Purchasing integrated Diabetes Care

Indicators for good health care

Costs and costs-coverage

0%

2%

4%

6%

8%

10%

12%

Kosten Personen opbouwLG

FKGinsuline

alle FKG's

Per

cen

tag

e va

n t

ota

le k

ost

en Z

FW

Te dekken kosten

Effect FKG

Effect Lftd/geslacht

Kosten obv aantallen

Prevalence Agis insurees medicinal treated diabetics,conform age, 1999 t/m 2002 (database Agis)

0

20

40

60

80

100

120

140

160

0 10 20 30 40 50 60 70 80 90 100

Leeftijd (10-jaarsklassen)

Pre

vale

nti

e p

er 1

.000

ver

zeke

rden

1999 2000 2001 2002

Diabetic chance

• 60.000 insurees with diabetic (4%)

• Growing prevalence

• Growing costs

• Incomplete coverage

Activities Agis?

• Budgetmodel (income Agis)– focus: financing HIC’s

– Maintenance en improvement

• Purchasing diabetes care– focus: care providers

– Best practice (guidelines and standerds)

– Interaction (‘working together’) between care providers (hospitals, GP’s, homecare, nurses)

• Pay for Performance– focus: interaction care provider – diabetic patiënt

– 2000 – 15.000 patiënts

– Group level

Indicators for Diabetes

• Ministery of Health Care,Welfare and Sports• Council of inspectors• Dutch Specialist Group• Dutch Diabetec federation (NDF)• Dutch Primary Care Diabetic Guideline• Agis Health care Insurance company• WHO• OECD

Value based purchasing

Value based purchasing

• Medical outcome– Health improvement

• Quality of life• Patiënt Experiences

• BPR• Costprice• Pay for performance-

bonus

Value based purchasing

• Commitment HIC• Commitment care

providers• Partnership HIC –

Care provider• Diabetes contract• Continous

improvement

Medical Outcome (NDF)

• Diabcare indicators data base - GP’s– Facilitaded bij Agis– GP’s ownership– Agis management information on group level

• D4H organisation– Facilitates GP’s implementing treatment proces

Diabetic care, including information technology

• TTP

Health improvement

• Risk profile Diabetic Group

• Indicators Diabetic group t0 –t1

Health improvement• 1% < HbA1c

25% lowering microvasc. compl.

• 4 - 5 mg/dl < LDL8% - 10% lowering card. vasc. event

• glucose < 1%25% lowering amputations

• vet < 4-5 mg/dl10% lowering MI

Patiënt experiences

• CAHPS diabetes

Cumulatieve respons t/m 18/1,relatief t.o.v. uitgezette lijsten

0%

10%

20%

30%

40%

50%

60%

70%

0 5 10 15 20 25 30 35 40 45 50

Werkdag na eerste verzending

Agis GE Algemeen Diabetes Ziekenhuis

Score losse vragen en composiet Communicatie,incl. betrouwbaarheidsinterval 95%

0%

25%

50%

75%

100%

vraag1 vraag2 vraag3 vraag4 composiet

Huisarts Internist Verpleegkundige Diëtist

Composiet scores Afstemming, Begeleiding, Communicatie en Voorkomendheid,

incl. betrouwbaarheidsinterval 95%

0%

25%

50%

75%

100%

Huisarts Internist Verpleegkundige Diëtist

Afstemming Begeleiding Communicatie Voorkomendheid

Huisarts: Diabetesspecifieke communicatie

0% 20% 40% 60% 80% 100%

Bloedglucose regulatiewordt met huisarts

besproken

Goede diabetesvoorlichting

Goede begeleidingdagelijkse omgang met

diabets

Besproken of huidigebehandeling optimaal is

Nooit/somsMeestalAltijd

N =

328

N =

339

N =

340

N =

345

Huisarts: overige vragen

0% 20% 40% 60% 80% 100%

Afstemming metandere zorgverleners

Geen tegenstrijdigeinformatie

Goede begeleiding vandosering van insuline

Niet moeilijk tebegrijpen i.v.m.taalproblemen

Nooit/somsMeestalAltijd

N =

334

N =

227

N =

321

N =

307

HbA1c CAHPS Diabcare

< 9 79% 87%

9 or up 21% 13%

RR CAHPS Diabcare

< 90 74% 80%

90 or up 26% 20%

     

< 140 47% 45%

140 or up 53% 55%

  CAHPS Diabcare

Eye controle 70% 68%

feetcontrole 60% 65%

Urine control 60% 82%

RR 90% 92%

HbA1c 87% 87%

complications

• 10 % one or more severe hypo’s• 15% treated for retinopathie• 2% any form of amputation• 9% kidney problems• 5% CVA or MI

 parameter proces Uitkomsten Punten

HbA1c 93% HbA1c measeurement in the last 12 months

55% < 8%≤ 21% ≥ 9,5%

510

Lipiden profiel 85% lipid profile measurement in the last 12 months

63% LDL ≤ 130 mg/dl

20

Risico profiel 90% riskprofile known 10% improvement

40

parameter proces uitkomst bonus

Patiëntexperiences

90% is informed about HbA1c, RR en life style

80% knows HbA1c RR, life style advices

20

Working together   80% recieves uniform information from different care providers

20

contract

• Price per patiënt per year– Excluding medicin, measurement equipment

• Cost price after bussiness proces redesign

• Three years

• Risk sharing

monitoring

• Indicators– health outcome– health improvement

• Patiëntexperiences (CAHPS)

• ttp