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Insurance companies' view on outpatient treatment
lNTERNAT,ONALJOURRILOF
Antimicrobial Agents ELSEVIER
International Journal of Antimicrobial Agents 5 (1995) 35-38
Insurance companies’ view on outpatient treatment J.A.M. van Adrichem* ANOVA Insurance Company, Van Asch van Wjckstraat 55, Postbus 19, 3800 HA Amersfoort, Netherlands
Received 26 July 1994; accepted 4 October 1994
Abstract Now that outpatient
treatment of bacterial infections is becoming a clinical reality for some patients, many medical insurance companies have expressed an interest in the increased patient benefits and reduced costs of this kind of patient care. The practicalities of transferring treatment to an outpatient setting and the regulations that would surround its initiation are discussed. Keywords:
Outpatient
parenteral antibiotic treatment (OPAT); Health insurance; Regulations
1. Introduction Outpatient treatment is an issue that interests most medical insurance companies - sickness funds as well as private insurance companies - for two reasons: firstly because the management is patient centred, and second, because outpatient treatment might be a cheaper alternative for more conventional methods of treatment; that is, there is a possible substitution of health-care functions. The strategic goals for any medical insurance company are shown in Table 1. At the ANOVA Insurance Company, the strategic goals are evaluated by stirnulating reallocation of healthcare functions from clinic to outpatient treatment, and, if possible, to home care. Outpatient and home care treatments are then compared with hospital care to see if they are equally effective and efficient. Among the questions asked are whether the standards or protocols used are based on good medical decision theories, and whether adequate agreements regarding quality of care have been made by all professionals and organizations involved. Finally, an acceptable price level is calculated before it is decided which professionals and organizations will give the appropriate care for the given price.
*Tel. (+31-33) 646911; Fax (+31-33) 612733 and Tel. (+31-30) 825574; Fax (+31-30) 825650. 0924-8579/95/$29.00 0 1995 Elsevier Science B.V. All rights reserved SSDI 0924-8579(94)00054.-9
This process can be summarized in the words ‘costbenefit analysis’ or ‘medical technology assessment’.
2. Different approaches to patient care From an insurer’s point of view, there are four possible ways to give a patient parenteral antibiotic therapy. The advantages and disadvantages of these are shown below. (a) Historically, this therapy is given inclinic following admittance to hospital. In this case, high quality professional standards are seen but relatively low appreciation by the patient for the clinic environment and high costs. (b) Treatment can also be given via hospital-based homecare by the hospital organization at the home of the patient. This results in high professional quality, high client appreciation and lower costs. (c) When complex parenteral antibiotic therapy only was given at the patient’s home by extramural professionals, and others such as pharmacists, home nursing organizations and the general practitioner, then the professional quality needed extra attention; the patient’s appreciation, however, was much higher because he could stay at home, and costs were lower.
36
J.A.M. van Adrichemllnternational Journal of Antimicrobial Agents 5 (1995) 35-38
Table 1 Strategic goals for medical insurance companies To give the insured persons a good professional qualified care e.g. are the right antibiotics given via good quality pumps, administered by a qualified nurse or doctor? To give them care on a good customer service level e.g. is the care given in a place the patient likes? Has he had to wait long? Is the communication good between doctor and patient? To give them the care they need (no less and no more): to ensure a good availability e.g. are there sufficient hospital beds, doctors, home nursing organizations available in a region in relation to the needs of the population of that region? To give them this care for a competitive premium (or contribution)
Higher quality might be achieved when all involved professionals are willing to use a treatment protocol, under the responsibility of the general practitioner with the possibility of consulting a specialist. (d) Finally, the treatment may be given via a predefined cooperation between the hospital, specialist and extramural professionals and organizations such as the general practitioner and professional homecare organizations. In this case one could have the optimum balance between quality, client appreciation and costs, We favour this last option which is based on true transmural cooperation between all the groups involved, with clear agreement about the role each has to play. This should ensure continuity and high quality treatment and care. The last approach agrees with the ideas that are postulated by the Biesheuvel committee, a Dutch governmental committee that advises on health care by specialists, hospitals and general practitioners. In the coalition agreement of August 1994 this advice led to a health-care reform policy. New forms of health-care functions should be continually developed between inclinic treatment and home care by general practitioners.
