1DG SANITA’

PRIMARY CARE:Regional strategies to improve efficacy and equity while guaranteeing

economic sustainability

Pisa, June 13, 2011

STRATEGIES AND NEW MEASUREMENTS IN PRIMARY CARE:

THE CREG PROJECTIN LOMBARDY REGION

Carlo ZOCCHETTI

Direzione Generale Sanità – Regione Lombardia

Rome

LOMBARDY

LOMBARDY

24,000 SqKm

9.8 million inhab’s (17% Italy)

17 Billion Euros health expen’s (17% Italy)

A significant proportion of mountaineous terrain

Just for starting …

DG SANITA’

Lombardy Region

•GDP (per cap) 33,648 € (Italy 26,278 €)

•220 Hospitals (30% profits)•4 beds x 1,000 inhab’s•8,150 GPs•2,700 Pharmacies•730 Outpatient ambul’s

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Lombardy Region

•2 Mln discharges•10% discharges for non residing people (50% in oncology, cardiosurgery)

•3,8% passive mobility•160 Mln outpatient services•60 Mln drug prescriptions

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15 LOCAL HEALTH AUTHORITIES (ASL)

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100 Districts

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• L.R. Health System:– Universal coverage; funded by general

taxation; separation between Purchasers (ASL) and Services Providers (Hospitals, Ambulatories, GPs, …)

– Purchasers funded by weighted capitation; Services Providers funded (mainly) on delivery of services (DRGs, List of outpatient activities, tariffs)

General rules: Lombardy Region HS

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• L.R. Health System:– Centered on hospitals, and acute care:

inadequate to manage chronicity• Requires different ideas, culture,

competence, tools, instruments• CReG: Accent on Chronicity, not primary

care

– People is getting older:• Big proportion of citizens with chronic

diseases or conditions

– Some figures about chronicity in Lombardy Region

CReG: the problem

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0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

1,656,380

5,297,280

2,676,224

87,044

Population

(17,0%)

(54,5%)

(27,5%)

(0,9%)

Non_Cons Acute Chronic Death

70% of expend’s

0 3 6 9 1215182124273033363942454851545760636669727578818487909396990

10

20

30

40

50

60

70

80

90

100

%Non-Consumers %Non-Chronic %Chronic

Percentage of population

00

-04

05

-09

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

-89

90

-94

95

+

0

200,000,000

400,000,000

600,000,000

800,000,000

1,000,000,000

1,200,000,000

Total expenditures (Euro)Tota

l

Chronic

Acute

Only Not Only

Disease Number % Euro/PC Number % Euro/PC

         

Transplants 618 0,0 5.543 6.857 0,2 21.846

Kidney Insuff 2.245 0,1 7.815 41.701 1,0 12.956

HIV-AIDS 15.227 1,0 7.455 27.425 0,6 9.486

Cancer 104.720 6,6 3.518 297.704 6,9 5.195

Diabetes 87.371 5,5 895 426.424 9,9 2.921

Cardiovascular 835.231 52,8 1.166 1.754.271 40,9 2.450

Pulmonary Dis 116.701 7,4 1.169 242.828 5,7 2.981

Gastro&Liver 143.076 9,0 1.269 494.394 11,5 4.014

Neurological 93.662 5,9 2.449 225.720 5,3 4.133

Autoimmune Dis 18.314 1,2 1.146 77.658 1,8 2.306

Endocr_Methabol 164.445 10,4 904 693.816 16,2 2.710

             

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• The chronic patient uses many services which do not resolve his problems– Live longer with chronicity– Delay negative consequencies– Needs control, monitoring, and

organizational acitivities: no specialization

• The chronic patient requires treatment planes, guidelines, for specific diseases– Agreed– Finalized to obtain “continuity of care”– Some problems

CReG: the motivations

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Anti-diabetics StatinsAnti-

hypertensiv

Treated Mal Fem Mal Fem Mal Fem

Sporadic 19,7 22,5 24,3 24,7 19,8 22,5

Adherent 38,6 38,2 26,4 20,8 42,0 34,7

Not adherent 61,4 61,8 73,6 79,2 58,0 65,3

Persistent 57,6 58,6 51,5 46,5 57,1 50,6

Not persistent 42,4 41,4 48,5 53,5 42,9 49,4

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• The chronic patient needs to be maintained “on care”– Not guaranteed by hospitals acute

approach– Coordination between hospitals and

primary care

• Is primary care prepared to face chronicity?– It lacks some necessary attributes:

• Contractual conditions• Clinical, management and administrative

expertise

CReG: the motivations

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• We need a new institutional subject:– A manager of a group of many cases

• In the context of L.R. health system general characteristics:– Freedom of choice of provider– Purchaser-provider split– Accreditation– Parity between public and private

companies

• The approach emerged after some experiences, mainly with GPs

CReG: the approach

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• CReG: “Chronic Related Group”– Innovative way of taking care of chronic

cases– A group of predefined resources (tariff)

assigned to an institutional subject to guarantee the delivery of an established treatment plan to chronic patients it has in charge

– Services excluded:• Hospital discharges• GPs fees

CReG: the approach

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• CReG requires three technological pillars:– Ability to classify people with regard to

chronicity (type of diseases, staging, …)– An established treatment plan, guidelines– A reimbursement scheme (CReG tariff and

some administrative stuffs)

