Performance information and health system efficiency in France
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The February 2016 meeting focused on enhancing health system performance and efficiency in France, addressing high health expenditures and various inefficiencies within the centralized health insurance system. Key strategies discussed included implementing financial and non-financial incentives for stakeholders, utilizing extensive health data to inform policy decisions, and empowering patients with information on care quality to promote competition among providers. The meeting highlighted both the challenges and potential impacts of these tools on behavior and health system efficiency.
Performance information and health system efficiency in France
- 1. 1February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Performance information and health system efficiency in France CNAMTS (National Health Insurance Fund for salaried workers) Ayden Tajahmady – Grégoire de Lagasnerie Deputy director of the Division of Statistics and Strategic research
- 2. The two ways to implement performance budgeting 2 The French health care system: • Centralized health insurance system • Main issues: – High Health expenditure as a share of GDP, 2013 : 10,9% (6th OECD country) – Medical practice variation – Equity Change stakeholders’ behaviors to improve efficiency: 1. Financial incentives towards main health care system’s stakeholders (professionals, structures and patients) 2. Non Financial incentives thanks to huge data collection: increase stakeholders’ empowerments to implement medico-economic management February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
- 3. Main challenge : Making sense of the huge amount of data collected to improve efficiency 3 Source: http://networkingnerd.files.wordpress.com/ February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Political decision Health care professionals’ management tools Patients’ empowerment Indicators
- 4. 4February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Data and political decision
- 5. Data and political decision 5 One of the Medico-administrative database in France : • National Health Insurance Information System (SNIIRAM): exhaustive anonymous data about >60 millions individuals • Information available on ambulatory care (drugs, medical visits and procedures, biological tests, dental care, ...), inpatient care, payment for sick leave,... • Daily reimbursements follow-up Use of the data for policy decision-making • Improve healthcare pathways • Contribute to a better management of the health insurance • Contribute to a better management of health policies • Provide healthcare providers with relevant information relative to their activity, receipts and prescriptions February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
- 6. e.g. Describe the health inequalities due to socioeconomic status in 2013 (a geographic index of deprivation) 6February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Source : SNIIRAM/EGB-PMSI, 2013 2% 3% 4% 6% 8% 11% 14% 20% 26% 35% 42% 48%49% 3% 5% 7% 10% 13% 17% 21% 27% 32% 39% 45% 48% 45% 0% 10% 20% 30% 40% 50% Age groups Prevalence of polypathology 1 (10% les plus favorisés) 2 3 4 5 6 7 8 9 10 (10% les plus défavorisés) 10 % most well-off 10 % least well-off
- 7. Map the burden of disease and their costs in France 7February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Source : SNIIRAM/EGB-PMSI, 2013 Cardiovascular diseases, acute Cardiovascular disease, chronic Treatment of vascular risk factors (no CVD) Diabetes Cancers, active Cancers, surveillance Psychiatric diseases Psychiatric treaments Neurologic diseases Chronic respiratory disease Inflammatory or rare diseases or HIV Diseases of the liver or pancreas Maternity Isolated hospitalisation 0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000 8,000,000 9,000,000 0 2,000 4,000 6,000 8,000 10,000 12,000 Numberofpatients Average cost per patient (€)
- 8. Medicalized approach of expenditure to target specific policies on costly disease: Sick leave 8February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Source : SNIIRAM/EGB-PMSI, 2013 22% 3% 6% 6% 5% 5% 28% 25% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Soins courants/traitements antalgiques ou anti- inflammatoires Hospitalisations ponctuelles (avec ou sans pathologies, traitements ou maternité) Maternité (avec ou sans pathologies) Autres Cancers Diabète (avec ou sans pathologies) ou traitements du risque vasculaire (hors pathologies) Maladies cardioneurovasculaires Maladies psychiatriques ou psychotropes Basic care and treatments with pain killers Isolated hospitalisations Maternity (maternity leave excluded) Others Cancer Diabetes and other vascular risk treatments Cardiovascular diseases Psychiatric diseases or treatments Total 10,2 Billion out of 147 Billion € (7%)
- 9. 9February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Data and health care professionals management tools