3. Practical difficulties A number of practical difficulties need to be resolved before any proposed outpatient treatment scheme can be put into general use. (1) Hospital specialists must agree to spend the necessary time consulting patients at home or consulting with their general practitioner. General practitioners and home nursing organizations may have to improve their quality in medical and nursing practice especially in areas that are new to them. (2) Standardization
of the delivery of pharmaceutical
preparations and the devices one needs for administration of the medications may also be needed. (3) The medical responsibilities of specialists compared with general practitioners for the care given at a patient’s home need to be redefined, while the pharmaceutical competence of the outclinic pharmacist versus the hospital pharmacist should be assessed. (4) There are a number of legislative matters that need to be considered which can make it difficult to innovate health-care functions. These are shown in Table 2.
4. Current status An overview of the possibilities of administering parenteral antimicrobial agents at home must centre on cystic fibrosis patients, where most research has been performed. Cystic fibrosis patients require frequent hospitalization for the treatment of bacterial infections. Many of those infections can be treated at home using new parenteral application systems. A variety of pump systems, suitable for using at home accompanied by the aid of specialized nursing personnel, are now available. Several studies have been performed in cystic fibrosis patients in The Netherlands. In Leiden, a research group acquired funds from the Sickness Fund Council for an
Table 2 Legislative issues in outpatient treatment Central governmental planning cannot easily lead to reallocation of hospital beds to beds at home. Reallocation of funds may be difficult or impossible. The current way of financing health care in The Netherlands appears to indicate that each payment of extra hospital activities leads to higher overall costs of health care despite the lower actual costs of those activities.* The budget structure of the sickness funds means that when efforts are made to introduce substitution of patient management the funds are unable to compensate for their additional personnel costs by using the savings produced by lower health-care costs. The obligation of the insurance company to ensure professional medical care, and the claim with which the insured confronts the insurance company for having treatment at home. When a medicine, medical device or service that is needed for the application of that medicine is not described in rules as an insurer’s right, then the insurance company is not allowed to pay for this, owing to the AWBZ (a law by which each inhabitant has rights to medicines and special devices). *Because of the budget structure of the hospitals in The Netherlands, when less is done by the hospitals and more by home-care organizations and general practitioners, the hospital budget will not be appropriately decreased.
.KA.M. van Adrichemllnternational Journal of Antimicrobial Agents 5 (1995) 35-38
experiment with outpatient treatment with parenteral antimicrobial therapy (see article by Wijlhuizen et al. in this issue) [ 11. Patients were included if: they required parenteral antimicrobial therapy for longer than 14 days they had good eyesight and undisturbed hand function a protocol describing th(e responsibilities of the hospital specialist, general practitioner, pharmacist, nurse and family members was provided all treatment was decided by the hospital specialist who had the responsibility for starting, controlling, changing and stopping therapy all infusions, medicines and infusion devices, elastomere balloon pumps, portable electric pumps etc. were provided by the pharmacist or a relevant commercial organization. In this trial, 48 patients received 54 treatments in 15 months. A further 171 patients were refused admittance to the project, in 50% of cases because of lack of adequate family support. In Groningen, a government-funded (WVC) project involved two hospitals and KITTZ (a quality institute for innovations in home care) [2]. The study had three important aims. l to make a child with cystic fibrosis independent of its disease l to make the child and family maximally self-supporting l to integrate outpatient antimicrobial treatment into the normal health-care facilities In this trial, 34 cystic fibrosis patients received a total of 135 treatments. The results showed that outpatient treatment was as effective as hospital treatment, while the quality of life of pati’ents treated at home was improved. A further multicentre trial has been performed in centres in The Hague and Amsterdam [3]. Here, 24 cystic fibrosis patients received 45 treatments during an average of 21.5 days. In this study, a cost analysis was made to compare the costs of hospital treatment and outpa-
Table 3 Cost analysis comparing the costs of outpatient and hospital antimicrobial treatment in cystic fibrosis patients Charges
Outpatient treatment sickness fund private patient
NLG = Dutch guilders NLG 9800 NLG 9950
Hospital treatment (price Leyenburg Hospital) sickness fund NLG 18 950 private patient NLG 20 200 Real costs
outpatient treatment hospital treatment
NLG 10 250 NLG 17 650
31
tient treatment (based on 21 days’ treatment). The results are shown in Table 3. In this study the outpatient treatment was organized by the hospital; only in exceptions was a specialized nurse needed. Currently in Utrecht (see article by van der Laag et al. in this issue), a project is being carried out in which paediatricians, general practitioners, pharmacists, district nurses and physiotherapists are working together to provide outpatient antimicrobial treatment. Treatment starts in the clinic and after 3 or 4 days is transferred to the child’s home. The antimicrobial agents are prepared by the pharmacist who is paid by the insurance company; the pumps are supplied by the insurance company or hired directly from a supplier. A specialized hospital nurse is available for parental instruction and consultation before starting home treatment.
