Forsberg Knezevic EHMA 2008 Stockholm County Council Reimbursements in psychiatry in Sweden –...

Forsberg Knezevic EHMA 2008

Stockholm County Council

Reimbursements in psychiatry in Sweden – models and experiences

Birger Carl Forsberg. MD MPH BSc

Milan Knezevic, MBA

Stockholm County Council Administration

Dept of Public Health Sciences

Karolinska Institutet

Stockholm

Sweden

www.sll.se



Reimbursements in psychiatry in Sweden- models and experiences

Stockholms County CouncilRegion Västra Götaland

Region Skåne/Scania



Objective The overall:

– to contribute to the development of psychiatric health services for the overall attainment of good health and client satisfaction

The specific: – to study and understand key characteristics of the

purchaser/provider (PP) models in psychiatric health services and

– to explore the development of reimbursement models in psychiatric care



Methods

Interviews with health care managers

Review of policy and implementation documents



Background

Purchaser-provider models introduced in the early 90es in Sweden

Introduction in phases depending on experience gained and political majority shifts in county councils and at national level

However, gradually purchaser-provider models have been established, particularly in larger county councils



Background

Cost pressures on health services increase the need for cost control

Political developments favoured new systems

Background



Results - Historical developments

Purchaser-provider models introduced in psychiatry in the mid-nineties

However, traditional historical budget based reimbursement models were used throughout most of the 90es

Performance based reimbursement models were introduced in small scale around 2000 in Stockholm

The first private providers were contracted in 2002 in Region Skåne



Results -Reasons for introduction of purchaser-provider

models in psychiatry

Poor access to services (waiting times, non-availability of staff and treatments)

Poor coordination within services and between psychiatry and other relevant services

Poor flexibility



Results - Aims

All three regions have developed the same aims:– To increase productivity – To decrease in-patient care– To improve availability of personnel, in particular

psychiatrists– To improve quality– To create a pluralistic supply of services



Results - Models

All models contain: – Fixed reimbursement– Performance-based reimbursement– Quality based/target based reimbursement for

delivered patient care In addition, several contracts included specific tasks

that were reimbursed on a lump-sum basis (like special services, training etc.)



Results - Models Region Västra Götaland

– Fixed/performance-based Started 50/50, target now

– 90/10 for in-patient and

– 70/30 for out-patient Actual mix in 2007 52% fixed, performance-based 48%

– Reimbursement based on discharges (IPD) and visits (OPD)

– Classification systems for case-mix tested for a more diversified and truly need-based reimbursement system

– Targets for volumes set – penalty/bonus related – Quality indicators (15) developed - to be implemented 2008 –

basis for 2-3% of total reimbursement



Results - Models Region Skåne

– Out-patient service in two wards through purchasing of private provider: 100% performance based reimbursement Reimbursement based on visits and separated into three categories Geographic area responsibility Financial ceiling set – above that only patient fee Quality indicators (7) developed – not bound to reimbursement but

important for evaluation Clear terms of reference based on a common value ground and clear

targets and expectations



Results - Models Region Skåne

– From 2006 a new reimbursement model for publicly produced

health services 60% fixed and 40% performance based from 100% fixed budget

Performance based reimbursement for inpatient care based on days of

care

Performance based reimbursement for outpatient care based on visits



Results - Models Stockholm County Council 2006-2007

92%

72%

5%

25%

3% 3%

0%

20%

40%

60%

80%

100%

Inpatient care Outpatient care

Quality basedreimbursement

Performancebasedreimbursement

Fixedreimbursement



Results - Models Stockholm County Council

– Performance based reimbursement inpatient care (5%)

– Day 1 SEK 400– Day 2-10 SEK 240– > 11 days SEK 200

outpatient care (25%)– Visit to clinic SEK 350– Home visit SEK 700– Group visit SEK 175– For each patient (individual) SEK 700



Results - Models

Stockholm County Council 2008– Fixed/performance based 50/50% in both inpatient and

outpatient care– This will be achieved through doubling payment for

visits and increasing reimbursement for inpatient days ten-fold

– A ceiling on volumes will be put on reimbursement. Above the ceiling producers will only get 10% of rates set.



Results - Experience

Increased production Less inpatient care, more outpatient Increased accessibility Improved coordination among care providers and other

actors in Skåne Significant tensions between purchasers and providers Significant time spent on negotiations around quality

indicators (that represent a small part of reimbursement)



Results - Experience

Providers feel purchasers are over-simplifying description of services, emphasizing quantity rather than quality

In Skåne, both providers and purchasers are overall pleased with the cooperation

Purchasers felt that presence of private providers had resulted in increased attention on key issues like productivity in public services



Discussion

All three regions have independent of each other set up strikingly similar targets concerning psychiatric health services, much as a result of facing the same problems.

Emphasis is put on increasing productivity and accessibility and the ambition is to work towards increased quality of care and thereby improved medical outcomes.

Purchasers aim to increase outpatient care and decrease inpatient care. The regions employ the same base reimbursement model, but with

different structures and levels of services, products and prices. The reimbursement models for outpatient care have to a higher extent

performance based reimbursement that inpatient care.



Discussion- Preconditions

Clarity in contracted task and targets are essential Well defined and precise terms of reference is a vital

precondition for a well functioning reimbursement model The contracted task should be based on obligatory tasks

and defined target levels Few but well thought-out quality indicators for

evaluation



Discussion- Problems

Lack of well functioning and generally accepted classification systems.

Preventive and health promoting activities are not rewarded.

Reimbursement models not adapted to individual needs of care.



Conclusion

Performance based reimbursement models in psychiatric care work well given when overall aims are set to increase productivity and structural conditions are similar to those in the regions studied.

Terms of reference and clear definitions of contracted tasks are essential even if they are not specifically linked to payments.



Conclusion

The demand for further development and knowledge concerning the usage and effects of reimbursement models in psychiatric health services is significant.

The knowledge could be used to improve the models for further contribution to reaching the overall aims of services – improved access, client satisfaction and good health.

Forsberg Knezevic EHMA 2008 Stockholm County Council Reimbursements in psychiatry in Sweden –...

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