A RESEARCH & DEVELOPMENT PROJECT FROM TURKEY. Bogdan Martian Conferinta INCDS Sinaia, Octombrie 2005

Transcription

1 UNVEILING NG INFORMATION ON FOR DECISION SUPPORT A RESEARCH & DEVELOPMENT PROJECT FROM TURKEY Bogdan Martian Conferinta INCDS Sinaia, Octombrie 2005

2 TURKEY - OVERVIEW Population: ~ 70,000, % Urban 75% % Rural 25% 65+ 6% Gross Domestic Product 3,336 US$ (2003 prices, estimated) 6,158 US$ (2002, ppp)

3 TURKEY HEALTH DATA Health Expenditure ( NHA) GNP 199,043 Billion US$ Total H.E. 13,726 Billion US$ Total H.E./GNP 6,9 % Total H.E. per capita 202 US$

4 HEALTH PROBLEMS Health Indicators (2002) Life expectancy at birth 69.1 (total) Crude birth rate 21.3 Crude death rate 7.0 Population growth rate 15.7 Infant mortality rate 28.7

5 COMPLEX HEALTH SYSTEM

6 HEALTH FINANCING Social insurance (compulsory scheme) Government contributions Benefits are variable and not standardized Multiple insurance agencies SSK Bag-Kur Emekli Sandigi Green Card for non ability to contribute Private insurance

7 HEALTH CARE REIMBURSEMENT Government payments Salaries (20-50%) MF/ML MoH payments Utilities (inconsistent) Green card patients Fee For Service Scheme Reimbursement of provided health services Private insurers Out of pocket payments Co-payments Private providers

8 HOSPITAL SERVICES DELIVERY Purchasing Agency Payment Relationship Health Provider Bag-Kur 13.7 Million ES 10.9 Million Wealthy PRIVATE PARTIAL PAYMEN T CASH / PRIVATE INSURANCE Referral & Contract Only HOSPITALS UNIVERSITY HOSPITALS Ministry of SSK 28.0 Million FREE Referral Only SSK HOSPITALS Health 11.8 Million FREE PAYMENT BASED ON PATIENT INCOME (Free for Poorest) MOH HOSPITALS

9 THE PROJECT Infrastructure Development for Strengthening and Restructuring of Healthcare Services Financial Hacettepe University TC C Health Turkey Management in Turkey Tepe Teknoloji Ankara Health Insurance Commission Australia TC Health Australia NCCH Australia

10 PROJECT OWNERSHIP Project financing agencies Ministry of Finance Ministry of Health Ministry of Labor and Social Security Project owner Hacettepe University Research & Development Project

11 PROJECT COMPONENTS A. Restructuring of Fee-For For-Service Payment System: 15 months B. Development of a Prospective Payment and Budgeting System Based on Diagnosis Related Groups (DRGs): 19 months A. Development of Infrastructure for Medical Material Management: 18 months

12 BUTCE UYGULAMA TALIMATI BUT The FFS schedule used for all health care providers and all services (includes drugs) Revised yearly and ad hoc Maintained by the Ministry of Finance Problems Increase in health expenditure 300$/capita Some services/procedures not included No diagnosis - procedure link Lack of proper coding for diagnosis and procedures Lack of proper classification for medical materials and devices Insufficient medical and administrative rules for avoiding over utilization and billing Fees not reflecting proportionate resource consumption among items Yet most of BUT is worth keeping: keep what works!

13 BUT REVIEW Expectations from a new BUT A new structure to ease usage, including IT version Improved content, in line with modern medical practice (new/obsolete procedures) Evaluation and monitoring of activity Fair prices across specialties and providers, given by realistic relative value units Accurate billing process Accurate track of drugs and medical devices used Clear rules for equity across providers and prevention of misuse of the schedule

14 BUT REVIEW Expectations from the project Provide a new improved BUT in line with the international best current experience, yet adapted to the Turkish reality Provide a framework for identifying BUT problems and consequently generate a phased action plan for ongoing BUT revision

15 INPUTS IDENTIFY PROBLEMS REVIEW C O V E R A G E Key stakeholder opinion Coverage and scope Policy review of treatment benefits covered by BUT -inclusion/exclusions - guiding principals/legislation -medical/non medical benefits -influence of hospital payment tools (long term) -cost included/not included Overarching changes to BUT policy for medical benefits Rules/standards Policy and administration S T R U C T U R E CPT CMBS ACHI Structure Evaluate: chapter structure definitions financial reporting Service category structure Content Rework BUT generic structure in line with policy direction, rule definition and clinical appropriateness TMA Review BUT frequency data for gaps and usage across all items in BUT - start with procedures Identify obsolete items C O N T E N T Evaluate number of items within specialty -use current specialty splits Compare numbers of items in BUT specialty groups against external schedules: CPT/CMBS/TMA list Evaluate high frequency x high cost items for a) differences in procedural components b) difference in payment relativities Equitable splits of items for specialty groupings Splitting variables across schedules: procedural component location Definitions Payments/cost Rank items according to payments and evaluate BUT relative weights R E L A T I V I T I E S CMBS/CPT relativities and patient level cost data from DRGs (as available) ACHI/BUT maps CPT/BUT maps Review: Potential for clinical and/or costing Standardize all reference fee schedule relativities and BUT relativities OR develop regression models Establish maps between BUT and reference schedules Analyse BUT scale against international scale OR compare regression estimates against actuals Review BUT mapped item relativities for appropriateness Total BUT budget: policy Determine method to extrapolate relativities to non mapped BUT items Establish dollar value for BUT prices - convert to RV and Unit price Relative value (?formula based) Unit price OUTPUTS Revised BUT Structure and content Revised BUT fee schedule/rv

