Value Based Healthcare. Tobago, 6 November 2014

Value Based Healthcare Tobago, 6 November 2014

ACSION Group

ACSION Nederland

ACSION Curaçao

Address

Orteliuslaan 850 3528 BB Utrecht

Van Engelenweg 21A Curaçao, NA

Phone

+31 (0)20 8200338

+(599-9) 737-3595

eMail

[email protected]

Website

www.acsiongroup.com

ACSION: ‘Advanced Care Solutions and Insights for Optimization.’ ACSION is a group of companies located in the and Curaçao. ACSION provides strategic consultancy, concepts, tools and services to enable optimization of chronic care. Our customers are parties willing to ensure optimal care for chronic patients with optimal patient outcomes. These clients include health authorities, health insurers, pharmaceutical companies and care institutions.

The information in this document may not to be copied, stored in an electronic database, made publicly available in any way or form, either electronically, mechanically, by means of photocopying, recording or any other way without the prior written consent of ACSION

2

2

We have to make sure that the health budget is well spent And is considered an investment rather than cost to society COSTS TO SOCIETY

Population

Balance between affordability of care and funding for exploitation of care practices and institutes

POPULATION: WHY DO WE HAVE TO PAY THAT MUCH?

VALUE FOR SOCIETY Balance between care needs and quantity and quality of care

National Health Budget

Care providers

Care products

PROVIDERS: WE NEED MORE MONEY Balance between what care providers are paid and the care products they deliver

POPULATION: BURDEN AND COSTS OF DISEASE AVOIDED PROVIDERS: WE NEED MORE CAPACITY AND DESERVE MORE COMPENSATION FOR THE VALUE CREATED

In a balanced system, persons are willing to pay for care, because care professionals are eager to deliver highly valued care CREATE WILLINGNESS TO PAY Health Insurer Customer satisfaction

Care professional Satisfaction

CREATE WILLINGNESS TO PARTICIPATE

Care consumer staisfaction

Value of care delivered

INCREASE PERCEIVED VALUE OF CARE

4

Paradigm shift is needed to balance the budget Implement services to manage costs and increase willingness to pay at the same time INCOME • Number of insured • Premium • Compliance with mandatory Insurance and premium payments

Increased willingnes to pay

Increase perceived value

Manage Care Costs

EXPENDITURES • Overhead costs • Care costs • Public Health and prevention 5

Payers and care professionals should team up to fight avoidable costs They have more common objectives than you currently perceive

6

Examples from Dutch speaking countries How to engage with care professionals and the population to enhance results

Paradigm shift is needed

3 Balances to create value

Smoking 1. Bruto marge Op dit moment

COPD exacerbations

wordt er geen maximum bruto marge gehanteerd. De marges die gehanteerd worden variëren van -50% t/m 344%.

Hardlopers (o.b.v. kosten) Interventie 1: de bruto marge is maximaal

25% (maximaal bruto marge)

Interventie 1: de bruto marge is maximaal


Interventie 2: de bruto marge is gelijk aan

25% (bruto marge)


25% (bruto marge)

Overzicht kosten/besparingen Interventie 1 ZV ANG 37.023,33 OZR ANG 21.217,12 FZOG ANG 3.612,32 Totaal ANG 61.852,76

Overzicht kosten/besparingen

ZV OZR FZOG Totaal

Interventie 2 ANG (81.239,58) ANG (28.604,96) ANG (6.903,25) ANG (116.747,80)

ZV OZR FZOG Totaal

Interventie 1 ANG 58.674,09 ANG 22.440,99 ANG 5.543,02 ANG 86.658,10

ZV OZR FZOG Totaal

10% (percentage fout voorgeschreven)

Situatie 2


Situatie 3


Pulmonary function / dyspnea

Overweight Physical (in)activity

8 6

Nutrition

4


Retinopathy

Alcohol

2 0

Neuropathy

2. Doelmatiger voorschrijven Besparingen op medicatie kunnen gerealiseerd worden door ondoelmatig voorschrijven tegen te gaan.

