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HEALTH CARE FINANCING REFORM AND THE ROLE OF HII
Mag. Elvana HANAGeneral Director of HII
Ohrid 31 May – 01 June 2010
REPUBLIC OF ALBANIA THE HEALTH CARE INSURANCE INSTITUTE
Page 2
What was the aim of the financing reform in the primary health care?
Reforms in the manner of financing and managing of the health centers
Restructuring of the primary health care institutions
Reforms in the manner of motivating the health’s employers according to their performance’s quality
Contracts based on the health services package provided from the HC and improvement of the accountability
The measurement of the performance and services quality provided from the HC
Main aim: “Improving the patient’s health state”
Page 3
How did the primary health care reform develop?
Through the restructuring of the primary institutions we achieved:
Increase of the HC autonomy in the managing of the human and financial resources
By the reforms in the manner of financing and contracting, the financing of the HC were focused on the improvement of the health services at 85% - payments, insurances and goods and services, 10% for the performance and 5% bonus for the quality
The contracts were based on the basic package of services by aiming the services standardization of the services in all the HC all over the country
The motivation of the HC’s employers” from the beginning of the reform the payments of the nurses increased with 60% and the general and family doctors with 40%
At the center of the realization of the performance and quality indicators the employers of the HC have been financed up to two rewarding wages
Page 4
What did this reform bring?
There have been a significant improvement of the population access to the primary care
With the realization of the performance and quality indicators from the HC, they managed to absorb more funds
The improvement of the HC management in accordance to the financial and human resources related to the changing needs of the inhabitants
The implementation of the supervising process of the HC brought the identification and the rapid solution of the problems, improvement of the accountability
Improvement of the information technology, in order to implement the information system in the primary care
Increase of the expenditures transparence for the primary care
Page 5
The Contracting process in the Primary care
It has been an essential process for the reform in the primary care, which consisted of:
During 2009 – 2010 have been singed contracts regarding the financing in order to provide health services in the primary health care for 419 HC
The services provided were based on the basic services package, which were significantly improved in 2009
The improvement of the quality indicators (5% bonus), increasing it from 6 in 2008 to 9 in 2010, by introducing the results indicators for the first time in the Albanian primary health services, like: chronic patients with HTA and Mellitus Diabetes that have clinic parameters within norms, follow-up of the children from 0-1 years old
No. of differentiated visits according to the areas, in order to easy the access to the health services in the remote mountainous area
Page 6
Contracts with the HC
Implementation of the information system in the primary care
Implementation of the supervising process
Implementation of the referential system
Improvement regarding the implementation of choosing freely the doctor
Improvements in the process of negotiation with the HC for the reimbursement expenditures planning, based on evidence
Improvement in the manner of reporting, accountability and financial control in the primary care
Giving more tasks to the RDHII (Regional authorities), as a direct authority in the contracting process with the HC
Page 7
The evolution of the financing based on the performance
2007
20082009
0
200000
400000
600000
Performance Financing (10%) The performance of the HC have improved from year to year, and in the third year of the reform it was almost doubled the level of the payment per performance, from 49.8% to 81.4%.
0.020.040.060.080.0
100.0120.0
%
Districts
Performance Financing Comparison
2007
2008
2009
Page 8
The performance’s evolution
During 2009 the HC have absorbed financial sources per performance 31% more that it was in 2007 and 7% more than in 2008.
240 HC have realized over 80% of the indicators in 2009 compared to 170 that it was in 2008.
0
50
100
150
200
250
240
170
24
Numbers of HC which got more than 80% of performance financing
2007
2008
2009
Page 9
Average no. of visits as indicator of performance
During 2009 have been effectuated 4.95 million visits from the doctors of the primary health care centers, while in 2008 have been effectuated 4 million visits. The increasing of the average number of visits per doctor per day, from 7.9 to 9.9.
0
1000000
2000000
3000000
4000000
5000000
Performance of visits's number
2007 2008 2009
Visists's Average
0
2
4
6
8
10
12
14
2007 2008 2009
Rurale
Urbane
Page 10
Financing the quality indicators (5%)
2008
2009
58
60
62
64
66
68
70
Quality Indicators Financing
In 2009 the HC have been financed 23.4% more than it was in 2008; over 321 HC have profited over 60% of the bonus, from 17 that it was in 2008;
2008 2009
0
100
200
300
400
1
17
321
Number of HC which got more than 60% of quality bonus
2008
2009
Page 11
Contacting for the first time the patients
In 2009 the contact for the first time (PVHP) with the patient have increased up to 17% more than it was before the reform; and 10% more than in 2007. The most important indicators as: tracking of pregnant women and the children’s vaccination, as indicators that show a direct relation to the diseases prevention, it have been realized over 95%.
