Payment by Results Jonathan Storey 15 October 2008
Agenda <ul><li>What is PbR? </li></ul><ul><li>Why is PbR necessary? </li></ul><ul><li>How was it introduced? </li></ul><ul...
What is PbR? <ul><li>A transparent, rules-based system for paying Trusts and other providers </li></ul><ul><ul><li>fair an...
Why is PbR necessary? <ul><li>Situation prior to PbR was unsustainable – unregulated market ‘free for all’ </li></ul><ul><...
How was it introduced? <ul><li>Preparatory phase - 2003/04 - 2004/05  </li></ul><ul><ul><li>Rebasing exercise 2005 to asse...
Introduction of PbR 2004/05 2005/06 2006/07 2007/08 2008/09 Introduce Tariff [HRGv3.5] Rebasing Exercise #1 Change Tariff ...
How does PbR work? <ul><li>National Tariffs derived from actual cost data (annual provider ‘Reference Cost’ data collectio...
What is the scope of PbR? <ul><li>General list of services not covered by tariff </li></ul><ul><ul><li>See lists of exclus...
What are PbR Exclusions? <ul><li>General Exclusions </li></ul><ul><ul><li>List of general exclusions </li></ul></ul><ul><l...
General PbR Exclusions <ul><li>Mental health services </li></ul><ul><li>Learning disabilities </li></ul><ul><li>Walk in Ce...
Admitted Patient Care Exclusions Decompression and Effusion for Degenerative Spinal Disorders R03 Primary or Revisional Sh...
Out Patient Exclusions Paediatric Dentistry 142 Transplantation Surgery 102 Restorative Dentistry 141 Allergy 317 Clinical...
Drugs and Devices Exclusions Drugs AIDS/HIV antiretrovirals Antifungals Antifibrinolytic drugs/ haemostatics blood product...
Drugs and Devices Exclusions Devices Aortic stents Aneurysm coils Bespoke orthopaedic prostheses Bone anchored hearing aid...
Drugs and Devices Exclusions Procedures/other : Cleft lip and palate Dynamic graciloplasty Endoprosthetic replacement for ...
A&E Tariff Calculation Payment High Cost Standard = depends on Minor A&E Tariff V01, V02 V03, V04 V07, V08 V100MC V100MI V...
OP Tariff Calculation Payment Adult  Tariff Children’s Tariff First Attendance Adult FA Tariff Follow Up Attendance Adult ...
OP Procedure Tariffs
APC Tariff Calculation Payment HRG Tariff Emergency Short Stay Adjustment Specialised /Children’s Adjustment Long Stay Adj...
What does it mean for commissioning? <ul><li>Service level agreements are in the form of cost and volume contracts based o...
What are the checks and balances? <ul><li>Who Pays? - Establishing the Responsible Commissioner (from 2005/06 - revised Oc...
What does the future hold for PbR? <ul><li>Large scale public consultation during Spring 2007 on the ‘Options for the Futu...
Features of HRG4 <ul><li>Updated procedure codes (OPCSv4.3, 4.4, 4.5…) </li></ul><ul><li>Improved procedure hierarchy </li...
Impact on Chapter E <ul><li>72% more HRGs across two sub chapters </li></ul><ul><ul><li>EA – Cardiac Procedures (46 from 1...
HRG4 Examples <ul><li>Sub Chapter EA </li></ul><ul><ul><li>OPCS  =  K652  Catheterisation of right side of heart NEC </li>...
Sources of further information <ul><li>Department of Health www.dh.gov.uk /pbr </li></ul><ul><ul><li>PbR Homepage </li></u...
