The Development of Hospice programme in Hungary
Integration of hospice-palliative care into the Hungarian national health care
by the cooperation of Ministry of Health, National Health Insurance Fund Administration and hospice service providers
Csaba Dózsa health policy expert
assistant professor of Institute of Health Care Studies, University of Miskolc
Workshop on hospiceBrassó-Poljana 26 of Octobre 2011
Outline of the presentation
• Overview of the Hungarian Health Insurance System
• History and development – from health policy and management perspectives
• Capacity and performance data of hospice in Hungary
• Future development issues
National Health Insurance Fund of Hungary (NHIF)
Current challenges in health care systems
• Ageing growing number of patients with chronic diseases
• Consumer needs, demands service orientation• Information society informed patients• Technological development new, innovative
drugs, devices, IT…
• Cost containment move to cutback mechanism
Patients, entitled and insured
persons10 millions in Hun
The third party - payerNHIF Administration
[OEP, 1993-]
Providers 33 thousands of doctors
6750 GPs 446 outpatient facilities
175 hospitals (71 th. beds) 2620 pharmacies
Links within the health insurance system, 2011
2% employer,6% employeehealth insurance contribution+ tax revenues
Payment system:capitation, DRGs, German scores, visit fee, daily fee
provision
NHIFA Financing
Monitoring Controlling
MOH Professional
regulation
Professional bodies Regulation
Protocols
Government Financial
techniques
Parliament Budget
Environment of HIF financing
Benefits and services of the Hungarian Health Insurance Fund
Benefits in kind:
• Curative-preventive provisions:– Primary care– Dental care– Outpatient care– Acute and long-term hospital care– Emergency services– Home health care– Kidney dialysis
• Reimbursement of medicines, medical devices, spa services, refunding of travel expenses;
Benefits in cash
• Pension-type social provisions
• Benefits in cash
• Accident-related provisions
Planned structural change of the Hun health care system
County hospital
Middle size town hospital
Small size town hospital
Town hospital
Outer site
Outer site
Nursing, chronic care
Basic professions, emergency care unit
Outpatient care, one-day surgery,
screeningRegional central hospital
Progressive provisions, Emergency centre,
central operating block, intensive unit
Restructuring and clearing of profiles at territorial level
Primary care, outpatient care,
screening
Rehabilitation hospital
Polic
linic
s, ou
tpat
ient
ca
re
Acute hospital care
Social sphere
Home nursing
One-day surgery
Serial treatments
Day care
HazaengedésD
isch
arge
Discharge
Emergency care units
DischargeNursing
Chronic care
Rehabilitation
Hospitalized cases,
programmed care
Improve the cost Effectiveness of acute hospital care
Opportunities for further reduction of no. of active hospital beds - key fields
Emergency care; 1350 beds
One-day surgery; 3300 beds
Serial treatments; 1200 beds
Development of rehabilitatation in
the field of traumatology,
ortopedy, cardiology, stroke,
gastroent.; 4500 beds
Elderly care - nursing, home care;
6000 (3300 + 2700)beds
50 th. cases, 8 days hospitalization, 78 % bed occupancy rate, 5 patients/bed
250 th. cases -5 nursing days 150 th. Cases, home care instead of 6 days
hospitalization, other 150 th. cases -5 day hospitalization
150 th. cases, 2,5 days hospitalization, 60 ECU, 7 patient/day, without hospitalization
300 th. cases, 3 days hospitalization, 78 % bed occupancy rate
Strategic purchaser role of the NHIF Administration (OEP)
The main roles of the Ministry (Secretariate) of Health
• Setting the strategy, the directions of the developments
• Operating the accreditation system• Setting the minimal requirements for
health care providers• Publishing professional rules, protocols,
guidelines• Supervising the national institutes• Coordinating the Professional Colleges
Info: www.eum.hu
The alternative roles of the NHIFA
• Administration role– Controlling the „bills” and paying
• Financing role:– A little influence on the origin of bills
• Purchasing role– To decide what, from who and how much to
„buy”– Real autonomy
• Insurance role– risk management– paying fees– loss adjustment
Special fields of purchaser role
Purchasing System
From what? ffect on revenues, analysis and monitoring
What? Basic package, coverage policy
From who? Capacity regukation, progressivity, quality development and monitoring
How? Development of financial techniques, intergation of sub-budgets, allocative effectiveness, reimbursement policy
For how much? Systematic and continuous cost data collection, cost based and flexible specification of tariffs
Financial techniques of the main types of provision in Hungary
• Primary care (GP)
• Outpatient care
• Active in-patient care
• Chronic in-patient care
• Capitation fee (1992)
• German score system• Full fee for service (1998)• Fixed point value: 1,46 Ft/point
• HBCs (1993)• Nation-wide the same base-rate • 146.000 Ft/weight
• Per diem rate• 5600Ft/day
Risk sharing model: tendencies in Europe
