Concurrentie tussen verzekeraars op kwaliteit en kosten van de zorginkoop vormt de hoeksteen van ons stelsel

Concurrentie tussen verzekeraars op kwaliteit en kosten van de zorginkoop vormt de hoeksteen van ons stelsel Achtergrond huidige zorgstelsel Pre-2006: Macro effectief maar micro inefficiënt

Groeiende druk op het systeem

• Effectief macro instrument - Kostenbeheersing op (nationaal) niveau

• Kostengroei

– Directe interventie in het systeem

• Vergrijzing (zorgvraag en arbeidsmarkt)

• Maar problematisch op micro niveau – Lage productiviteit, weinig ondernemerschap en weinig innovatie – Wachtlijsten

Bron:

• Technologische ontwikkelingen

Volume

Prijs

Tijd Zorgverzekeraars staan centraal – zij moeten concurreren om verzekerden door de meest concurrerende contracten bij de beste aanbieders en tegen de laagste prijs te sluiten

Booz & Company analyse

Coöperatie VGZ | Booz & Company

2005-06 stelselwijziging: hogere productiviteit om meer zorg mogelijk te maken

0 Lessons from the Dutch Health Care Reform AK.pptx

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Concurrentie op zorgkwaliteit is slechts in zeer beperkte mate gerealiseerd, mede omdat geschikte maatstaven ontbreken • De werking van het huidige zorgstelsel is gebaseerd op concurrentie op prijs en kwaliteit

Concurrentiemodel (ideaalsituatie)

• Echter, in veel gevallen ontbreken algemeen erkende maatstaven voor zorgkwaliteit - Voor een beperkt aantal ingrepen bestaat overeenstemming over uitkomstindicatoren

Consumenten

Concurrentie op prijs, dekking en kwaliteit van • Voor zorgverzekeraars is het moeilijk om de zowel afhandeling als selectieve inkoop te kunnen legitimeren op grond van gecontracteerde zorg

Concurrentie op zorgkwaliteit

kwaliteitsoverwegingen

Zorgaanbieders

Verzekeraars

• Zorgaanbieders kunnen niet méér patiënten aantrekken met betere kwaliteit en stimuleren innovaties dus niet

Concurrentie op zorgkwaliteit en prijs voor gecontracteerde zorg


• Consumenten hebben geen inzicht in de kwaliteit van gecontracteerde zorg en kiezen laagste premie


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Concurrentie heeft geleid tot lagere prijzen Prijsindex Medisch Specialistische Zorg Index

115

Inflatie (CPI)

110

A-segment

105

Prijsontwikkeling o.b.v. CBS

100

B-segment1)

95 Het doel is om het B-segment tot 2014 naar 70% van het totale budget uit te breiden waardoor prijzen verder dalen

90 85

• Prijsindex Medisch Specialistische Zorg stijgt minder snel dan de inflatie • De prijzen die door de overheid zijn vastgesteld (A-segment) zijn sneller gestegen dan de prijzen in het vrij onderhandelbare B-segment • Het B-segment bestaat uit behandelingen waarvoor het budget met de verzekeraars wordt onderhandeld

80 2005 2006 2007 2008 2009 2010 2011 2012 1) Bron:

Gewogen gemiddelde uit toevoegingen B-segment in 2005, 2008 en 2009 CBS, NZa, Booz & Company analyse



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Mede als gevolg hiervan heeft de markt voor zorgverzekeringen zich vooral tot een prijsmarkt ontwikkeld Achtergrond in bijlage

Ontwikkelingen zorgverzekeringsmarkt Verzekerden kiezen steeds vaker voor een hoger eigen risico om hun maandelijkse lasten te verlagen

5.1%

Consumenten met lage verwachte zorgkosten stappen steeds vaker over naar een andere zorgverzekeraar

Vrijwillig eigen risico

Overstapper

(% van aantal verzekerden)

(% van aantal verzekerden)

5.3%

5.9%

9.6% € 500

8.3%

€ 400

6.9%

€ 300

5.5% 4.4%

€ 200

3.6% 3.6%

6.0%

4.3%

€ 100 2009

2010

2011

2012

2013

2007

Verzekerden kiezen steeds vaker voor (landelijke) collectieve verzekering Collectief vs. Individueel verzekerden

