Research project SO/10/040 (Research action SO)
This research has two aims:
1. Development of analyses and instruments that allow progressive fixed-price health packages to be introduced both for medicines and medical services (in particular, diagnoses...). Evaluation of needs, optimisation of incentives, highlighting of implementation risks and problems as well as proposals for correcting or minimising these.
This section will be supported by experiences from the Centre of Interdisciplinary Studies in Health Economics (CIES) based on:
- knowledge of foreign experiences in this sphere;
- studies already carried out involving the impact of the structure of disease types and their severity, the impact of social and geriatric factors on lengths of stay in hospital, studies of fixed-price health packages and evaluation of medicine prescriptions, and the development of feedback for hospitals from practice evaluations.
2. Development of a strategy for training doctors and health professionals.
Progressive fixed-price health packages are only possible if the doctors and health professionals who prescribe medicines and carry out actions "see the light". For the past decade or so, CIES has been compiling a database with 70 hospitals that lists data for each stay concerning disease type, services provided and medicine consumption. It sends each hospital user-friendly feedback, thus enabling the hospital to compare its treatment profile and certain quality indicators for each set of disease types. Very wide variations in medical practices (notably in the use of medicines) have been highlighted. Despite conveying these disparities to the hospitals, there have been no changes in practices towards greater quality and efficiency. There are several reasons for this:
a) Lack of incentive, since actions are financed retrospectively
b) Difficulties with understanding the feedback received, owing to differences in the way disease types are classified, the difficulty in establishing "evidence-based medicine" models in "medical culture", allowance made for economic constraints and cost-efficiency evaluation methods.
Fears on the part of many doctors, who face increasing transparency and the risk of inspections and sanctions from people outside the medical profession. These difficulties with the way in which information systems impact on changes to practices are clearly illustrated in the related literature.
This research is aimed at remedying these deficiencies by finalising, in collaboration with doctors (scientific organisations and groups evaluating the quality of care, hospitals and voluntary workers), a training programme to allow better understanding of the information available and the potential it offers. It is essential for doctors to be able to appropriate the information in accordance with their own particular interests. It is also essential to introduce care-programming and care-financing incentives within the system in order to allow the aims of the doctors to tally with the care-efficiency, quality and accessibility improvement aims being pursued by the public authorities. A pilot project will be finalised in the cardiology and heart surgery sphere in collaboration with scientific organisations and groups evaluating care quality, organised within the framework of the Ministry of Public Health.
The PROJECT tasks are as follows:
A. More fixed-price financing for medicines and medical services
A.1 Summary of results and lessons drawn from research conducted by CIES on this topic over the past ten years.
A.2 Fixed-price health packages for medicines.
At least partial fixed-price health packages for medicines appear to be a priority for the Social Affairs Minister.
Research financed by the Public Health Ministry (MSP) into fixed-price health packages for medicines and prescription evaluation has been conducted for five years by CIES in collaboration with two pharmacists: H. Robays (University of Ghent), and J.P. Delporte (University of Liege). The result is a series of recommendations for fixed-price health packages and evaluation based as much on data analysis as on the expertise of health professionals.
In order to valorise investment made by the Health Ministry in this sphere, we see it as essential to convey the experiences acquired during this research to MSP and INAMI, validate the results obtained in the CIES database and the RCM-RFM national database and discuss the recommendations issued with the working groups set up at national level on this matter (MSP-INAMI).
Naturally, this task can only be carried out in close collaboration with the agencies of the Public Health Ministry and INAMI (Institut National d'Assurance Maladie-Invalidité).
By the end of 2001, the result should be concrete proposals for partial and progressive fixed-price health packages, an inventory of unresolved research questions and proposals for monitoring the impact of measures.
A.3 The cabinet of the Minister for Social Affairs wants to extend fixed-price health packages progressively to other medical services, in particular diagnostic services (radiology, internal medicine services....).
The experiences acquired by CIES in how to address this problem in other spheres (length of stay, medicines...) may be used to bring to fruition a study of the applicability of such fixed-price health packages in these spheres on the basis of the database available at CIES and in collaboration with care providers (radiologists, etc.).
A.4 The direction taken by the reform of funding for medical services towards more widespread fixed-price health packages appears to be a progressive one through each category of medicines or category of services. Nevertheless, CIES studies have demonstrated that such an approach precludes any optimal allocation of resources between the various types of care or medicines. Partial fixed-price health packages that involves all medical services or medicines appears better suited to improving the accuracy of estimates of fixed charges and to optimising payment (even when analysis shows - as was the case with the study of fixed-price health packages for medicines - that it is better to keep certain medicines or services outside of fixed-price health packages).
A study of the applicability and advantages of broader fixed-price health packages would appear to be very useful. Initially, this could be conducted using the CIES database.
A.5 Recommendation involving research topics to be promoted in order to successfully bring about the progressive fixed-price health packages of hospital funding: status and funding of doctors, co-operation between doctors and managers inside the hospital, development of "same-day" hospital care, better integration of hospital and ambulatory care, etc.
B. Training for doctors within the framework of fixed-price health packages: pilot project in cardiology and heart surgery
B.1 Discussion of the different types of feedback finalised at CIES for managers and doctors in order to allow them to evaluate their "performance" in terms of cardiology disease types and heart surgeries in collaboration with assorted specialists in cardiology and heart surgery.
Highlighting of difficulties with comprehension, classification, etc.
Criticisms and alternative/additional information requested by doctors in order to make feedback more accessible and more useful for them in line with their fears about their practices.
Selection of a problem field (care programme, use of medicines...) or of several disease types or target interventions (cardiac arrest, PCTA, etc.).
B.2 Drawing-up of further feedback in accordance with comments and suggestions made by experts.
Presentation and discussion in front of scientific organisations and groups evaluating care quality.
B.3 Setting-up of working groups based on doctors and volunteer hospitals on the chosen problem(s).
Training for doctors in the understanding of feedback and comparing it with the expectations and criticisms of doctors.
Analyses of data, comparison of medical practices between doctors, hospitals and, where applicable, in relation to guidelines or "evidence-based medicine".
Recommendation in terms of both medical practices as well as incentives to be introduced by the public authorities.
B.4 Proposal to monitor the impact of recommendations on the evolution of practices.
B.5 Critical evaluation of action pursued involving appropriation of the information by doctors and proposed general application to other types of speciality field or disease.
Problèmes actuels en matière de cohésion sociale. Financement plus forfaitarisé des médicaments et des prestations médicales : rapport final
Bruxelles : Politique scientifique fédérale, 2004 (SP1372)
Financement plus forfaitarisé des médicaments et des prestations médicales : résumé
Bruxelles : Politique scientifique fédérale (SP1373)
Towards a prospective financing of inpatient drugs and medical services
Brussels : Federale Science Policy, 2004 (SP1374)