Situatie 1

10

Exercise tolerance

Hardlopers (o.b.v. volume)

Stress

Farmaceutische uitgaven ANG 900.000,00 ANG 800.000,00

Diabetic foot

ANG 700.000,00

Depression

Axis Title

ANG 600.000,00

Overzicht besparingen Omschrijving Uitgangssituatie Hardlopers (o.b.v. kosten) ANG 625.991,03 Hardlopers (o.b.v. volume) ANG 267.902,07 Totaal UR medicatie ANG 766.138,82

Situatie 1 ANG 62.599,10 ANG 26.790,21 ANG 76.613,88

ANG ANG ANG

Situatie 2 Situatie 3 125.198,21 ANG 187.797,31 53.580,41 ANG 80.370,62 153.227,76 ANG 229.841,64

ANG 500.000,00 ANG 400.000,00

Glucose

ANG 300.000,00 ANG 200.000,00

Anxiety

ANG 100.000,00 ANG -

Hardlopers (o.b.v. kosten)


Totaal UR medicatie

Uitgangssituatie

ANG 625.991,03

ANG 267.902,07

ANG 766.138,82

Situatie 1

ANG 563.391,92

ANG 241.111,86

ANG 689.524,93

Situatie 2

ANG 500.792,82

ANG 214.321,66

ANG 612.911,05

Situatie 3

ANG 438.193,72

ANG 187.531,45

ANG 536.297,17

Nefropathy Blood pressure

Somatisation Cholesterol

T0

Automization & reimbursement strategy

Rationalize Pharmaceutical care

T1

CVRM program and OSS 7

Data pyramid Registration primarily meant for primary process support

Budget management Integral quality management

Support multidisciplinary care

Support primary processes individual care professional

8

Episode registration to ensure all relevant information is readily available at the right moment •

All data from care contacts are organized and saved within the care episode Episode title: ICPC2 diagnose code plus name

•

Doctor notes: SOEP

Doctor notes: SOEP

Doctor notes: SOEP

Codes: ICPC2

Codes: ICPC2

Codes: ICPC2

Correspondence: In- and outgoing letters

Diagnostic results: Lab Images

Relevant and important information can be found by episode or by type of information Care Episodes

•

Medication dossier: Medication Contra-indications

Medication dossier

Diagnostics

Correspondence

Additional information – Family history, Social history – Profylaxis, contra-indications, allergies

•

Medical summary and attention page

9

Support multidisciplinary cooperation and continuity of registration – integral set of requirements

Specialist / Huisartsenpost (HAP) Hospital

Huisarts

Referrals

GP

Electronic claims

Referrals

Claims administration Specialist/ Other care Paramedicus providers

Health Repository Broker

Electronic prescribing

Lab forms and results

Apotheek Pharmacy Laboratorium Laboratory

10

Episode registration: what needs to be registered? An episode of care is a health problem from its first presentation to a health

care provider until (and including) the last encounter for it : an individual patient’s problem followed over time

Three key components :

1

Reason for Encounter

2

Diagnosis

1st Encounter

‘I’m feeling tired’ A04

Tiredness A04

2nd Encounter

‘what’s the test result?’ A60

iron deficiency

3rd Encounter

‘what’s the test result?’ D60

Ca Colon

Anemia

3

Process

Coded in ICPC-2 / ICD-10

Hb A34

Colonoscopy D40

B80

D75

Referral D67 Advice D45

11

Reporting on the main care episodes Example: Uncomplicated hypertensie (K86) Duration of the episode

Activities 1%1% 1% 1%

64% > 1 year 50% > 2 years 100 75 50 25 0

49%

Cum % of episodes / duration

Other blood test Electrical tracings Provid init episode new/ongoing

23%

Diagnostic radiology/imaging 1 yr

4 yr or more

duration

Care contacts

?

Medication/prescript/injection Advice/health education

19%

%

Med exam/health evalua/partial

6%

Other

Prescribed medication 3% 2%1% 1%

~6 times a year Median: 1 per 55 days Average: 1 per 65 days

Beta-blocking agents, plain, selective Angiotensin system blocking agents

7% 28%

9%

Thiazides and combinations Calcium channel blockers

200 150 100 50 0

N

Interval of encounters

13% 20% 18%

Combinations with potassium sparing diuretics Angiotensin II blocking agents High-ceiling (loop) diuretics

0

6 months

Source: international data on episodes in family practice, Transitieproject

12

Mul;tiple reports possible with episode registration and automatic claims handling

Disease Episode (from the start of the disease)

Illness episode (from the start of complaints) Underdiagnosis Unknown

Care episode (from the first contact with the health system)