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PbR

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PbR

  1. 1. Payment by Results Jonathan Storey 15 October 2008
  2. 2. Agenda <ul><li>What is PbR? </li></ul><ul><li>Why is PbR necessary? </li></ul><ul><li>How was it introduced? </li></ul><ul><li>How does PbR work? </li></ul><ul><li>What does it mean for commissioning? </li></ul><ul><li>What does the future hold for PbR? </li></ul>
  3. 3. What is PbR? <ul><li>A transparent, rules-based system for paying Trusts and other providers </li></ul><ul><ul><li>fair and consistent basis for provider funding </li></ul></ul><ul><ul><li>payments proportionate to activity levels and adjusted for case-mix reward efficiency </li></ul></ul><ul><ul><li>encourages additional activity for sustainable waiting time reductions </li></ul></ul><ul><ul><li>supports patient choice & promotes diversity of provision </li></ul></ul><ul><li>A National Price tariff for the most common treatments together with set of rules prescribing how it is to be applied </li></ul><ul><li>Current scope of Admitted Patient Care (HRG3.5), Outpatients and A&E </li></ul>
  4. 4. Why is PbR necessary? <ul><li>Situation prior to PbR was unsustainable – unregulated market ‘free for all’ </li></ul><ul><li>International examples – similar systems in most other developed economies </li></ul><ul><li>Support for NHS Reforms – Access (Waiting times), Patient Choice and Plurality of Provision </li></ul><ul><li>Deliver benefits for patients, clinicians and commissioners and providers </li></ul><ul><ul><li>Transparency </li></ul></ul><ul><ul><li>Equity </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><ul><li>Incentives </li></ul></ul>
  5. 5. How was it introduced? <ul><li>Preparatory phase - 2003/04 - 2004/05 </li></ul><ul><ul><li>Rebasing exercise 2005 to assess impact on commissioners & providers </li></ul></ul><ul><li>Transitional phase - 2005/06 - 2008/09 </li></ul><ul><ul><li>Purchaser parity & Provider transition adjustments (+/- 2% pa) </li></ul></ul><ul><ul><li>Market Forces Factor (MFF) with central payment by DH </li></ul></ul><ul><li>Live operational phase - 2008/09 onwards with… </li></ul><ul><li>Major changes planned for 2009/10 </li></ul><ul><ul><li>New tariff structure based upon HRG4 </li></ul></ul><ul><ul><li>MFF payments devolved to PCTs </li></ul></ul><ul><ul><li>Increased reliance on SUS </li></ul></ul>
  6. 6. Introduction of PbR 2004/05 2005/06 2006/07 2007/08 2008/09 Introduce Tariff [HRGv3.5] Rebasing Exercise #1 Change Tariff [HRG4] Payment by Results fully live Provider impact Transitional Phase Rebasing Exercise #2 2009/10 25% 50% 75% 100%
  7. 7. How does PbR work? <ul><li>National Tariffs derived from actual cost data (annual provider ‘Reference Cost’ data collection exercise) adjusted for… </li></ul><ul><li>Market Forces Factor (MFF) – unavoidable cost differentials incurred by providers (in terms of excess manpower & estate costs) </li></ul><ul><li>Payment = Activity x Price + MFF </li></ul><ul><li>Additional complexity </li></ul><ul><ul><li>Short stay – reduced tariffs </li></ul></ul><ul><ul><li>Long stay – excess bed day tariffs </li></ul></ul><ul><ul><li>Specialist top-ups – service specific uplifts </li></ul></ul>
  8. 8. What is the scope of PbR? <ul><li>General list of services not covered by tariff </li></ul><ul><ul><li>See lists of exclusions on next slide </li></ul></ul><ul><li>Separate tariffs published for: </li></ul><ul><ul><li>Admitted Patient Care - HRG spells </li></ul></ul><ul><ul><ul><li>Elective </li></ul></ul></ul><ul><ul><ul><li>Short Stay Emergency (<2 days) </li></ul></ul></ul><ul><ul><ul><li>Non-Elective (>1 day) </li></ul></ul></ul><ul><ul><li>Outpatients - Attendances </li></ul></ul><ul><ul><ul><li>First Attendance </li></ul></ul></ul><ul><ul><ul><li>Follow Up Attendance </li></ul></ul></ul><ul><ul><ul><li>Procedures (from 2006/07) </li></ul></ul></ul><ul><ul><li>Accident & Emergency – Attendances </li></ul></ul><ul><li>See lists of exclusions on next slide </li></ul>
  9. 9. What are PbR Exclusions? <ul><li>General Exclusions </li></ul><ul><ul><li>List of general exclusions </li></ul></ul><ul><li>APC exclusions </li></ul><ul><ul><li>List of HRGs </li></ul></ul><ul><li>Outpatients exclusions </li></ul><ul><ul><li>List of Specialties </li></ul></ul><ul><li>Drugs and appliance exclusions </li></ul><ul><ul><li>List of drugs and treatments </li></ul></ul>