5. Conclusions The results of these studies appear to support the feasibility of outpatient antimicrobial therapy. Already, ANOVA has begun supplying pumps for the administration of chemotherapeutics in neoplastic diseases (see article by Witteveen in this issue), five of which are stationed at the academic hospital of Utrecht. For pain relief, ANOVA also has several pumps for parenteral administration of analgesic drugs, and the company has supplied electric pumps for antimicrobial agents several times. ANOVA has developed links with a pharmacist who is able to prepare the medication if the patient’s regular pharmacist is unable to do so. While at present, AWBZ regulations prohibit insurance payments for pump systems for antimicrobial agents, it is possible to provide solutions to help the patients who require them. In The Netherlands, an estimated 1000 cystic fibrosis patients will require parenteral antimicrobial agents at some stage in their life and it is clear that this is not a minor health-care problem. ANOVA is currently promoting the idea that such patients can and should be treated at home. To achieve this, agreements are being drawn up with specialists and hospitals about: the selection of patient groups suitable for this treatment the protocols to be used the organization of this kind of patient management the selection of suppliers of medications and homecare technology. In this selection, quality and the price of the products will play an important role. We invite the group that started this development to give, in cooperation with ANOVA, a solid base for this outpatient treatment, so we can pass through the experimental phase. This should enable us to join our strategic goals with the patients’ wishes and the professionals’ knowledge and skills.
38
J.A.M.
van Adrichemllnternational
Journal of Antimicrobial Agents 5 (1995) 35-38
References [1] Van den Broek PJ, Wijlhuizen ThJ, van Haaren CPLC. Thuisbehandeling met parenterale antibiotica; een nieuwe ontwikkeling. Mod Med 1994;560&563. [2] Bosma ES, Thie J, Heymans HSA. Introductie van geavanceerde
apparatuur in de thuissituatie. Ned Tijdschr Geneeskd 1993;137:248&2482. [3] Bakker W, Vinks AATMM, Mouton JW et al. Continue intraveneuze thuisbehandeling van luchtweginfecties met ceftazidim via een draagbare pomp bij patienten met cystische fibrosis; een multicentrisch onderzoek. Ned Tijdschr Geneeskd 1993;137:24862491.
Antimicrobial Agents ELSEVIER
International Journal of Antimicrobial Agents 5 (1995) 35-38
Insurance companies’ view on outpatient treatment J.A.M. van Adrichem* ANOVA Insurance Company, Van Asch van Wjckstraat 55, Postbus 19, 3800 HA Amersfoort, Netherlands
Received 26 July 1994; accepted 4 October 1994
Abstract Now that outpatient
treatment of bacterial infections is becoming a clinical reality for some patients, many medical insurance companies have expressed an interest in the increased patient benefits and reduced costs of this kind of patient care. The practicalities of transferring treatment to an outpatient setting and the regulations that would surround its initiation are discussed. Keywords:
Outpatient
parenteral antibiotic treatment (OPAT); Health insurance; Regulations
1. Introduction Outpatient treatment is an issue that interests most medical insurance companies - sickness funds as well as private insurance companies - for two reasons: firstly because the management is patient centred, and second, because outpatient treatment might be a cheaper alternative for more conventional methods of treatment; that is, there is a possible substitution of health-care functions. The strategic goals for any medical insurance company are shown in Table 1. At the ANOVA Insurance Company, the strategic goals are evaluated by stirnulating reallocation of healthcare functions from clinic to outpatient treatment, and, if possible, to home care. Outpatient and home care treatments are then compared with hospital care to see if they are equally effective and efficient. Among the questions asked are whether the standards or protocols used are based on good medical decision theories, and whether adequate agreements regarding quality of care have been made by all professionals and organizations involved. Finally, an acceptable price level is calculated before it is decided which professionals and organizations will give the appropriate care for the given price.
*Tel. (+31-33) 646911; Fax (+31-33) 612733 and Tel. (+31-30) 825574; Fax (+31-30) 825650. 0924-8579/95/$29.00 0 1995 Elsevier Science B.V. All rights reserved SSDI 0924-8579(94)00054.-9
This process can be summarized in the words ‘costbenefit analysis’ or ‘medical technology assessment’.
