Introduction of Complex Capitation Standard Rate (CCSR) in outpatient care

organizations

Network public MOs, rendering OPP

polyclinics-361

CPMSH -15

PD of dispensary with beds -130

TB dispensary-51Oncologic-17

Dermatovenerologic-20Psychoneurologic-18Endocrinological -1

Narcological -19Cardiologic dispensary -4

Women’s health centres under obstetric

organizations-26Perinatal centres-16

Maternity hospitals-10

OC-1086

Total- 2206

Outpatient-polyclinic organizations– 612 PD and OCof hospital organizations – 1304

Municipal polyclinics – 119

CDC – 3

Child polyclinics– 14

CPMSH – 17

CRP, RP, VP – 36

OC – 409

Network of МОs, rendering PHC, on the situation on January 1, 2013

OC – 1082

PD of city hospitals– 20

PD of CRH, RH, VH – 192

CPMSH - 10

MW without rooms – 128МS, village first-aid station

- 4311

Private OPO 1082

City184 Village179

MP 122

CP14 RP 29CPMSH 9 CDC 3

OC12

MH 24

CRH133

RH 12

VH 5

Total number of organizations 363

Independent organizations, rendering PHC

Medical organizations, providing CDS

Outpatient-polyclinic organizations -174 Polyclinic departments (PD) of hospital organizations - 225

RP - 25

Pediatric polyclinics

- 14

CDC -11

Municipal polyclinics- 124

Total- 399

PD of regional hospitals - 12

PD of regional pediatric hospitals - 16

PD of CRH, RH - 158 PD of VH - 9

PD of cityhospitals - 30

NETWORK OF ORGANIZATIONS, PROVIDING PHC. EXAMPLE OF ZHAMBYL REGION.

NETWORK OF ORGANIZATIONS, PROVIDING PHC. EXAMPLE OF KARAGANDA REGION

Objective: Improving availability and quality of primary medical and sanitary care by introducing economic incentives

Tasks:1. Stimulating preventing direction in work of PMSC organizations2. Expanding the range of primary medical and sanitary help services3. Provision of rational and effective usage of means dedicated for outpatient-polyclinic and hospital care4. Increasing payment of PMSC workers by introducing economic incentive mechanisms

Tasks and objectives

Stimulating preventing direction in work of PMSC organizations

Covering not lesser than 70% of target group of assigned population with screening assays

Increasing the number of diseases detected at early stage Decreasing the number of chronic non-contagious

diseases and their complications by integrating the chronic diseases management program

Systematic explanatory and promotion work with population on disease preventing and forming healthy lifestyle

Expanding the range of primary medical and sanitary care services

1. Delegation of consultative and practical skills on most frequent diseases from dedicated experts (subject matter experts) to the specialists of PMSC :

cardiology– hypertension, CHD endocrinology– hypothyroidism, diabetes

gastroenterology– ulcer, gastritis, duodenitis and hepatitis

ophthalmology – conjunctivitis

neurology – acute cerebrovascular disease, root disorders

pulmonology– pneumonia, COPD, bronchial asthma

obstetrics and gynecology – pregnancy follow-up

2. Expanding SMW powers and independence : - independent admission of patients including case follow-up of dispensary patients;

- being able to use basic practical skills in surgery and obstetrics and gynecology;

- providing services for house-calls;

- prenatal nursing, postnatal nursing, nursing of healthy children younger that 1 year, patients with chronic diseases;

- consulting on disease prevention and healthy lifestyle, social and psychological help

Provision of rational and effective usage of means dedicated for outpatient-polyclinic and hospital care

Decreasing the number of unreasonable hospitalizations to twenty-four hour hospitals

Decreasing CDS consumption Decreasing the number of emergency calls in

PMSC organizations working hours

Increasing payment of PMSC workers by introducing economic incentive mechanisms

Introduction of differentiated payment for doctors’ and SMW work for:

expanding the list of consultative and diagnostic and practical skills expanding prevention direction of work (covering not lesser than

