alzira model

Development and implementation of the Alzira Model

A new health management approach

11th Primary Care Congress.Sovigliana/Vinci (Firenze)

21-23 May 2009

The Alzira Model

• Public and free service for everyone. However, over 8 million Spaniards have a

private health insurance, 2’5 of them are public servants while the other 5’5 pay

”double insurance”.

• Authority on public health service in hands of autonomous communities since the

end 2001. A “reorganization” of the different systems is needed

• Significant budget deficits faced by every regional government while Central

Government struggles to balance the national budget

• Bureaucratic and inefficient system with high operative costs

• Some local governments already charging an extra-tax on gasoline to finance public

health.

• Several Communities involved in new hospitals building process, despite the deficit

Public health in Spain

Torrevieja: Oct. 2006

Alzira: since Jan. 1999

The Alzira Model

Public concessions in Valencia

Denia: Dec. 2008

Elche: 2010

Manises: 2009

Public Financing: Valencian Government. Capitative payment.

Public Control: Valencian Government, through the commissioner working in the Hospital.

Public Property: Property will refund to Valencian Government.

Private service allowance:

Builds new Hospital. New infrastructures and technology.

Own Medical staff

Own Management: “Know how”

Assumes Risk transfer

Free & Public Healthcare Services

Split between public financing, control and property and privateservice allowance

The Alzira Model

Model basis

Lightening the burden of public expenditure in social services

• Public Administration deficit

• Nation’s budget stability as a must

Private responsibility

• Efficiency and efficacy

• Entrepreneur patrimonial responsibility

Public Control

• Limited contract period. Duration and possible extensions clearly set out in the

contract

• Administrative granting for a private contractor to manage a public service

The Alzira Model

Subsidiarity. Money for Value

The private contractor receives a fixed annual sum per inhabitant for the fifteen-year

duration of the contract.

The annual fee is €597, as of 2008, (rising in successive years in line with public health

budget increase) for each of the inhabitants of the health area.

In return, the company runs the entire health department and must offer universal access to

its wide range of services.

TRANSFERRED RISK: Expenses become fixed for Valencian Government. In effectivelytransferring financial risk from the public to the private sector, this measure helps control localspending thus making local government more transparent. The costs per inhabitant that thegovernment pays the contractor are around 20% below average per person costs elsewhere inthe Valencian Autonomous Community.

The Alzira Model

Capitative payment

This system is focused on financing people’s health:

“Money follows the citizen”, therefore Disease Prevention and Health Promotion are a must

Accordingly to patients’ right of access to the hospital of their choice:

Hospital has to cover the 100% treatment costs of local people who avail of hospital facilities elsewhere.

On the other hand, Hospital is paid an 80% of health services given to any other health area patients.

The Alzira Model

Capitative payment

Money follows the citizen entails a patient-oriented organitazion. It is of criticalimportance for the organization to prevent local patients from going to other public areas byoffering them the best public health service:

• Efficient and “user friendly” medical assistance at all levels (Hospital and PrimaryCare), with no barriers or “steps to climb” between different medical areas or levels

• Sophysticated diagnostic and therapeutic care in most specialties and subspecialties ofmedicine and surgery

• Modern buildings and hi-tech facilities supported by a shared WAN for the entireDepartments

• No waiting lists (mean surgical waiting time: 40 days and wide timetables, from 8 a.m.to 10 pm.

• Quality: Hospital de La Ribera has been named the “Best Spanish Large GeneralHospital” in the 2000, 2001 and 2002, 2003 and 2005 while Torrevieja Hospital has justbeen elected as the “Best Medium General Hospital”.

The Alzira Model

Capitative payment

Initial Investment by the Private Management: Over 600 MM euros in five health

departments in the Valencian Community.

Chance to build public hospitals and primary care centers without increasing local public

debt.

More reliable public expenditure forecast: Hospital service cost (due to capitative system)

known in advance over the 15 year granting period.

Public health service cost lower than other areas (> 20%)

Better use of Public Resources: More efficiency, more activity, better service, higher

number of citizens (voters) satisfied with the government’s performance.

Introduction of modern management tools in a “slow” and bureaucratic environment.