Bron:

2010

2011

2012

2013

Personen met een aanvullende polis (% van Nederlandse bevolking)

Overig collectief

21%

24%

26%

28%

40%

40%

40%

39%

37%

40%

36%

34%

33%

31%

2007

2008

2009

2010

2013

32%

90%

89%

89%

88% 85%

Werkgever collectief Individueel 2009

2010

2011

2012

2013

NZa Marktscan Zorgverzekeren 2013, Booz & Company analyse


2009

Ruim 85% van de Nederlanders is aanvullend verzekerd maar dit aandeel staat onder druk door verslechterd imago

(% van totaal zorgverzekeringen) 100%

2008


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Negotiations for the free DRG segment resulted in lower prices Price Development Hospital DBCs 2006–2010 (%, Nominal) 3.8 2.5 1.5

2.9 2.6

2.3

2.1 1.3

0.4

1.5 1.4

1.1

1.1 0.3

0.0

-1.8

2006

2007

2008

2009

Main Additions to B-Segment

Knee Arthritis Cataract Hip Arthritis Slipped Disc Diabetes

Pregnancy Birth Cataract Pacemaker Meniscus Breast Cancer

Cardio Stroke Follow-up Cardio Skin Cancer

Share % B-Segment

10%

19%

34%

A-Segment

A-Segment corrected for budget reductions

Fixed Prices – Set by health regulator

B-Segment 2005

B-Segment 2008

-2.1 -2.0

2010

B-Segment 2009

Free Prices – to be Negotiated Between Insurers and Providers

Sources: Marktscan Medisch Specialistische Zorg 2011; Nza. Onderhandelen over ziekenhuiszorg; Vektis 2009 Booz & Company 9 April, 2014

Lessons from the Dutch Health Care Reform AK.pptx

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Health care reform succeeded in lowering prices, but it did not curb volume growth Total Growth In Hospital Expenditures (%)1) Strict Budgeting

Wait List Reduction

13.8

Price Increase (%) 11.0

Health Care Reform: Competitions

7.4

Generic Inflation2)

12.9

5.6 5.3 2.1

10.9

5.8

6.2

5.4

6.5 4.1

05

06

1.0 1.3

0.1

0.3 -0.54)

-0.9

6.8

5.6 3.7

3.5

 Health care reform (competition) has indeed led to lower prices (driven by B-segment)

5.5

99 00 01 02 03 04 05 06 07 08 09 10

Volume Growth (%) 99

00

01

02

03

04

07

08

09

10

The 2005–2006 Reform Paradigm  Volume growth is a fact of life: ageing, innovation  More efficiency is needed to deal with volume growth  Competition will lead to more efficiency and lower prices

6.4

5.4 4.1 2.8

5.4

4.6

4.3 3.2

6.4 4.0

0.2 0.1

 But since the health care reform volume growth accelerated  Today’s challenge: volume growth reduction without the waiting lists of the nineties

99 00 01 02 03 04 05 06 07 08 09 10 1) Hospital expenditure include day and/or night cost and include specialist health care (4) Estimate based on “Marktscan Medisch specialistische zorg 2011” 2) Consumer Price Index CBS Sources: CBS Statline (Zorgrekeningen; expenditures at current and constant cost); RIVM Performance Of Dutch Health Care 2010; Stijging Zorgkosten ontrafeld; VGE; Marktscan Medisch specialistische zorg 2011; Booz & Company analysis Booz & Company 9 April, 2014


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The US experience also suggests controlling prices may focus on the wrong part of the equation

Example US Medicare

Growth (%) in physician fees compared with growth in total expenditures

7.4

 Medicare has committed significant effort to figuring out the “ideal” price paid per unit of service to curb spending, when use rate is actually the more important variable

7.4

3.4

Total Cost = Price × Use Rate  The use rate is a direct function of the medical practice style in the delivery system

-0.7 1997–2001

2001–2005

Physcicain fees Physician expenditure per Medicare Benificiary1) Sources: Mayo Clinic - Robert Smoldt Booz & Company 9 April, 2014


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The Medicare price control cycle: cutting prices drives volume up

Cost Too High

Reduce Line Item Payment Rate to Providers

Providers

See More Patients per Day

Order More Tests, Images

Costs Go Up Anyway Sources: Mayo Clinic - Robert Smoldt Booz & Company 9 April, 2014


