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Cabina di Regia

22 Maggio 2008

Performance evaluation systems and financing

Rome - November 22, 2011

Ufficio “VI”- Federalismo

DG della Programmazione Sanitaria Ministero della Salute

Lucia Lispi, Antonio Nuzzo

2 Ufficio VI - “Federalismo” - Direzione Generale della Programmazione Sanitaria –

Dipartimento della Programmazione e dell’ Ordinamento del Servizio Sanitario Nazionale

Health in Italian Constitution

Article 32 of the Constitution says that

“The Republic protects health as a fundamental right of the individual

and as a concern of collectivity and guarantees free care to the indigent.”



Italian National Health Service

Italy has a National Health Service (SSN) established

in 1978 to replace a system of health insurance

funds with the declared goal of providing uniform and

comprehensive care, financed by general taxation.

The expression “levels of care” mentioned for

the first time



1978: Servizio Sanitario Nazionale (SSN)

Central Government level, Regional level, Local level (LHAs)

1992: First SSN Reform

Increased responsibility and autonomy of regional and local authorities

1999: Second Reform

Growing autonomy, responsibility and planning of the Regions on the objectives of prevention, treatment and

rehabilitation

Major Reforms of the Italian National Health Care Service (SSN)



2000: Constitutional Reform and Fiscal Federalism

General legislative and administrative authority in several

sectors of society, including health care, attributed to the Regions

National Parliament and central Government: definition and monitoring of the “Essential levels of care” (Health Basket –

LEA)

New health care financing system

Central level monitoring and assessment of the delivery of health across Regions

Major Reforms of the Italian National

Health Service (SSN)



Over the years, there has been notable devolution of revenue raising capacity to the Regions.

Currently SSN funding sources are

partly Regional, from a regional business tax (IRAP), a “piggy back” tax on the national personal income tax and a motor vehicle tax;

partly National, from a central grant financed with value added tax (VAT) revenues.

The amount of the central grant is set annually by the State with the aim of

ensuring that all Regions have adequate financial resources to guarantee

LEA to their citizens.

SSN funding : devolution



Overall, SSN funding is covered by: Regional share of VAT and motor vehicle tax: ………... 46%

Regional Business Tax (IRAP): ………...………. . 34%

Regional general taxes: ……………………… … ….. 8%

Regional addition on the national personal income tax: .. 6%

Other national general taxes: ……………………………. 4%

Regional healthcare self-financing (copayments): …….. 2%

Due to interregional variability in regional tax bases,

there is considerable interregional variation in the

importance of own-source revenues:

a few Regions have become completely self-sufficient

most Regions still rely to some degree on central

financing, some very heavily so.

SSN funding : coverage (2)



Aggregate SSN funding is allocated among the Regions

according to a formula based on population,

weighted by :

age and gender-specific utilisation rates for hospital care,

drugs and residential care for the aged

the standardised mortality rates as a proxy for need

geographical epidemiological indicators

Indicators related to particular geographical situations

Ex-post adjustments for interregional patient flows

SSN funding : regional distribution



External budget constraints on SSN

Italy has built up a large public debt over time,

which has a high opportunity cost in terms of

reduced resources for funding SSN and other

public services as well as of limited scope to

reduce taxes and which imposes

• a hard budget constraint in public health care

• the adoption of a strict inter institutional,

central-regional, SSN stewardship approach



Reform of chapter V of the Italian Constitution art. 117

The State has exclusive power to set:

• the general principles of the SSN,

• the “essential levels of care” (Livelli Essenziali di Assistenza – LEA), national healthcare entitlements which must be available to all residents throughout the country,

• the corresponding level of current funding

The Regions have responsibility for the organisation

and administration of the regional healthcare services



Areas of health care services

Resources for financing essential levels of health care were

established and further responsabilities were given to the Region with

regard to the organization of health services and to control health

expenditures

Agreement between the Central and Regional Governments of 8 August 2001



All citizens are entitled to receive health care services included in the “essential

level” either at no cost or with co-payment for services that are not fully covered

by the National Health System

DPCM 29 November 2001 - Essential levels of health care (LEA)

Necessary

Appropriate

Homogeneous

1 Collective health care

2 District health care

3 Hospital health care



Interministerial decree 12 December 2001

Monitoring Health care

Monitoring of actual provision of the services included in the LEA on the national territory and of uniformity of the performance of healthcare systems across

Regions

THROUGH

A set of relevant indicators for the assessment of health care provision

IN ORDER TO

• inform about levels of care guaranteed in every Regions;

• identify and report the major critical issues in the country;

• address correction actions to the appropriate levels of SSN government (programming, evaluation, organization, management of the provision of health and social care to the citizens).