- 10. Data and health care professionals’ management tools 10February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Financial tools: P4P Non-financial tools: benchmark and information Hospital Financial incentives for quality improvement (IFAQSS) • Pilot phase • Quality : assessing pain, screening for denutrition… • Reward : 0 to 0.5 % of previous year budget Web platform (http://hospidiag.atih.sante.fr/) • Activity, Quality, • Organization, Human resources • Finance Outpatient Financial incentive for public health targets (ROSP) • Generalized since 2011 • 29 indicators (organization, chronic disease follow-up, prevention, efficiency) • 1300 points / 7€ per point • In 2014, av. 5,900 € / GP • Total expenditure : 376 M€ Medicalized management of spending (maîtrise médicalisée) • Any prescirption is eligible (drugs, physiotherapist, sick leace…) • Information and benchmark is procided according to prescription profile • Prior authorization schemes are possible
- 11. Global surgical performance of my hospital ? 11February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Source : ANAP - ATIH © 2015-2016
- 12. Global financial performance of my hospital? 12February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Source : ANAP - ATIH © 2015-2016
- 13. Medicalized management of spending (maîtrise médicalisée) 13February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Interview with high prescribing (drugs, cash allowances…) physicians to give them some data about their activity in comparison with « same » physicians
- 14. 14February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Data and patients’ empowerment
- 15. Data and patients’ empowerment : increase competition between providers 15 Lack of information for patients is one of the main cause of inequality in the health care system Collection of data should be used to inform patients about the quality of care… • Reluctance from professionals to be ranked and compared according to subjective indicators Some tools exist but there is still a large scope for further improvements • www.annuairesante.ameli.fr/ : information about average costs of different medical procedures billed by the health professional • http://www.scopesante.fr/ : Help to choose an hospital through organizational and quality indicators (nosocomial illness, organization) February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
- 16. Increase competition between health care providers by circulating average costs in function of the type of care 16 E.g. Choose a dentist: a type of care associated with high out-of- pocket • Dentist A’s tariff for tooth crown on dental implant • Dentist B’s tariff for tooth crown on dental implant February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Source : www.annuairesante.ameli.fr/
- 17. 17 February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Conclusion: how does it contribute to increase the efficiency of the health care system?
- 18. Conclusion 18 Difficult to evaluate the impact of these tools… • For instance: difficulty to estimate the impact of P4P programs But they may have an impact on patients’ and professionals’ behaviors in mid or long term To go further: • Political decision – Health law 2015: Open data for database without risks of re- identification (increase access for researchers to evaluate of health policies …) • Health care professionals’ management tools and patients’ empowerment – E-Satis: online satisfaction survey after hospital discharges February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
- 19. 19 Thank you for your attention ! February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
- 20. 20February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Annex: The French health care system in a nutshell
- 21. 21 February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems The French health care system in a nutshell Source : Health at a glance 2015
- 22. Outpatient care : • Majority of general practitioners and specialists • Fee for services with private practice for physicians • Pay for performance • Freedom of establishment for physicians and weak gatekeeping Inpatient care : • Majority of DRG payment + Global budget for specific missions (teaching, research, emergency care) • All hospitals are financed by the public health insurance but managerial autonomy for hospital director • Majority of public beds (62% of public beds, 14% of private not for profit beds, 24% of private for profit beds) Supply side 22February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems
- 23. Health expenditure and financing 23February 2016 - CNAMTS - DELSA GOV meeting on sustainability of Health systems Expenditures : • Health expenditure per capita, 2013 : 4124 USD PPP (12th OECD country) • Health expenditure as a share of GDP, 2013 : 10,9% (6th OECD country) – High share of impatient care : 35% (3rd OECD country) Financing : • Centralized health insurance funds financed by taxes and social security contributions : 79% • Private complementary insurance financed by premiums : 14% • Out-of-pocket : 7%