pay-for-performance (p4p) performance (p4p) · 11. avoidance of antibiotic treatment of adults with...

Pay-for-Performance (P4P)

Sichern neue Vergütungsbedingungen

Pay for Performance (P4P)

bessere Ergebnisse?

Univ.-Prof. Dr. oec Volker E. AmelunggBerlin, Mai 2009

1Pay-for-Performance (P4P)

Univ.-Prof. Dr. Volker Eric Amelung

Pay-for-Performance

1. P4P - Neue Impulse für das Gesundheitssystem

2. Vergütungssysteme in der Praxis

3 P f P f Zi l d G dl3. Pay-for-Performance – Ziele und Grundlagen

4 Meßmethoden und Indikatoren4. Meßmethoden und Indikatoren

5. Public Reporting5 ub c epo t g

6. Internationale Erfahrungen

7. Fazit



Definition

„Pay for performance is not simply a mechanism toreward those who perform well or to reduce costs Itsreward those who perform well or to reduce costs. Itspurpose is to align payment incentives to encourageongoing improvement in a way that will ensure high-

quality care for all.“q y

The Institue of Medicine, Rewarding Provider Performance, 2006, S.2



g

P4P – Neue Impulse für das Gesundheitssystem

P4P – Erfolgsorientierung und Transparenz

P4PP4P

erfolgs-orientierte

erfolgs-orientierte Public Public orientierte Vergütungorientierte Vergütung

Public Reporting

Public Reporting



Selektives Kontrahieren

Es müssen…

Kriterien zur Auswahl von Vertragspartnern gefunden werden,

Kriterien zur Auswahl von Vertragsgegenständen (Leistungsumfang muss definiert werden) und

Erfüllungskriterien (Qualitätskriterien) definiert werden



Selektives Kontrahieren

Di I t i t V h §140 d SGB V

Stellschrauben für Selektivverträge

Die Integrierte Versorgung nach §140a-d SGB V Die besondere ambulante ärztliche Versorgung nach §73c SGB V Die ambulante stationäre Versorgung nach §116 SGB VDie ambulante stationäre Versorgung nach §116 SGB V Rabattverträge nach §130a SGB V Wahltarife nach §53 SGB V



Pay-for-Performance







7. Fazit



Vergütungssysteme in der Praxis

Ziel e eines Vergütungssystems

St d Ak tSteuerungs- und Anreizfunktion Verteilungsfunktion Innovations-

funktionAkzeptanz,

Transparenz,Einfachheit,

PraktikabilitätVergütungsformen

Gehalt Kopfpauschale Fallpauschale Tagespauschale

Leist ngskomple Einzelleistung ErfolgsorientierteLeistungskomplex Einzelleistung ErfolgsorientierteVergütung

(Faktor)-Kostenerstattung

Vergütungsverfahren

Marktsteuerung Kollektivverhandlung Regulierung

Einstufiges Zweistufiges



Einstufiges Verfahren

Zweistufiges Verfahren


Gegenläufige Probleme

Gefahr der Überversorgung Gefahr der Unterversorgung

FFS DRG FP Capitationp




Vergütungsformen im Vergleich

Vergütungsform Erwünschter Effekt Unerwünschter EffektVergütungsform Erwünschter Effekt Unerwünschter EffektGehalt Anreiz zur Gesunderhaltung

des Patienten Keine Wirtschaftlich-

keitsanreize Warteschlangen

Kopfpauschale Anreiz zur Gesunderhaltung des Patienten

Risikoselektion Kostenverlagerungdes Patienten

Wirtschaftlichkeitsanreize geringe Verwaltungskosten

Kostenverlagerung Qualitätsgefährdung

Fallpauschale Ohne Anreiz zur Leistungsausweitung

Wirtschaftlichkeitsanreize

Unterlassen erwünschter Leistungen

Upgradingpg g Kostenverlagerung




Vergütungsform Erwünschter Effekt Unerwünschter EffektTagespauschale Minimierung der Kosten pro

Tag Ausdehnung der VerweildauerTag Verweildauer

Leistungskomplex kein Anreiz zur Ausweitung von Einzelleistungen

Inhalte der Leistungen nur durch Zusatzmaßnahmen gesichert

Einzelleistung Leistungsorientierte Vergütung

Unerwünschte Leistungs-ausweitungVergütung

Produktivitäts- und leistungs-steigernd

ausweitung Rosinenpicken, z. B.