National System of Warranty (art. 9 D.Lgs 18/2/2000, n. 56)



DM 12.12.2001

Establishes a set of indicators (53), classified by level of care, with the purpose of monitoring the «essential levels of assistance» Lea (warranty system).

These Lea indicators are integrated with :

outcome indicators (9)

social-demographic, economic and environmental indicators (29)

Sets the rules for the use of the indicators at regional and national level, in order to use all available and appropriate information.

Sets the criteria for data collection, separately for data already available in the NSIS (National Health Information System) and for ‘ad hoc’ data

Warranty System (D.L. 56/2000)



The system adopted includes:

a minimum set of reference indicators and parameters

to monitor “essential levels of health care” delivered

over the national territory;

rules for the identification, assessment and elaboration

of the information and statistical data that are necessary

for the implementation of the above-mentioned indicator

system;

procedures to inform the public on a regular basis

regarding the results of the monitoring exercise.

DM 12.12.2001



An example



New System of indicators : criteria for updating the warranty system

At central level, the new warranty system will prioritively consider the dimensions relating to the basic principles of LEA :

equity-universalism,

efficacy-appropriateness,

quality,

allocative effectiveness (include the composition of public/private expenditure).

At regional level, monitoring and evaluating systems consider also organizational-managerial dimensions such as:

productive effectiveness,

organizative appropriateness,

clinical, prescriptive appropriateness, etc.



The working group created to review the indicators for LEA monitoring system shared the

conceptual schema of the new warranty system, based on a modular system of indicators,

built on 2 levels:

FIRST LEVEL

Indicators on phenomena and fundamental dimensions, with respect to which the system highlights macroscopic problems, significant differences compared to predetermined values (target values) and provides indications for possible decisions at central and regional levels.

These selected indicators play a key role for analitical purposes or for the selection of critical issues which should need particular political attention.

Indicators that allow an inter-regional and international comparison, in order to underline particular situations for further analitical-evaluation.

The second level indicators are currently being tested.

SECOND LEVEL

Updating of the New System of indicators


Dipartimento della Programmazione e dell’ Ordinamento del Servizio Sanitario Nazionale Ufficio VI, X “SiVeAS” - Direzione Generale della Programmazione Sanitaria –


The team that is working for the updating of the “warranty system for LEA monitoring”, composed by representatives of central and regional bodies, has tested and valitaded a set of 21 indicators of first level, divided in 3 areas:

Collective health care (7)

Vaccinations

Screening

Veterinarian health

Food safety

Controls on healthcare structures

District health care (9)

Appropriateness of assistance

Territorial emergency care

Assistance to elderly

Assistance to terminal patients

Hospital care (5)

Adequacy of hospital services:

•Basic services

•Specialistic services

•Emergency

Efficacy of care

Updating of the New System of indicators




Collective health care

Livello Sottolivello Indicatore

A1.1 - Copertura vaccinale nei bambini a 24 mesi per ciclo base (3 dosi)