  10. 10. General PbR Exclusions <ul><li>Mental health services </li></ul><ul><li>Learning disabilities </li></ul><ul><li>Walk in Centres </li></ul><ul><li>Primary Care Services </li></ul><ul><li>Community services </li></ul><ul><li>Continuing/intermediate care </li></ul><ul><li>Respite care </li></ul><ul><li>Direct access radiology and pathology </li></ul><ul><li>Ambulance services (≠ PTS) </li></ul><ul><li>NSCAG commissioned specialised services </li></ul><ul><li>Critical care - [apart from discrete Coronary Care Units] </li></ul><ul><li>Renal dialysis </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Radiotherapy </li></ul><ul><li>Rehabilitation in discrete rehabilitation ward or unit (314) </li></ul><ul><li>Private patients in NHS hospitals </li></ul><ul><li>Regular day/night attenders </li></ul><ul><li>Well babies </li></ul><ul><ul><li>All excluded services continue to be commissioned at locally agreed prices until such time as mandatory tariffs are introduced </li></ul></ul><ul><ul><li>Indicative tariff published for some areas </li></ul></ul>
  11. 11. Admitted Patient Care Exclusions Decompression and Effusion for Degenerative Spinal Disorders R03 Primary or Revisional Shoulder, Elbow, or Ankle Replacements H07 Other Burn without significant graft procedures J28 Other Burn with inhalation injury J19 Chemotherapy *98 Bone Marrow Graft S09 Surgery for Scoliosis or Other Spinal Deformity R10 Spinal cord injury with fusion or decompression R07 Cystic Fibrosis P02 Kidney Transplant L01 Other Burn with multiple significant graft procedures J23-J25 Other Burn with 1 significant graft procedures J22 Major Burn > 29% TBSA with/without Significant Graft Procedure J13-J18 Pancreas – Complex Procedures G21 Liver Transplant G01 Oesophagus – Complex procedures F01 Heart Transplant E02 Heart and Lung transplant E01 Cystic Fibrosis D17 Lung Transplant D01
  12. 12. Out Patient Exclusions Paediatric Dentistry 142 Transplantation Surgery 102 Restorative Dentistry 141 Allergy 317 Clinical Immunology 316 Palliative Medicine 315 Rehabilitation 314 Clinical Genetics 311 Audiological Medicine 310 Haemophilia 309 Bone Marrow Transplantation 308 Clinical Pharmacology 305 Accident and Emergency 180 Cardiothoracic Transplantation 174 Thoracic Surgery 173 Cardiac Surgery 172 Cardiothoracic Surgery 170 Neurosurgery 150 Family Planning Clinics 990 Chemical Pathology 822 Neonatology 422 HIV / AIDS 987 Cystic Fibrosis 984-6 Spinal Injuries 982 Occupational Medicine 901 Anti Coagulation Clinics 824 Haematology 823 Midwife Episodes 560 Dental Medicine Specialties 450 Paediatric Neurology 421 Neurology 400 Nephrology 361 Tropical Medicine 352 Infectious Diseases 350 Dermatology 330 Respite Care 319
  13. 13. Drugs and Devices Exclusions Drugs AIDS/HIV antiretrovirals Antifungals Antifibrinolytic drugs/ haemostatics blood products Betaine Cytokine Inhibitors Drugs affecting bone metabolism Drugs affecting the immune response Drugs used in metabolic disorders Drugs used in neutropenia Growth hormone and growth hormone receptor antagonists Hyperuricaemia associated with cytotoxic drugs Immunomodulating drugs Intravenous/subcutaneous human normal immunoglobulins Somatostatin analogues Torsion Dystonias and other involuntary movements Vasodilator Antihypertensive drugs/ Primary Pulmonary Hypertension drugs Viral Hepatitis (B & C) and Respiratory Syncytial Virus Allergen Immunotherapy Ocular diagnostic and peri-operative preparations and photodynamic treatment
  14. 14. Drugs and Devices Exclusions Devices Aortic stents Aneurysm coils Bespoke orthopaedic prostheses Bone anchored hearing aids (BAHA) Carotid, iliac and renal stents CPAP/BiPAP Deep brain, vagal, sacral and spinal cord stimulators Gliadel wafers Implantable defibrillators (ICD) Cardiac Resynchronisation Therapy (CRT) ICD with CRT capability IIlizarov frames Insulin pumps and pump consumables Intrathecal drug delivery pumps Implantable loop recorders 3 dimensional navigation system mapping catheters Occluder septal devices
  15. 15. Drugs and Devices Exclusions Procedures/other : Cleft lip and palate Dynamic graciloplasty Endoprosthetic replacement for benign bone tumours Gastric banding Head and neck cancer reconstructive surgery PDT for wet Age Related Macular Degeneration Pelvic reconstruction
  16. 16. A&E Tariff Calculation Payment High Cost Standard = depends on Minor A&E Tariff V01, V02 V03, V04 V07, V08 V100MC V100MI V05, V06 and DOA
  17. 17. OP Tariff Calculation Payment Adult Tariff Children’s Tariff First Attendance Adult FA Tariff Follow Up Attendance Adult FU Tariff = OR Child FA Tariff Child FU Tariff depends on Procedure Tariff OR Eight Procedures
  18. 18. OP Procedure Tariffs
