1. Forsberg Knezevic EHMA 2008 Stockholm County Council Reimbursements in psychiatry in Sweden – models and experiences Birger Carl Forsberg. MD MPH BSc Milan Knezevic, MBA Stockholm County Council Administration Dept of Public Health Sciences Karolinska Institutet Stockholm Sweden www.sll.se

2. Forsberg Knezevic EHMA 2008 Stockholm County Council Reimbursements in psychiatry in Sweden - models and experiences Stockholms County Council Region Västra Götaland Region Skåne/Scania

3. Forsberg Knezevic EHMA 2008 Stockholm County Council Objective  The overall: –to contribute to the development of psychiatric health services for the overall attainment of good health and client satisfaction  The specific: –to study and understand key characteristics of the purchaser/provider (PP) models in psychiatric health services and –to explore the development of reimbursement models in psychiatric care

4. Forsberg Knezevic EHMA 2008 Stockholm County Council Methods  Interviews with health care managers  Review of policy and implementation documents

5. Forsberg Knezevic EHMA 2008 Stockholm County Council Background  Purchaser-provider models introduced in the early 90es in Sweden  Introduction in phases depending on experience gained and political majority shifts in county councils and at national level  However, gradually purchaser-provider models have been established, particularly in larger county councils

6. Forsberg Knezevic EHMA 2008 Stockholm County Council Background  Cost pressures on health services increase the need for cost control  Political developments favoured new systems Background

7. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Historical developments  Purchaser-provider models introduced in psychiatry in the mid-nineties  However, traditional historical budget based reimbursement models were used throughout most of the 90es  Performance based reimbursement models were introduced in small scale around 2000 in Stockholm  The first private providers were contracted in 2002 in Region Skåne

8. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Reasons for introduction of purchaser-provider models in psychiatry  Poor access to services (waiting times, non-availability of staff and treatments)  Poor coordination within services and between psychiatry and other relevant services  Poor flexibility

9. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Aims  All three regions have developed the same aims: –To increase productivity –To decrease in-patient care –To improve availability of personnel, in particular psychiatrists –To improve quality –To create a pluralistic supply of services

10. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  All models contain: –Fixed reimbursement –Performance-based reimbursement –Quality based/target based reimbursement for delivered patient care  In addition, several contracts included specific tasks that were reimbursed on a lump-sum basis (like special services, training etc.)

11. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  Region Västra Götaland –Fixed/performance-based  Started 50/50, target now –90/10 for in-patient and –70/30 for out-patient  Actual mix in 2007 52% fixed, performance-based 48% –Reimbursement based on discharges (IPD) and visits (OPD) –Classification systems for case-mix tested for a more diversified and truly need-based reimbursement system –Targets for volumes set – penalty/bonus related –Quality indicators (15) developed - to be implemented 2008 – basis for 2-3% of total reimbursement

12. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  Region Skåne –Out-patient service in two wards through purchasing of private provider:  100% performance based reimbursement  Reimbursement based on visits and separated into three categories  Geographic area responsibility  Financial ceiling set – above that only patient fee  Quality indicators (7) developed – not bound to reimbursement but important for evaluation  Clear terms of reference based on a common value ground and clear targets and expectations

13. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  Region Skåne –From 2006 a new reimbursement model for publicly produced health services  60% fixed and 40% performance based from 100% fixed budget  Performance based reimbursement for inpatient care based on days of care  Performance based reimbursement for outpatient care based on visits

14. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  Stockholm County Council 2006-2007

15. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  Stockholm County Council –Performance based reimbursement  inpatient care (5%) –Day 1 SEK 400 –Day 2-10 SEK 240 –> 11 days SEK 200  outpatient care (25%) –Visit to clinic SEK 350 –Home visit SEK 700 –Group visit SEK 175 –For each patient (individual) SEK 700

16. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Models  Stockholm County Council 2008 –Fixed/performance based 50/50% in both inpatient and outpatient care –This will be achieved through doubling payment for visits and increasing reimbursement for inpatient days ten-fold –A ceiling on volumes will be put on reimbursement. Above the ceiling producers will only get 10% of rates set.

17. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Experience  Increased production  Less inpatient care, more outpatient  Increased accessibility  Improved coordination among care providers and other actors in Skåne  Significant tensions between purchasers and providers  Significant time spent on negotiations around quality indicators (that represent a small part of reimbursement)

18. Forsberg Knezevic EHMA 2008 Stockholm County Council Results - Experience  Providers feel purchasers are over-simplifying description of services, emphasizing quantity rather than quality  In Skåne, both providers and purchasers are overall pleased with the cooperation  Purchasers felt that presence of private providers had resulted in increased attention on key issues like productivity in public services

19. Forsberg Knezevic EHMA 2008 Stockholm County Council Discussion  All three regions have independent of each other set up strikingly similar targets concerning psychiatric health services, much as a result of facing the same problems.  Emphasis is put on increasing productivity and accessibility and the ambition is to work towards increased quality of care and thereby improved medical outcomes.  Purchasers aim to increase outpatient care and decrease inpatient care.  The regions employ the same base reimbursement model, but with different structures and levels of services, products and prices.  The reimbursement models for outpatient care have to a higher extent performance based reimbursement that inpatient care.

20. Forsberg Knezevic EHMA 2008 Stockholm County Council Discussion- Preconditions  Clarity in contracted task and targets are essential  Well defined and precise terms of reference is a vital precondition for a well functioning reimbursement model  The contracted task should be based on obligatory tasks and defined target levels  Few but well thought-out quality indicators for evaluation

21. Forsberg Knezevic EHMA 2008 Stockholm County Council Discussion- Problems  Lack of well functioning and generally accepted classification systems.  Preventive and health promoting activities are not rewarded.  Reimbursement models not adapted to individual needs of care.

22. Forsberg Knezevic EHMA 2008 Stockholm County Council Conclusion  Performance based reimbursement models in psychiatric care work well given when overall aims are set to increase productivity and structural conditions are similar to those in the regions studied.  Terms of reference and clear definitions of contracted tasks are essential even if they are not specifically linked to payments.

23. Forsberg Knezevic EHMA 2008 Stockholm County Council Conclusion  The demand for further development and knowledge concerning the usage and effects of reimbursement models in psychiatric health services is significant.  The knowledge could be used to improve the models for further contribution to reaching the overall aims of services – improved access, client satisfaction and good health.