Bevorzugung von GeräteleistungenGeräteleistungen

Erstattung der Faktorkosten

Planungssicherheit fürLeistungserbringer

Keine wirtschaftlich-keitsanreize,

Innovationsfördernd Leistungsausweitung

Erfolgsorientierte Vergütungsformen

Qualitätsverbesserung Arztinteresse und Patienten-

Messprobleme Hohe Kontrollkosten



Vergütungsformen Arztinteresse und Patienteninteresse sind deckungsgleich

Hohe Kontrollkosten


1 Zweistufige Vergütungssysteme d h die Kombination

Ansätze

1. Zweistufige Vergütungssysteme, d.h. die Kombination verschiedener Anreizausrichtung (z.B. Capitation oder DRG plus erfolgsorientierter Vergütung oder FFS und Capitation

2 Unterschiedliche Vergüt ngss steme a f den nterschiedlichen2. Unterschiedliche Vergütungssysteme auf den unterschiedlichen Systemebenen(Capitation für das gesamte System, FFS für die einzelnen Leistungserbringer)

3 Di h ll V ä d d V üt t3. Die schnelle Veränderung der Vergütungssysteme, um Anpassungsstrategien zu erschweren(wenn jedes Jahr die Bemessungsgrundlagen und ähnliches verändert werden, werden Anpassungsstrategien ausgesprochen riskant)Anpassungsstrategien ausgesprochen riskant)

4. Ganzheitliche Vergütungssysteme zu entwickeln, bei denen nicht offensichtlich ist, welche einzelnen Aspekte den Erfolg definieren. Hi t i k d lli A ät b i d di V ütHier setzen risk modelling-Ansätze an, bei denen die Vergütung an den relativen Veränderungen des Gesundheitsstatus einer Subpopulation gemessen wird.



Pay-for-Performance







7. Fazit



P4P - Entwicklung

Markteinwirkungen1990 Leitlinien Standardisierung des ärztlichen

1995 QM

1993GSGHandelns?

1995 QMKann man Qualität messen?

2000 EBM 2000GKV2000Wie belastbar ist das medizinische Wissen?

20052007

Safety2004

2007

GMG

WSGIst die Versorgung sicher?

2010Disclosure

2010Verbessert Transparenz die


Univ.-Prof. Dr. Volker Eric AmelungQuelle: M. Schrappe, SVR

2010 und P4P 2010Versorgung?

P4P - Entwicklung

Der P4P-EntwiclungsplanStage 1 Stage 2 Stage 3Stage 1

1996‐2004

Stage 2

2004‐2006

Stage 3

2007‐2010

PCP HEDIS measure PCP + Facility measures Enhanced data collection PCP HEDIS measure hospital measure Minimal consumer

reporting HMO Sortimentat

ures

PCP + Facility measures, Multiple specialities

Balanced Scorecard EB quality and affordability

measures

Enhanced data collection, clinical data exchanges, data aggregation

Standardized measures + outcomes HMO Sortiment

Withhold or Bonus based payoutsFe

a measures All product lines Differential fee schedules

outcomes Efficiency Actionable info – registries,

reminder alerts PHR EHR integration

Informational Low impact on costfit

s

Static consumer report cards

PHR – EHR integration Transparency

Enhanced Provider Directories (Provider ratings) Low impact on cost

Preventive care Existing data sets

Ben

e cards Safety and medication

errors Provider IT investment Collection of non claims

(Provider ratings) Demonstrable ROI Financially Sustainable Member engagement (PHR) Points of care notification


Univ.-Prof. Dr. Volker Eric AmelungQuelle: G. Baker, Leapfrog 2008

Collection of non-claims data (lab values etc.)

