This document discusses various aspects of continence care provision and funding across different healthcare systems. It notes that provision of continence products varies significantly between countries and regions due to differences in healthcare models and policies. The document advocates for standardized assessment of patient needs and eligibility criteria for products. It also presents evidence that implementing integrated continence care services following clinical guidelines can improve outcomes, quality of life, and reduce overall healthcare costs through lower social care needs.

1. The times, they are a' changin': It's
more than just "cost"
Adrian Wagg

2. I have received either directly or indirectly, monies for
research, consultancy or speaker honoraria from:
Astellas Pharma
Pfizer Corp
SCA
Conflict of interest

3. The global aging population

4. Multimorbidity and aging
Lancet 2012; 380, No. 9836: 37–43

5. Perry S et al. J Public Health Med 2000; 22(3):427-34 (the Leicestershire MRC incontinence study)
Females
0
5
10
15
20
25
30
35
40-49 50-59 60-69 70-79 80+
Age group (years)
Prevalence%
Monthly and slight
Monthly and damp
Monthly and wet
Monthly and soaked
Prevalence and severity of incontinence in women

6. Prevalence and severity in men
Males
0
5
10
15
20
25
30
35
40-49 50-59 60-69 70-79 80+
Age group (years)
Prevalence%
Monthly and slight
Monthly and damp
Monthly and wet
Monthly and soaked Perry S et al. J Public Health Med 2000; 22(3):427-34 (the Leicestershire MRC incontinence study)

7. Healthcare funding systems vary widely across the globe
Soviet model Beveridge
model
Bismarck
model
Private health
insurer
•Central budget
•Citizenship
•Single scheme
•Public providers
•No demand
control
•Focus on care
•Tax funded
•Citizenship
•Single or
differentiated
schemes
•Mainly public
providers
•Strong demand
control
•Prevention = care
•Tax funded or
social health
insurance
contribution
•Insured status
•Single or
differentiated
schemes
•Various providers
•Elements of
demand control
•Care > prevention
•Individual savings
•Insured status
•Differentiated
schemes
•Mainly private
providers
•Strong demand
control
•Care > prevention

8. Who should pay?
Should products be covered, at all?
(Social equity, means testing, personal health care
budgets, social consensus, willingness to pay?)
Many payers still see incontinence as a lifestyle limiting or
quality of life condition, not a disease entity
WORK TO DO!
Philosophically…

9. In Europe:
• most countries have provision
except for France and Romania
• provision in Hungary is scant
• Variable mechanisms for cost
containment
- Number of products /day
- Waiting lists for supplies
- bureaucracy
- Arbitrary assessment of “severity of
incontinence”
Likewise, the provision for continence products
within healthcare systems varies

10. Medicaid coverage varies from state to
state. In some states, Medicaid recipients are
eligible for complete coverage of absorbent
products.
In some states, Medicaid has "preferred
vendors“
Medicare does not cover adult diapers or
continence products
Veterans Administration coverage varies
In the US, provision varies by State

11. BC: employment and assistance
programme, full coverage
SK: quantity limited, average monthly
cost limited
MB: must be on employment and
income support, fixed monthly $
amount
ON: must meet both financial and
medical need, fixed coverage
QC: either hospitalized, in nursing
home or physical or intellectual
disability, full coverage
In Canada, provision varies by Province – most
systems are “payers of last resort”
NFLD: community dwelling disabled
persons, means tested
PEI: LTC residents, >60y
NS: recipients of continuing care only
NB: means tested, “social development
clients”, full coverage

12. Eligibility: daily, non-resolving urinary or bowel incontinence
Many systems use a variety of “rules” for
regulating eligibility, for example:

13. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Many systems use a variety of “rules” for
regulating eligibility, for example:

14. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Minimum 250mL of urine / stool at each incontinence episode
Many systems use a variety of “rules” for
regulating eligibility, for example:

15. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Minimum 250mL of urine / stool at each incontinence episode
Must be assessed by: uro / gynae / obstetrician / gastroenterologist /
proctologist / NP and certified as intractable – also not amenable to
surgery
Many systems use a variety of “rules” for
regulating eligibility, for example:

16. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Minimum 250mL of urine / stool at each incontinence episode
Must be assessed by: uro / gynae / obstetrician / gastroenterologist /
proctologist / NP and certified as intractable – also not amenable to
surgery
Severe dementia diagnosis must be certified by neuropsychological
testing
Many systems use a variety of “rules” for
regulating eligibility, for example:

17. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Minimum 250mL of urine / stool at each incontinence episode
Must be assessed by: uro / gynae / obstetrician / gastroenterologist /
proctologist / NP and certified as intractable – also not amenable to
surgery
Severe dementia diagnosis must be certified by neuropsychological
testing
Cannot have diagnosis of stress urinary incontinence or urgency
urinary incontinence (unless severely demented)
Many systems use a variety of “rules” for
regulating eligibility, for example:

18. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Minimum 250mL of urine / stool at each incontinence episode
Must be assessed by: uro / gynae / obstetrician / gastroenterologist /
proctologist / NP and certified as intractable – also not amenable to
surgery
Severe dementia diagnosis must be certified by neuropsychological
testing
Cannot have diagnosis of stress urinary incontinence or urgency
urinary incontinence (unless severely demented)
Cannot have only nocturnal enuresis
Many systems use a variety of “rules” for
regulating eligibility, for example:

19. Eligibility: daily, non-resolving urinary or bowel incontinence
All possible interventions tried – for a minimum of three months
(except palliative care / severe dementia)
Minimum 250mL of urine / stool at each incontinence episode
Must be assessed by: uro / gynae / obstetrician / gastroenterologist /
proctologist / NP and certified as intractable – also not amenable to
surgery
Severe dementia diagnosis must be certified by neuropsychological
testing
Cannot have diagnosis of stress urinary incontinence or urgency
urinary incontinence (unless severely demented)
Cannot have only nocturnal enuresis
Can only have 1 category of product
Many systems use a variety of “rules” for
regulating eligibility, for example:

20. 2013-14 annual spend for continence supplies in AB
was
For
10,767 recipients of diapers, liners and underpads,
2,500 underpads only
4,400 recipients of catheters and catheter supplies
Administrative cost not included!
Despite controls:
Category Funding (CAN$)
Diapers and liners 9,888,024
underpads 141,099
Catheters and catheter supplies 1,903,170
Total 11,932,293

21. Many health care systems deal with the increase and
overspending of the health care budget by
• allocating more budget
• limiting the spending by limiting reimbursement to citizens
• limiting quality or choice.
None of these options are sustainable and will lead in
the end to limited access to health care for a major
part of the citizens
Trends

22. For example:
Absorbent products, hand held urinals and toileting aids
should not be considered as a treatment for UI. Use them
only as:
• a coping strategy pending definitive treatment
• an adjunct to ongoing therapy
• long-term management of UI only after treatment options
have been explored.
Many National and International Continence
Guidelines recommend where in the treatment
pathway products should be used:
Urinary incontinence in women: the management of
urinary incontinence in women CG 171 NICE UK 2013

23. Recommendations for service organization in
order to deliver guideline compliant care exist
2
1
3Case
co-ordination3
Enabling
technologies
Community-
based
support
Containment
products
4
Case
detection
Initial
assessment
and
treatment
Specialist
assessment
and
treatment
PLoS One. 2014 Aug 14;9(8):e104129. doi: 10.1371/journal.pone.0104129.

24. Use a comprehensive standardised assessment of user, product,
and usage-related factors to assess needs with regards to
containment products
• Use standardised assessment of following factors as per international
standard (ISO 15621: 2011):User –related factors; Product-related factors;
Usage-related factors
• Needs of each patient must be reassesed periodically
For payers: in order to provide the highest quality continence care,
ensure care standards are incentivised
Transparency on outcome indicators can motivate improved performance
Financial incentives linked to outcomes can also motivate powerfully
Operational performance measures can indicate level of efficiency
Recommendation 6
Recommendation 8

25. Outcome-orientated standard
Outlook 2014

26. Using recommendations from the optimum continence
service specification
• placing a fully qualified NP in primary care in the
Netherlands
• applying this model for continence care to older people
with multimorbidity (4 co-existing conditions or more)
Can a call for investment in integrated continence
services save money?

28. Outcomes, costs and QALYs per patient per 3
years

29. The majority of any cost saving comes from a
reduction in social care need for this section of the
population
Budget impact over a period of 3 years

30. Implementing the optimum continence service
specification in the Netherlands by having a
continence nurse practitioner in the GP practice is
likely to:
reduce the level of incontinence
improve quality of life
reduce costs - from a payer’s perspective as well as from the
patient’s and carer’s perspective
Savings total €29 million in health cost and €117 million in social
costs over 3 years

31. Outcomes from incontinence products
Product
Function
Outcome
Materials
Quality of life
Courtesy of SCA

32. Functional description of care insured in laws and regulation:
to what care people are entitled
products provided, that best fit patients /caregiver needs:
Insurers/ providers look for a system in which prescribers
prescribe based on functional characteristics to achive best
possible outcome
Prerequisite is objective assessment of care-need to make the
best possible match between care needs and medical device
solutions available.
Functional prescribing

33. Netherlands: In December 2008, Ministry of Health,
Welfare and Sport (VWS), decided the client is entitled to
the "most appropriate functional solution.
search for the perfect match between what a person wants,
can and may (in terms of objective function) and what tool
(medical devices) can be offered.
That means that in providing tools (medical devices) not
the device, but the performance of the client will be central
– person centred care
Function-claim
Courtesy of SCA

34. Functional prescription cycle
Detect
Problem
Formulate
care need
Define
care
direction
Program
of
demands
Select
samples
,
try and
decide
Delivery
and
instruction
Use Evaluate
Care plan
Courtesy of SCA

35. Acquisition cost is a poor indicator of “cost”
Products are soft targets for cost cutting in times of financial
hardship
Limiting either choice, availability or quality may not give the
desired impact
The major savings in improving continence care come from a
reduction in societal costs
Integrated continence services, providing incentivized, guideline
adherent care result in savings
Principle driven eligibility should be the norm
Standardised assessment with person centred provision is
desirable
Take away menu