Packages of completed episodes of treatment in specialist consultative health care

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Packages of completed episodes of treatment in
specialist consultative health care

• Tatjana Lukanovska, MA / Manager of the Finance
  Sector
• Work Group Branislava Katushevska, Snezana
  Kovkaroska Shiloska, Snezana Kitanceva, Marija
  Petreska

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Content
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HIF and funding of health services
Meaning and reasons for implementation of
specialist packages
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The present versus new system of grouping
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Development steps
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Advantages from implementation of packages
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HIF Budget- Incomes
Contributions from gross salary
Other levels of governance
Incomes of HIF
Other no tax incomes
Budget of the Fund in 2009 321.7 millions Euro
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HIF Budget- Incomes
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Budget of HIF- Expenditures
HIF expenditures
Other payments
Health services
Operating costs
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Budget of HIF- Expenditures
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Structure of expenditures for health services in
2009
For specialist-consultative health care 81.3
millions Euro in 2009.
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Public Health Institutions
Incomes in 2009 HIF Budget of RM Personal
Expenses in 2009 Salaries and
contributions Pharmaceuticals and
materials Residual expenditures
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Incomes of PHI (2009)
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Expenditures of PHI (2009)
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Private Health Institutions in Specialist
Consultative Health Care
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Private Laboratories in Specialist Consultative
Health Care
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Types of specialist consultative services in
private sector
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What exactly are the packages of completed
episodes of treatment in the specialist
consultative health care?
A method that is used for recording purposes and
payments to hospitals and ambulances for
specialist services
Service providers receive fixed amounts for
individual services
The services are categorized in packages per
professional activities
Introduction of prospective planning
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What exactly are the packages of completed
episodes of treatment in the specialist
consultative health care?
Specialist packages are result of Macedonian
experience
The quantity and type of resources that are used
in ambulance health services are grouped in
specialist packages
Services in each package have similarities in
clinical characteristics, used resources and in
costs.
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What exactly are the packages of completed
episodes of treatment in the specialist
consultative health care?
Each package has referent price that is received
as a result of a prepared methodology
Labour costs (minute x price)
Medical consumables and pharmaceuticals
Overheads
Other expenses
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Reasons for implementation of the packages

• Simplification of the way of presentation
  of the health services for
• Hospitals, health homes, ambulances, clinics
• Unification of the way of invoicing
• Increase of the transparency of the
  service providers
• Improvement of the control of expenditures
• Provision of better budgeting and planning
  of resources

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Development steps
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• Way of classification by groups
• DRG uses major diagnostic groups
• Packages use categorized procedures
• Definition of the procedures that are not
  included in the hospital services
• Hospital versus ambulance

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Development steps

• Performed ambulance procedures are
  classified in groups
• Major procedure
• Contains the reason for visit
• Ancillary procedure
• With a purpose to help during diagnostics and
  selection of appropriate treatment

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Development steps

• Major procedures in the packages are divided
  into 12 professional activities

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• Ophthalmology
• Otorhinolaryngology
• Dermatology
• Physical medicine and rehabilitation
• Paediatrics
• Gynaecology and obstetrics

• Hearing, speech and voice
• Internal medicine
• Psychiatrics
• Neurology
• General surgery
• Orthopedics

1 group of general packages applicable for all
12 professional activities
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Ambulance services that are not included in
specialist packages
Laboratory
Histopathology
Radiology
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Invoicing and payment

• Ambulance services
• Package ???1 Expanded dermatological package
  790 Den
• Specialist examination
• Written report
• Taking of anamnestic data
• Inspection of the skin on the whole body and
  visible mucous membranes and/or inspection of
  genital organs
• Use of a magnifier ordinary or electrical
• ?valuation of dermatological-allergological or
  venereological (in a case of STD) anamnesis
• Diet plan
• Measuring of tension
• Auscultation of heart and lungs
• Additional specific services BA2 Hematological
  status 250 den
• Sedimentation of erythrocytes
  100 den
• Blood count with differential blood count 150
  den

790 Den
250 Den
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ADVANTAGES

• Simpler recording of services
• Unified grouping of the services for all
• Unified participation for all
• Less administrative work
• Better analysis and planning
• Increased control over expenditures
• Increased transparency