Survey

Episode registration

Morbidity registration

• Prevalence • Incidence • Mortality

• • • • •

Care process Care outcomes

Health Service Coverage Process indicators Care algorithms Care products Care behavior

• • • •

Costs

Intermediate End Mortality Complications

• Total • Per diagnosis • Avoidable

13

Medical tariffs study St. Maarten Pro’s and con’s of different reimbursement systems Pay for Service (Activity based)

Pay for products (Value based)

Subscription fee (Capitation based)

Stimulates productivity where it is needed







Limits overtreatment

Predictable expenses

   

   

   

Administrative burden minimized







Fraud proof







Implementable in daily practice







Criteria

Limits overconsumption Stimulate quality

14

From budget to activities to products Care products

Hospital Activities Cost Efficiency Budget Manpower Materials Instruments Management

Cost effectivity Care activities Consultations Hospital days Lab tests Radiology Surgery PA

Care Products Cataract Total hip replacement Total knee replacement VSD Hernia inguinalis Kidney stone Essential activities Quality indicators 15

Start with a relatively simple hybrid tariff system with predictable expenditures Suggested revenues structure

Cost structure

Costs

Normative income

Required revenues

Disadvantages of each system compensate for each other

Income from consultations & procedures

Revenues to be generated by available earning capacity

Income from capitation fees

To be covered by fixed amount per registered patient or predetermined production 16

Short term registration strategy: Reporting for reimbursement and to build new tariff structure Registration strategy

R • Health Information Systems for GPs, Hospitals, Pharmacies and Laboratories • International standards for health record keeping • Continuity of Care Record (CCR) / Continuity of Care Document (CCD)

r+ • Reporting mandatory + information for further development of funding system • Data to monitor care consumption linked to diagnoses (DIS)

r • Reporting mandatory for reimbursement • Short term solution

17

Health Information Management System (HIMS): Episode registration → same data serves multiple purposes Episode Registration at GP X

Hospital Information system / EPD

GP system

Pharmacies Laboratories

NHS

eGov

Health Repository Broker

Conceptual Model of the CCR 1

Document Identifying Information

2

Patient Identifying Information

3 4

5

“From/To” info re Provider/Clinician Reason for Referral/Transfer

Insurance and Financial Info Health Status of Patient Diagnosis/Problems/Conditions Adverse Reaction/Alerts Current Medications Immunizations Vital Signs Lab Results Procedures/Assessments

Care Documentation

Health Reporting Duration of episode

1% 1% 1% 1%

Extension

Eligibility, Co-payment, etc.

Advice/health education

Extension

Disease Management-specific Info

Extension

Personal Health Record Info Documented by the Patient

Extension

Med. Specialty-specific Info

Extension

Disease Management-specific Info

Extension

Institution-specific information

Extension

Care Documentation for Payers (Attachments) Personal Health Record Info

Provid init episode new/ongoing

Diagnostic radiology/imaging 1 yr

duration

4 yr or more

Prescription pattern 3% 2% 1% 1%

~6 times per annum Median: 1 per 55 days Average: 1 per 65 days

N

28%

13%

20% 18%

39,00

1980022591

12-04-2012

10002

Thiazides and combinations

65,00

1980022591

10-04-2012

10001

39,00

Combinations with potassium sparing diuretics Angiotensin II blocking agents

High-ceiling (loop) diuretics 0

6 months

Documented by the Patient

Care Plan Recommendation Version 6– 10/31/03

R: CCR / CCD

Amount

10001

Angiotensin system blocking agents

Health Budget and Consumption

Mandated Core Elements of the CCR

Consult/ Treatment

12-04-2012

Beta-blocking agents, plain, selective

7%

Interval of encounters

Date

1972043090

Other

Calcium channel blockers 200 150 100 50 0

ID

Other blood test Electrical tracings

23%

9%

Med. Specialty-specific Info

Medication/prescript/injection

49%

Cum % of episodes / duration

Encounters

?