9.8
15.9 17.3
26.1
0
5
10
15
20
25
30
2006 2007 2008 2009
% of PVHP Indicator
Page 12
The increasing number of people which become eligible to profit from scheme
Persons who obtain for the first time in years the Insurance booklet
177802
105953
163280190803
300577
0
100000
200000
300000
400000
2005 2006 2007 2008 2009
During 2009 the number of people that become eligible to profit health services financed by the scheme have doubled compared to 2007 and tripled compared to year before the reform. During the first 3-Months we have an increase of 86% more than in the first 3-Months of 2009 of the people who ask for insurance booklet.
0
50000
100000
150000
200000
First 3-M 2009 Fourth 3-M 2009 First 3-M 2010
Equipment with new insurance booklet
Page 13
The performance of drugs’ reimbursement financing
1,8679,66816,34542,117
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
Pension. Inv/Pl employed Unemployed CA
Patient's categories
Nr.
of
pre
sc
rip
tio
ns 2009 2008
Main categories profiting rembursable drugs
4.3%5.9%7.4%
29.3%
46.2%
0%
10%
20%
30%
40%
50%
Pension Invalid CA Veteran Activ
Patient's categories
Page 14
The financing of the reimbursable chronic diseases
About 98% of the reimbursement expenditures is occupied by the chronic diseases
171,088200,261
226,818
0
50,000
100,000
150,000
200,000
250,000
2007 2008 2009
Chronic diseases The yearly average of cases in years
Page 15
Increase of the new chronic cases during the years
32,660
43,506 44,700
05,000
10,00015,00020,00025,00030,00035,00040,00045,000
2007 2008 2009
Increase of the new cases during the last 3 years
During 2009 have been treated 13% of new chronic cases more than in 2008 and 33% more than in 2007.
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
2007 2008 2009
The reimbursment expenditures for the new cases of the last 3 years
Page 16
Ease of the population’s access in the PC services
The coverage of the population by the medical personnel have always been in improvement, the number of the problematic areas have been reduced up to a minimum, from 40 that they were before the reform to 6 areas in 2009
0
5
10
15
20
25
30
35
40
45
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
The No of catchment areas with difficulties to cover with GP in Years
Page 17
The exact registration of the population from the HC
Registering the active inhabitants that are covered by the HC with service have been a very important process during 2009, which aimed:
The exact illustration of the number of people enrolled nearby each HC
The exact illustration of the chronic disases diagnosticated according to the FD of the HC
The exact illustration of the resident and non- resident people for which the FD is paid, also by taking into consideration that the a major part of the Albanian citizens have emigrated
The creation of an electronic data base for the registered population according to each FD/HC, which will help HII to have a better planning of the respective budget and improvement of the payments scheme for the FD
Page 18
The Health Information System in the Primary Care
The informatization of the HC performance for the services in the primary health was one of the aims of the health reform
Through the HIS we are going to digitalize the whole performance effectuated by the FD and the nurses of the HC
A better monitoring of the performance performed in the HCs, the type of performance effectuated, the job attendance from the health personnel, the bugdet planning per performance as well as the financing based in the indicators realization
HIS is going to help HII and the Ministry of Health in the decision-making based on evidence
Page 19
The HII challenges for the Primary Care
Improvement of the financing system, focusing on increasing the performance and quality of the services (changing the financing report);
Concluding the electronic registration of the population and the improvement of the payment system per capita.
Improvement of the quality and performance standards
Perfecting the supervising system regarding the financial managment, human resources and performance.
Supporting the process of Drafting the clinical practise guidance and give support in the training programs of the Continual Medical Education.
The functioning of a unique informative system.
Cooperating with the Ministry of Health for the fulfillment of the Standards in the primary health services
Page 20
The start of the reform in Hospital care in 2009 enabled:
Hospital legal status (public, non-budgetary, non-profitable, provides medical services approved by the Ministry of Health)
Contracts with 39 hospitals :
- 4 University hospitals
- 12 Regional hospitals
- 23 Municipal hospitals
Individual contracts between director – staff
Financing by historical budgeting based on a service list
Application of a new method of reporting
– Clinical activities
– Economic and financial activities
Page 21
What have been observed by monitoring the contracts during the first year?