vaccinazioni: poliomielite, difterite, tetano, epatite virale B, pertosse, Hib

A1.2 - Copertura vaccinale nei bambini a 24 mesi per una dose di vaccino

contro morbillo, parotite, rosolia

Tutela della salute e della

sicurezza degli ambienti aperti e

confinati

B1 - Controlli igienico-sanitari nelle strutture residenziali e

semiresidenziali : percentuale strutture controllate su strutture presenti

Sorveglianza, prevenzione e tutela

della salute e sicurezza nei luoghi

di lavoro

C1 - Percentuale delle unità controllate sulle unità da controllare

Salute animale e igiene urbana

veterinaria

D1 - Livello di copertura delle principali attività di gestione per la sicurezza

alimentare del cittadino, con particolare riferimento alla sanità animale

nella filiera produttiva

Sicurezza alimentare – Tutela

della salute dei consumatori

E1 - Livello di copertura delle principali attività di gestione per la sicurezza

alimentare del cittadino, con particolare riferimento agli esercizi di

commercializzazione e ristorazione, alla presenza di residui negli alimenti

di origine animale e vegetale

Sorveglianza e prevenzione delle

malattie croniche, inclusi la

promozione di stili di vita sani ed i

programmi organizzati di

screening

F1 - Proporzione di persone che ha effettuato test di screening di primo

livello, in un programma organizzato, per cervice uterina, mammella, colon

retto

Sorveglianza, prevenzione e

controllo delle malattie infettive e

parassitarie, inclusi i programmi

vaccinali

1. Prevenzione




District health care

Z1. Accessi in Pronto Soccorso di assistiti con codice bianco

Z2. Tasso di ospedalizzazione per alcune condizioni/patologie evitabili:

asma pediatrico, complicanze del diabete, scompenso cardiaco, infezioni

delle vie urinarie, polmonite batterica nell’anziano, broncopneumopatia

cronica ostruttiva (BPCO)

Pronto soccorso B1.Intervallo Allarme-Target dei mezzi di soccorso

E2. Consumo di alcune selezionate tipologie di prestazioni ambulatoriali (o

assimilabili) a minore rischio di inappropriatezza (radioterapie in caso di

tumore, fundus oculi ed emoglobina glicata in caso di diabete, …)

E3.1 - Percentuale di donne che hanno effettuato la 1° visita ostetrica

entro la 13 settimana di gestazione

E3.2 - Percentuale di donne che hanno effettuato meno di 3 ecografie in

gravidanza

ass. domiciliareG1. Percentuale di anziani ≥ 65 anni trattati in ADI (Assistenza Domiciliare

Integrata)

ass. domiciliareH1. Numero di posti equivalenti per assistenza agli anziani in strutture

residenziali ogni 1000 anziani residenti

ass.residenziale H2 Posti letto attivi in hospice sul totale dei deceduti per tumore

ass.residenzialeH3. Numero di posti equivalenti residenziali e semiresidenziali in strutture

che erogano assistenza ai disabili ogni 1000 residenti

ambulatoriale2. Distrettuale

Complessivo





Hospital care

A1 Adeguatezza dell’offerta per servizi ospedalieri di base

A2 Adeguatezza dell’offerta per servizi ospedalieri di alta specialità

A3 Adeguatezza dell’offerta per l’emergenza/urgenza

efficaciaD1 Ricoveri ripetuti dai 7 ai 30 giorni nello stesso o in altro ospedale per la

stesso MDC, per patologie ad alta percentuale di remissione

presa in caricoE2. Percentuale soggetti con diagnosi di frattura del collo del femore

operati entro 3 giornate in regime ordinario

3. Ospedaliera

accessibilità ai servizi




Since the Constitutional amendment in 2001, a series of

agreements between the central Government and the Regions were

signed, aimed at making SSN budget constraint respected and

good quality healthcare services (LEA) provided to citizens.

Major Contents of the Agreements :

o Integrations to National Contribution to SSN Funding

o 3% of the Annual State SSN Funding is withheld until positive

Central Assessment of the conditions contained in the accord

(e.g.: actions to cut labour costs, plans to avoid unnecessary and inappropriate care,

compliance to National Health Information System flows; actual introduction of detailed cost

accounting systems in all ASL; action to rationalise the hospital sector, to implement home care

and extra-hospital care to non selfsufficient patients; adoption of National Prevention Plan; etc)

State-Region Cooperation in the Stewardship of SSN and the Use of Central Spending Power



Central Assessment of Regional Health Services

a) Regional Health Service Financial Management :

public expenditure trends and respect of the budgeted levels

b) Regional Health Service Performance :

quality, appropriateness, safety, efficiency, equity in healthcare

delivery

Positive assessment >> regional access to 3% State funding

Negative assessment >> central withholding of 3%, until positive

assessment

If assessment a) highlights regional deficit ≥ 5% of planned spending

The Region can have access to a Special Central Financial Aid on condition they demonstrate to follow a detailed

Budgetary Balance Plan (Piano di Rientro) which sets measures aimed at resolving

their problem of structural budgetary imbalance



State-Region Cooperation in the Stewardship of SSN

The Central level, both the central Government and the

Interregional Coordination, is involved in

Performance Assessment of all Regions

and

Support/Tutoring

in Regions in Critical Conditions

which are also required to enter into a “partnership” with a

Region in budgetary balance,

to facilitate the procurement of know-how and experience



2006: A National System of Performance Evaluation (Sistema Nazionale di Verifica e Controllo sull’Assistenza Sanitaria - SiVeAS)