Risk at the buyer
Fee
for
serv
ice
Ger
man
scor
e(o
utpa
tient
car
e)
Per
diem
rat
e(lo
ng te
rm c
are)
DR
Gs (
Acu
te c
are)
Ris
k ad
just
ed (g
loba
l) ca
pita
tion
(MC
Os)
Year
ly b
udge
t
Risk at the provider side
Cap
itatio
n fo
r G
Ps
DR
Gs w
ith v
olum
e co
ntro
l
There are two tendencies in Europe: - to introduce DRGs in many countries and- to integrate services and to finance by a risk-adjusted capitation formula
History & Development of hospice care in Hungary
Brief history of hospice care in Hungary
• 1993 - Association• 1996 – Introduction of home health care into the
HUN health insurance system• 1993 – 2003 slow development of hospice, 4-5
institutions with appr. 50 beds
• 2003 - Professional harmonizing process, conception of the application for the reimbursement from the National Health Insurance Fund
Main priorities of the development
Integrated approach Holistic approach: community care = family and social care +
health care + volunteers Psychological, social and spiritual support Multidisciplinarity – development of multidisciplinary teams Need-based, direct provision, care-management, equal access Indicator system, monitoring - later: accreditation Specific finance to get an effective incentive to develope hospice Communication between the levels and actors Networking Education, training
Aim: development of the complex, integrated system of hospice-palliative care, reaching the nationwide provision, improving the equity in the accessibility for the provision
The main elements of the complex development of hospice care
Development of Hospice
Team works and home care
Human resource Development
– team building
Professional regulation, protocols
quality monitoring
Hospital care development
Financing at different level
Main fields of the development of hospice-palliative care
• Volume-capacity– Increase of volume and capacity in order to reach a nationwide extension
– Enlargement of education– Improvement of device availability
• Quality & HR development– Increasing of the level of education and professional complexity– Development of team work and integrity – Intensive connection with the professional programmes – Enlargement of competencies
• Finance– Enlargement of the financed capacity– Elaboration of new types of finance (medical visits, pharmaceutical therapies)
Introduction and development of health insurance reimbursement of hospice-palliative care
Professional harmonizing, conception of the application for the reimbursement from the National Health Insurance Fund, preparation and authorization of the announcement / from September 2003/
Invitation to tender for the complex development of the home and institutional hospice-palliative care Inviting applications: 7th May 2004; Evaluation Contracting: from 1st
September 2004 New capacity tender: 31st October 2004 Invitation to tender for the enlargement of the home hospice-palliative care Inviting applications: 30th June 2005, Evaluation Contracting: from
1st November 2005 Further capacity development:
In home hospice – titled to availability, equityIn inpatient care – under restructuring of hospital system – development of
chronic care by switching of acute care bedsby EU development tenders – outpatient care units, rehabilitation
Financial background since 2004• In Hungary the home care/home special nursing is financed
according to the number of visits, one visit costs for the NHIFA 3200 HUF (~12 EUR). The base of the reimbursement of the hospice-palliative home care is the so called hospice-day which is the 120% of the basic home care visit costs (~14 EUR/day).
• In case of hospital care the hospice-palliative care is a kind of chronic provision. In Hungary the chronic provisions are financed according to daily fees (5600 HUF~20 EUR/day), and the special chronic provisions (e.g. different types of rehabilitation) have additional multipliers. It means for the providers accepted on the tender a 1,7 multiplier (35 EUR/day).
• Mobil team – there is not special reimbursement
After the first tender, 2004
Yellow: home hospice careGreen: Institutional and home hospice care
Extension of home care hospice in 2007
Hospice care in Budapest
and in counties of Hungary
Home care: 63 providers Other: 4 instutitions (nursing homes)Hospital care: 9+3 units Mobil teams: 3 units
Total: 81 service providers
…and nowadays (2009* supplemented)
Capacities and performace data
Capacities and performaces: home hospice care - 2004-2009*
2004. 2005. 2006. 2007. 2008. 2009. 2011.No. of service providers 14 22 26 25 29 59 63 on 84 sites
2004. 2005. 2006. 2007. 2008. 2009.Amount of financing (million HUF) 12,8 129,2 192,4 186,2 213,7 387,7
-per patient (thousands HUF) 67 113 122 118 124 125-per nursing day (HUF) 3565 3692 3800 3800 4023 4037
190
1147
1577 15721727
3098
3590
34994
5131949008 53117
96045
0
20000
40000
60000
80000
100000
120000
0
500
1000
1500
2000
2500
3000
3500
2004. 2005. 2006. 2007. 2008. 2009.
No.
of n
ursi
ng (h
ospi
ce) d
ays
No.
of p
atien
ts
No. of patients treated
Number of nursing days
Performance in home hospice careX. 2004. – II. 2011.