• CReG requires an organizational platform

CReG: the approach

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• 1. CReG: how to classify people– A specific information system

• Hospital discharges, outpatient ambulatory services, drug consume

• On an individual basis (PIN)• Paid with a pps scheme (tariffs)• Services purchased outside the region• Large coverage (98% of expenditures)• No GPs activities• No “pure private” activities

– A classification scheme• Also with “disease exemptions”

CReG: the pillars

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CITIZEN

DRUGS ConsumesHospital DISCHARGES

OUTPATIENTS Activities

MORTALITY

PATHOLOGY Exam’s

CANCER Registries

SUPPORT and Others

PSYCHIATRY

SUPPLY

20

• 1. CReG: how to classify people– A specific information system

• Hospital discharges, outpatient ambulatory services, drug consume

• On an individual basis (PIN)• Paid with a pps scheme (tariffs)• Services purchased outside the region• Large coverage (98% of expenditures)• No GPs activities• No “pure private” activities

– A classification scheme• Also with “disease exemptions”

CReG: the pillars

DG SANITA’

CancerCancer

orcode 048* (or code

0043)

code 048* (or code

0043)

if

1exemption

1exemption

2discharges

2discharges

3drugs

3drugs

4out-patient

4out-patient

code ICD9-CM between

140* and 208* Or V10*

code ICD9-CM between

140* and 208* Or V10*

ATC L01 orChemiother.

ATC L01 orChemiother.

Radiother.(code 92.24*)

Radiother.(code 92.24*) or or

11 22 33 44

if if if

23

• 1. CReG: how to classify people– The classification scheme produced a huge

number of classes– Ranking of the diseases (according to

expenditures), and selection of the first two– A manageable number of CReGs (some

hundreds)

• 2. CReG: treatment plans– They identify needs for specific diseases– Experts collected and discussed treatment

plans and guidelines

CReG: the pillars

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• 3. CReG: a reimbursement scheme– To reimburse a global treatment plan (like

DRG), not individual activities (like drugs, visits, examinations, …)

– Two methodological questions:• How to set a tariff• How to manage reimbursement from the

administrative point of view

– How to consider complexity (more than two diseases in the same patient)

• For each CReG: number of diseases • Linearity in expenditures according to

complexity

CReG: the pillars

DG SANITA’

L4 - Ipertesi, Ipercolesterolemie Familiari E Non

0500

10001500200025003000350040004500

L42 L43 L44 L45

Totale

Lineare (Totale)

B1 - Parkinson, Cardiopatici

0

500

1000

1500

2000

2500

3000

B12 B13 B14 B15

Totale

Lineare (Totale)

C9 - Cardiopatici, Ipertesi

0

500

1000

1500

2000

2500

C92 C93 C94 C95

Totale

Lineare (Totale)

F6 - Gastropatici, Ipertesi

0

500

1000

1500

2000

2500

3000

3500

F62 F63 F64 F65

Totale

Lineare (Totale)

A1 - Neoplastici, Parkinson

0

500

1000

1500

2000

2500

3000

3500

4000

A12 A13 A14 A15

Totale

Lineare (Totale)

28 - Insufficienti Renali Cronici, Neoplastici

02000400060008000

1000012000140001600018000

282 283 284 285

Totale

Lineare (Totale)

Examples of linearity of expendituresAccording to complexity

CREGMediaMediana

Ipertesi

30

• 3. CReG: a reimbursement scheme– 150 different CReGs– A basic tariff for each CReG– An incremental tariff for each additional

disease– Examples

CReG: the pillars

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CReG Basic Tariff

Incremental Tariff

Chronic kidney insuff. with dialisis, hypertension 34.702 1.356

Chronic kidney insuff. without dialisis, hypertension 1.666 1.049

Chronic kidney insuff. without dialisis, gastro&liver 1.149 375

Hypercholesterol, hypertension 1.014 530

Hypercolesterol, asthma 1.391 534

Insulinic diabetes, transplant (inactiv) 5.252 389

Diabetes, Parkinson 2.504 289

COPD, cardio-vasculopatic 2.262 579

Asthma, diabetes 1.588 235

Cardio-vasculopatic, systemic Lupus heritematosus 1.477 650

Hypertension, rheumatoid arthritis 1.003 566

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• 4. CReG: the organizational platform– A new institutional subject

• A group of GPs• Association of patients, or professionals• Any type of provider (hospitals, ambulatories,

…) private or public• Must be accredited (establish criteria and rules)• Must sign a contract with ASL

– Patients will receive a defined set of activities (treatment plan)

CReG: the organizational platform

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• 4. CReG: the organizational platform– Accreditation:

• Organizational and managerial attributes• Professional skills (clinical expertise)• Information system• … … …

– Contract:• Duties for the institutional subject

– Patients interested, expected needs, treatment plans, managerial activities, information exchanged

• Duties for the ASL– Reimbursement scheme, control activities

CReG: the organizational platform

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• Next months:– A restricted application of CReG approach– In five areas:

• Bergamo, Como, Lecco, Melegnano, Milano

– For some diseases:• Diabetes, hypertension, COPD, kidney

insufficiency, …

– Objectives:• To fine tune the CReG approach• Particularly: organizational, managerial,

administrative aspects

… and just for closing …

DG SANITA’

Thank youforattentionand patience

Marc Chagall: The Violinist

DG. SANITA’

Carlo Zocchetti