Med exam/health evalua/partial

6% 19%

Extension

Electronic Claim for GP X

Activity pattern

64% > 1 year 50% > 2 years % 100 75 50 25 0

Optional Extension

Extension

6

Claims Processing

Health Monitoring and Analysis

Optional Extension

r+: reports

r: claims • • • • •

Care product definitions Reimbursement and Tariff system National Health Accounts Performance improvement 18 Premiums and packages




Smoking 1. Bruto marge Op dit moment

COPD exacerbations


Hardlopers (o.b.v. kosten) Interventie 1: de bruto marge is maximaal





25% (bruto marge)


25% (bruto marge)



ZV OZR FZOG Totaal


ZV OZR FZOG Totaal


ZV OZR FZOG Totaal


Situatie 2


Situatie 3




8 6

Nutrition

4


Retinopathy

Alcohol

2 0

Neuropathy


Situatie 1

10

Exercise tolerance


Stress

Farmaceutische uitgaven ANG 900.000,00 ANG 800.000,00

Diabetic foot

ANG 700.000,00

Depression

Axis Title

ANG 600.000,00



ANG ANG ANG


ANG 500.000,00 ANG 400.000,00

Glucose

ANG 300.000,00 ANG 200.000,00

Anxiety

ANG 100.000,00 ANG -



Totaal UR medicatie

Uitgangssituatie

ANG 625.991,03

ANG 267.902,07

ANG 766.138,82

Situatie 1

ANG 563.391,92

ANG 241.111,86

ANG 689.524,93

Situatie 2

ANG 500.792,82

ANG 214.321,66

ANG 612.911,05

Situatie 3

ANG 438.193,72

ANG 187.531,45

ANG 536.297,17



T0

Registration & reimbursement strategy


T1


Average expenditures pharmaceutical care in the region

Pharmacy / pharmacist is your friend rather than your enemy

• COGS account for 70% of the expenditures on pharmaceuticals • Biggest saving potential 20

Cost of goods sold (COGS) COGS

Volume Volume can be rationalized by • Reducing the package of reimbursed medication • Stimulating rational prescribing of medication

Price Prize can be rationalized by • Reviewing the pharmaceutical value chain • Analyze cost(driver)s and profit margins 21

Policy support dashboard Virtual savings with different measures 1. Bruto marge Op dit moment wordt er geen maximum bruto marge gehanteerd. De marges die gehanteerd worden variëren van -50% t/m 344%.








25% (bruto marge)


25% (bruto marge)



ZV OZR FZOG Totaal


ZV OZR FZOG Totaal


ZV OZR FZOG Totaal



Situatie 1


Situatie 2


Situatie 3


Farmaceutische uitgaven ANG 900.000,00 ANG 800.000,00 ANG 700.000,00

Axis Title

ANG 600.000,00

Overzicht besparingen Omschrijving Hardlopers (o.b.v. kosten) Hardlopers (o.b.v. volume) Totaal UR medicatie

Uitgangssituatie ANG 625.991,03 ANG 267.902,07 ANG 766.138,82


ANG ANG ANG


ANG 500.000,00 ANG 400.000,00 ANG 300.000,00 ANG 200.000,00

ANG 100.000,00 ANG -



Totaal UR medicatie

Uitgangssituatie

ANG 625.991,03

ANG 267.902,07

ANG 766.138,82

Situatie 1

ANG 563.391,92

ANG 241.111,86

ANG 689.524,93

Situatie 2

ANG 500.792,82

ANG 214.321,66

ANG 612.911,05

Situatie 3

ANG 438.193,72

ANG 187.531,45

ANG 536.297,17

22




1. Bruto marge Op dit moment



Smoking







25% (bruto marge)


25% (bruto marge)


Overzicht kosten/besparingen Interventie 2 ZV ANG (81.239,58) OZR ANG (28.604,96) FZOG ANG (6.903,25) Totaal ANG (116.747,80)

Interventie 1 ZV ANG 58.674,09 OZR ANG 22.440,99 FZOG ANG 5.543,02 Totaal ANG 86.658,10


Situatie 2


Situatie 3


10




8 6

Nutrition

4 Retinopathy

Alcohol

2 0

Neuropathy


Situatie 1

COPD exacerbations Exercise tolerance

Stress

Farmaceutische uitgaven

Diabetic foot

ANG 900.000,00

Depression

ANG 800.000,00 ANG 700.000,00

Axis Title

ANG 600.000,00




ANG ANG ANG


Glucose

ANG 500.000,00

Anxiety

ANG 400.000,00 ANG 300.000,00


ANG 200.000,00

ANG 100.000,00 ANG -



Totaal UR medicatie

Uitgangssituatie

ANG 625.991,03

ANG 267.902,07

ANG 766.138,82

Situatie 1

ANG 563.391,92

ANG 241.111,86

ANG 689.524,93

Situatie 2

ANG 500.792,82

ANG 214.321,66

ANG 612.911,05

Situatie 3

ANG 438.193,72

ANG 187.531,45

ANG 536.297,17



T0

T1


CVRM and diabetes care Summary and results of projects in Suriname, St. Maarten and NL Urgent need to optimize CVRM and diabetes care CVRM Care standard and optimization strategy

Define norms and identify room for improvement

CVRM pilot

Implement part of the recommendations

Roll out

One Stop Shops 24

Importance of optimizing CVRM/DM2 care: urgent! Diabetes population in Suriname: Peak 20 years younger dan elsewhere!