Points of care notification

P4P - Entwicklung

Wachstum in P4P-Programmen nach Sponsortyp


Univ.-Prof. Dr. Volker Eric AmelungQuelle: G. Baker, Leapfrog 2008

P4P - Grundlagen

Bewertungsdimensionen

Bewerber unterstützt durch Pay-for- Performance Sponsoren, die spezifische


Univ.-Prof. Dr. Volker Eric AmelungQuelle: Health Affairs, Vol. 26 No. 6

y p , pBewertungsverfahren benutzen, in Prozent, 2003 und 2006

P4P - Ziele

Q lität d Kli ik höh

Ziele für das VBP Program

Qualität der Kliniken erhöhen Probleme von über- und untermäßigem Gebrauch und Missbrauch

von Dienstleistungen angeheng g Auf den Patienten zentrierte Behandlung fördern Patientensicherheit erhöhen und negative Einflüsse reduzieren Unnötige Kosten in der Behandlung vermeiden Investitionen in strukturelle Komponente und in den

innerbetrieblichen Strukturwandel des Behandlungsprozessesinnerbetrieblichen Strukturwandel des Behandlungsprozesses systemübergreifend fördern

Behandlungsergebnisse transparent und verständlich für den Konsumenten machenKonsumenten machen

Bestehende Missverhältnisse im Gesundheitswesen abbauen und neue vermeiden


Univ.-Prof. Dr. Volker Eric AmelungQuelle: CMS, Option paper on value-based purchasing, April 2007

Pay-for-Performance







7. Fazit



Parameter und Methoden

1 Di b l t Zi l i h (B i ht)

Wie wird gemessen?

1. Die absolute Zielerreichung (Bonus, wenn x erreicht)2. Die relative Zielerreichung (Bonus, wenn zu den 10% Besten

gehörend)g )3. Die Veränderung im Gegensatz zum Vorjahr (20% besser als…)4. Der Vergleich mit einer Kontrollgruppe55. Kombinationen aus den drei vorangegangenen




Type of Performance Target Upside Downside

Absolute achievement Clear expectations reduceuncertainty

Cost-ineffective; most bonuses goto already high perfomersuncertainty

Allow providers to planto already-high perfomersNo incentive to improve beyond theupper-most targetCan discourage improvementamong poor perfomersg p p

Relative performance Can increase competition among Less certainty that compliancehigh performers efforts will be rewarded

Can discourage compliance amongpoor performers

Improvement Encourage low-performers toimproveTargeting absolute improvementreduces uncertainty

Already high-performers have lessroom for improvementPoor performers could receivelarger bonuses than highperformersperformers

Combining two or more types ofperformance targets

Encourages compliance among all providers

Adds complexity and costPoor perfomers could receive larger bonuses than high performers


Univ.-Prof. Dr. Volker Eric AmelungQuelle: Cannon, P4P, Yale J HP L E, 2006

bonuses than high performers


Example of Hospital Earning Quality Points by Attainment or Improvement


Univ.-Prof. Dr. Volker Eric AmelungQuelle: CMS, Options Paper on value-based purchasing, April 2007

Ergebnisindikatoren

MY 2009 P4P Measurement SetYear 6 Measures:2008 Measurement Year / 2009 Reporting Year

Year 7 Measures:2009 Measurement Year / 2010 Reporting Year

Clinical Domain

Measures tobe collected,

1. Childhood Immunization Status w/ 24/-monthcontinuous enrollment

2. Appropriate Threatment for Children with UpperRespiratory Infection

3. Breast Cancer Screening

1. Childhood Immunization Status w/ 24/-monthcontinuous enrollment

2. Appropriate Threatment for Children with UpperRespiratory Infection

3. Breast Cancer Screeningbe collected, reported andrecommendedfor payment

3. Breast Cancer Screening4. Cervical Cancer Screening5. Chlamydia Screening in Women6. Use of Appropriate Medication for People with Asthma7. Cholesterol Management LDL Screening (includes

Pts. w/ Cardiovascular Conditions)