The Alzira Model

Advantages for the Public Administration

Better access to health services

– Integration between Hospital and Primary Care, with no “disruptions” in the medical assistance

– Wide timetables and non-stop medical assistance at both levels, Hospital and Primary Care

Less reply-time from the System:

– Mean surgical waiting time: 40 days.

– Mean OP visit waiting time: 15 days

Better quality services:

– Free choice: “Money follows patient”

– Citizen becomes a customer: Single room with companion bed: better comfort and privacy.

High level of patient’s satisfaction:

– 91% are happy with the service received

– 95% will come back to the hospital

– 80% don´t know the hospital management type.

The Alzira Model

Advantages for the citizen

Human Resources Management: empowering professionals

– Stability at work

– Doctors manage their own time: OP, theatre, IP visits, within the hospital needs and

objectives.

– Professional Development: Functional Units

– Continuing Medical Education and Research Committee

Incentives System: Greater incomes:

– Objectives achievement (individual).

– Outcome : More activity, better results, less complications…

– Efficency achievement (Management Units): Savings sharing

– Doctors Mean Income is 25% higher than the NHS doctors

The Alzira Model

Advantages for the professional

Durable, profitable and reliable collaboration with the local government

– Achievement of the “know-how” of running a large general public hospital.

– Return on the investment guaranteed.

– Collaboration can be extended to other health areas.

– Opportunity to demonstrate that the “Alzira model” is a valid option for the early

future of the public health system.

– Gains in terms of public image.

The Alzira Model

Advantages for the company

Our health integrationapproach

As well as offering modern buildings and

hi-tech facilities, our health departments

have embraced a range of new practices.

Quality assurance mechanisms have been

introduced and health professionals are

expected to participate in Continuous

Professional Development (or CPD).

Clinicians are set fixed targets and offered

pay incentives on top of their salaries. Pay

rates with incentives are, in most cases,

far higher than those in the public sector.

• Goal-incentives system

• Education Committee.

• Management Units: self-managed units, seeking best medical practice and cost-cutting strategies

• Pharmacological guide with generic drugs

• Long-term agreements with providers

• Human Resource, Marketing and PR Management

• Information Systems

Health integration approach

What make our Health Departments different?

Motivation: medical staff get involved

and participate with a greater degree of

satisfaction and professional recognition.

Quality: Quality-oriented processes are

designed and implemented

Productivity: Increases efficacy and

efficiency

Integration between all Department

areas: Medical staff have a vision of the

health department as a whole which

helps to find the better way to achieve

the desired outcomes.

Re-organised the health department as a

map of processes: Define in the

department who, when, where and how

will do an intervention in a defined and

agreed process.

• Primary Care and Hospital work together

• Implementation of new services in Primary Care

• Shared clinical pathways

• Outpatient major surgery

• Functional Units

• Hospitalists system

• Professional career development

• Information Systems

MEDICAL AREAWhat make our Health Departments different?

Ribera Salud

Integrated health areas

• To develop a new culture among professionals to become a “flat”

organization. No steps between different medical levels.

• To implement integrated medical processes for the health area as a whole

defining the “best diagnostic, therapeutic and control place”. Medical paths

shared by all medical levels

• To provide PC professionals with required means and tools for higher

“medical performance”.

• To increase management efficiency

Some keys for a successful integration process


• Doctors as links from Hospital to PC. Several specialists (internal,

dermatology, urology, psychiatry, etc) acting like “bridges” and

“counselors”.

• Integrated Primary Care Centers: covering specialized outpatients,

scan, lab and radiology tests. With strong A&E units (number of A&E in

the Hospital steadily decreasing since 2003). Pre-surgical tests made at

PC centers, etc.

• To have motivated and involved professionals.



• Shared medical committees

• Shared IS network for Hospital and PC centers: Shared information (Access

to test results on-line from all PC centers [radiology, lab, scan,etc]), , wider

service offer (appointment for the specialist managed from the PC center,).

• New services in PC centers: bringing more and better services closer to the

citizens’ homes, so they need to come to the Hospital more seldom.

• Investment in new infrastructure and updating: new PC centers, renovation

of most existing ones, updating in IS and medical equipment, etc.


