Manuel García-Goñi

Prevalence and Costs of Multimorbidity by Deprivation Levels in the Basque Country: A Population Based Study Using Health Administrative Databases

Background Multimorbidity is a major challenge for healthcare systems. However, currently, its magnitude and impact in healthcare expenditures is still mostly unknown. Objective To present an overview of the prevalence and costs of multimorbidity by socioeconomic levels in the whole Basque population. Methods We develop a cross-sectional analysis that includes all the inhabitants of the Basque Country (N = 2,262,698). We utilize data from primary health care electronic medical records, hospital admissions, and outpatient care databases, corresponding to a 4 year period. Multimorbidity was defined as the presence of two or more chronic diseases out of a list of 52 of the most important and common chronic conditions given in the literature. We also use socioeconomic and demographic variables such as age, sex, individual healthcare cost, and deprivation level. Predicted adjusted costs were obtained by log-gamma regression models. Results Multimorbidity of chronic diseases was found among 23.61% of the total Basque population and among 66.13% of those older than 65 years. Multimorbid patients account for 63.55% of total healthcare expenditures. Prevalence of multimorbidity is higher in the most deprived areas for all age and sex groups. The annual cost of healthcare per patient generated for any chronic disease depends on the number of coexisting comorbidities, and varies from 637 € for the first pathology in average to 1,657 € for the ninth one. Conclusion Multimorbidity is very common for the Basque population and its prevalence rises in age, and unfavourable socioeconomic environment. The costs of care for chronic patients with several conditions cannot be described as the sum of their individual pathologies in average. They usually increase dramatically according to the number of comorbidities. Given the ageing population, multimorbidity and its consequences should be taken into account in healthcare policy, the organization of care and medical research.

La medida de la morbilidad atendida en una organización sanitaria integrada

INTRODUCTION Understanding the quality, costs and outcomes of healthcare services requires precise determination of the morbidity in a population. Measurement of morbidity in a population and its association with the services provided remains to be performed. The aim of this article was to present our experience of using clinical risk groups (CRGs) to measure morbidity in an integrated healthcare organization (IHO). METHODS We studied the population attended by an IHO in a county (approximately 120,000 patients) from 2002 to 2005. CRGs were used to measure morbidity. A descriptive analysis was performed of the populations distribution in CRG categories and utilization rates. RESULTS One or more chronic diseases was found in 15.5% of the population, significant acute illness was found in 9%, minor chronic diseases was found in 7% and very severe diseases was found in 0.5%. Between 2002 and 2005, the number of individuals with chronic disease increased by 8%. The burden of illness increased with age. However, at all ages, at least 40% of the population remained healthy. Comorbidity in chronic illnesses was a crucial factor in explaining healthcare resource utilization. CONCLUSIONS The CRG grouping system aids analysis at different levels for clinical administration. Due to its composition, this system allows better understanding of the use, costs and quality of the set of services received by a population.

Estimates of patient costs related with population morbidity: can indirect costs affect the results?

A number of health economics studies require patient cost estimates as basic information input. However, the accuracy of cost estimates remains generally unspecified. We propose to investigate how the allocation of indirect costs or overheads can affect the estimation of patient costs and lead to improvements in the analysis of patient cost estimates. Instead of focussing on the costing method, this paper will highlight observed changes in variation explained by a methodology choice. We compare four overhead allocation methods for a specific Spanish population adjusted using the Clinical Risk Groups model. Our main conclusion is that the amount of global variation explained by the risk adjustment model depends mainly on direct costs, regardless of the cost allocation methodology used. Furthermore, the variation explained can be slightly increased, depending on the cost allocation methodology, and is independent of the level of aggregation in the classification system.

Hybrid risk adjustment for pharmaceutical benefits

This paper analyses the application of hybrid risk adjustment versus either prospective or concurrent risk adjustment formulae in the context of funding pharmaceutical benefits for the population of an integrated healthcare delivery organisation in Catalonia during years 2002 and 2003. We apply a mixed formula and find that, compared to prospective only models, a hybrid risk adjustment model increases incentives for efficiency in the provision for low risk individuals in health organisations, not only as a whole but also within each internal department, by reducing within-group variation of drug expenditures.

Addressing multimorbidity to improve healthcare and economic sustainability

Patients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level – something that is now supported within the framework of the European Unions Stability and Growth Pact.

Mandatory aged care insurance: a case for Australia

ABSTRACT This paper assesses the feasibility and welfare-improving potential of an insurance market for aged care expenses in Australia. As in many other countries, demographic dynamics coupled with an upward trend in costs of personal care result in consumer co-contributions imposing a risk of expenses that could constitute a significant proportion of lifetime savings, in spite of the presence of a government-run aged care scheme. We explore issues around the development of an insurance market in this particular setting, considering adverse selection, moral hazard, timing of purchase, transaction costs and correlation of risks, as well as such contextual factors as longevity and aged care cost determinants. The analysis indicates aged care insurance is both feasible and welfare-enhancing, thus providing a gainful alternative to the aged care reform proposed by the Productivity Commission in 2011. However, while the insurance market would benefit the ageing Australian population, it is unlikely to emerge spontaneously because of the problem of myopic individual perceptions of long-term goals. Consequently, we recommend regulatory action to trigger the market development.