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Usage is not a US problem: Higher rates in NL for hip replacements, TURPs and tonsillectomies Incidence rates in the Netherlands and the USA Number of treatments per 1000 population 3.8 3.5 3.3

2.2

2.1

1.9

2.1

1.8 1.5 1.3 0.8

1.7

1.2

1.0

0.6 0.3

Tonsillectomy2

Benign prostatic hyperplasia (BPH) - TURP2

Hip replacement1

Appendectomy2

Cholecystectomy3

Knee replacement1

Congestive heart failure Hospitalization4

Coronary angioplasty1

Treatment rates higher in NL than in the US

Sources:

1) OECD 2009, 2) NL: DIS 2006-2007; USA: HCUP 2006, 3) Laparoscopic versus small-incision cholecystectomy, F.Keus , 2008, 4) NL: DIS 2006-2007; USA: CDC 2010

Booz & Company

Lessons from the Dutch Health Care 8 Reform AK.pptx

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NL

USA

The US is not an outlier in health usage – Budget based German health care ranks high Hip replacement surgery, per 1000 population, 20091 Germany Switzerland Belgium Denmark Norway France Sweden Netherlands United Kingdom Finland United States Australia OECD Italy New Zealand Greece Canada Ireland Spain Portugal

Israel Poland Chile Korea

Knee replacement surgery, per 1000 population, 20081

2.96 Germany Germany Brazil 2.13 5.82 2.87 United States 2.13 Belgium China 4.27 2.40 Switzerland 2.00 United States Turkey 3.77 2.36 Finland 1.78 Norway Mexico 2.50 2.32 Denmark 1.68 Austria Italy 2.30 2.24 Belgium 1.68 Slovenia Switzerland 2.07 2.14 Australia 1.58 Israel United States 1.98 2.13 Canada 1.43 1.94 France Australia 1.94 United Kingdom 1.41 1.88 OECD Germany 1.88 Sweden 1.27 1.84 United Kingdom Canada 1.78 Netherlands 1.24 1.54 Greece Ireland 1.77 France 1.54 1.19 Sweden OECD 1.75 1.50 OECD 1.18 Poland Spain 1.73 1.49 Spain 1.02 Netherlands New Zealand 1.66 1.40 New Zealand 1.02 Australia United Kingdom 1.59 1.23 Italy 1.00 1.17 Switzerland France 1.34 Korea 0.98 0.93 Spain Israel 1.34 Norway 0.75 0.88 Italy Russian Federation 1.33 Portugal 0.62 0.51 Portugal India 1.18 Israel 0.47 0.44 New Zealand Belgium 1.17 Ireland 0.42 0.19 Canada Norway 1.05 Chile 0.05 0.17 Mexico 0.02 Netherlands Mexico 0.03 0.08

Mexico 1) Or nearest year Source: OECD, Booz &Company Analysis Booz & Company

Coronary angioplasty (PCI), per 1000 population, 20091


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Caesarean Sections per 100 live births, 20091 0.47 0.46 0.43 0.42 0.38 0.32 0.32 0.31 0.30 0.27 0.26 0.26 0.25 0.24 0.24 0.20 0.19 0.18 0.18 0.17 0.17 0.14

The health care reform has been successful  Waiting lists have been virtually eliminated  Substantial increase in transparency as a result of DRGs

– Better view on real costs of treatment – Better registrations – Better view on practice variation  Prices have decreased  And … we are increasingly capable of controlling volume growth

Booz & Company 9 April, 2014


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As a result, we see health care systems move continuously in between forms of budgetting and fee for service Pay for services

Budgetting

Germany Netherlands US



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Verzekeraar stuit hierbij op lastige dilemma’s   Innoveren     Contracteren  

Aansluiten

Verzekeraar wil zorgverbetering, maar kan niet op de stoel van de professional zitten Niet alleen uitkomsten: gepaste zorg. Zorgverbetering die leidt tot kostenverlaging, ‘straft’ de goede aanbieders af De complexiteit van ziekenhuizen staat zorgverbetering en kostenverlaging vaak in de weg Kwaliteit en volume vereenzelviging Besparingen per patiënt leiden vaak niet tot kostenverlaging omdat capaciteit weer wordt opgevuld Niet contracteren is voornaamste drukmiddel, maar heeft slechts beperkte geloofwaardigheid Verzekeraar wordt maar beperkt geaccepteerd als partner om over kwaliteit te spreken