70% of assigned population with preventive activities) reaching basic indicators of productivity of PMSC activity

Primary medical and sanitary care

Premedical, qualified medical care without twenty-four hour medical observation, including complex of available medical services, provided at the levels of person, family and society:

1) diagnostics and treatment of most common ailments, as well as of traumas, poisonings and other emergencies;

2) sanitary and anti-epidemic (preventive) activities in sites of diseases;

3) hygienic education of population, family, maternity, paternity and child welfare services;

4) explanatory work on safe water supply and nutrition

Article 45 of Code on Health and Healthcare System

Expanding functions of PHC:

• premedical, qualified medical care,• examining patients for detecting ailments at an early stage, • appointment for hospitalization,• chronically ill patients for preventive medical examination, •rehabilitation treatment,•provision of medicines.

• making requirements for doctor and SMW training stricter • SMW status reinforcement• extending the staff size of SMW and keeping the relation between them in balance• improving the level of doctor and SMW training• improving the level and the quality of care workers’ and psychologists’ work• increasing payments by integrating differentiated payment for doctors’ and SMW work for expanding their functions and achieving targeted results

Problems:Capitation standard rate for 2000-2200 population

Complex capitation standard rate

assigned population using PHC

assigned population using PHC, primarily with preventive purposes

• decreasing the number of common chronic manageable diseases (CMD) at PHC level• systematic, explanatory, promotion work with population on disease prevention and forming healthy lifestyle• transferring focus from ill patients onto protection of healthy population• delegation of powers from dedicated expert to the specialists of PHC • expanding SMW powers and independence• strengthening social orientation of PHC

Existing functions of PHC:

• lack of doctors• lines in polyclinics• poor quality of medical care

Solutions:

Pilot studies results

on the example of pilot MO – municipal polyclinic №8 of Аstana – general practitioners’ actual salary rose 2.2 times, therapists – 2.0 times and pediatrists – 1.6 times, nurses actual salary rose 2.3 times; therapist nurses – 2.1 times; pediatrists nurses – 1.6 times

MP №8 General practice Therapy Pediatrics

Salary calculations

Base salary

Additional salary

Total Base salary

Additional salary

Total Base salary

Additional salary

Total

Doctor 85000 102330 187330 80000 85850 165850 80000 52180 132180

Nurse 65000 87280 152280 60000 68680 128680 60000 37060 97060

General practice Therapy PediatricsSalary calculations

Actual (without AGC)

With AGC (CCSR = 1196,98)

With AGC (CCSR= 1221,12)

Actual (without AGC)

With AGC (CCSR = 1196,98)

With AGC (CCSR= 1221,12)

Actual (without AGC)

With AGC (CCSR = 1196,98)

With AGC (CCSR= 1221,12)

Doctor 110428 166122 328922 110428 143095 283328 110428 130461 258313

Nurse 70941 109775 217354 70941 87224 172704 70941 91468 181106

on the example of pilot MO – Taiynshyn CRH, NKR – general practitioners’ actual salary rose 2.9 times, therapists – 2.5 times and pediatrists – 2.3 times, nurses actual salary rose 3 times; therapist nurses – 2.4 times; pediatrists nurses – 2.5 times (CCSR equals to 1221,12)

основной фонд ЗП - 215000 тг

44%дополнительный фонд ЗП -

276890 тг56%

CCSR fund distribution (on the example of MP №8)

491890 tenge– one division’s salary fund per month (1 doctor– 2-3 SMW), consists of:

215000 – base actual salary (as of today on actual basis)

276890 – additional actual salary (per 1 doctor and 2 SMW)

(+) For reaching lowest acceptable level of indicators

(-) In case of not reaching or partially reaching lowest acceptable level of indicators, financial means are redirected to divisions with better results (of lowest acceptable level)

Additional salary fund – 276890 KZT 56%Base salary fund – 215000 KZT 44%

Expenses structure (on the example of pilot organization – municipal polyclinic №8, Astana)

Действующий ПН 624

34,20%

34,30%

0,00%

8,40%

1,10%

2,30%

19,70%

0,0%

0,0%

Заработная платаКДУЗаработная платаПМСПдополнительно

Прочие товары

КоммунальныеуслугиПрочие услуги

Админ.хоз.и др.зат.