2. Different approaches to patient care From an insurer’s point of view, there are four possible ways to give a patient parenteral antibiotic therapy. The advantages and disadvantages of these are shown below. (a) Historically, this therapy is given inclinic following admittance to hospital. In this case, high quality professional standards are seen but relatively low appreciation by the patient for the clinic environment and high costs. (b) Treatment can also be given via hospital-based homecare by the hospital organization at the home of the patient. This results in high professional quality, high client appreciation and lower costs. (c) When complex parenteral antibiotic therapy only was given at the patient’s home by extramural professionals, and others such as pharmacists, home nursing organizations and the general practitioner, then the professional quality needed extra attention; the patient’s appreciation, however, was much higher because he could stay at home, and costs were lower.
36
J.A.M. van Adrichemllnternational Journal of Antimicrobial Agents 5 (1995) 35-38
Table 1 Strategic goals for medical insurance companies To give the insured persons a good professional qualified care e.g. are the right antibiotics given via good quality pumps, administered by a qualified nurse or doctor? To give them care on a good customer service level e.g. is the care given in a place the patient likes? Has he had to wait long? Is the communication good between doctor and patient? To give them the care they need (no less and no more): to ensure a good availability e.g. are there sufficient hospital beds, doctors, home nursing organizations available in a region in relation to the needs of the population of that region? To give them this care for a competitive premium (or contribution)
Higher quality might be achieved when all involved professionals are willing to use a treatment protocol, under the responsibility of the general practitioner with the possibility of consulting a specialist. (d) Finally, the treatment may be given via a predefined cooperation between the hospital, specialist and extramural professionals and organizations such as the general practitioner and professional homecare organizations. In this case one could have the optimum balance between quality, client appreciation and costs, We favour this last option which is based on true transmural cooperation between all the groups involved, with clear agreement about the role each has to play. This should ensure continuity and high quality treatment and care. The last approach agrees with the ideas that are postulated by the Biesheuvel committee, a Dutch governmental committee that advises on health care by specialists, hospitals and general practitioners. In the coalition agreement of August 1994 this advice led to a health-care reform policy. New forms of health-care functions should be continually developed between inclinic treatment and home care by general practitioners.
3. Practical difficulties A number of practical difficulties need to be resolved before any proposed outpatient treatment scheme can be put into general use. (1) Hospital specialists must agree to spend the necessary time consulting patients at home or consulting with their general practitioner. General practitioners and home nursing organizations may have to improve their quality in medical and nursing practice especially in areas that are new to them. (2) Standardization
of the delivery of pharmaceutical
preparations and the devices one needs for administration of the medications may also be needed. (3) The medical responsibilities of specialists compared with general practitioners for the care given at a patient’s home need to be redefined, while the pharmaceutical competence of the outclinic pharmacist versus the hospital pharmacist should be assessed. (4) There are a number of legislative matters that need to be considered which can make it difficult to innovate health-care functions. These are shown in Table 2.
4. Current status An overview of the possibilities of administering parenteral antimicrobial agents at home must centre on cystic fibrosis patients, where most research has been performed. Cystic fibrosis patients require frequent hospitalization for the treatment of bacterial infections. Many of those infections can be treated at home using new parenteral application systems. A variety of pump systems, suitable for using at home accompanied by the aid of specialized nursing personnel, are now available. Several studies have been performed in cystic fibrosis patients in The Netherlands. In Leiden, a research group acquired funds from the Sickness Fund Council for an
Table 2 Legislative issues in outpatient treatment Central governmental planning cannot easily lead to reallocation of hospital beds to beds at home. Reallocation of funds may be difficult or impossible. The current way of financing health care in The Netherlands appears to indicate that each payment of extra hospital activities leads to higher overall costs of health care despite the lower actual costs of those activities.* The budget structure of the sickness funds means that when efforts are made to introduce substitution of patient management the funds are unable to compensate for their additional personnel costs by using the savings produced by lower health-care costs. The obligation of the insurance company to ensure professional medical care, and the claim with which the insured confronts the insurance company for having treatment at home. When a medicine, medical device or service that is needed for the application of that medicine is not described in rules as an insurer’s right, then the insurance company is not allowed to pay for this, owing to the AWBZ (a law by which each inhabitant has rights to medicines and special devices). *Because of the budget structure of the hospitals in The Netherlands, when less is done by the hospitals and more by home-care organizations and general practitioners, the hospital budget will not be appropriately decreased.