Not a new Agency but a System of Relation among all existing

central Institutions, Organizations, Activity Lines

to which existing laws commit :

Healthcare Assessment Functions and

Good Practices Promotion within the SSN

The Law sets two Major Goals for SiVeAS :

Ascertains that actual provision of LEA corresponds to SSN funding

Ascertains that efficiency and appropriateness criteria are respected in the delivery of LEA



A National System of Performance Evaluation (SiVeAs)

Institutions, Organizations and Activity Lines involved

Ministry of Welfare

Italian Agency for Pharmaceuticals (AIFA)

Functions performed by the Nucleo SAR (Supporto per l‘Analisi delle disfunzioni e la

Revisione organizzativa),

National System of Warranty (art. 9 del dlgs 18/2/2000, n. 56),

National Monitoring System (art. 87, l 23/12/2000, n. 388 succ mod)

National Agency for Regional Healthcare Services (AgeNaS)

National Committee for LEA (art. 9 intesa Stato-Regioni 23/3/2005);

Collaborations from Research Institutes, Scientific Societies, Private and Public

Centres and Experts involved in Healthcare Performance Evaluation:

Istituto Superiore di Sanità, Roma

Istat, Roma

OECD, Paris

Università Cattolica Sacro Cuore, Roma

Università Bocconi- Cergas, Milano

CINECA, Pisa

……..

http://bd01.deaprofessionale.it/cgi-bin/FulShow?TIPO=5&NOTXT=1&KEY=01LX0000042658&






A National System of Performance Evaluation

Activity Lines for the Promotion of SiVeAs (1) 2007 - 2008

I. Monitoring of National Health Care Entitlements (LEA) I.1 Health services demand and supply in regional healthcare systems

I.2 Regulation of healthcare service exchanges among regional healthcare systems

I.3 Healthcare service costs in regional healthcare systems

I.4 Waiting times

II. Efficiency promotion and evaluation II.1 Management of personnel

II.2 Management of goods and services purchase within SSN

II.3 Internal control systems

III. Effectiveness and Quality promotion and evaluation III.1 Outcome evaluation

III.2 Quality evaluation

IV. Appropriatenes promotion and evaluation

IV.1 Organisation appropriateness

IV.2 Clinical appropriateness

V. Accreditation and organisation of health care provision V.1 Accreditation of SSN providers

V.2 Organisation of health care provision



VI. Accessibility VI.1 Cost sharing

VI.2 “Libera professione”

VII. Long Term Care

VII.1 Planning and financing

VII.2 Organisation and management

VII.3 Evaluation

VIII. International comparisons and DB integration

VIII.1 LEA indicator system: Italy vs Europe

VIII.2 OCSE indicators: information requirements and analysis systems

IX. Tutorship to Regions with Budgetary Balance Plan (BBP)

IX.1 Central level tutorship

IX.2 Monitoring of BBP implementation

IX.3 Monitoring of BBP impact

IX.4 Regional level tutorship

IX.5 Partnership among regions


Activity Lines for the Promotion of SiVeAs (2) 2007 - 2008




Activity Matrix 2007 - 2008

Efficiency

in Resource Utilisation

Efficiency ,

effectiveness,

quality in the delivery of LEA

Applied to all Regions I. “Monitoring of

National Health

Care Entitlements

LEA”

VIII. “International

comparisons and

DB integration”

Applied to all Regions which receive central

funding for SSN

Applied to the group of Regions centrally

supported under a Budgetary Balance Plan

Applied to individual Regions centrally




Efficiency

in Resource Utilisation

Efficiency ,

effectiveness,

quality in the delivery of LEA

Applied to all Regions

I.1- National System of

Warranty and

Monitoring of Health

Care Services

VIII.1- LEA indicator

system: Italy vs

Europe

Applied to all Regions which receive central

funding for SSN

Applied to the group of Regions centrally


Applied to individual Regions centrally



Activity Matrix 2007 - 2008



Lea Committee



Institutional body created by the art. 9 Agreement State-Regions 23 March,2005 and

settled within the Ministry of Health, that:

33

Permanent Commitee for the audit of regional health systems

1. Assess the level of the provision of «Essential Levels of assistance» in each Region (excl. : Valle d’Aosta, Friuli Venezia Giulia, the autonomous Provinces of Trento and Bolzano and since 2010 Sardinia);

2. Monitors and assess the course of «Budgetary Balance Plan»;

3. Identifies the reference standards for the definition of medical staffing levels (cfr. paragraph 1 letter b) art.12 «Pacts for Health 2010-2012»);

4. Approval of co-financed projects.



Processes the data and information that each Region has to transmit to the Ministry of health in order to document its level of provision of the Lea

Assess regional actions aimed at covering regional pharmaceutical expenditure

Certificates the level of ‘Lea fulfilment’ (“adempimenti”) for each Region to be used by the ‘Tavolo Adempimenti’ at the Ministry of Economy and Finance in order to authorize the «award financial 3% share» (art. 12 Agreement 23 marzo 2005)

Permanent Commitee for the audit of regional health systems



Tools for the monitoring of «essential level of care» «Griglia LEA»

The level of “Lea fulfilment” by individual Region is measured according to the

”Lea assessment grid” (Griglia LEA):

an essential set of indicators +

a system of Lea specific weights (different weigth for each level of care: collective, district, hospitale care).

GOAL

Global vision of effective Lea provision through a final score



Lea assessment grid

Level of care N. Indicators Overall weight

Prevention 6 5

District care 9 10

Hospital care 6 10

The selection of the indicators included in the “Lea assessment grid” reflects, on the one hand, the allocation of SSN resources among the Lea and, on the other hand, the main political-planning indications.

The contents of the grid are reviewed and updated annually : indicators, weights and score thresholds used to assess individual Regional healthcare systems. The year 2010 “Lea fulfilments” assessment grid was prepared following the proposal by the Working Group for the “New warranty system”, then evaluated and confirmed by members of the Permanent Committee for the audit of regional health systems.



The set of «Griglia LEA» indicators, year 2010



Collective healthcare



District healthcare



Hospital care



Normal value 9

Minimal gap 6

Substantial gap in improvement

3

Not acceptable gap 0

Missing or wrong data -1

Evaluation Interval

Performing > 160

Verification over previous year and other Lea fulfilments

130 - 160

Critical < 130

global vision of effective Lea provision through a final weighted score based on : - the weight of each indicator - the score range assigned to the same regional value.

E’ positivo un punteggio regionale >160, in un range che varia da -25 a + 225

LEA assessment grid



N. Livello di

assistenza Definizione Peso

Punteggi di valutazione

Valore

normale 9

Scostament

o minimo

6

Scostament

o rilevante

ma in

migliorame

nto 3

Scostamento

non accettabile 0

Dato mancante o

palesemente

errato -

1

1 Prevenzione

Copertura vaccinale nei bambini a 24 mesi per ciclo

base (3 dosi) 1

tutte >=

95%

tutte >=

93% una < 93% più di 1 < 93%

Vaccinazioni raccomandate (MPR, influenza

nell’anziano)

