Organizational & Economic prospective on Health Care sector in Ukraine sph, October 2010


НазваOrganizational & Economic prospective on Health Care sector in Ukraine sph, October 2010
Дата конвертації16.04.2013
Розмір445 b.
ТипПрезентации


Organizational & Economic prospective on Health Care sector in Ukraine

  • SPH, October 2010

  • Olena Zaglada


Plan

  • Health Care network

  • Effectiveness in network planning

  • Funds Allocation

  • Primary care funding

  • Secondary care funding

  • DRGs

  • Preparation instructions





Health care facilities network

  • Primary care units: first, direst (not emergency though) contact (private practice, medical centers, by-hospital polyclinics)*

  • Secondary care facilities: usually through a referral from primary care level (hospitals both inpatient and outpatient units)**

  • Tertiary care: high complexity, catchment population > 1 million

  • Emergency/acute care: short stay, highly intensive

  • Emergency/intensive care (resuscitation)

  • Long term care

  • Medical social/community-based care

  • * http://www.euro.who.int/observatory/ glossary/toppage?phrase=primary+health+care

  • ** http://www.euro.who.int/observatory/ glossary/toppage?phrase=secondary+health+care

  • ***http://www.euro.who.int/observatory/ glossary/toppage?phrase=tertiary+health+care





Gaps in the current structure

  • Not clear distinction btw levels

  • No regulation for acceptable case-mix per level

  • Poor referral system

  • Purchaser/provider chasm – lack of incentives to change



Actual changes in HC system

  • Проект Концепції Державної програми реформування системи охорони здоров’я

  • Постанова КМУ від 17 лютого 2010 р. № 208 Основні концептуальні напрями реформування системи охорони здоров’я



Move towards

  • Split btw primary, secondary and tertiary levels of care (organizational and financial), a list of services according to the level of care;

  • Defining scope of guaranteed free medical care and the list of paid services in the health sector;

  • Approval standards of care and clinical protocols;

  • Establishment of 1) PMSC centers, 2) inter-territory unions, 3) university clinics, 4) emergency services reorganisation

  • Introduction of obligatory medical insurance

  • Improved procurement of medication

  • Prevention programmes

  • Quality control

  • HR policy improvements

  • Investment projects



Private

  • Private

  • insurance

  • Social

  • insurance

  • Budget



Public funding:

  • Public funding:

  • tax based gen. taxation or earmarked tax

  • social insurance obligatory, income-based

  • Private funding:priv insurance | OOPs

    • (out of pocket payments, formal & informal)


Budgeting – витратні методи на основі “необхідних для функціонування” провайдеру витрат

  • Budgeting – витратні методи на основі “необхідних для функціонування” провайдеру витрат

    • Retrospective cost-based – за центрами витрат, за потужностями = Line-item Budget
    • Global Budget – на сонові наявних у платника ресурсів
  • Fee-For-service – за певну послугу чи вид лікування на основі норм витрат та класифікатора послуг

  • Per case – на один випадок: пролікований пацієнт, один візит, одне звернення тощо.

  • Capitation – подушне фінансування на основі кількості та характеристик населення, що проживає на території відповідальності даного провайдера



Best practices from neighbours

  • Regular needs assessment (social demographic profile)

  • Preventive programs

  • Best possible access to primary care (both sides driven). Capitation

  • Strict referral system. Defined case-mix per hospital/specialization, payment by case (DRG, DBC, etc)

  • Regular quality, safety checks, evaluation of effectiveness, benchmarking

  • Centralized encouragement of best possible choice in care delivery (HTA, standards, guidelines)



Lacks to account for

  • Yearly increase of HC expenditures (esp. due to long term and chronic conditions)

  • Waiting lines everywhere

  • No “universal” access to “universal” care

  • Continues cost reduction – wisely allocated, minimum necessary care in shortest time possible



Funds allocation in Ukraine

  • Sources of funding

  • State budget (operational budget by coefficients: population*socio-demography profile*staff levels*N; capital investment policy)

  • Local budget (oblast, rayon, village, etc)

  • On-purpose programmes

  • Paid services

  • Sponsorship

  • Mutual funds (e.g. Likarnyana kasa), private insurance

  • + informal payments



Обсяги видатків на охорону здоров’я в Україні у 2004–2008 рр



Обсяги власних надходжень у 2007–2008 рр.