Less than 10% of diabetics survives longer than 20 years! 300

25

264

250

20

200

15 150

127

10 100

5

56 40

50

0

47

0

18

25

31

35

39

43

47

51

55

59

63

67

71

75

79

83

87

0-4 jaar

79% of diabetics is not well regulated!

5-9 jaar

10-14 jaar

15-19 jaar

>=20 jaar

73% of diabetics has overweight 4% 23%

31%

21% normaal

79%

<20 20-25 25-30 >30

>6.5mmol

42%

25

Example St. Maarten Two thirds of highest costs are driven by CVR / CVD / Diabetes

Intramural care and pharmaceutical costs biggest cost driver

Intramural care costs driven by Ob&Gyn / HIV&Aids / CVD&DM

DM/CVRM cause almost 60% of costs prescription medication

26



CVRM pilot


Roll out

One Stop Shops 27

Chronic Care Model is starting point

28

Prioritization of strategies Complex problems, but once solved, rapid and high impact results Fast

1. Personalized treatment goals and targets 2. Motivate and coach patients

5,0

3. Information and education materials for patients 4. Awareness about patient involvement 5. Sufficient staff

4,0

Speed

6. Facilities in GP practices

3,0

7. Central care provider and multidisciplinary team 8. Electronic protocols and EHRs 9. Monitoring after identification

2,0

10. Knowledge and skills

Long

11. Multisectoral approach 1,0 1,0

2,0

Difficult

3,0

Complexity

4,0

5,0

12. Public campaigns

Easy 29

= Impact



CVRM pilot


Roll out

One Stop Shops 30

Pilot interventions •

Integral modular care program

•

Trained specialized nurses

•

Central caregiver (nurse supervised by GP)

•

Assessment and shared decision making (SDM) with electronic protocol

•

Intensive follow-up with multidisciplinary cooperation (teamwork)

•

Feedback and benchmark information

•

Assess population care needs and necessary capacity / investments

31

Visualize risk profile Scores from 1 to 10 for each relevant health problem Smoking COPD exacerbations

COPD

10

Exercise tolerance


8


6

LIFESTYLE

Nutrition

4 Retinopathy

Alcohol

2 0

Neuropathy

Stress

Diabetic foot

DIABETES MELLITUS

Depression

Glucose

Anxiety



T0

PSYCHOLOGICAL COMPLAINTS

T1

VASCULAR RISK

32

Spiderweb scores OVERWEIGHT

Co-morbidities1

No

Yes

Waist circumference (Other)

Waist circumference (Asian)

(cm)

(cm)

♂ < 94

♂ < 84

♀ < 80

♀ < 74

♂ < 94 – 102 ♀ < 80 – 88

BMI Asian 18,5 – 22,9

Asian 23 – 24,9

Asian 25 – 29,9

Asian 30 – 34,9

Asian >35

Other 18,5 – 24,9

Other 25 – 29,9

Other 30 – 34,9

Other 35 – 39,9

Other > 40

1

2

3

5

6

♂ < 84 – 92 ♀ < 74 – 82

2

3

4

6

8

♂ > 102 ♀ > 88

♂ > 92 ♀ > 82

3

4

5

7

9

♂ < 94 ♀ < 80

♂ < 84 ♀ < 74

2

4

6

8

10

♂ < 94 – 102 ♀ < 80 – 88

♂ < 84 – 92 ♀ < 74 – 82

5

7

8

9

10

♂ > 102 ♀ > 88

♂ > 92 ♀ > 82

6

8

9

10

10

2) Obesity related diseases: CVD, CVR, arthrosis, sleep apnoea

33

Make an individual care plan based on assessment Health issues Unhealthy lifestyle