• New “PRM 2.0”: a new way tointeract with patients

• Motivation

• Information

• Benchmarking

• Education & Research

• Internal Communication

• Centralized Call Center

• Shared HIS, PACS, LIS

• Medical paths

• Monitoring

• Cost control

• Activity planning

• Quality control

• Feed-back

Clinical Mgmt.Primary Careand Hospital Integration

PatientHHRR Mgmt.


IT for higher efficiency

From an scenario where Hospital and PC professionals work separately

……to a brand new framework where they all share the same

information.


IT for higher efficiency

• Providing professional staff with easy access to critical information for higher accuracy in decision making processes.

• KPIs available on-line

• Alert system for particular situations unlikely to meet the Hospital quality standards

• Activity monitoring


IT for better performance

• Inmediate patient demand analysis and its fluctuations allows for on-going resource adjustment.

• “guiding citizens“ in use of resources providing information in real time to achieve better assistance and better use of resources.

Patients have on - line time information about the

waiting time in all emergencycenters


IS to guide the patient

The company. Ribera Salud

Ribera Salud is the Spanish leading company in

the growing industry of PPPs in public health .

The company belongs to Spain’s third and fourth

savings banks: Bancaja and CAM, with 50% of

the shares each.

The purpose of Ribera Salud is the management

of hospitals and health and socio-health centres,

including the integrated management of clinical

services and working units.

Ribera Salud

Company Revenues Hospitals Beds

Ribera Salud 323,1 5 1.200

IDC Capio 322 11 1.673

Adeslas 229,4 13 1.131

Asisa 225 15 1.524

USP 225 12 1.177

Clín. Navarra 130 1 400

Hospiten 120 8 885

Main Spanish hospital groups

A new health management approach

Ribera Salud

• The five concessions running in the land of Valencia under the “Alzira model”: Alzira, Torrevieja, Denia, Manises and Elche. (main shareholder in Torrevieja an Elche).

These five public health departments mean covering nearly the 25% of the 4’5 million Valencia region population.

Five hospitals and over one hundred primary care centers, with 7.000 professionals. Total revenues nearly 900 million euros, on a yearly basis.

• A concession in Madrid under the “Alzira model”: Torrejón (open in 2011)

• The private company that covers the global MRI service in the public health system in the Valencian Community, Erescanner Salud

• The private company running a central clinical laboratory, which covers seven public hospitals in Madrid, which means 1’2 million people, BR Salud

Current projects

Ribera Salud

Financial figures

CAPEX EBITDA

(in MM €) (projected in MM €)

Alzira – La Ribera 140 14’7 (2008)

Torrevieja 120 15’1 (2008)

Denia 150 14 (2010)

Manises 131 15 (2011)

Elche 146 15 (2012)

Torrejon 130

Erescanner Salud 53 10’1 (2010)

BR Salud (central lab.) 4 2 (2011)

COMPANY

• Integral management of health and socio-health services:

• PPPs Model (Alzira)

• Private Sector

• Socio-health Sector

• Integral management of national and international projects:

• Management and/or Consultancy

• Search for technological and financial partners

• Strategic alliances

• Institutional relations

Ribera Salud

Business lines

Ribera Salud

* Also including public servants working in the health department

** Annual mean number for Alzira and Torrevieja. Surgery forecast for Denia, Manises, Elche and Torrejon

*** As included in the contract for the concession duration

Health Department global management. Some facts

BEDS POPULATION PROFESSIONALS* SURGERY** CAPEX***

Hospital Universitario de La Ribera 300 250.000 1.800 21.000 140 MM €

Hospital de Torrevieja 264 180.000 1.400 16.000 90 MM €

Hospital de Denia 222 160.000 1.400 15.000 97 MM €

Hospital de Manises 220 150.000 1.400 15.000 137 MM €

Hospital del Vinalopo 212 150.000 1.400 15.000 146 MM €

Hospital de Torrejón 250 133.000 1.000 15.000 130 MM €

TOTAL 1.468 1.023.000 8.400 97.000 740 MM €

• Patient – oriented organization

• Global integration between Hospital and Primary Care

• Private management perspective in a traditional public system

• Technology / Information systems (own HIS, keeps updated over 10 years)

• Patients’ free choice of specialists

• Patients’ right of access to the hospital of their choice

• Single rooms, with free extra bed for companions

• Human resource management; Professional Career Development.

Ribera Salud.

What make our Health Departments different?

alzira model

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