating it being progressive reviews since its creation in the early 20th century. Specifically, it was the ninth revision of the ICD (ICD-9) that coincided in time with the process of developing information systems.

However, originally the ICD was designed only to classify causes of death, so there had to be a clinical modification to it that would allow it to be used in a morbidity analysis environment. This is what we know as the ICD-9-CM, which has a dual classification: diagnosis, on the one hand, and procedures, on the other.

A second element for updating exists linked to the need to expand the detail of the information with the progress of medicine, especially of procedures. For this reason, ICD-9-CM has annual U.S. editions, which are consolidated in Spain every two years. In this sense, the MBDS data for Catalonia in 2009 were encoded using the sixth edition of the ICD -9-MC.

But this whole review process has not stopped with ICD-9 and there are increas-ingly more elements driving a shift to ICD-10, which will surely be applicable in the near future and will allow, after the inevitable transition costs, the continuing improvement of knowledge about healthcare.

Regarding the process of coding, ICD-9-MC is not just a list of codes, but also the process of assigning codes. In particular, the criterion for determining which reason for admission is coded as the primary diagnosis (indexing) and which comorbidi-ties and complications are sufficiently relevant to be coded as secondary diagnoses. If the MBDS information is required to make comparisons, it is essential to ensure that everyone uses the tool in the same way. With this aim, the Coding Rules are developed.

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138 9.6 Hospitalisation case mix groupersThe MBDS is the information basis for finding out what care has been provided. But working with the MBDS is not suffice to assess it, because when working with the original coding in ICD-9-CM terms, there are over 14,000 alternative rea-sons for admission, which can possibly be combined with over 4,000 alternative procedures (assuming that there is no more than one) and any comorbidities and complications collected (with some 14,000 alternatives for each relevant secondary diagnosis).

Case mix groupers try to establish, based on the clinical information about the episode, a limited set of categories that are homogeneous from the clinical and cost standpoints. The aim with limiting the number of groups is to make a potentially infinite clinical detail manageable.

The inpatient case mix groupers were beginning to be developed at about the same time the MBDS was defined, between the late sixties and early seventies. The first applications emerged in the United States, specifically in the state of New Jersey, which in 1982 started a prospective payment system which was extended in 1983 to the entire Medicare programme, and whose objectives were to establish a reference framework for assessing the quality of care and monitoring hospital services.

Over the years various grouping algorithms have appeared, promoted by different organisations. As this is a tool for obvious practical use and applicable to many po-tential clients, it is hardly surprising that in the hospital groupers market commer-cial competition has always existed. Moreover, most countries have tried to adapt them to their reality. In the case of Catalonia, and also of Spain, this line has not been followed, partly because of the systematic lack of cost accounting data to allow evaluation of which are the most important adaptations (although Catalan hospitals have recently joined the EuroDRG project with quality data).

Meanwhile, in Catalonia we continue working with original algorithms, in this case diagnosis-related groups (DRGs).

• For the payment per activity system (Chapter 4) we use the same version as the U.S. Medicare programme (DRG of the Centers for Medicare & Medicaid Serv-ices: CMS-DRG).

• There are other versions of DRG, such as that used by the Ministry of Health to move closer to Spanish weightings and apply compensation for patients displaced between autonomous communities (DRG-All patients: DRG-AP). In Catalonia we use the DRG-AP in the activity reports of the centres because they allow better fine-tuning of the calculations for the standard performance ratio (SPR), a key indicator to analyze centres’ efficiency.

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• There is also a refined version of this grouper (Refined AP-DRG: APR-DRG), which details the levels of severity and risk of death with greater accuracy and is particularly useful for qualitative assessment indicators.

• Finally, a robust version exists of the refined groupers that allows international comparisons (international refined DRG: IR-DRG), which has the advantage of structurally integrating outpatient activity with inpatient activity, unlike the previ-ous DRGs, defined originally only for admissions (despite the fact that in Catalo-nia, their applications, with bias, is also admitted for MAS).

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140 9.7 Case mix groupers for other care lines

The primary healthcare data have case-mix groupers, the best known being the Am-bulatory care groups (ACG), which allow identification of the patient’s complexity and, therefore, the need for dedication of time by professionals, according to the combination of appointments by a single patient and the consideration of chronic-ity of the same. It is important to bear in mind that primary care, apart from using ICD-9-CM (especially in primary care teams linked to hospitals), also uses the ICD-10 or specific tools (International Classification for Primary Care, ICPC-2). Moreover, primary healthcare does not use hospital activity indexing criteria.