3. Breast Cancer Screening4. Cervical Cancer Screening5. Chlamydia Screening in Women6. Use of Appropriate Medication for People with Asthma7. Cholesterol Management LDL Screening (includes

Pts. w/ Cardiovascular Conditions))8. Cholesterol Managements LDL Control <100

(includes Pts. w/ Cardiovascular Conditions9. Colorectal Cancer Screening10. Appropriate Testing for Children with Pharnyngitis11. Avoidance of Antibiotic Treatment of Adults with Acute

)8. Cholesterol Managements LDL Control <100

(includes Pts. w/ Cardiovascular Conditions9. Colorectal Cancer Screening10. Appropriate Testing for Children with Pharnyngitis11. Avoidance of Antibiotic Treatment of Adults with Acute

Bronchitis12. Use of Imaging Studies for Low Back Pain13. Medication Monitoring (ACE/ARBs, digexin, diuretics

Bronchitis12. Use of Imaging Studies for Low Back Pain13. Medication Monitoring (ACE/ARBs, digexin, diuretics14. Asthma Medication Ratio15. Evidence-based Cervical Cancer Screening

Clinical PO encounterthreshold forreporting

3.75 Encounters per member per year(using Encounter Rate by Service Type Specs)

4.0 Encounters per members per year (using EncounterRate by Service Type specs)


Univ.-Prof. Dr. Volker Eric AmelungQuelle: IHA

Clinical Weighting

40 % 40 %

Struktur- und ProzessindikatorenIT-Measure 1 Description Eligible Qualifying Activities (Group must

demonstrate capability and actual use byphysicians as of 12/31/04)

Examples of Eligible Qualifying Activities

Measure 1 –Integrate

Population managementindependent of patient

1) Use of electronic diesease regitstry or datawarehouse or other electronic data capability to

Credit for one acitivity (each) A list of patients diagnosed with CHF byg

clinicalelectronic datasets forpopulation-basedmanagement

p pcontacts.Rewards group-levelintegration of relevant electronic data sets, including only*: Visits/claims

p yproduce any of the following on all eligible patients, for all practice sites, updated at least twiceannually:- actionable reports on patients at the physicians orpractice site level, or production of a query list forphysicians or practice sites which integrate at least

p g ypractice site (visits) showing hospitalizationsand ER visits in the past year (inpatient orER records)

A list of each physicians diabetic patients(visits and/or pharmacy data) with HbA1c above 9 5(lab results)management Visits/claims

Lab results or claims Prescribtions Inpatient stays or ER

visits Radiology findings or

physicians or practice sites, which integrate at least 2 of the data sets at left- registries of patients at the physicians or practicesite level that integrate at least 2 of the data sets atleft

above 9.5(lab results) Electronic query list for a practice site of

children who visited the ER for asthma andhad no follow-up visit to PCP(ER recordsplus visit data)

Any of the 4 specific HEDIS measures thatclaims

Clinical findings: bloodpressure, BMI, tobaccouse, substance abuseor other findingsrelevant to clinical

2) Internally – and electronically – generatednumerator and denominator results for any of the 4 specific HEDIS measures that include lab results orclinical findings in numerator. Those measuresinclude only the following*:- Cholesterol Management – LDL Control

include lab results or clinical findings in numerator

A list of eligible patients (visit data to find patients with contraindications) missingBCS(radiology findings or claims) or CCS (laboratory findings or claims)relevant to clinical

guidelines

and the ability to report atthe patient level to practicesites or individual

h i i

Cholesterol Management LDL Control- Comprehensive Diabetes Care – HbA1c control- Comprehensive Diabetes Care – LDL control- Controlling High Blood pressure.[Therefore, any group self-reporting either of thefirst two control measures, which are also in theli i l t f Y 2 t dit f IT

(laboratory findings or claims) Electronic query list or report for a practice

site of each physician‘s patients withdiabetes(visits and/or pharmacy data), andtheir clinical lab results, most recent visit(s) and most recent pharmacy fills(1 condition, 3 d t t )physicians.