There are absences of the Specialist Doctors and this is more visible in the hospitals of the municipal level
o Lack of provision of the defined services in the services packages
Not good indicators of the medical performance
The medical equipments in some hospitals are not of the appropriate standards
Inadequacy according to the type of service that should be provided
Inappropriate level of qualification regarding the hospital management and the frequent changing of the leading staff
Not appropiate informative system regarding download of the data and the results’ extration.
Page 22
Bed's occupancy rate (district hospitals)
0%
20%
40%
60%
80%
100%
Bed's occupancy rate The average (D. Hospital) Country's average
0%
20%
40%
60%
80%
Bulq
ize
Delv
ine
Devo
ll
Gra
msh
Has
Kavaja
Ko
lonje
Kru
je
Kuco
ve
Lush
nje
Lac
Lib
razh
d
M. M
ad
he
Mallaka…
Mat
Mir
dite
Peq
in
Perm
et
Po
gra
dec
Puke
Sara
nd
e
Skra
par
Tep
ele
ne
Tro
poje
Bed's occupancy for the municipalities hospitals Bed's occupancy rate The average ( Mun. hospitals) Country's average
42%
33%
Page 23
What are going to bring the proposed changes?
Improvement of the population access
Improvement of the cost – effectiveness report
Better services quality
Increase of the services security:
» The patient deserves a safer and qualitative service
The standardization of services
Drafting the guidance and medical protocols, the services costs and changing in the manner of financing, dictates the need of hospitals’ reconfiguration
A better relation with the primary health care services
» The increase of the diagnostics role with prevention effects
» The strengthen of the out-patient service
Page 24
Options for the changesThe first option
Maintaining of the status quo
39 hospitals with services according to the CMD 39 contracts with HII
This requires: Fulfillment of the standards in 39 hospitals Fulfillment with human resources (especially Specialist Doctors) equipments,
devices, etc Larger investments in the infrastructure
Advantages: Maximal possible access
Disadvantages: Unaffordable financial costs
Impossibility for real resources and mainly with specialists
Can not respond to the level of the country development
Page 25
The second option
District level:
11 District hospitals that have to provide 19 obligatory services based on DCM
I Level 5 Municipality hospitals with a level of services between the district hospitals and the municipality existing ones
II Level 11 Municipality hospitals. The possibility to fully provide eight basic services according to the DCM
III Level 8 Municipality hospitals are going to be transformed into centers which will provide these services: Emergency 24 hours, micro-surgery, radiology, lab clinical/biochemical.
Advantages: Better access compared to the existing one in the 5 mentioned municipalities
Services’ standardization
Disadvantages: absence of the flexibility in the provision of the specialized services; contracting in three levels and inappropriate
management; social costs
Page 26
The third option Regionalism of the services
Reconfiguration of the hospital services in the District level
11 Hospitals in the districts which manage all the services within the District
16 Municipality hospitals of the I level
– With the necessary basic services according to D.C.M (8 + 1) services
– By adding the out-patient as a separate service
In the cases of absence this service will be provided from the regional hospital
8 Municipality hospitals of the II level
The conversion of these hospitals in daily hospitals with a limited number of beds for: emergency services, general medicine, micro-surgery services, labs, radiology services, pharmaceutical services, obstetric and gynecological services, the consolatory ambulatory services (out-patient)
The tendency of this daily hospitals, according to the results and efficiency, is going to be turning them into primary health care facilities.
Page 27
Advantages & disadvantages of the III option
Advantages:
Contacting only with 11 District Hospitals
Providing 19 (+1) basic services in the district hospitals by outlining the service out-patient as a separated and measurable service
The efficiency and flexibility in the usage of the human resources, financial and technological, etc
– This enables the providing of the basic services, absent in 16 municipality Hospitals
– Enables the contracting of the SD with more attractive payments
Improvement of the access and increase the quality of the services
Standardization of the services and provision of the services according to the needs of the community and make people trust in the hospital services
Disadvantages: - Absence of managers of this reconfiguration
- Not appropriate infrastructure regarding the human resources
Page 28
Photos from ALBANIA
Mag. Elvana HANAGeneral Director of HII
Ohrid 01/06/2010
THANK YOU !