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Preparation of the packages
Specialist packages
Ideas and mutual work
Ministry of Health
Doctors chamber
HIF
PHI
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Implementation of the packages with examples
and most frequently asked questions and given
answers
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Implementation of the packages
Implementation started from May 2010
Coverage on the national level
148 PRIVATE health institutions
102 PUBLIC health institutions
First results are expected at the end of 2010
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Implementation of the packages

• In 2009 the Fund was making intensive
  preparations for implementation of one more
  acceptable system of payments for health services
  in specialist consultative health care with a
  goal to replace the Price List for health
  services from 1992.
• Instead of system of points per individual health
  services with a possibility for individual
  groping by the doctors teams, or in other words
  by the health institutions towards implementation
  of a new , for the first time applicable system
  in RM, of packages of completed episodes of
  treatment in specialist consultative health care
  with total value (referent price).
• Packages of completed episodes of treatment are
  method for a first time used in the neighbouring
  countries and in the wider area, that is a
  stabile, efficient, unified system of recording,
  reporting and payment of the health services in
  the ambulance professional activities- acceptable
  system of classification of health services.

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What is represented by a package of completed
episode of treatment?

• The system- packages of completed episodes of
  treatment should be observed at the same time as
  a method of recording and payment and as a
  fundamental (basic) stimulative mechanism within
  the frames of the health system
• Usage of the packages as a mechanism of payment
  enables
• - more rightful allocation of budget funds to
  the health institutions that provide specialist
  consultative activities according to performance
  indicators,
• - encourage provision of health care with
  better quality and efficiency and
• - discontinuation of provision of unnecessary
  health services.

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What is represented by a package of completed
episode of treatment?

• Appropriate group (package) of more individual
  health services that represent a whole in the
  diagnostic treatment or in a curative treatment
  in specialist consultative health care, as a
  completed episode of treatment for the insuree,
  in the period of validity of the referral, issued
  by the chosen doctor or other type of referral in
  accordance with determined health regulations,
  for a diagnosis.
• Individual health services covered in respectible
  packages are integral part of the package-type of
  procedures, that are to be executed in order for
  the package to be defined.

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Content of the package

• The package of completed episode of treatment
  contains
• -individual health services of which the whole
  episode of treatment is consisted in the period
  of validity of one referral, per one insuree, per
  professional activity and per one diagnosis.
• Individual health services included in
  respectable packages are types of procedures,
  that have to be performed in order for the
  package to be defined.
• ( individual health services for each package
  are published on the Web page of the Fund)

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• Packages are published with
• Code, description of the package and referent
  price.
• - The code is assigning the type of package
  according to which the same is recognised
• Example
• To Ophthalmology packages the following code is
  assigned ???
• (? -ambulance, ? ophthalmology and ? -
  medicine).
• Physical medicine packages are assigned the
  following code ??? ?- ambulance, ? physical
  and ? - medicine

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EXAMPLE 1

• COMMON-GENERAL PACKAGES

ASK2 Basic specialist package with control 450
  Specialistic examination  
  Written report  
  Control examination  
  Written report  
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EXAMPLE 2

• PHYSICAL MEDICINE

A?M4 Minimal package for physical and rehabilitation treatment for 10 days (from 3 to 5 procedures) 3.500
  Specialist examination and written report  
  Control examination  
  Electrotherapy diadynamic currents, interferential, galvanic, electrophoresis with pharmaceutical, TENS exponential currents  
  thermotherapy infrared lamp, ultraviolet radiation, paraffine, shortwave diatermia, cryotherapy  
  Sonotherapy (ultrasound therapy)  
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Present versus new system of grouping

• An example Present system
• Examination with intervention
• Examination (labour)
  320 den
• Intramuscular application
  40 den
• - Needle
  50 den
• - Pharmaceuticals
  300 den
• Total for invoicing
  690 den
• Participation
  60 den
• Payment by HIF
  630 den
• Second visit to doctor control

An example New system Only
system Package ???5 control package
with diagnostics/ 600 den Medicamentous
therapy

Participation
60 den Payment by the Fund
540 den

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Participation

• Participation is calculated and charged per
  package.
• It is calculated and charged in accordance to the
  existing decisions for determination of the
  percentage of the copayment of the insurees in
  total costs of the health services and
  pharmaceuticals (Official Gazette no. 48 from
  2001 number 47 from 2005 number 48 from 2007
  and number 130 from 2007)
• Decisions are published on the web page of the
  Fund.