*Note: Eligibility lists do notcount as a relevant data set– the use of eligibility data isassumed.

clinical measure set for Year 2, gets credit for an IT Investment activity also]

*Note: HEDIS measures of the presence ofscreening or testing, such as HbA1c testing orcervical cancer screening, do not count.

data sets) Electronic query list or report for a practice

site, of all patients most recent lab resultsand office visits

A list covering all a practice‘s patients withhypertension(visits) and their last three blood



g yp ( )pressure readings (clinical findings)

Patientenzufriedenheit

Messung der Patientenzufriedenheit (MY 2003)Domain 1: Comumunication with MD Proposed Item

WeightingIndividual ItemWeighting

Doctor – Patient Communication Composite

Listen carefully to you 3,34 %

10 %Explain things in way you could understand 3,33 %

Providers spend enoungh time with you 3,33 %

Domain 2: Overall Ratings Proposed Item Weighting

Individual ItemWeightingWeighting Weighting

Ratings of personal doctor ornurse question item

Your rating of your personal doctor or nurse 5,00 %

10%Ratings of all health care questionitems

Your rating of all health care from providers 5,00 %

Domain 3: Speciality Care Proposed Item Weighting

Individual ItemWeighting

Problem seeing specialistquestion item

How much of a problem was it to see a specialist that you needed to see? 5,00 %

10%Rating of specialist question item Your rating of the specialist you saw most often 5,00 %

Domain 4: Timely Access to Care Proposed Item Weighting

Individual ItemWeighting

How often did you get an appointment as soon as wanted? 2,00 %

Timely Care and Service

y g pp

10 %

When called during regular office hours, how often did you get advice/help? 2,00 %

When needed care right away, how often did you get care as soon as wanted? 2,00 %

When needed after hours care, how often did you get care/help needed? 2,00 %

How often did you see the person you came to see within 15 minutes of your 2 00 %



How often did you see the person you came to see within 15 minutes of yourappointment time?

2,00 %

Quelle: Nach Emmert, P4P, 2008

Pay-for-Performance







7. Fazit



Public Reporting

IHA Public Reporting: 2006 data reported in 2007



Public Reporting

MN Community Measurement Provider Group Profile



Beispiel



Pay-for-Performance







7. Fazit



IHA

Gewichtung der Maßgrößen2003 2005 2005 2006

Klinisch 50 % 40 % 50 % 50 %

Patienten- 40 % 40 % 30 % 30 %Patientenzufriedenheit

40 % 40 % 30 % 30 %

IT-Investitionen

10 % 20 % 20 % 20 %

Individuelles Ärzte

X XÄrzte-FeedbackProgramm



IHA

P4P Measurement Set Evolution2003 Measurement Year /2004 Reporting Year

2004 Measurement Year /2005 Reporting Year



Clinical 1 Childhood Immunization w/ 12-month 1 Childhood Immunization w/ 24-month 1 Childhood Immunization w/ 24-month 1 Childhood Immunization w/ 24-monthClinical 1. Childhood Immunization w/ 12-month continuous enrollment

2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. LDL Screening (patients w/ cardiac

event only

1. Childhood Immunization w/ 24-month continuous enrollment

2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. HbA1c Control7. LDL Screening (patients with cardiac

event and diabetics)


2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. HbA1c Control7. LDL Screening 8 LDL Control <130


2. Cervical Cancer Screening3. Breast Cancer Screening4. Asthma Mgmt.5. HbA1c Screening6. HbA1c Control7. LDL Screening 8 LDL Control <130

Encounter threshold > 2.7 enc. PMPYevent and diabetics)

8. LDL Control <130

Encounter threshold >3,25 enc. PMPY

8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for Children

with Upper Respiratory Infection

Encounter threshold >3,25 enc. PMPY

8. LDL Control <1309. Chlamydia Screening10. Appropriate Treatment for Children

with Upper Respiratory Infection11. Nephropathy Monitoring for Diabetic

Patients12. Obesity Counceling

Encounter threshold >3 5 enc PMPYEncounter threshold >3,5 enc. PMPY

Weighting 50 % 40 % 50 % 50 %

Patient Experience

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Overall ratings of care

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Overall ratings of care

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Care coordination (CAS Composite)