Diferencias y similitudes entre los procesos de adopción de innovaciones tecnológicas y organizacionales en los hospitales

Objectives: With the aim of improving the provision of he- alth services, providers implement innovation processes of eit- her technological or organisational nature. As a consequen- ce, health expenditure increases and its control has become a concern in health policy. Therefore, it becomes relevant to study the process of adoption of innovations itself, whether there is a direct relationship between the use of the innovations and the increase in health expenditures, and the differences bet- ween technological and organisational processes. Methods: This paper presents a survey of the literature re- lating the process of adoption of innovation and their diffusion with health expenditures and the effects of the innovations in health status, comparing technological and organisational in- novations. This paper uses 2 case studies: the adoption of the Digital Radiology and Ambulatory Surgery at a public hospi- tal. Results: During the adoption of innovations, a learning pro- cess in health professionals and patients takes place that may delay the positive expected results. There is a spill over ef- fect in the use of the service, which in the form of an expan- sion treatment, increases health expenditures. Innovations im- prove the provision of health services and solve the existing bottlenecks, bringing as a consequence the appearance of new bottlenecks, and therefore, new incentives to innovate. Conclusions: There are no big differences in the way in which technological and organisational innovation processes are analysed. Furthermore, the cost-effectiveness analysis seems to be the right way in the decision taking stage on every type of innovations. words: Technological innovation. Organisational inno-

Pathways Towards Health Care Systems with a Chronic-Care Focus: Beyond the Four Walls

Increasing health care expenditure is a matter of concern in many countries, particularly in relation to the underlying drivers of such escalation that include aging, medical innovation, and changes in the burden of disease, such as the growing prevalence of chronic diseases. Most health care systems in developed countries have been designed to cure acute episodes, rather than to manage chronic conditions, and therefore they are not suitably or efficiently organized to respond to the changing needs and preferences of users. Hospitals provide much of that health provision and they are in need of adapting to the needs of the population. New models of chronic care provision have been developed to respond to the changing burden of disease, taking into account the role of hospitals. Further, there is considerable practical experience in several different countries showing their advantages but also the difficulties associated with their implementation. In this paper, we focus on the international experiences in terms of policy changes and pilot studies focused on testing the feasibility of moving toward chronic care models. In particular, we discuss a framework that identifies and analyzes key prerequisites to achieving high performing chronic care-based health care systems and apply it to various countries and link this proposal with the concept of the boundaryless hospital.

Is utilization of health services for HIV patients equal by socioeconomic status? Evidence from the Basque country.

IntroductionAccess to ART and health services is guaranteed under universal coverage to improve life expectancy and quality of life for HIV patients. However, it remains unknown whether patients of different socioeconomic background equally use different types of health services.MethodsWe use one-year (2010–2011) data on individual healthcare utilization and expenditures for the total population (N = 2262698) of the Basque Country. We observe the prevalence of HIV and use OLS regressions to estimate the impact on health utilization of demographic, socioeconomic characteristics, and health status in such patients.ResultsHIV prevalence per 1000 individuals is greater the lower the socioeconomic status (0.784 for highest; 2.135 for lowest), for males (1.616) versus females (0.729), and for middle-age groups (26–45 and 46–65). Health expenditures are 11826€ greater for HIV patients than for others, but with differences by socioeconomic group derived from a different mix of services utilization (total cost of 13058€ for poorest, 14960€ for richest). Controlling for health status and demographic variables, poor HIV patients consume more on pharmaceuticals; rich in specialists and hospital care. Therefore, there is inequity in health services utilization by socioeconomic groups.ConclusionsEquity in health provision for HIV patients represents a challenge even if access to treatment is guaranteed. Lack of information in poorer individuals might lead to under-provision while richer individuals might demand over-provision. We recommend establishing accurate clinical guidelines with the appropriate mix of health provision by validated need for all socioeconomic groups; promoting educational programs so that patients demand the appropriate mix of services, and stimulating integrated care for HIV patients with multiple chronic conditions.

FINGER (Forming and Identifying New Groups of Expected Risks): developing and validating a new predictive model to identify patients with high healthcare cost and at risk of admission

Objective Predictive statistical models used in population stratification programmes are complex and usually difficult to interpret for primary care professionals. We designed FINGER (Forming and Identifying New Groups of Expected Risks), a new model based on clinical criteria, easy to understand and implement by physicians. Our aim was to assess the ability of FINGER to predict costs and correctly identify patients with high resource use in the following year. Design Cross-sectional study with a 2-year follow-up. Setting The Basque National Health System. Participants All the residents in the Basque Country (Spain) ≥14 years of age covered by the public healthcare service (n=1 946 884). Methods We developed an algorithm classifying diagnoses of long-term health problems into 27 chronic disease groups. The database was randomly divided into two data sets. With the calibration sample, we calculated a score for each chronic disease group and other variables (age, sex, inpatient admissions, emergency department visits and chronic dialysis). Each individual obtained a FINGER score for the year by summing their characteristics’ scores. With the validation sample, we constructed regression models with the FINGER score for the first 12 months as the only explanatory variable. Results The annual FINGER scores obtained by patients ranged from 0 to 57 points, with a mean of 2.06. The coefficient of determination for healthcare costs was 0.188 and the area under the receiver operating characteristic curve was 0.838 for identifying patients with high costs (>95th percentile); 0.875 for extremely high costs (>99th percentile); 0.802 for unscheduled admissions; 0.861 for prolonged hospitalisation (>15 days); and 0.896 for death. Conclusion FINGER presents a predictive power for high risks fairly close to other classification systems. Its simple and transparent architecture allows for immediate calculation by clinicians. Being easy to interpret, it might be considered for implementation in regions involved in population stratification programmes.