The social healthcare network has specific groupings that synthesize the care burden associated with the patient. These groupings are called Resource use groups (RUG) and pay particular attention to the two most prominent and variable cost elements depending on the patient’s condition, the intensity of rehabilitation and the time needed to support the core activities of everyday life such as dressing, washing, walking or eating. The RUG are fed by a MBDS with over a hundred variables as-sociated with resource consumption.

Data for mental healthcare have no specific groupers like the other lines. In this sphere, there is a prominent need to employ the tenth revision of the ICD as the structuring element for the information. As seen, the ICD-9 was initially designed to classify causes of death and so in the psychiatric field its clinical modification is not very useful.

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9.8 Capitation based case mix groupers

The data from the same patient can be treated in an aggregated way in the sense expressed when we were talking about primary healthcare. In this case there is also commercial competition between organisations to develop algorithms. Aside from using the ACG in an integral environment, there exists the possibility of using Clin-ical Risk Groups (CRG), as do some organisations providing comprehensive health services in Catalonia.

The capitated case mix groupers pay special attention to the identification of clini-cally homogeneous groups, as always, but that in this case have a cost homogene-ity that is non-concurrent in time, but in the future. Explicitly designed as a tool to measure the prospective cost expectation, rather than to explain expenditure in retrospect.

Therefore, these groupers concentrate on those pathologies that are more likely to last a long time and that generate foreseeably high expenditure. For this reason they are focused on chronic diseases and especially measure chronic multi-pathological combinations while leaving acute diseases on the back burner.

In the case of Catalonia, it is quite true that the perfect identification of clinically homogeneous patients presents some difficulties with respect to private activity. Although this is not a priority issue for the health authorities, it is important to be aware of it in order to evaluate the evolution of the boundary between publicly and privately funded healthcare.

Even if information on this private activity is collected in a practically exhaustive way (the MBDS-HD already collects information from virtually all centres not belonging to the XHUP), the identification of patients according to their individual healthcare card (TSI) is not systematically included. And even less so in private primary healthcare, where detailed and individual collection is not included in the calendar of any healthcare authority worldwide.

Despite this limitation, the possibility of making use of all publicly funded activity should allow a reasonable profile of population morbidity to be drawn. The longitu-dinal analysis of the care patterns of homogeneous patients should allow comparison of care provision performance indicators depending on the involvement or otherwise of the different care levels and the sequence of participation of the different facilities.

It may help, therefore, to identify areas for improvement in quality and efficiency in integrated healthcare networks. In a future environment such as that proposed in Catalonia in relation to population-based territorial allocation, it is an element that possibly could be incorporated into the model.

143

Authors

AuthorsEnric Agustí. A graduate in Medicine and Surgery from the Autonomous University of Barcelona 1977. Master in Health Economics from the University of Barcelona 1991. He has occupied various posts in the Catalan Health Service. He is currently the managing director of GINSA (Grupo SAGESSA. Reus).

Josep M. Argimon. Doctor in Medicine and Surgery from the Autonomous University of Barcelona. Master in Evidence-based Healthcare from the University of Oxford and Master in Epidemology and Healthcare Planning from the University of Wales. He is currently manager of Healthcare Services Purchasing and Evaluation for the Catalan Health Service.

Francesc Brosa. A graduate in Medicine and Surgery from the Autonomous Univer-sity of Barcelona, Master in Health Economics from the Barcelona and Pompeu Fabra universities. He holds a diploma in Hospital Management from the ESADE School of Business Management and Administration. He is currently director of the Services and Quality Department of the Catalan Health Service.

Montse Bustins. A graduate in Medicine and Surgery from the University of Barcelona (1981). Master in Medical Documentation from the Instituto para el Desarrollo Informático para Directivos, SA. She is currently head of the Activity Records Management Division of the Catalan Health Service.

Carme Casas. A graduate in Medicine and Surgery from the Autonomous Univer-sity of Barcelona (1987). Master in Business Administration (MBA) from the IESE – Advanced Business Studies Institute-University of Navarra (1991). She holds a diploma in Hospital Management (1993) from the ESADE School of Business Management and Administration. She is currently head of the Healthcare Services Purchasing Division of the Services and Quality Department of the Catalan Health Service.

Josep Jiménez Villa. Doctor in Medicine and Surgery from the University of Barce-lona. Master in Health Sciences Methodology from the Autonomous University of Barcelona. He is currently head of the Services Evaluation Division for CatSalut.

Montse Llavayol. A graduate in Economics from the Autonomous University of Barcelona (1984). Coordinator of the Services Purchasing Division of the Services and Quality Department of CatSalut.

Xavier Salvador. A graduate in Economics from the Autonomous University of Barcelona (1987). Postgraduate qualification in Population Studies Methods and Techniques from the UAB’s Demographic Studies Centre. Coordinator of health-care information analysis for the purchasing of services of the Services and Quality Department of CatSalut.

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