0
2000
4000
6000
8000
10000
12000
14000
0500
100015002000250030003500400045005000550060006500700075008000
Oct
.Ja
n.Ap
r.Ju
lyO
ct.
Jan.
Apr.
July
Oct
.Ja
n.Ap
r.Ju
lyO
ct.
Jan.
Apr.
July
Oct
.Ja
n.Ap
r.Ju
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ct.
Jan.
Apr.
July
Oct
.Ja
n.
2004. 2005. 2006. 2007. 2008. 2009. 2010. 2011.
Hosp
ice
days
perf
orm
ed
Basic
fee
(HU
F)
Basic fee
No. of hospice days
Capacities and performaces:in inpatient hospice care units - 2004-2011*
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
80,0%
0
500
1 000
1 500
2 000
2 500
3 000
3 500
/2003/ 2004 2005 2006 2007 2008 2009 2010 2011*
Bed
occu
pany
rate
(%)
No.
of c
ases
No. of cases (per month) No. of cases (per year) Bed occupany rate (%)
/2003/ 2004 2005 2006 2007 2008 2009 2010 2011*0
2
4
6
8
10
12
0
50
100
150
200
250
7 units with 1,7 multiplier
+2 units (under other professional code)
Performaces in inpatient hospice care units - 2004-2010
/2003/ 2004 2005 2006 2007 2008 2009 2010 2011*Amount of financing (thousands HUF)
34 703 80 665 175 869 246 278 253 928 344 762 342 831 351 405 29 000
Amount of mothly financing per bed (thousands HUF) 72,3 68,6 109,5 143,5 100,7 165,9 166,1 192,7 190,8
/2003/ 2004 2005 2006 2007 2008 2009 20100.00
5.00
10.00
15.00
20.00
25.00
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
No. of nursing days DMI No. of mothly cases per 1 bed
DMI,
No. o
f mot
hly
case
s pe
r 1 b
ed
No. o
f nur
sing
day
s
Defficiencies of the current system
1. Lack of accredeted professional curriculum on hospice-palliative care or any formal postgraduate programme for physicians
2. There is no department of hospice-palliative care in any of the 4 Medical Universities –
to be professional leader of the programme3. Weak communication between different service
providers, still fragmented health care system: gap between primary – secondary and tertiary care
Lack of continuoum of care in the majority of the country
Future development issues
ActualitiesDevelopment of rehabilitation services (EU tender) Regional, integrated development of rehabilitation
services development of infrastructure, equipments In 4 regions – aimed to the development of long term care In-patient hospice-palliative care units – for the palliative
care of terminally ill patients Max.10% from the whole subsidization (from 250-800 million
HUF / sites) confirmed by professional concepts, protocols; horizontal
and vertical cooperations; education Deadline of the Rehabilitation tender: 2011.11.30
Strategic plan of several Hungarian hospitals include the establishment of new hospice unit or
increase the capacities of current ones
Indicators investigated during the two-year monitoring period
• Admission form– Stadium of decubitus– Social needs (form and extent of the needed social
care – family support, nutrition, day care, others; and the care giver person – family, social worker, civil helper)
• Monthly report of performance– Number, extension and stadium of decubitus– Average VAS– Date of the last visit (in home care), number of
performed visits, time spent by the patient
Main directions of the intermediate term development programme
According to the WHO recommendations1. To disseminate hospice-palliative care in
residential homes for elderly2. To improve day care for patients3. To develop palliative mobil teams in the
framework of hospitals, university clinics4. To extend hospice-paliative care to other
indications (further group of patients: COPD, hearth fealiure)
5. To develop management of care a. between different service levels and b. among service providers
Conclusions
1. We’ve managed to reach a breakthrough by the 2003-2004 programme (tenders and the increase of public funding)
2. Every programme element is to be developed and held on simultaneously for the success of the programme
3. Continuous quality-monitoring and feedback in regulation, education and reimbursement are necessary
4. Continuous development is also essential so much as the governmental intention for the support of plus resources
Thank you for your attention !
Contact us:
What to do? – experiments v. experiences1. Because of the comprehensive financing dataset the indicator
lists determined in the application have lost their significance (the dataset must be sent by the providers consists these indicators or they can be calculated from the data). Lesson learned: Indicators must be determined after considering the financing dataset.
2. The over-dimensioning of nursing activities comes up at the expense of the mentality of hospice. The „nursing at all hazards” is still typical, instead of complementary activities (social organization, determination and supervision of medication).
3. The low level of financing was indicated also by the lack of additional sources. The costs of provision are not completely covered by the health insurance reimbursement.
4. Inequality in territorial availability - 5. The provision is not well known by the GPs - 6. The inequality in capacities (because of the low starting
number of applicants) needs to be corrected timely -