 Verzekeraar wil zich onderscheiden, maar grote veranderingen worden vaak opgepakt door ZN  Landelijke concentratie agenda kan concurrentie tussen ziekenhuizen laten afnemen

 Verzekeraar wil voordeel voor eigen verzekerden maar aanbieders hebben patiënten van alle Differentiëren verzekeraars  Verz zou beste aanbieders willen contracteren, maar patiënten zijn sowieso vaak vrij zelf te kiezen  Verz wil zich kwalitatief onderscheiden, maar kwaliteit is vooral onderscheidend voor de aanbieder Organiseren Bron:

 Inkoop organisatie is georganiseerd per zorgsoort, maar innovaties spelen vaak ‘over de schotten’  Beleid en innovatie vindt vaak moeilijk aansluiting op de zorginkoop




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Challenges to overcome for the payors

We pay volume instead of quality

Bron:

Booz & Company

Booz & Company


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We pay in a fragmented way

Acceptable medical practice is an enormous grey area – offering lots of room to respond to volume incentives Acceptable Medical Practice

Underuse

Everything that is generally accepted as necessary

Many sources of medical uncertainty  Vague boundaries between wellness and disease (e.g., elevated PSA levels)  Iterations between diagnosis and treatment  Clarity about the desired outcome of care (e.g., life expectancy versus quality of life)  Multiple interventions to chose from with different risks and benefits  Skewedness of clinical trials to healthy, young single condition patients  Information loss caused by handovers

Overuse

Nothing that is generally accepted as inappropriate

The human body is a nearly endless source of revenues” – A medical specialist



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We may be inclined to overestimate the effectiveness of medical care Attitude of an Average Patient 1

Ever Increasing (Early) Diagnostic Capabilities

 It is better to know  The earlier you know the better

Evidence for Every Day Care

 If the doctor offers it, it will be effective  No harm in trying

Alignment Doctor and Patient Preferences

 The doctor will know what is best for me

2

3



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1 Diagnostic Effectiveness

Over diagnosis is a real-risk; example lung cancer screening U.S. EXAMPLE

Smokers are at 17 Times Higher Risk of Death as a Result of Lung Cancer

But the Number of Abnormalities Identified Spiral CT Diagnosis of Lung Cancer is Similar for Smokers and Non-smokers

Number of Deaths per 1,000 Over Five Years

Diagnosed Cancer per 1,000 Scans 11.5 10.5

3.35

0.20 Never Smokers

Smokers

Never Smokers

Smokers

Sources: Over diagnosed (Welch); Booz & Company analysis Booz & Company 9 April, 2014


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Over diagnosis for kidney cancer? New Kidney Cancer Diagnoses and Deaths Per 100,000 People

14

New Diagnoses

12 10 8 6

Mortality

4 2 0 1975

1980

1985

1990

1995

2000

2005

Sources: “Over diagnosed”; Welch; Booz & Company analysis Booz & Company 9 April, 2014


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What about other cancers? Cancer and Diagnoses U.S. Skin Cancer

Pancreas cancer

Per 100,000

Per 100,000 Mensen

25

12

New diagnoses

20 15

4

5

Mortality 1980

1985

1990

1995

2000

2005

Mortality 1980

1985

1990

1995

Breast Cancer Per 100,000

New Diagnoses

150 100 50


0 1975

Per 100,000

200

Mortality 1980

2

Prostate Cancer 250

0 1975

8 6

10

0 1975

New Diagnoses

10

1985

1990

1995


2000

2005

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175 150 125 100 75 50 25 0 1975

2000

2005

New Diagnoses

Mortality 1980

1985

1990

1995

2000

2005

18








2

3



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2 Evidence

No evidence for more than half of our common medical treatments U.K. EXAMPLE

51% of ~ 3,000 Commonly Used Treatments in The U.K. was of Unknown Effectiveness Rating by a Team of Advisors, Peer Reviewers, Experts, Information Specialists, and Statisticians