.KA.M. van Adrichemllnternational Journal of Antimicrobial Agents 5 (1995) 35-38
experiment with outpatient treatment with parenteral antimicrobial therapy (see article by Wijlhuizen et al. in this issue) [ 11. Patients were included if: they required parenteral antimicrobial therapy for longer than 14 days they had good eyesight and undisturbed hand function a protocol describing th(e responsibilities of the hospital specialist, general practitioner, pharmacist, nurse and family members was provided all treatment was decided by the hospital specialist who had the responsibility for starting, controlling, changing and stopping therapy all infusions, medicines and infusion devices, elastomere balloon pumps, portable electric pumps etc. were provided by the pharmacist or a relevant commercial organization. In this trial, 48 patients received 54 treatments in 15 months. A further 171 patients were refused admittance to the project, in 50% of cases because of lack of adequate family support. In Groningen, a government-funded (WVC) project involved two hospitals and KITTZ (a quality institute for innovations in home care) [2]. The study had three important aims. l to make a child with cystic fibrosis independent of its disease l to make the child and family maximally self-supporting l to integrate outpatient antimicrobial treatment into the normal health-care facilities In this trial, 34 cystic fibrosis patients received a total of 135 treatments. The results showed that outpatient treatment was as effective as hospital treatment, while the quality of life of pati’ents treated at home was improved. A further multicentre trial has been performed in centres in The Hague and Amsterdam [3]. Here, 24 cystic fibrosis patients received 45 treatments during an average of 21.5 days. In this study, a cost analysis was made to compare the costs of hospital treatment and outpa-
Table 3 Cost analysis comparing the costs of outpatient and hospital antimicrobial treatment in cystic fibrosis patients Charges
Outpatient treatment sickness fund private patient
NLG = Dutch guilders NLG 9800 NLG 9950
Hospital treatment (price Leyenburg Hospital) sickness fund NLG 18 950 private patient NLG 20 200 Real costs
outpatient treatment hospital treatment
NLG 10 250 NLG 17 650
31
tient treatment (based on 21 days’ treatment). The results are shown in Table 3. In this study the outpatient treatment was organized by the hospital; only in exceptions was a specialized nurse needed. Currently in Utrecht (see article by van der Laag et al. in this issue), a project is being carried out in which paediatricians, general practitioners, pharmacists, district nurses and physiotherapists are working together to provide outpatient antimicrobial treatment. Treatment starts in the clinic and after 3 or 4 days is transferred to the child’s home. The antimicrobial agents are prepared by the pharmacist who is paid by the insurance company; the pumps are supplied by the insurance company or hired directly from a supplier. A specialized hospital nurse is available for parental instruction and consultation before starting home treatment.
5. Conclusions The results of these studies appear to support the feasibility of outpatient antimicrobial therapy. Already, ANOVA has begun supplying pumps for the administration of chemotherapeutics in neoplastic diseases (see article by Witteveen in this issue), five of which are stationed at the academic hospital of Utrecht. For pain relief, ANOVA also has several pumps for parenteral administration of analgesic drugs, and the company has supplied electric pumps for antimicrobial agents several times. ANOVA has developed links with a pharmacist who is able to prepare the medication if the patient’s regular pharmacist is unable to do so. While at present, AWBZ regulations prohibit insurance payments for pump systems for antimicrobial agents, it is possible to provide solutions to help the patients who require them. In The Netherlands, an estimated 1000 cystic fibrosis patients will require parenteral antimicrobial agents at some stage in their life and it is clear that this is not a minor health-care problem. ANOVA is currently promoting the idea that such patients can and should be treated at home. To achieve this, agreements are being drawn up with specialists and hospitals about: the selection of patient groups suitable for this treatment the protocols to be used the organization of this kind of patient management the selection of suppliers of medications and homecare technology. In this selection, quality and the price of the products will play an important role. We invite the group that started this development to give, in cooperation with ANOVA, a solid base for this outpatient treatment, so we can pass through the experimental phase. This should enable us to join our strategic goals with the patients’ wishes and the professionals’ knowledge and skills.
38
J.A.M.
van Adrichemllnternational
Journal of Antimicrobial Agents 5 (1995) 35-38
References [1] Van den Broek PJ, Wijlhuizen ThJ, van Haaren CPLC. Thuisbehandeling met parenterale antibiotica; een nieuwe ontwikkeling. Mod Med 1994;560&563. [2] Bosma ES, Thie J, Heymans HSA. Introductie van geavanceerde
apparatuur in de thuissituatie. Ned Tijdschr Geneeskd 1993;137:248&2482. [3] Bakker W, Vinks AATMM, Mouton JW et al. Continue intraveneuze thuisbehandeling van luchtweginfecties met ceftazidim via een draagbare pomp bij patienten met cystische fibrosis; een multicentrisch onderzoek. Ned Tijdschr Geneeskd 1993;137:24862491.