General wellbeing

Cardiovascular risk-management

Diabetes mellitus

Stepped-care modules

Smoking

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Disease specific

Physical activity

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Disease specific

Alcohol

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Disease specific

Nutrition

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Disease specific

Depression

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Stress

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Participation

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Obesity

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Hypertension

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Dyslipidemia

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Nephropathy

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Glucose

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Retinopathy

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Neuropathy

Sc module 1

Sc module 2

Sc module 3

Sc module 4

Feet

Sc module 1

Sc module 2

Sc module 3

Sc module 4

34

Individual Care Plan based on chosen SCMs Individueel Behandelplan Roken 2

Adviezen

R2.A Leefstijladviezen

Overgewicht 3 R2.F FarmacotherapieO3.A Leefstijladviezen R2.V Verwijzing

O3.F Hypertensie 3 Farmacotherapie H3.A R2.M Monitoring & Leefstijladviezen O3.V Verwijzing Controle H3.F Farmacotherapie O3.M Monitoring & Controle H3.V Verwijzing

Medicatie

Verwijzingen

Leef- en behandeldoelen

H3.M Monitoring & Controle

Follow-up

35

Follow-up: Monitoring visits Patient recruitment

• • • • • •

Intake

Additional diagnostics

Individual care plan

Follow up

Feedback & Benchmark

Shared care provided by specialized nurse and patient’s GP Compliance support and lifestyle change Specialized foot care Progress is periodically monitored by nurse New targets New appointments

36

Feedback & benchmark every 3 months Patient recruitment

Intake

Risk and care profiles

Individual care plan

Follow up

Feedback & Benchmark

37

Aggregate individual profiles to a population profile

Aggregate individual patient profiles

Insights in types and volumes of care to be delivered

38

Pay for reporting, output and changes

Pay for reporting You only get paid when data is registered consistently and correctly

Smoking COPD exacerbations

10

Exercise tolerance Pulmonary function / dyspnea


8 6

Nutrition

4 Retinopathy

Pay for tailored care Patients will receive the care they need and not only what the GP is paid for

Alcohol

2 0

Neuropathy

Stress

Diabetic foot

Depression

Glucose

Anxiety



T0

T1

Engage with patients Shared Decision Making incentive for making a difference 39

Summary • Assessment preparation – Information from GP charts / system – Lab / function tests – Questionnaires

GP system 4

• Assessement (yearly) – Shared Decisionmaking – Individual care plan

Tablet App

Aggregate

3 Casemix 1.Standaard informatie • Administratief • Logistiek 2. Zorgprogramma • Casemix • Zorgbehoeften

Planning and execute

3. Lokale afspraken • • •

Capacity / resources

Populatiekenmerken, Uitkomsten Zorginnovatie

Contract interface 40

CVRM and diabetes care Summary and results of projects in Suriname, St. Maarten and NL Urgent need to optimize CVRM and diabetes care

CVRM program 2009 - 2010

CVRM Care standard and optimization strategy


CVRM pilot

CVRM pilot 2010 - 2012


Roll out

OSS 2013 One Stop Shops 41




1. Bruto marge Op dit moment



Smoking







25% (bruto marge)


25% (bruto marge)


Overzicht kosten/besparingen Interventie 2 ZV ANG (81.239,58) OZR ANG (28.604,96) FZOG ANG (6.903,25) Totaal ANG (116.747,80)



Situatie 2


Situatie 3


10




8 6

Nutrition

4 Retinopathy

Alcohol

2 0

Neuropathy


Situatie 1

COPD exacerbations Exercise tolerance

Stress

Farmaceutische uitgaven

Diabetic foot

ANG 900.000,00

Depression

ANG 800.000,00 ANG 700.000,00

Axis Title

ANG 600.000,00




ANG ANG ANG


Glucose

ANG 500.000,00

Anxiety

ANG 400.000,00 ANG 300.000,00


ANG 200.000,00

ANG 100.000,00 ANG -



Totaal UR medicatie

Uitgangssituatie

ANG 625.991,03

ANG 267.902,07

ANG 766.138,82

Situatie 1

ANG 563.391,92

ANG 241.111,86

ANG 689.524,93

Situatie 2

ANG 500.792,82

ANG 214.321,66

ANG 612.911,05

Situatie 3

ANG 438.193,72

ANG 187.531,45

ANG 536.297,17



T0

T1


Thank you!

Value Based Healthcare. Tobago, 6 November 2014

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