5%

51%

100%

Unkown Effectiveness

Total

3%

7% 23%

11%

Beneficial

Likely to be Beneficial

Trade Off Between Benefits and Harm

Unlikely to be Beneficial

Likely to be Ineffective or Harmful

Note: Study based on ~ 3,000 treatments Sources: Clinical Evidence website 2011; How much of orthodox medicine is evidence based? 2007; Booz & Company analysis Booz & Company 9 April, 2014


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2 Evidence

Practice variation for common elective surgeries Indexed Between Hospitals in 20091) Practice Variation2) Spinal Disc Herniation

220%

Constricted Carotid Artery

82%

Peripheral Arterial Occlusive Disease

71%

Varices

70%

Carpal Tunnel Syndrome

64%

Benign Prostate Hypertrophy

48%

Disease Of Adenoids And Tonsils

46%

Knee Replacement

45%

Cataract

28%

Hip Replacement Due To Osteoarthritis

25%

Inguinal Hernia

20%

Gallstones And Cholecystitis

20%

10

1) 2) Note: Sources:

Low

25p

Mean 100

75p

Corrected for Sex, Age, and SES Difference between p25 and p75 > 50% are regarded high practice variation, differences > 25% and, < 50% are regarded mediocre variations Hospitals with 10 or less operative DBC’s are not taken into account Rapport indicator indication setting Plexus; Booz & Company analysis



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1,000

High X%

High practice variation

X%

Above average practice variation

X%

Low practice variation

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2 Evidence

Practice variation is common in health care – Also in The Netherlands Risk Adjusted Conversion Ratio Benign Prostatic Hyperplasia per Hospital Number of Surgeries per 1,000 BPH-patients per Year 300 250 200 150 100 50 0 Academic institutions

Average

Hospitals (in The Netherlands)

Risk Adjusted Conversion Ratio Cataract Surgeries 2,000

Number Surgeries per 1,000 Cataract Patients

The Differences Between High and Low Conversion Ratio’s are too Large to be Interpreted as Care of the Same Quality

1,500 1,000 500 0 Academic institutions

Average

Hospitals (in The Netherlands) Source: Plexus Booz & Company 9 April, 2014


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2 Evidence

Practice variation is as much a Dutch problem as a US problem Practice variation Systemic Component of Variation (SCV) – 2006-2007

252 148 129 110 86

81

75

66

65 57

52

55 47

49

53

19

COPD

Bacterial pneumonia

Hip fracture

Congestive heart failure

Knee replacement

Cholecystectomy

Hip replacement

Benign prostatic hyperplasia (BPH)

More practice variation in NL than in the US Note:

NL variation determined over about 450 municipalities. Population corrected for age and income differences; USA variation determined over average treatment rates per Hospital Referral Region (200). Population corrected for age, sex and race differences Source: Plexus ‘Voorstudie naar praktijkvariatie in Nederland’, Dartmouth Atlas of Healthcare, Booz & Company analysis Booz & Company DATE


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NL USA








2

3



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3 Patient Preferences

Patients usually chose differently (and more conservatively) than their doctors Change in Number of Treatments after Shared Decision Making with Simple Decision Aids Ø-30% Breast Cancer Surgery: Surgery or Wait PSA Screening: Screening or Not

-74% -36%

PSA Screening: Screening or Wait

-33%

Ischemic Heart Disease Treatment: Surgery or Wait

-29%

Benign Prostate Disease Treatment: Uptake or Not

-30%

Hormone Replacement Therapy: Uptake or Not

-4%

Atrial Fibrillation Treatment: Uptake of Warfarin or Not

-5%

Breast Cancer Genetic Testing: Screening or Not

Insignificant Results

Birthing Options After Previous Caesarean: Vaginal Birth

Insignificant Results

Colon Cancer Screening: Screening or Not

64%

Hepatitis B Vaccine: Uptake or Nothing

76%

Sources: The Cochrane Collaboration (Wolf; 1996; Volk; 1999; Man-Son-Hing; 1999; Morgan; 2000; Dodin; 2001; Auvinen; 2002; Frosch; 2003; Whelan; 2004); Booz & Company analysis Booz & Company 9 April, 2014


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Decision aid also have substantial impact in practice Geïnformeerde patiënt zijn vaak conservatiever (implementatie bij 9500 patiënten in Washington State) -26%