0,2 >= 90% 87% -

90%

< 87% e in

aumento

< 87% e non in

aumento

0,2 >= 70% 60% -

70%

< 60% e in

aumento

< 60% e non in

aumento

2 Prevenzione

Proporzione di persone che ha effettuato test di

screening di primo livello, in un programma

organizzato, per cervice uterina, mammella, colon retto

0,6 score >= 9 score 7 - 8 score 5 - 6 score 0 - 4

3 Prevenzione Costo pro-capite assistenza collettiva in ambiente di

vita e di lavoro 1 >= 85 80 - 85

< 80 e in

aumento

< 80 e non in

aumento

mancante dopo

il 30 giugno o

espresso in altra

unità di misura

4

Prevenzione

salute nei

luoghi di

lavoro

Percentuale di imprese attive sul territorio controllate 0,5 >= 5,0% 2,5% -

5,0%

< 2,5% e in

aumento

< 2,5% e non in

aumento

mancante o

espresso in altra

unità di misura

5 Prevenzione

Percentuale di allevamenti controllati per TBC bovina 0,4 >= 98% 95% -

97,9%

90% -

94,9% < 90%

Percentuale di allevamenti controllati per brucellosi

ovicaprina, bovina bufalina 0,4 >= 98%

95% -

97,9%

90% -

94,9% < 90%

Percentuale di aziende ovicaprine controllate (3%) per

anagrafe ovicaprina 0,1 >= 98%

95% -

97,9%

90% -

94,9% < 90%

6 Prevenzione

Percentuale dei campioni analizzati su totale dei

campioni programmati

PIANO NAZIONALE RESIDUI (farmaci e

contaminanti negli alimenti di origine animale) -

Decreto legislativo 158/2006

0,3 >= 98% 90% -

97,9%

80% -

89,9% < 80%

Percentuale di campionamenti effettuati sul totale dei

programmati, negli esercizi di commercializzazione e

di ristorazione, articoli 5 e 6 del DPR 14/07/95

0,3 >= 70% 50% -

69,9%

30% -

49,9% < 30%

7 Distrettuale

Somma ponderata di tassi specifici per alcune

condizioni/patologie evitabili in ricovero ordinario:

asma pediatrico, complicanze del diabete, scompenso

cardiaco, infezioni delle vie urinarie, polmonite

batterica nell'anziano, BPCO. (Indice pesato per fasce

d'età)

1 <= 600 600 - 650

> 650 e in

diminuzion

e

> 650 e non in

diminuzione

8 Distrettuale

anziani Percentuali di anziani ≥ 65 anni trattati in ADI 1 >= 4% 3,5% - 4%

< 3,5% e in

aumento

< 3,5% e non in

aumento

indicatore

calcolato con

dati carenti o

incompleti

9 Distrettuale

anziani

Numero di posti equivalenti per assistenza agli anziani

in strutture residenziali ogni 1000 anziani residenti 1,25 >= 10 6 - 9,9

< 6 e in

aumento

< 6 e non in

aumento

indicatore

calcolato con

dati carenti o

incompleti

10 Distrettuale

disabili

Numero di posti equivalenti residenziali e

semiresidenziali in strutture che erogano assistenza ai

disabili ogni 1000 residenti

1 >= 0,6 0,5 - 0,59 < 0,5 e in

aumento

< 0,5 e non in

aumento

indicatore

calcolato con

dati carenti o

incompleti

11

Distrettuale

malati

terminali

Posti letto attivi in hospice sul totale dei deceduti

per tumore (per 100) 1 > 1

>= 0,5 e

in

aumento

>= 0,5 e

non in

aumento

< 0,5

indicatore

calcolato con

dati carenti o

incompleti

12 Distrettuale

farmaceutica

Costo percentuale dell’assistenza farmaceutica

territoriale (comprensiva della distribuzione

diretta e per conto)

2 <= 13,6 % 13,6% -

15%

> 15% e

in

diminuzio

ne

> 15% e non in

diminuzione

mancante dopo

il 30 giugno

13 Distrettuale Numero prestazioni specialistiche ambulatoriali

di risonanza magnetica per 100 residenti 0,75

5,1 - 7,5

estremi

inclusi

3 - 5,1 o

7,5 - 9

< 3 e in

aumento o

> 9 e non

in

aumento

< 3 e non in

aumento o > 9

e in aumento

14

Distrettuale

salute

mentale

Utenti presi in carico dai centri di salute mentale

per 100.000 ab. 1 >= 1.000

500 -

1.000

< 500 e in

aumento

< 500 e non in

aumento

dati mancanti o

palesemente

errati

15 Ospedaliera

Tasso di ospedalizzazione (ordinario e diurno)

standardizzato per 1.000 2 <= 180 180 - 190

>190 e

non in

aumento

>190 e in

aumento

Tasso di ricovero diurno di tipo diagnostico 1 <= 10 10 - 15

> 15 e in

diminuzio

ne

> 15 e non in

diminuzione

16 Ospedaliera Percentuale di ricoveri con DRG chirurgico in

regime ordinario sul totale dei ricoveri ordinari 1 >= 36%

33% -

36%

< 33% e

in

aumento

< 33% e non in

aumento

17 Ospedaliera

Tasso ospedalizz. stnd. di ricoveri ordinari (di 2 o

più giornate) attribuiti a DRG a alto rischio di

inappropriatezza (Patto della salute 2010-2012)

2 <= 23 23 - 27

> 27 e in

diminuzio

ne

> 27 e non in

diminuzione

18 Ospedaliera Percentuale parti cesarei 1 < 30% 30% -

35%

> 35% e

in

diminuzio

ne

(almeno

1%)