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Participation

• - Packages are collection of individual
  services, and in accordance to the same and
  following the Decision, copayment is paid per
  scale (depending on the referent price of the
  package) except for the packages for physical
  medicine and psychiatry in which days are
  assigned is paid per day.
• - For the basic package ???1 that is a package
  with examination, copayment is paid in accordance
  with the Decision in amount of 50 denars.

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Invoicing and payment

• In accordance to signed agreements, the health
  care institution makes an invoicing of delivered
  health services once per month that is until 5-th
  in the actual month for the previous month.
• For the provided health services to the insuree
  on the base of referral of the chosen doctor the
  health institution prepares special calculation.
  That calculation contain (as for now) all basic
  data for the health institution and for the
  insuree, referral diagnosis, signature and
  facsimile of the doctor, signature of the
  insuree, seal of the health institution and date
  of calculation.

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Invoicing and payment

• For an insuree referred to specialist-consultative
  health care is compulsory
• With one referral, for one professional activity,
  for one diagnosis one calculation
• Exception
• The professional activity internal
  medicine that beside of the appropriate package
  of the basic or from other activities has a right
  also in calculation to invoice the services from
  internal professional activity ( ???1 , etc.)
  published as completed health services.

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CALCULATION

• Calculation contains
• all basic data for the health institutions and
  for the insuree, professional activity,
• referral diagnosis,
• the package of completed episode of treatment
  with the referent price and with the individual
  services that are integral part,
• calculated and paid copayment and basis for
  release of copayment (if there is a release),
• amount for payment by the Fund,
• signature and facsimile of the doctor,
• signature of the insuree,
• seal of the health institution and date of
  calculation.

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Calculation

• With the calculation it is compulsory to be
  submitted
• - referral of the chosen doctor or other
  appropriate referral established in accordance
  with existing legal regulations
• and
• - proof for paid contribution for health
  insurance.

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Invoicing and payment

• For delivered packages of health services within
  the month specification and invoice are prepared,
  separately per professional activity.
• Health institutions that provide health services
  from several professional areas also have to
  submit collective summary report with all
  individual invoices per professional areas.

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Specification

• Specification contains the following data
• - basic data of the health institution,
• - title of the branch office to which the
  specification is submitted and
• - list of all individual calculations per
  insuree, code of the package, description of the
  package, referent price of the package,
  calculated copayment, basis for release of
  copayment, and amount for payment.

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Invoicing and payment

• The health services for
• biochemical, microbiological and other
  laboratory examinations and also for
  radiodiagnostics are calculated separately with
  separate calculations, under already established
  referent prices, that is valid prices.

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Invoicing and payment

• For provided health services to the insuree that
  are not covered by the packages, the most
  appropriate package is invoiced or one of the
  common, or in other words general packages.

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Invoicing and payment

• For the health services and professional
  activities for which packages are not
  established, the Health Institution obligatory
  submit a proposal for new package to the
  Commission for establishment of referent prices
  of packages for completed episodes of treatment,
  because of preparation and completion of the same
  if there is a justification for that.
• Those proposals have to contain the package title
  and individual health services from the Price
  List of health services in Republic of Macedonia
  from 1992, with a total value.
• Those proposals are submitted to ?-mail
  specijalisticki_at_fzo.org.mk

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Invoicing and payment

• Because of electronic submission of data, the
  Fund is going to prepare a software solution
  similar to DRG method by which a simplified
  invoicing of the packages of completed episodes
  of treatment in specialist-consultative health
  care will be made.

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• EXAMPLES

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Thank you for your attention !

• Contact
• E-mail
• tatjanal_at_fzo.org.mk
• Tel
• 389 2 3289 000

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