  19. 19. APC Tariff Calculation Payment HRG Tariff Emergency Short Stay Adjustment Specialised /Children’s Adjustment Long Stay Adjustment Elective EL Tariff Not applicable Tariff x Specialised or Children’s Supplement % LOS > trim[EL]: x days @ HRG Bedday Rate Non Elective NEL Tariff LOS > trim[NEL]: y days @ HRG Bedday Rate = + x + depends on and where applicable Tariff [alos] 50% [2] 35% [3-4] 20% [5+]
  20. 20. What does it mean for commissioning? <ul><li>Service level agreements are in the form of cost and volume contracts based on planned activity levels – now using the new standard NHS contract </li></ul><ul><li>Contract payments (made monthly ‘on account’) are subsequently adjusted (initially quarterly but now increasingly monthly) in order to reflect the volume and case-mix of treatments actually delivered </li></ul><ul><li>This calculation is increasingly being delivered through data submitted to the National Care Records Service (NCRS) - Secondary Uses Service (SUS). Single authoritative source from 2009/10. </li></ul>
  21. 21. What are the checks and balances? <ul><li>Who Pays? - Establishing the Responsible Commissioner (from 2005/06 - revised Oct 2007) </li></ul><ul><li>PbR Code of Conduct (since 2005/06 - revised Feb 2008) – sets out expected behaviours of providers & commissioners </li></ul><ul><li>Clinical Coding Assurance (from 2007/08) – Audit Commission’s continuing targeted review of providers’ clinical coding standards </li></ul><ul><li>New Standard NHS Contract (from 2008/09) – mandates a consistent set of (legally enforceable) commissioning rules applicable to all providers </li></ul>
  22. 22. What does the future hold for PbR? <ul><li>Large scale public consultation during Spring 2007 on the ‘Options for the Future of PbR’ </li></ul><ul><li>Conclusions drawn: </li></ul><ul><ul><li>Confirmed introduction of HRG4 tariffs from 2009/10 </li></ul></ul><ul><ul><li>Established extensive network of PbR development sites including: </li></ul></ul><ul><ul><ul><li>Mental Health & Ambulance </li></ul></ul></ul><ul><ul><ul><li>Cardiac examples </li></ul></ul></ul><ul><li>Next Steps….HRG4 </li></ul>
  23. 23. Features of HRG4 <ul><li>Updated procedure codes (OPCSv4.3, 4.4, 4.5…) </li></ul><ul><li>Improved procedure hierarchy </li></ul><ul><li>Introduction of diagnosis hierarchy (for non procedure driven HRGs) </li></ul><ul><li>Introduction of paediatric age splits </li></ul><ul><li>Improved grouper logic </li></ul><ul><li>Greater granularity and specificity </li></ul><ul><li>Better able to differentiate true resource variation </li></ul>
  24. 24. Impact on Chapter E <ul><li>72% more HRGs across two sub chapters </li></ul><ul><ul><li>EA – Cardiac Procedures (46 from 14) </li></ul></ul><ul><ul><ul><li>Grouping based primarily on procedure – but also influenced by diagnosis </li></ul></ul></ul><ul><ul><ul><li>No age splits or ccs </li></ul></ul></ul><ul><ul><li>EB – Cardiac disorders (16 from 22) </li></ul></ul><ul><ul><ul><li>Grouping driven by primary diagnosis – removal of age 70 split </li></ul></ul></ul><ul><ul><ul><li>Different levels of ccs dependent upon subsequent diagnoses </li></ul></ul></ul><ul><li>98% of activity contained within new sub chapters </li></ul>
  25. 25. HRG4 Examples <ul><li>Sub Chapter EA </li></ul><ul><ul><li>OPCS = K652 Catheterisation of right side of heart NEC </li></ul></ul><ul><ul><li>HRG35 = E14 Cardiac Catheterisation and Angiography without complications </li></ul></ul><ul><ul><li>HRG4 = EA36Z Catheter 19 years and over </li></ul></ul><ul><li>Sub Chapter EB </li></ul><ul><ul><li>OPCS = R073 Other chest pain </li></ul></ul><ul><ul><li>HRG35 = E36 Chest Pain <70 w/o cc </li></ul></ul><ul><ul><li>HRG4 = EB01Z Non interventional acquired cardiac conditions 19 years and over </li></ul></ul><ul><li>Sub Chapter EB </li></ul><ul><ul><li>OPCS = I210 Acute transmural myocardial infarction of anterior wall </li></ul></ul><ul><ul><li>HRG35 = E12 Acute Myocardial Infarction w/o cc </li></ul></ul><ul><ul><li>HRG4 = EB10Z Actual or Suspected Myocardial Infarction </li></ul></ul>
  26. 26. Sources of further information <ul><li>Department of Health www.dh.gov.uk /pbr </li></ul><ul><ul><li>PbR Homepage </li></ul></ul><ul><ul><li>Costing Guidance </li></ul></ul><ul><ul><li>Reference Costs Collection </li></ul></ul><ul><li>Connecting for Health </li></ul><ul><ul><li>Clinical Interventions Coding systems (OPCS) </li></ul></ul><ul><ul><li>Summary Care Record Service (CRS) </li></ul></ul><ul><li>Information Centre </li></ul><ul><ul><li>Currencies (HRGs) </li></ul></ul><ul><ul><li>Secondary Uses Service (SUS) </li></ul></ul><ul><li>Audit Commission </li></ul>

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