-38%

100

100

Nijmegen: IVF Patiënten kiezen vaker voor de doelmatige optie

74 62

 Keuze tussen dubbele embryo transfer (hogere zwangerschap kans, ook hogere kans op medische complicaties van meerling) en single embryo transfer  Cyclus 1: 43% van de patiënten voor een single transfer versus 32% in de controle groep

Heup vervanging Zonder gebruik video keuzehulp

Knievervanging

 Cyclus 2: 26% van de patiënten voor een single transfer versus 16% in de controle groep

Met gebruik video keuzehulp

12%–22% Lagere Kosten



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Person centered care increase quality and lowers costs: Example hip fractures Sweden Patient Centred Care for Hip Fractures Fewer Hospital Days  Care pathway tailored to the individual’s needs  Startpingoint: Tailored to the patient’s needs? – What was the patient capable of before the fracture? – What is the social network of the patient? – What are her objective in life? – Which steps to independence are mostly valued (e.g., taking care of personal hygiene)  Differentiated care for different personality types, e.g., – Autonomous patients – Modest patients – Detached people

26 -54%

Control Group Intervention group

12

Successful Rehabilitation Control Group

48

+33% Intervention group

64

Lower Costs (€) Control Group Intervention Group

16,002 40% 9,685

Source: Patients with acute hip fractures, motivation, effectiveness, and costs in two different care systems Booz & Company 9 April, 2014


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Patient centeredness is especially important in end of life settings Quality of Live and Health Care Costs Last Week of Life 2008 U.S. $

–

Quality of Life -36%

+

2,917

1,876

No End of Life Conversations

With End of Life Conversations

Sources: Health Care Costs in the Last Week of Life, 2009; Booz & Company analysis Booz & Company 9 April, 2014


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End of life care can actually increase life Hospice Care Increases Survival Time1) …

… As Does Early Palliative Care2)

Average Number of Survival Days After Diagnosis

Average Number of Survival Days After Diagnosis

414

+19%

402

381

381 321

321 279 240 210 189

Colon Cancer

Congestive Lung Cancer Pancreatic Heart Failure Cancer Non-hospice care

Regular Care

Early Palliative Care

Hospice care

1) n = 4493 2) n = 151 Sources: Comparing Hospice and Nonhospice patient survival among patients who die within a three-year window; Journal of pain and symptom management; March 2007; Early palliative care for patients with metastatic non–small-cell lung Cancer; The new England journal of medicine; 2010; Booz & Company analysis Booz & Company 9 April, 2014


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In the context of high expectations, a focus on prices can well turn out to be counterproductive Cost too High

Reduce Line Item Payment Rate to Providers

Providers

See More Patients per Day

Order More Tests, Images

Costs Go Up Anyway



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The challenges to overcome for the payors


Bron:

Booz & Company

Booz & Company


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The challenge is to use contracting and reimbursement to create a flywheel from quality The Doom Circle of Efficiency

Higher Costs

More Treatments


Quality as Flywheel for Better Health Care

More Time for Quality

Improve Efficiency

Lower Costs

Less Time per Patient Less Time for Quality


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Improve Quality of Decision Making

Less Treatments

32

Three levers for reimbursement and contracting

New product definitions • E.g. shared decision making consultations, therapy adherence

Reimburse differently • Shared savings • Transition paths

Contract selectively and in a differentiated way • Steer patients to Quality • provides



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Example of redefining product definitions in order to encompass quality instead of volume Performance Definitions NZa 1

6 Medication Dispensing (Receptregel)

 Distribute prescription medication in standard/weekly form  Check correctness/safety of prescription

2

Self Management Education

 Provide education in group format on self-management to optimize medication utilization (medication adherence/ utilization)

Self Management Counseling

 Provide counseling per individual patient’s request on potential drug-drug interactions in medication therapy (e.g., combination prescription/OTC)

Medication Related Travel Counseling

 Provide counseling per individual patient’s request on medication utilization and storage during travelling

Disease Prevention Travel Counseling

 Provide information per individual patient’s request on risk of diseases for certain travel destinations

Mutual Services

 Support other healthcare providers in execution of activities as defined under performance definitions

7 Medication Instructions

 Provide usage instructions in case of first time issuance or non-compliance with user instructions