Обсяги видатків на охорону здоров’я в Україні у 2004–2008 рр



Funding by levels of care: slices

  • Primary

  • Secondary

  • Tertiary



Distribution btw levels

  • Unclear in Ukraine, facility-specific

  • Normally: 35% primary care, 65% secondary and tertiary care

  • Expenditures per 1 citizen (2008) in Ukraine: 537 UAH per year (excl OOPs)

  • In 2009 state expenditures per 1 citizen = 89 USD (56%) + OOPs per citizen 71 USD (44%). Total 160 USD per capita. This makes 6,1% of GDP





Primary care issues

  • Only half of population of Ukraine are covered by PC services

  • Financing is low 18-46 UAH (2006) per capita per year

  • 80% and > of the budget goes to cover salary expenditures (simply see the doctor)

  • Referral system is not working



A little rough calculation for PC

  • Take 35% of 537 UAH = 188 UAH

  • If 1 FD/GP serves 1500 patients, yearly pool = 282 000 UAH

  • Decent salary?

  • 1 doc = net ~4 000 (*12)= 60 000

  • 2 nurse = net ~ 6 000 = 100 000

  • 1 support staff = net 2000 = 33 000

  • Remaining 89 000 – operational budget (premises, transport, drugs)

  • This is an assumption for 1 FD ambulatory.

  • 2 FD or 4 FD would be more effective?



Видатки на виконання заходів і завдань Загальнодержавної програми розвитку ПМСД на засадах сімейної медицини на період до 2012 року



Secondary care issues

  • Almost 100% rayons in Ukr has a SC hospital (central rayon hospital or central municipal hospital), even when population is < 10,000. Average population 20-35,000

  • Effectiveness?

  • Intensivity/workload?

  • Access?

  • Quality?



History

  • A little secret:

  • Almost every EU-15 country had the same situation in 70-80s

  • France – step by step closed surplus facilities

  • UK – introduction of Trusts

  • Germany – specialization of hospitals within one Land



Catchment area & effectiveness







DRGs

  • Diagnostics related groups

  • Basis for reimbursement policy

  • Originated in USA

  • Modifications – NORD DRG (Sweden, Danemark, Finland)

  • German DRG

  • UK – Health related groups

  • Bulgaria, Romania… use German, Australian DRGs

  • Netherlands – did their own DBC system



Utilization of DRGs in Europe



DRG: short explanation

  • DRGs – at discharge

  • Based on type of procedure (inpatient/outpatient, surgical/conservative treatment), its result and personal characteristics of a patient (age, sex, health status)

  • Each DRG has a value (+coefficients) – money hospital receives by case basis



  • NordDRG Users' Manual Version 2009 NC FULL PR1b

  • From http://www.nordclass.uu.se/verksam/norddrgmanual/NordDRG_2009_NC/Flow/MDC_2_10.htm



Simplified logic

  • MDC (medical diagnostic combinations) based on ICD-10

  • surgical/non surgical

  • Operation room used

  • Complications & second diagnosis

  • Age, sex if influences

  • Result of treatment



Disadvantages

  • Wrong coding

  • Adverse desire to treat patients cheaper and faster

  • Necessity to establish strong quality control



Usual steps for implementation:

  • Methodology (1-2 years)

  • Purchase of a DRG groupper (NordDRG, German, American, Australian, etc)

  • Data collection on site of certain hospitals (2-3 years)

  • Adaptation, development of coefficients for levels of care

  • Stage-by-stage introduction



Lessons learned

  • Attempts to apply in Ukr have shown:

  • Low readiness to adopt

  • System failures:

  • Poor IT system – lacks of coding

  • Lack of knowledge of coding

  • Lack of proper checks

  • Possible although

  • For more details go to www.eu-shc.com.ua



Conclusions

  • Resources circulating in Ukrainian health care system can be used in a more rational way

  • Offer you to try to make rational choices!



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