> 35% e non in

diminuzione di

almeno 1%

19 Ospedaliera

Percentuale di pazienti (età 65+) con diagnosi

principale di frattura del collo del femore operati

entro 3 giornate in regime ordinario (sono esclusi

decessi, dimissioni volontarie e trasferiti)

1 >= 60% 50% -

60%

< 50% e

in

aumento

< 50% e non in

aumento

20 Ospedaliera Degenza media trimmata standardizzata per case-

mix 2 <= 6 6 - 6,2

> 6,2 e

non in

aumento

> 6,2 e in

aumento

21 Emergenza Intervallo Allarme-Target dei mezzi di soccorso 1 <= 18 19 - 21 22 - 25 >= 26

La Griglia LEA - the evaluation thresholds




Hospital healthcare…examples

% caesarean

deliveries

% hip femur

fractures operated

within 48 hours, age

65 or older Indicatore dell’inappropriata

erogazione di parti cesarei



An important element ….. Lack of continuity of care (hospitalization rates for

avoidable pathologies)

Indicatore ospedaliero indiretto che valuta l’inefficacia dei servizi di prevenzione e specialistici

dedicate alla cura di alcune patologie.

Valore normale 9 Scostamento minimo

6 Scostamento rilevante ma

in miglioramento 3 Scostamento non

accettabile 0 Dato mancante o palesemente errato

-1

<= 600 600 - 650 > 650 e in

diminuzione

> 650 e non in

diminuzione

-

100,00

200,00

300,00

400,00

500,00

600,00

700,00

800,00

900,00

BPCO

Polmonite battericanell'anziano

Infezioni delle vie urinarie

Scompenso cardiaco

Complicanze a lungotermine tardive deldiabete

Complicanze a brevetermine del diabete

Asma pediatrica

Tassi di ospedalizzazione patologie evitabili - Anno 2010



District healthcare (1) - N° of bed in residential structures per 1.000 elderly (≥ 65 age)

ANNO 2009

Indicatore di offerta della residenzialità territoriale rispetto alla popolazione anziana




District healthcare (2)… other examples

Percentages of elderly ≥ 65 treated in

residential structures

Percentages of elderly ≥ 65

treated in Integrated home care Indicators for

elderly

services

utilization




> 1 >= 0,5 e in aumento >= 0,5 e non in

aumento < 0,5

indicatore calcolato con dati

carenti o incompleti

Valore normale 9 Scostamento minimo

6 Scostamento rilevante ma

in miglioramento 3 Scostamento non

accettabile 0 Dato mancante o palesemente errato

-1

Rates of Beds in terminally ills hospices over Deaths for cancer – Year 2010



Griglia LEA 2009 : results



Maintenance of the Lea provision

The reports with the results of the analyses based on the “Lea assessment

grid” for the years 2008 and 2009 are published on the portal of the Ministry

of Health:

http://www.salute.gov.it/programmazioneSanitariaELea/paginaInternaMenuProgrammazioneSanitariaELea.jsp?menu=lea&id=1301&lingua=italiano

Follows the indicators list

included in the Griglia Lea























Define the coaching for the Region involved in a BBP;

Identify actions needed to reach healthcare financial balance while guaranteeing the essential levels of care ( “Lea fulfilments”);

Define the procedure for the certification and the monitoring of the implementation process of the Budgetary Balance Plan;

A pact to three (as set out in Article 8 of the State-Regions in March 23, 2005) laid between the regions involved, Ministry of Economy and Finance and Ministry of Health to:

Define how the Region should make a survey over the causes of the healthcare deficit and design an operative program for the reorganization, requalification or upgrading of the Regional Health Service, lasting no more than three years.(the Budgetary Balance Plan: Piano Di Rientro);

Regions agreeing the BBP have access to “award financing share” , gradually and according to the results of the monitoring of the implementation of the content of the BBP , after a “starting share”

The Budgetary Balance Plan (BBP)