лаборатория

резерв

КПН 900

21,2%

27,4%

12,7%

5,2%

2,1%

3,1%

14,6%

3,3%

10,4%Заработная платаКДУЗаработная платаПМСПдополнительно

Прочие товары

КоммунальныеуслугиПрочие услуги

Админ.хоз и др затр.

Лаборатория

Резерв

Действующий ПН 624

51%49%

ПМСП

КДП

КПН 900

45,7%

12,6%

41,7%

ПМСП

КДП

Высвободившаяся сумма

Relation between PHC/CDPexpenses on the example of pilot MO MP №8 of Astana

Additional 95 tenge per one assigned person per month

Differentiation of PHC and CDP services, included to CCR (896 KZT)

PHC – 55 services(596 KZT)

Doctor admissions

General clinic examinations

Biochemical examinations

ECG

Bacteriologic examinations

Immunoprophylaxis

Procedures and operations

CDP – all the other services including high-cost services (300 KZT)

Specialized doctors admissions

Extended biochemical examinations

Radiologic examinations

Ultrasound

Function studies

Procedures and operations

Primary surgical treatment of wounds, cast application/removal

High-cost services (are limited by the local executive bodies) for certain population classes

PCR, angiography, PET, CT, medicogenetic examinations and others in accordance with the GVFMC

PHC volume within the GVFMCService name For healthy persons For patients with

acute forms of chronic diseases

For children under 18 For pregnant women

Prevention Carrying out activities on health protection and promotion, informing population on healthy lifestyle, healthy nutrition, planning family

Teaching sanitary-hygienic skills of teeth and mucous tunic of mouth care

Preventive medical surveys of targeted population groups in accordance with the order set by the authorized body

Doing preventive injections against infections and infestations, according to the National Calendar of Immunization

Children, including infants nursing

Nursing of the pregnant

Sanitary and anti-epidemic (preventive) activities in sites of contagious diseases

Teaching patients and their family members to self-control, self, and mutual care

Trainings in prophylactic rooms, health promotion schools.

Telephone consultation of people, taking part in ailments management program (AMP)

Sociomedical and psychological services on prescription.

Primary prevention Dispensary admission and case follow-up. Primary and secondary prevention of illnesses for dispensary cases.

Service name For healthy persons For patients with acute forms of chronic diseases

For children under 18 For pregnant women

Diagnostics Admission and consultation

Admission and service at home

Laboratory and diagnostic examinations with PHC specialist referral at hand

General blood and urine test

Vaginal smear microscopy

Vaginal smear microscopy and vagina sanitation

Sputum analysis for TB detection (smear microscopy)

HIV-infection and Wassermann reaction blood sampling

Microreaction, statoscopy

Material sampling for microbiologic examinations

Biochemical examinations: blood clotting time, bleeding time, bile pigments in urine, cholesterol, tryglycerides, blood sugar (express-methods with test system usage )

Electrocardiogram

Fluorography Fluorography from 15 years

Treatment First aid when necessary

Medication treatment prescription: intravenous, intramuscular, hypodermic injection on prescription; immobilization (application of gauze bandage casts, splints) on prescription

Paid medical services are rendered when PHC is done on patient’s initiative, as well as without PHC specialists’ referrals, basing on the agreement, concluded between the patient and the healthcare subject

PHC volume within the GVFMC

Expected results

Expanding PHC availability by private PHC organizations network expansion, as well as on the base of PPP

Increasing the number of finished cases of visits for medical care at PHC level (not lesser than 70%)

Provision of PHC development priority Transfer of focus from hospital care onto outpatient

services

Thank you for your attention!