Here Nieves Ehrenberg, Senior Researcher at the International Foundation for Integrated Care (IFIC) provides a summary of a session focusing on funding and financing at ICIC19.
This interactive and informative session was chaired by Andrew Terris, Senior Associate, IFIC and Hali Tarum, Head of Social Welfare Department, Ministry of Social Affairs, Estonia who asked three questions to the panel made up of international experts, including:
• Ellen Nolte, London School of Hygiene and Tropical Medicine, UK
• Andrew Smith, COBIC/ Optimedis
• Jeroen Struijs, RIVM, Netherlands
• Ri de Ridder, Belgium
• Stephen Shortell, Berkeley, USA
How to find the right balance between flexibility / local empowerment, specifically when defining a care coordination model? How can financing and incentive models help use flexible models more effectively?
• This is about the tension between centralisation / de centralistion.
• It is useful to think about what are core elements of the IC model you are seeking to implement versus the ability/ flexibility for variation that you need to retain.
• Example of a CCO in Oregon for medicaid population (those with less coverage) wrestled with this question: ’What package should everyone get, while retaining the ability to adapt the package according to the local community needs’. In Orgegon, they set up local advisory boards to work out what needs to change from one place to another and what needs to stay the same
• Also useful to inform this process is the collection of data to learn quickly as you go along and for accountability.
• In Belgium as manager of health insurance scheme we tried to incentivise health coordination. Particularly for long term care –18 years ago we set up payment for care coordination.
• Context: fee for service context and freedom in organising system, which has resulted in scattered decisions about priorities. When providers receive funds for care coordination, it can become an instrument for them to try to gain bigger market share in a fee for service system.
• So the lesson is: Think about how you influence provider behaviour. Any incentive or financial instrument needs to be considered within the local context so as to avoid unintended consequences.
• The policy mantra used to be let 1000 flowers bloom but the feedback was that some guidance was needed and important.
• There needs to be a national framework with local flexibility
• A good idea would be to provide a set of options and allowing local systems to select from these options (she mentioned this has worked well elsewhere)
• Alignment of finance goals with system goals across the country, building in flexibility through allowing local decision making on how to achieve these goals
• Payment models should also be aligned to the system goals – the way we pay our staff
• Shift accountability from providers to payers
• It’s about the outcomes you’re seeking to achieve and involving the citizens and patients in identifying these outcomes
• Incentivising providers to meet these outcomes
• Have ’must do’ requirements at a national level but the outcomes become more local service specifications
• How these outcomes are delivered are up to the provider – what will we do and how
• Longer term contracts for providers to invest in prevention is also important
What have been the international lessons learned from joint-commissioning solutions? What is the optimal number of stakeholders that should be included in the contract?
• Joint budgeting is how we distribute a big pot of money
• He reiterated that we need to ensure the way we reimburse staff is aligned with our system goals
• Ideal population number 50,000 for GP catchment
• Shared saving contracts work well – GPs decide and specify care packages for population they look after. If savings are made, who gets to see them? (this is where incentives come in). If GP works extra to prevent patients coming in, but savings go to Commissioners who spend it elsewhere, it doesn’t work.
• He mentioned an example in Hampshire where they are developing a shared service contract between commissioners and GPs, using evidence from Gesundes Kinzingtal. The discussion goes like this: ’if we (the partners) do these interventions and we deliver savings, can we agree how we share the savings? On that basis, you draw up a contract
• Pump priming might be required- Invest early to save later. It’s hard work, but it’s worth it.
• Agreed pump primed funding is important
• Time – giving people time to learn and change is crucial
• Need to secure providers acting in teams (close to the communities) from income concerns
• The discussion on bundle payments should be at a high level – what are you going to do with the savings to provide high value care
• ACOs find it difficult to gain savings – too small.
• Example of an organisation aggregaring small rural practices to 100,000 to have enough critical mass to implement care coordination models and realise savings. They provide infrasturcure for these. Population health nurse (RN trained to work with local physician in local community). There are quality metrics and working better than larger ACOs and even making some money.
• In Hampshire – 40,000 pop with 10 GPs, they have come together to manage population recognising they’re too small alone. Easier to get commissioners around the table, for example. Primary care networks are now part of the NHS’s plan because they want accountbale care being delivered locally
How to best introduce performance elements in coordination model?
• Ask these questions:
i. What are you trying to achieve? And Who are major stakeholders?
ii. What success looks like?
iii. What needs to be true for this to occur?
• In terms of measurement – Dont’ ignore patient reported outcomes. Keep it small/ don’t over do it
• Involve key stakeholders / patients in designing measures
• Wait a long time before connecting it to money. Start with trying to inform what you are doing and quality improvement otherwise you kill the initiaitve. On the other side, you could tie things to money, but complement it with quality activities having quality circles and getting clinicians together to learn from each other
• What motivates physician behaviour – more than money. 1. sense of mastery – with visibility of good quality data to show they are good doctors 2. help patients 3. money
• Helmut says: you can’t do it without money as an incentive. Look at what are your false incentives so you can reduce these instead of trying to counteract these with money, which gets expensive.
You can watch Stephen Shortell’s Plenary Keynote Adopting and implementing innovations to create high performing health systems: lessons from ACOs and other models in the US here.
Nieves Ehrenberg, Senior Researcher at the International Foundation for Integrated Care (IFIC)