REGION AGREEMENT DATE ACT

LAZIO 28 FEBBRAIO 2007 DGR n. 149 del 6 marzo 2007

ABRUZZO 6 MARZO 2007 DGR n. 224 del 13 marzo 2007

CAMPANIA 13 MARZO 2007 DGR n. 460 del 20 marzo 2007

MOLISE 27 MARZO 2007 DGR n. 362 del 30 marzo 2007

SICILIA 31 LUGLIO 2007 DGR n. 312 del 1 agosto 2007

SARDEGNA 31 LUGLIO 2007 DGR n.30/33 del 2 agosto 2007

CALABRIA 17 DICEMBRE 2009 DGR n. 845 del 16/12/09 ad integrazione e modifica della DGR n.585 del 10/09/09 e della DGR n.752 del 18/11/09

PUGLIA 29 NOVEMBRE2010 DGR n. 2624 del 30/11/2010

Regions with a BBP

REGIONE DATA STIPULA DELL’ACCORDO CHE RECEPISCE IL

PIANO DELIBERA APPPROVAZIONE PIANO

LIGURIA 6 MARZO 2007 DGR n. 243 del 9 marzo 2007

PIEMONTE 29 LUGLIO 2010 DGR n. 415 del 02/08/2010

Central and Southern Regions

Northern Regions




BPP: State and Regions

Comitato Lea ex art. 9 Intesa 23 marzo 2005

Tavolo tecnico ex art.12 Intesa 23 marzo 2005

STEM ex art.3 Patto per la salute 2010-2012

Strutture tecniche paritetiche

Riunioni di Verifica, dell'andamento dei

PdR, congiunte, ordinariamente

trimestrali e annuali

Regione Amm. Centrali

•Ministero della salute

•Ministero delle economia e delle finanze

•Dipartimento degli Affari Regionali




The definition of targets follows a “multi-level path”: (i) identification of the relevant areas

(General Objectives) (ii) definition of specific objectives to be achieved through the

implementation of a series of operative actions.

General Aims

Hospital provision

District healthcare

Pharmaceutical expenditure

Staff costs

Purchasing of gooods and services

Common to all BBPs

Region specific

BPP: the objectives

Specific Aims

Intervention

Intervention

Intervention




Tools for the monitoring of «essential level of care»

Regional healthcare systems’ assessment: performance indicators




Regional healthcare systems’ assessment: performance indicators

•Fonte: Scuola Superiore Sant’Anna di Pisa




„Target‟ System

Performance evaluation system

From measurement To evaluation

Definition of 5 classes of

reference (quintiles)




Northern Regions (1/2)




Northern Regions (2/2)



Central Regions





Southern Regions (1/2)





Southern Regions (2/2)




Percentage shares of NHS funding:

a) 5% for Collective health care;

b) 51% for District health care;

c) 44% for Hospital care.

Towards Standard Costs

Decreto Legislativo 6 maggio 2011, n. 68



"definition and implementation of

adequate indicators of national health

planning in order to complete fiscal

federalism, to enable the regions to

ensure the efficient and appropriate

delivery of Lea“

Why Standards Cost?



The SSN funding…, is determined in the first phase of implementation beginning

since 2013, applying to all Italian regions the values costs recognized in

benchmark regions.

Benchmark regions are the three regions, including the first mandatory, which

have been chosen by the State-Regions Conference in a set of five regions

mentioned by the Ministry of Health, ..., as the top five regions, that ensuring the provision of essential levels of assistance in economic balance and with a positive assessment in Committee LEA evaluation, ..., are identified on the basis of quality,

appropriateness and efficiency criteria determined by decree of President of the

Council ....

The identification of the regions will reflect the need to ensure representativeness in

terms of geographical location to the north, center and south, with at least a small

geographic region.

Benchmark Regions



a)Collective health care;

b)District health care;

c) Hospital health care.

Standard costs are calculated at the aggregate level

for each of the three macro levels of assistance:

Standard Costs

The standard cost value is given, for each of the three macro levels of

health care provided in condition of efficiency and appropriateness, by the

weighted average cost per capita recorded of the benchmark regions.



Health Ministry role



This health system performance assessment

contributes to the achievement of public finance

objectives, including the reduction of health care

expenditure fixed on a yearly basis by the finance

bill (internal stability pact in accordance with the

stability and growth pact signed by our country in

the European Union).

Conclusions




Cabina di Regia 22 Maggio 2008

Thanks you for your attention

Lucia Lispi, Antonio Nuzzo

Rome - November 22, 2011

Italian-Moldavian Training Course on

“Health Financing and Auditing”

Performance evaluation systems and financing

lucia lispi, antonio nuzzo - ministero della salute · 2011-12-13 · back” tax on the national...

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