1. PERFORMANCE BASED SUPPLEMENTARY PAYMENT SYSTEM IN PUBLIC HOSPITALS: EVIDENCE FROM TURKEY Prof. Dr. Sabahattin AYDIN Ministry Of Health, TURKEY 17. Nov. 2008 Washington DC

2. Shortfalls in supply of health personnel Overcrowding in public hospitals Long waiting times Low provider satisfaction Low patient satisfaction Lack of capacity Long patient queues Low salaries Doctors prefering private sector. Problems requiring new reforms

3. Hospital Reforms in Turkey The hospital reforms carried out to date: –Granting hospital managers more autonomy and flexibility over the management of revolving funds, as well as procurement and investment decisions –Implementation of hospital quality and efficiency audits. –Outsourcing of hospital clinical services (diagnostics) to the private sector (public-private partnerships), –Upgraded health information systems, –Implementation of a performance based supplementary payment system

4. Performance Based Supplementary Payment System

5. Objective  The main objective of the PBSP system was to encourage job motivation and productivity among public sector health personnel.

6. Development and implementation of the model First introduced in 2004. Initially pilot has been realized for ten hospitals & Subsequently expanded to all MoH Health Facilities. Developed by strictly monitoring the changes and evaluating the feed backs. Currently all 850 MoH hospitals have in place within the PBSP system.

7. 2003 2004 2005 2006 2008 PILOT STUDY Development and implementation of the model INDIVIDUAL MANAGERIAL INSTITUTIONAL CLINIC INDICATOR SPECIFICATION

8. What is the PBSP system? An additional payment in addition to regular salaries. Base salary from line item budget. Performance-based payment from hospital earnings Bonus payments linked to performance of health personnel. Standardized and transparent process.

9. Payment to health personnel Each personnel earns a fixed salary + A bonus related to their own performance and the performance of the hospital Line-item budget Hospital Revenues Salary + PBSP Fixed Individual performance Institutional performance

10. Individual performance measurement Each service is rated with a point Each clinician collects points from his/her tasks (load of service)

11. All procedures made by the mentioned units are billed and priced according to tariff (SUT)

12. There are some awarding and punishment elements which result in increasing or decreasing the net performance scores of the personnel Hospital managers have, but limited filexibility in rewarding and punishing + / - bonuses

13. How does PBSP system work ?

14. How does it work? Factors which determine how much health personnel will receive as performance-based payments: –The total amount capped at 40% of revenues. –This total (capped) amount is subsequently adjusted based on institutional performance of the hospital (0-1). –An individual level performance score is calculated for each staff member. –Total points score for a physician is adjusted by a job title coefficient

15. Distribution of Hospital Revenues Hospital Revenues 15 % Treasury Share 0 – 40 % PBSP Budget 45 – 85 % Regular Hospital Expenditures Management Board the total amount that health facilities can allocate to performance-based payments to health personnel is capped at 40% of revenues

16. 40 % capped amount 0.8 institutional performance adjustment* > 40% of hospital revenue 0 - 1 x = 32 % devoted to staff bonuses Effect of institutional performance on the amount to be transferred to the staff Healthcare institution’s revenues

17. Individual performance measurement Each service was rated with a score Each clinician collects scores from his/her tasks (load of service)

18. Example for medical procedures and grading for clinicans

19. Example for medical procedures billed but not scored

20. Individual scores and Hospital average 1000 21 300 10 30 1000 21 300 10 30 10 21 300 10 30 21 300 13.0007.00015.0005.000 17.000 ++++ Dr 1Dr 2Dr 3Dr 4Dr 5 57.000 /5 11.400 Σx 1...x n /n

21. Indirect performance score estimation for those who do not have scores of medical procedures x BIOCHEM. SPEC. x AUX. x CIV. SER. x NURSE x ANES.TEC x MANAGER =2.5x =.25x =.4x =.5x =1x OTHER x HEAD PHYSICIAN =4.5x

22. Adjustments The total points score for a physician is adjusted by, –a job title coefficient: to measure workload aside from providing clinical care (i.e. administrative duties, teaching etc.) –the number of days the person has worked in that month. –depending on whether the person is doing private practice or not (0.4/1.0).

23. Institutional Performance Component 40 % capped amount 0.8 institutional performance adjustment* > 40% of hospital revenue 0 - 1 x = 32 % devoted to staff bonuses

24. categories of indicators for institutional performance Institutional Performance 0 - 1 Access to examination Infrastructure and process Patient satisfaction Institutional productivity Institutional targets N 1 + N 2 + N 3 + N 4 ∑: N 1 -N 4 / 4

25. Check Points Hospital Revenues PBSP Budget Social Security Institution MEDULA Examination Comisson Invoicing / Recording has 2 check points Hospital Revenue Blling / Recording Electronic & manual controll Service Delivery

26. Types of upper cap restrictions in the system: –Cap for distributing hospital revenues (40 %) –Control of fluid cash (Managerial Board) –Multiplier of basic salary for profession Upper Cap Restrictions

27. Caps for bonuses as multiplier of basic salary Coefficient Full time clinic chiefs and associate chiefs 8 Full time specialist physicians, specialist dentists 7 Ful time practitioners and dentists 5 Clinic chief, associate chiefs, specialist physicians, specialist dentists doing private practice (part time) 3,5 Practitioners and dentists doing private practice (part time) and hospital managers and pharmacists 2,5 Head nurses and the staff working in specific services such as ICU (Intensive Care Unit), delivery, newborn, nursing infant, burn, dialysis, surgery, bone marrow transplantation unit, ER, mental health and the psychiatry services in the hospitals 2 The other staff 1,5 Individual bonuses for staff are capped at a certain multiplier of basic salary.

28. Differences in other settings PHC facilities Some preventive healthcare service indicators are used for scoring. Adjustments are made according to the characteristics of the region where the personnel is working. Training Hospitals Additional scores are given for; –Training activities and –Scientific publications

29. What has changed after PBSPS ?

30. Ratio of full time and part time working doctors

31. Number of patient visits by years

32. There has been a large increase in physician productivity in public hospitals Number of people examined in public hospitals in 2006 has increased by 75 % when compared to 2002. In the same period, the number of patients per physician has decreased by 25 %. Number of examination in public hospitals Note: the figure for 2002 covers SSK hospitals.

33. Number of examination rooms in public hospitals Number of examination rooms in public hospitals has increased by 145 %. Idle capacity has started to be used with the principle of “an examination room for each physician”. Referral rate from public hospital to a senior institution(%)

34. Highly organized and improved digital recording system for invoice producing is constituted. Almost all of the public hospitals have HIS now. Informal procedures and alike are decreased.Thus contribution is made to the reliable data collection to run the health financing more accurate. As the working time in hospitals became longer, surgery, lab, imaging services are given for a longer period of time. Waiting periods for imaging and pathology labs became shorter.  Income-expenditure balances of the healthcare institutions are started to be followed sensitively as if they work on totally professional health sector enterprises.  As all hospital personnel gained the awareness that they become like the partners of the institution, they started to question actions, to develop, to adapt the capacity and quality building steps, to support and to get tasks. Other improvements

35. People “satisfied” with health center services (%) People “satisfied” with public hospital services (%) Ratio of the out-of-pocket health expenditure (%) People generally satisfied with healthcare services (%) Source: TUİK TUİK Life Satisfaction Survey