3

8 Medication Review

 Periodically review individual (elderly) medication therapy of patients with chronic medication use

4

9 Continuity of Care Hospitalization

 Conduct one-on-one interview with patient  Ensure correct transition of medication details to other providers of care

Continuity of Care Discharge

 Conduct one-on-one interview with patient  Provide clear guidance on medication therapy, including changes due to hospitalization

5



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Paying for quality instead of volume can result in higher prices but lower costs: The need for sophisticated “products”

Objective to Control Volume with Quality Initiatives

Incentivized by Product Definitions

(Not Care Rationing) Volume  Need to counter the volume incentive in the system – Income compensation – Compensation for extra cost (e.g., admin, IT)  Need for hard – inescapable – volume agreements – To eliminate leak-away effects at the level of the participating and non-participating hospitals

Price

 Benefits can be used by the hospital for more quality improvement investments  Every 1% decline in hospital volume frees up €200Mn

Time



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€ 35

Connecting quality and financing in contracting policies

 Translate quality initiatives into new revenues

 Identify quality initiatives per hospital and per region New Performance Definitions

Selective Care Contracting  Contract quality hospitals  Referrals to quality hospitals by GPs  Cap other hospitals

Quality Initiatives

Reward Quality Initiatives  Evaluate revenue potential of quality initiatives  Determine gain sharing mechanism

Source: Booz & Company analysis Booz & Company 9 April, 2014


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The challenges to overcome for the payors


Bron:

Booz & Company

Booz & Company


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Fragmentation needs to be solved in order to capture the benefits of investing in quality INDICATIVE

The Theoretical Business Case Versus the Fragmented Business Case Illustrative Money Flows 20,000

20,000 750

The business case on paper  Invest in medication review and therapy adherence, and reap rewards by lowering hospital admissions

5,000

375

Budget Pharmacists


Investments


750

The business case in reality  Hospitals typically fill up freed up capacity in the grey zone of medication

5,375

New Budget Pharmacists

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Hospital Budget

Theoretic Freed Up Capacity

Refilled Capacity

Budget After Quality Improvement

38

Concluding: Contract and reimburse based on quality and break fragmentation in the system to encourage new ways of working 1 Volume (q) Contracting and reimbursement:

Volume (q)

Pay more for less

Price (p) Price (p) Tijd

Tijd

2

Break fragmenation

Bron:

Booz & Company

Booz & Company

Primary careijn

Hospitals


Welfare

Prepared for Achmea

Primary care

Hospitals

Welfare

Verzekeraar stuit hierbij op lastige dilemma’s   Innoveren     Contracteren  

Aansluiten

Verzekeraar wil zorgverbetering, maar kan niet op de stoel van de professional zitten Niet alleen uitkomsten: gepaste zorg. Zorgverbetering die leidt tot kostenverlaging, ‘straft’ de goede aanbieders af De complexiteit van ziekenhuizen staat zorgverbetering en kostenverlaging vaak in de weg Kwaliteit en volume vereenzelviging Besparingen per patiënt leiden vaak niet tot kostenverlaging omdat capaciteit weer wordt opgevuld Niet contracteren is voornaamste drukmiddel, maar heeft slechts beperkte geloofwaardigheid Verzekeraar wordt maar beperkt geaccepteerd als partner om over kwaliteit te spreken

 Verzekeraar wil zich onderscheiden, maar grote veranderingen worden vaak opgepakt door ZN  Landelijke concentratie agenda kan concurrentie tussen ziekenhuizen laten afnemen

 Verzekeraar wil voordeel voor eigen verzekerden maar aanbieders hebben patiënten van alle Differentiëren verzekeraars  Verz zou beste aanbieders willen contracteren, maar patiënten zijn sowieso vaak vrij zelf te kiezen  Verz wil zich kwalitatief onderscheiden, maar kwaliteit is vooral onderscheidend voor de aanbieder Organiseren Bron:

 Inkoop organisatie is georganiseerd per zorgsoort, maar innovaties spelen vaak ‘over de schotten’  Beleid en innovatie vindt vaak moeilijk aansluiting op de zorginkoop




Prepared for Achmea

Concurrentie tussen verzekeraars op kwaliteit en kosten van de zorginkoop vormt de hoeksteen van ons stelsel

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