APPLYING PBR IN DRUG TREATMENT AND RECOVERY SERVICES - OPPORTUNITY OR THREAT? DR LINDA HARRIS CLINICAL DIRECTOR
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Applying PbR in drug treatment
and recovery services
opportunity or threat?
Dr Linda Harris
Clinical Director
Wakefield Integrated Substance Misuse ServicesWhat is your understanding of Payment by Results/outcomes? Thoughts from the floor ?
PbR – we don’t all talk the same language ? PbR in acute care PbR in mental health PbR in employment services PbR in drug misuse
PbR in acute care A system in which PCTs (commissioners of care) pay providers for the number and complexity of patients treated, using a price list – the national tariff – for all activity within the scope of PbR Tarrif relates to a Healthcare Resource Group (HRG) Covers admitted patient care, outpatients and A&E Introduced in 2003-04 Replaced block contracts based on historic costs Price x activity = income
Why was PbR introduced in the acute sector? • Increase efficiency e.g. reduce length of stay in hospital • Focus on quality by removing price competition • Create an open and transparent system • Support Patient Choice • Following international best practice
What makes up the costs for each
HRG?
Staff Consumables
e.g. hospital food
Drugs Reported Diagnostics
Costs
Cost of
building Medical
EquipmentResearch and evaluation
• PbR has been the subject of
rigorous research and evaluation
by academics, e.g. the Health
Economics Research Unit,
University of Aberdeen.
Findings show:
Evidence of reductions in unit
costs of care
No negative impact on carePbR in mental health
Mental health clusters
Classification system based
on need
Practitioner utility
Service user value and
CPPP
support
Criteria for a currency
- Resource homogeneity
Care Pathways and Packages Project - Ability to implement
Developing currencies for mental health payment by results - Data collectable
- Resilient to gamingDECISION TREE CPP
(RELATIONSHIP OF CARE CLUSTERS TO EACH OTHER)
P
Working-aged Adults and Older People with Mental Health Problems
C
A B
Non-Psychotic Psychosis Organic
a b a b c d a
Mild/ Very First Ongoing Psychotic Very Severe Cognitive
Severe Episode or crisis engagement impairment
Moderate/
and recurrent
Severe complex
1 2 3 4 5 6 7 8 10 11 12 13 14 15 16 17 18 19 20 21Currency representation Currencies and care transition points
Care Transition Points
Periodic Review
Unscheduled Review
Cluster Weighting Cluster 10
Cluster 8
Duration
Period end Period end
Period start Period end
Period Period start
startPbR – employment PL Pathways to Work a national back- to-work programme available to people on incapacity related benefits Outcome based contracts held with providers of Pathways to Work 30 per cent service charge Job outcome payments Sustained job outcome payments
Payment for Outcomes in Drug Treatment
Context of reform Political principle Universal access/market disciplines Inefficient large inflexible state bureaucracies Innovative responsive lean third and private sector providers Coalition agreement Real outcomes not process focused targets Big society/small state
Ambitious PbR Framework
Government: outcomes/tariff/who
Providers: what/how
Market: quality/efficiency/effectiveness/survival
Payment for outcomes only (loans)
Evidence neutral
Minimum regulation
Purchased, not commissioned
Multiple providers
Random allocation
Tariff linked to complexity
Third party assessment
Advocacy to facilitate client choiceIt’s a complex area
Healthcare Complex outcomes:
Regulated Drug use
Evidenced Health
Commissioned Public health
Patient centred Crime
Jobs
Parenting
Varying timeframes:
Public
Health/crime :
immediate
Full recovery : long
termChallenging the perceived wisdom Residential/community Criminal Justice System/health Belief/evidence Clinical/psychosocial
Overview of the thinking thus far
Funding objectives
Annual budgets
‘Simple’ and ‘outcome based’ PbR
Challenges in applying PbR to drug
treatment and recovery services Funding objectives
Control overall expenditure
Ensure ‘fair’ reimbursement – equal pay for
equal work
Incentivise good practiceBudget = Expected x Local price
number of per typical
clients client
Good expenditure control
Equal pay for equal work?
What if expected ≠ actual?
What is clients are atypical?
How agree local price?
No incentive for good practiceIncome = Actual number x National price
of clients of per client of
type j type j
How control expenditure?
Equal pay for equal work
Equal work – more accurate
definition of clients
Equal pay – national price
No incentive for good practice Outcome based PbR
Bonus (penalty) based on meeting
(missing) some standard
Client-specific payments – price settingNational = Fixed price x p [Outcome
price per per client based
client of of type j payment per
type j per client of
type j]
Price = A x p [B]A p [B] Simple Fixed n/a n/a PbR payment Pure zero 0
PbR works best for those with a
straightforward problem, requiring a single
intervention, from a single provider – acute
care
Applying PbR to drug treatment and recovery
services
How classify clients?
How set prices?
How determine outcomes?What are the strengths, weaknesses, opportunities and threats of operating a PbR system in drug treatment How would you pilot this?
Applying PbR to drug treatment and
recovery services
How classify patients with complex needs?
How divide payments across multiple
service providers?
How deal with small number of providers?
How deal with multiple outcomes and
multiple influences on outcome?And finally … What explains variation in cost? In mental health, patient characteristics explain little of cost variation Most is explained by providers doing different things for the same type of patients Why is there so little consensus across providers about what constitutes best practice?
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