Pere Ibern

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.

Seguros sanitarios colectivos y desgravación fiscal

Gac Sanit 1999;13(3):233-238 ramiento sanitario privado y la expereincia liberal anglosajona. Revista de Administración Sanitaria 1998;Vol 2,8:13-32. 13. Carrasquillo O, Hilmmelstein DU, Woolhandler S, Bor DH. A Reapprisal Of Private Employers’ Role in Providing Health Insurance. NEJM 1999;340:109-14. 14. Kirkman-Liff B The United States. En Ham C (edit) Healthcare Reform, learning from international experience. Open University Press, 1997. 15. Ministerio de Sanidad y Consumo. Consolidación y modernización del Sistema Nacional de Salud. (Acuerdo Parlamentario del 18 de diciembre de 1997). Secretaría General Técnica. Madrid, 1998. 16. Para un análisis del texto y toda la discusión y citas que sigue ver, Freire JM. Comentarios a propósito del Documento de la Subcomisión parlamentaria para la reforma del SNS español. Revista de Administración Sanitaria, 1998;2(5):23-50. 17. NERA (National Economic Research Associates). The Economics of Health Care Reforms: A Prototype. Vol 2, London 1993.

Analysing the Costs of Integrated Care: A Case on Model Selection for Chronic Care Purposes

Background: The objective of this study is to investigate whether the algorithm proposed by Manning and Mullahy, a consolidated health economics procedure, can also be used to estimate individual costs for different groups of healthcare services in the context of integrated care. Methods: A cross-sectional study focused on the population of the Baix Empordà (Catalonia-Spain) for the year 2012 (N = 92,498 individuals). A set of individual cost models as a function of sex, age and morbidity burden were adjusted and individual healthcare costs were calculated using a retrospective full-costing system. The individual morbidity burden was inferred using the Clinical Risk Groups (CRG) patient classification system. Results: Depending on the characteristics of the data, and according to the algorithm criteria, the choice of model was a linear model on the log of costs or a generalized linear model with a log link. We checked for goodness of fit, accuracy, linear structure and heteroscedasticity for the models obtained. Conclusion: The proposed algorithm identified a set of suitable cost models for the distinct groups of services integrated care entails. The individual morbidity burden was found to be indispensable when allocating appropriate resources to targeted individuals.

A case of integration in Baix Empordà (Catalonia), 20 years on the road

Background : Catalonia healthcare system sat up a process of diversification of providers of services as a result of the publication of the healthcare management act (Llei d’Ordenacio Sanitaria de Catalunya, 1990). Around 20% of the primary care attention, the greater part of the specialized ambulatory care and hospitals and the almost whole of the residential long-term care had been managed by providers different to the public manager (ICS), although all of them receive public funding. Some of these providers of services moved away from forms of organization, which were fragmented by lines or levels towards systems that integrate all types of care within the same organization. Every organization made this process on their way. In the year 2002 the Health Department of the Government of Catalonia improved this initiative by means of the set up of a pilot proof for the implantation of a model of per capita payment system. Description of practice change implemented and aim : Serveis de Salut Integrats del Baix Emporda (SSIBE), an integrated healthcare management organization (HMO) responsible for providing public healthcare services of some 130,000.000 people at Baix Emporda county, including primary care, specialized care, acute hospitalizations and long-term residential care, adhered to these initiatives and had developed during the last 20 years an intense process of integration patient centred. Along 20 years SSIBE have developed diverse strategies of implementation of changes standing out: creation of an unique information system centred in the patient (includes clinical, administrative and economic information) that facilitates analysis of burden of disease and cost based in individual data; unification of the clinical direction by areas with only and common aims without differentiating levels of attention; implantation of guides of clinical practice identifying the responsibility of the different actors involved (primary care, specialist care, emergency department physicians, rehabilitation, …); common politics of human resources and utilization of incentives for the achievement of clinical aims and of management. The aim of this work is to show the results obtained in this process analysing the organizational changes developed, the instruments used and a series of performance indicators to valuate the model. We compare performance of SSIBE through some benchmarking indicators elaborated by CatSalut (Catalonian healthcare contracting and payment authority) and Atlas of Variations in Medical Practice in the National Health System (a nationwide Health Services Research (HSR) Program concerning the analysis of unwarranted variations in medical practice and healthcare outcomes in Spain). We also use PLAENSA© Satisfaction Surveys results, a tool for assessment and improvement proposals addressed to the insurance services provided by contracted public entities. Key Findings : Some performance indicators like primary care visits, specialized ambulatory care visits, number of urgent hospitalizations and days of hospitalization are about 10% lower than Catalonia as a whole after adjusting by age, sex and comorbidity. In 2014 the hospitalization rate for determinate chronic pathologies in the Hospital of Palamos is of 405.7/100,000 hab in front of 625.5/100,000 for the group of Catalonia. For the potentially avoidable hospitalizations the rate is of 645.6/100,000 persons in front of 980.1/100,000 persons. The percentage of readmissions within 180 days of discharge for determinate selected pathologies is 13.46% in front 17.65% and the one of readmissions for chronic pathologies is 19.52% in front of 23.67%. All these differences are significant according to a model adjusted by age, sex and comorbidity. The probability of readmission within 52 weeks of discharge for chronic pathologies diminishes of 0.35 in the group of Catalonia to 0.25 in the Baix Emporda. In 2012 Hospital of Palamos obtained a level of satisfaction of 8.89/10, situated it in the top1 of hospitals of similar characteristics (1 of 22) and in the top4 of the group of hospitals of Catalonia (4 of 58). In the same year, all the centres of primary assistance had a level of satisfaction (between 7.99 – 8.30/10) above the average of Catalonia (7.9/10). In a qualitative study about continuity of care between primary and specialized level Baix Emporda is generally better qualified than two other areas in Catalonia managed by other providers of service. Healthcare expenditure in 2012 was of 731€ per person. Pharmaceutical expenditure was 10% lower than Catalonian adjusted by age, sex and comorbidity. Conclusion : Although it is not possible to establish a cause-effect relation between managerial strategies utilized in SSIBE and the good performance results obtained it seem to show that the model is effective and sustainable.