1. Speciality Care2. Timely acces to care3. Doctor-patient-communication4. Care coordination (CAS Composite)

5. Overall ratings of care 5. Overall ratings of care

Weighting 40 % 40 % 30 % 30 %

Information TechnologyInvestment

1. Integrate clinical electronic data setsat group level for populationmanagement

2. Support clinical decision making at





1. ntegrate clinical electronic data sets atgroup level for populationmanagement

2. Support clinical decision making atpoint of care through electronic tools

Requires 2 activities, at least one in each Measure, each activity is worth 5 %

point of care through electronic tools

Requires 4 activities of which at least 2 arein Measure 2, each activity is worth 5 %

Added more qualifying activities



Added more qualifying activities





Weighting 10 % 20 % 20 % 20 %

IHAYear 6 Measures2008 Measurement Year/2009 Reporting Year

Year 7 Measures2009 Measurement Year/2010 Reporting Year

Efficiency Domain 1. Generic Prescribing See appropriate resource use domainb lbelow

Efficiency Weighting Separate from quality incentivepool Separate from quality incentivepool

Appropriate Resource UseDomain

1. Inpatient utilization – acute caredischargesg

2. Inpatient utilization – Bed3. Outpatient surgeries utilization4. Emergency department visits5. Inpatient readmissions withing 30

DaysDays6. Generic Prescribing

Appropriate resource useweighting

Gain-sharing arrangement in development Gain-sharing arrangement in development

T iti Cli i l 1 Bl d t l i di b tiTransition measuresMeasures to be collectedbut not publicly reported orrecommended for payment. These measures have been

Clinical:1. Asthma Medication Ratio2. Evidence-based cervical cancer screeningAppropriate resource use measures(will be used to establish a baseline):

1. Blood pressure control in diabetics2. Optimal diabetes care3. Adolescent immunizations (Tdap,

meningococcal, HPV)

tested and approved foraddition to the P4P measureset in the following year.

1. Inpatient utilization – acute care discharges2. Inpatient utilization – Bed3. Outpatient surgeries utilization4. Emergency department visits5 Inpatient readmissions withing 30 Days



5. Inpatient readmissions withing 30 Days6. Generic Prescribing

IHA

Neue Vergütungsformen: Point-of-Care Technologie



Leistungsorientierung im britischen NHS(disease) area N b f I di t i t i

Domain

(disease) area Number of Indicators points in

structure process outcomeTotal in

area domainarea domain

CHD w/ LVD 2 1 12 15 121

Clinical quality 550

TIA 1 1 8 10 31

Hypertension 1 2 2 5 105

Diabetes mellitus 1 0 17 18 99

COPD 1 2 5 8 45Clinical quality 550

Epilepsy 1 0 3 4 16

Hypothyroidism 1 0 1 2 8

Cancer 1 0 1 2 12

Mental health 1 0 4 5 41

Asthma 1 1 5 7 76 72

Practice organisational

Records and information 18 85

184

Patient communication 8 8

Education and training 9 29organisational g

Medicines management 10 42

Practice management 10 56 20

PEPatient survey 3 70

100Consultation length 1 4 30Consultation length 1 4 30

APS

Cervical screening 6 22

36Child health surveillance 1 6

Maternity services 1 6

C t ti i 2 10 2



Contraceptive services 2 10 2

Total 146 870

Leistungsorientierung im britischen NHS(disease) area Indicator Description point threshold

range(%)No type

CHD 6 outcome % of patients with CHD in whom the last blood pressure reading 0-19 25-70CHD 6 outcome % of patients with CHD, in whom the last blood pressure reading(measured in the last 15 months) is 150/90 or less

0 19 25 70

TIA 1 structure The practice can produce a register of patients with stroke and TIA 0-4 >25

Hypertension 5 outcome % of patients with hypertension in whom the last blood pressure 0-56 25-70Hypertension 5 outcome % of patients with hypertension in whom the last blood pressure(measured in the last 9 months) is 150/90 or less

