1. Does outcome of Public Procurement process based on Lowest Price criterion has any influence on clinical outcomes/costs of care ? Example: Croatia, hip/knee replacements, 2011. – 2015. Analyis of DRG and ACHI volume dynamics as indicators of clinical outcomes based on publicly available data published by National Health Insurance Fund. (Croatia runs AR DRG ver. 5.2) Ratko Štimac Beograd, 2016

2. Primary arthoplasty = patient gets implant for the first time i.e. damaged part of bone/joint is replaced by metallic implant, considered fairly routine procedure with low riske for patient (complications and death rate), success depends on patient condition (age, helath status), surgeon (skill, expirience) and implant (type, design, survivorship data) Revisional arthroplasty = implant primarily implanted failed in function (get loosened, infected, displaced) so it must be taken out and replaced by new implant, compared to primary arthroplasty it bears higher risk for patient and is asciated with much bigger costs of treatment (implant, OR time, longer stay in hospital etc.).

3. Total, all providers paid by NHIF, Croatia 250% I03A – revisional hip arthroplasty with CC (complications/comorbidities)

4. I03B – revisional hip artroplasty w/out CC or hip arthroplasty with CC 140% Total, all providers paid by NHIF, Croatia

5. I03C – hip arthroplasty w/out CC -1% Total, all providers paid by NHIF, Croatia

6. summary - 2015. vs. 2014. DRG volume dynamics -primary hip arthroplasties w/out CC (I03C) grew at -1% -primary hip arthroplasties with CC (I03B) grew at 140% -revisional artroplasties w/out CC (I03B) grew at 140% -revisional arthroplasties with CC (I03A) grew at 250% Results of National tender for hip/knee implants prepared on LP (lowest price) criteria w/out fulfillement of implant survivorship requirements ended in in Q4 2013.

7. ACHI codes volume as indicator of clinical outcomes – 49324-00, revison of total hip arthroplasty 33% coded in DRG codes I03A or I03B Total, all providers paid by NHIF, Croatia

8. 17 % Coded in DRG codes I03B or I03C ACHI codes volume as indicator of clinical outcomes – 49318-00, unilateral total hip arthroplasty Total, all providers paid by NHIF, Croatia

9. 97% Coded in DRG code I04Z ACHI codes volume as indicator of clinical outcomes – 49527-00, revision of knee total arthroplasty Total, all providers paid by NHIF, Croatia

10. 33% DRG coded in code I04Z ACHI codes volume as indicator of clinical outcomes – 49518-00, unilateral total knee artroplasty Total, all providers paid by NHIF, Croatia

11. -49324-00, revision of total hip arthroplasty grew at 33% -49318-00, unilateral total hip arthroplasty grew at 17% = revision arthroplasties grew 2 times faster than primary arthroplasties -49527-00, revision of knee total arthroplasty grew at 97% -49518-00, unilateral total knee artroplasty grew at 33% = revision arthroplasties grew 3 times faster than primary arthroplasties Results of National tender for hip/knee implants prepared on LP (lowest price) criteria w/out fulfillement of implant survivorship requirements ended in in Q4 2013. summary - 2015. vs. 2014. ACHI volume dynamics

12. Any difference between providers in Croatia ? I03A – hip revison with CC A – full compliance B – full compliance C – non compliance 840% Compliance = adherence to results on national tender = usage of implant selected without cosideration of survivorship but with with lowest price A B C

13. How implant selection (based on lowest price only) impacts clinical outcomes ? revision surgery rate morbidity rate - complications (bleeding, infection etc. ) rate mortality rate - death rate length of stay in hospital surgical site infection rate hospital acquired infection rate rate of administration of blood/blood derivates rate of thrombotic/embolic incidents – DVT, PE days out of work/inability for usual lifestyle And what are costs related to impacted clinical outcomes ? for payor for provider for patient for tax payer/citizen

14. Costs assesment for payor – hip revision Payment from NHIF for revisional DRG’s is higher than for primary DRG’s, if volume of revisional DRG’s increases = costs increases, especially if increase is 35% ! (avg. for 2011-14 is 98, avg. for 2011. – 2015. is 133 = 35 % increase) Due to steep increase in revisional DRG’s in 2015. (compared to 2014.) Croatian NHIF paid 517.968,00 € more = amount sufficient for purchase of 500 hip implants with EBM documented survivorship of 90% in 10 years post implantation ! I03A2011. - 2014.2011. - 2015.diff. 9813335% 2011. 2012.2013.2014.2015. I03A 109 9673111277

15. I03A2011. - 2014.2011. - 2015.diff. 9813335% 2011.2012.2013.2014.2015. I03A 109 9673111277 Average Length of stay in Hospital (ALOS) for revisional hip DRG is 5 days more than for primary hip arthroplasty DRG If increase of I03A from 2014. to 2015. was identical to increase from 2013. na 2014. (52%) then volume would be 169 instead of 277, so average length of stay will be: 15 x (ALOS za I03A) x 169 = 2535 15 x (ALOS za I03A) x 277 = 4155 this represents (4155 - 2535) savings od ALOS of 1620 days = days that may become available for treatment of 162 (1620/ALOS for I03C) more patients requiring primary arthroplasty – more potentially treated patients = reduction of waiting list + opportunity for provider to increase their income from NHIF. 2.783,00 € (price for I03C) x 162 = 450.846,00 € Costs assesment for provider – hip revision

16. We should not afford ourselves a luxury to do any public procurement in health care without thorough consideration on how goods and services procured may impact clinical outcomes and overal costs of care. We should strive for VBM (value based procurement) process looking for BPQR (best price quality ratio) = public procurement in health care on MEAT (most economically advantegous tender) criterion in bid selection

17. Thank you Questions?