Population Based Resource Allocation: The Use of Hybrid Risk Adjustment

The emphasis on integrated care implies new incentives that promote coordination between levels of care. Considering a population as a whole, the resource allocation system has to adapt to this environment. This research is aimed to design a model that allows for morbidity related prospective and concurrent capitation payment. The model can be applied in publicly funded health systems and managed competition settings. Methods: We analyze the application of hybrid risk adjustment versus either prospective or concurrent risk adjustment formulae in the context of funding total health expenditures for the population of an integrated healthcare delivery organization in Catalonia during years 2004 and 2005. Results: The hybrid model reimburses integrated care organizations avoiding excessive risk transfer and maximizing incentives for efficiency in the provision. At the same time, it eliminates incentives for risk selection for a specific set of high risk individuals through the use of concurrent reimbursement in order to assure a proper classification of patients. Conclusion: Prospective Risk Adjustment is used to transfer the financial risk to the health provider and therefore provide incentives for efficiency. Within the context of a National Health System, such transfer of financial risk is illusory, and the government has to cover the deficits. Hybrid risk adjustment is useful to provide the right combination of incentive for efficiency and appropriate level of risk transfer for integrated care organizations.

Hybrid Risk Adjustment for Total Health Expenditures

Objectives: Efficient use of health resources has become a major concern for health policy makers and researchers when health expenditures are continously increasing. Prospective risk adjustment, using ex ante information and relating health expenditures and individual or population characteristics and morbidity, is generally recommended as a tool for controlling the cost and promoting incentives for efficiency in the health provision. However, it also can promote incentives for risk selection. Concurrent risk adjustment, using ex post or actual information on health conditions and costs, improves the access and quality of the health services provision and avoids the incentives for risk selection although it also reduces the efficiency. This paper follows a relatively new literature on risk adjustment in which a mixed formula, using both prospective and concurrent risk adjustment, seeks to maximize the efficiency incentives involved in the prospective risk adjustment and minimize the incentives for selection through a concurrent risk adjustment for high risk individuals suffering a set of specific conditions. Methods: We utilize individual data on total health expenditures, including pharmaceutical, primary care, and hospital and specialised attention expenditures, and health conditions for the population belonging to an integrated healthcare delivery organization in Catalonia in years 2004 and 2005 in order to show the gain of a hybrid risk adjustment versus either an only prospective or only concurrent risk adjustment formula. The individual health conditions are classified by the Clinical Risk Group classification system. Results: Concurrent risk adjustment obtains better results in terms of R-squared than prospective risk adjustment although it decreases incentives for efficiency. However, the use of a hybrid formula with concurrent payments for individuals with specific conditions can solve the problem of selection while incentives for efficiency are maximum for a high proportion of the population. Conclusions: A hybrid risk adjustment system is expected to solve the trade-off between efficiency in provision and the risk selection problem and thus promoting efficient use of health resources. The interest of a hybrid risk adjustment proposal relies also on its feasibility and easy implementation.