0 56 25 70

Diabetes mellitus 12 outcome % of patients with diabetes in whom the last blood pressure is 145/85 orless

0-17 25-55

COPD 3 process % of all patients whith COPD where diagnosis has been confirmed by 0-5 25-90COPD 3 process % of all patients whith COPD where diagnosis has been confirmed byspirometry including reversibility testing

0 5 25 90

Epilepsy 2 outcome % of patients aged over 16 on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months

0-4 25-90

Hypothyroidism 2 outcome % of patients with hypothyroidism with tests recorded in the previous 15 months

0-6 25-90

Cancer 1 structure The practice can produce a register of all cancer patients defined as a ‚register of patients with a diagnosis of cancer excluding non-melatoninki f 1 A il 2003‘

0-6 >25

skin cancers from 1 April 2003‘

Mental health 2 outcome % of patients with severe long-term mental health problems with a reviewrecorded in the past 15 months

0-23 25-90

Asthma 3 process % of patients aged over 8 diagnosed as having asthma from 01.04.03 h th di i h b fi d b i t k fl

0-15 25-70



where the diagnosis has been confirmed by spirometry or peak flowmeasurement

Leistungsorientierung im britischen NHS

Gründe für Hausärzte, Patienten vom Pay-for-Performance Programm auszuschließen

Der Patient hat min. drei Aufforderungen zu einer Untersuchung in den letzten 12 Monaten erhalten, ist aber nicht erschienen

Der Patient hat sich erst kürzlich in der Praxis registriert oder esDer Patient hat sich erst kürzlich in der Praxis registriert oder es wurde kürzlich eine Erkrankung festgestellt

Der Patient bekommt die max. vertragbare Medikamentendosis, aber die Wirkung bleibt suboptimalaber die Wirkung bleibt suboptimal

Der Patient hat eine Allergie, verspürt Nebenwirkungen oder Gegenanzeigen gegen verabreichte Medikamente

Der Patient stimmt einer Untersuchung oder Behandlung nicht zu Eine vorgeschriebene Untersuchungsmöglichkeit ist für den

Hausarzt nicht möglichHausarzt nicht möglich


Univ.-Prof. Dr. Volker Eric AmelungQuelle: Doran et all 2206

Pay-for-Performance







7. Fazit



Fazit

E b i ht

Ergebnisse durch P4P aus Versicherungssicht

Es berichten 38 % von einer Steigerung der Qualität 42 % von „Mixed Effects“42 % von „Mixed Effects 20 % von keine Veränderungen


Univ.-Prof. Dr. Volker Eric AmelungQuelle: Rosenthal 2008

Erfolgsfaktoren und Hemmnisse

Folgende Aspekte müssen ausführlich betrachtet werden:

Valide Messparameter Einbeziehung der Anwender

B ü k i hti l k l U t hi d d dä t Berücksichtigung lokaler Unterschiede und adäquate Risikoadjustierung

Einsatz moderner Informationstechnologieg Ausreichende finanzielle Auswirkungen Einzel- und Gruppenmotivation Kombination mit nicht-monetären Anreizen Umfassende Evaluation



Erfolgsfaktoren und Hemmnisse

Hemmnisse

Auswirkungen auf nicht berücksichtigte Kriterien Zu starke Prozessorientierung

F ti Fragmentierung Selektionseffekte Bürokratie und Einbindung kleinerer LeistungserbringerBürokratie und Einbindung kleinerer Leistungserbringer Motivation von Leistungsschwächeren Kontinuierliche Motivation von leistungsstarken Anbietern Aufbau von Versorgungsbarrieren und Vergrößerung der

Versorgungsunterschiede



Herzlichen Dank für die Aufmerksamkeit!

Univ -Prof Dr Volker AmelungUniv.-Prof. Dr. Volker Amelung

Medizinische Hochschule HannoverAbteilung Epidemiologie Sozialmedizin undAbteilung Epidemiologie, Sozialmedizin undGesundheitssystemforschung OE 5410Carl-Neuberg-Str. 130625 Hannover

Tel.: 0511 – 532 [email protected]



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