16 BUT ADVISORY REPORT Consistent approach Inputs to BUT problem identification and review process Key stakeholder opinion Other schedules and classifications CPT, MBS Cost data from DRG project Mappings between BUT and other schedules and classifications Clinical review Systematically address 5 topics Scope and coverage Structure Content Relativities Rules and standards

17 BUT SCOPE AND COVERAGE Exploration of perceived issues associated with inclusions/exclusions of benefits Guiding principles in line with legislation Health Insurance Law Draft Medical and non medical benefits Care plans The influence of hospital payment systems Extensiveness of rules and budget policy for BUT

18 BUT STRUCTURE Explanatory chapters Structure based on service categories - that is general practitioner, diagnostic services, therapeutic procedures (on anatomical basis), dental, allied health Definitions of services Indexing

19 BUT CONTENT Revise BUT granularity Excessively bundled/aggregated Too detailed Revise obsolete items/new procedures Compare number of items per specialty Identify services that are part of others Missing items Duplicated items

20 BUT RELATIVE VALUES Move from price to resource based schedule Recognize current Relative Value Scale (RVS) Look at price equity within and across specialties Determine what fees cover Develop a RVS and calibrate it across specialties Develop a conversion factor Negotiate fees Develop a protocol for ongoing revision

21 METHODOLOGICAL OPTIONS Figure 1: Possible approaches for moving the BUT towards a more cost based relative value scale APPROACH 1: "Time and Motion Approach" Detailed Costing Study for individual BUT codes Approachs for Basing BUT on Costs APPROACH 2: "Relative Value Study" Repeat US/Australian studies but consider hospital costs rather than professional costs Develop Relative Values Scores for each BUT Item Determine/Negotiate Unit Value (ie Price) Develop Relative Value Scale for each Specialty Develop calibration curves to equate specialties Develop Mappings Identification of potentially anomalous BUT codes by comparison against mapped CMBS and CPT codes APPROACH 3: "Comparison Study" Compare BUT against existing Relative value scales (CMBS and CPT) Develop a clinical review process for identified BUT codes Study to compare patient costs against patient BUT and where necessary adjust BUT values

22 COMPARATIVE RVS FOR BUT A comparative study would compare the current fees in the BUT against an external source The external source should be validated by a RVS The study is essentially dependent upon accurate maps between the BUT and reference schedules CPT, MBS A review of the mapped BUT item relativities for appropriateness adopting clinical and costing approaches (mainly for outliers) Determine method to extrapolate relativities to non mapped BUT items Calibrate across specialties Conversion of BUT prices to RVs and Unit price

23 COMPARING MBS AGAINST BUT Hypothetical Results for Specialty BUT FEE BUT FEE= 1.86 * MBS Review MBS RV As both the MBS and BUT are linear scales then a straight line relationship should exist for equivalent codes. If imperfect maps are used then there will be an increase in the variability about the trend line Outlier points need to be subject to clinical and costing review.

24 ESTIMATED VALUES FOR ATYPICAL BUT FEES Hypothetical Results for Specialty Actual BUT Fee BUT FEE Estimated BUT Fee based upon MBS MBS RV MBS RV for codes mapping to the BUT item

25 WHERE SHOULD OUTLIER GO? BUT FEE CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); SINGLE ARTERIAL GRAFT BUT value Verses CPT relative value for mapped cardiothoracic items y = x R 2 = CPT Relative Value SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITH CARDIOPULMONARY BYPASS TRANSVERSE ARCH GRAFT, WITH CARDIOPULMONARY BYPASS

26 MOST WORK DONE Addressing outliers Reasons for outliers Inaccurate mapping Difference in medical practice Differences in fee coverage Unfair fee Outlier study Develop a protocol for review Find reason for outlier (mapping is critical) Conduct clinical and costing review Establish a review committee

27 ADMINISTRATIVE RULES Patient dispatch and transfer regulations Reporting and billing requirements (MBDS) Revision of the services that require a prior approval, Services NOT attracting benefits Rules for BUT revision Including committees Proper coding of procedures ICD 10 AM, (ACHI) adapted Conditions for denial of payment Penalties for misconduct/unethical practice, abuse, gaming, etc.

28 MEDICAL RULES Definition of procedures Diagnostic procedure link Special situations, such as abandoned surgery Patient safety issues, such as guidelines for minimum standards for performing gastrointestinal endoscopic procedures Exclusion rules (medical) what services cannot be billed together, as there are counter indications? Admission criteria - Services fit to be delivered for inpatients only/same day/as outpatient Obsolete procedures to be excluded

29 RUNNING PROJECT Accomplishments Advisory report Framework for BUT ongoing review Prioritization of objectives on short, medium and long term New structure template accepted Trainings for coding and RVS RV Study methodology accepted and tested Hospital costing exercise to advice costs New administrative rules accepted

30 NEW BUT 2006 TO BE PUBLISHED EARLY DECEMBER SEE YOU NEXT YEAR FOR AN UPDATE ON BUT REVIEW