Introduction of Complex Capitation Standard Rate (CCSR) in outpatient care organizations

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Introduction of Complex Capitation Standard Rate
(CCSR) in outpatient care organizations
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Network public MOs, rendering OPP
polyclinics-361
Womens health centres under obstetric
organizations-26 Perinatal centres-16 Maternity
hospitals-10
PD of dispensary with beds -130 TB
dispensary-51 Oncologic-17 Dermatovenerologic-20 P
sychoneurologic-18 Endocrinological
-1 Narcological -19 Cardiologic dispensary -4
CPMSH -15
OC-1086
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Network of ??s, rendering PHC, on the situation
on January 1, 2013
Total- 2206
Outpatient-polyclinic organizations 612
PD and OC of hospital organizations 1304
Municipal polyclinics 119
CDC 3
PD of city hospitals 20
PD of CRH, RH, VH 192
Child polyclinics 14
CRP, RP, VP 36
CPMSH 17
OC 409
CPMSH - 10
OC 1082
Private OPO 1082
MW without rooms 128
?S, village first-aid station - 4311
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Independent organizations, rendering PHC
Total number of organizations 363
City184
Village179
MP 122
OC12
CRH133
VH 5
CPMSH 9
CDC 3
RP 29
RH 12
CP14
MH 24
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Medical organizations, providing CDS

Total- 399
Outpatient-polyclinic organizations -174
Polyclinic departments (PD) of hospital
organizations - 225
Pediatric polyclinics - 14
Municipal polyclinics - 124
PD of regional hospitals - 12
PD of regional pediatric hospitals - 16
PD of city hospitals - 30
RP - 25
CDC -11
PD of CRH, RH - 158
PD of VH - 9
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NETWORK OF ORGANIZATIONS, PROVIDING PHC. EXAMPLE
OF ZHAMBYL REGION.
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NETWORK OF ORGANIZATIONS, PROVIDING PHC. EXAMPLE
OF KARAGANDA REGION
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Tasks and objectives
Objective Improving availability and
quality of primary medical and sanitary care by
introducing economic incentives Tasks 1.
Stimulating preventing direction in work of PMSC
organizations 2. Expanding the range of primary
medical and sanitary help services 3. Provision
of rational and effective usage of means
dedicated for outpatient-polyclinic and hospital
care 4. Increasing payment of PMSC workers by
introducing economic incentive mechanisms
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Stimulating preventing direction in work of PMSC
organizations

• Covering not lesser than 70 of target group of
  assigned population with screening assays
• Increasing the number of diseases detected at
  early stage
• Decreasing the number of chronic non-contagious
  diseases and their complications by integrating
  the chronic diseases management program
• Systematic explanatory and promotion work with
  population on disease preventing and forming
  healthy lifestyle

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Expanding the range of primary medical and
sanitary care services

• 1. Delegation of consultative and practical
  skills on most frequent diseases from dedicated
  experts (subject matter experts) to the
  specialists of PMSC
• cardiology hypertension, CHD
• endocrinology hypothyroidism, diabetes
• gastroenterology ulcer, gastritis,
  duodenitis and hepatitis
• ophthalmology conjunctivitis
• neurology acute cerebrovascular disease,
  root disorders
• pulmonology pneumonia, COPD, bronchial
  asthma
• obstetrics and gynecology pregnancy
  follow-up
• 2. Expanding SMW powers and independence
• - independent admission of patients
  including case follow-up of dispensary patients
• - being able to use basic practical skills
  in surgery and obstetrics and gynecology
• - providing services for house-calls
• - prenatal nursing, postnatal nursing,
  nursing of healthy children younger that 1 year,
  patients with chronic diseases
• - consulting on disease prevention and
  healthy lifestyle, social and psychological help

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Provision of rational and effective usage of
means dedicated for outpatient-polyclinic and
hospital care

• Decreasing the number of unreasonable
  hospitalizations to twenty-four hour hospitals
• Decreasing CDS consumption
• Decreasing the number of emergency calls in PMSC
  organizations working hours

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Increasing payment of PMSC workers by introducing
economic incentive mechanisms

• Introduction of differentiated payment for
  doctors and SMW work for
• expanding the list of consultative and diagnostic
  and practical skills
• expanding prevention direction of work (covering
  not lesser than 70 of assigned population with
  preventive activities)
• reaching basic indicators of productivity of PMSC
  activity

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Primary medical and sanitary care
Article 45 of Code on Health and Healthcare System
Premedical, qualified medical care without
twenty-four hour medical observation, including
complex of available medical services, provided
at the levels of person, family and society 1)
diagnostics and treatment of most common
ailments, as well as of traumas, poisonings and
other emergencies 2) sanitary and anti-epidemic
(preventive) activities in sites of diseases 3)
hygienic education of population, family,
maternity, paternity and child welfare
services 4) explanatory work on safe water
supply and nutrition
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Capitation standard rate for 2000-2200 population
Existing functions of PHC
Problems

• lack of doctors
• lines in polyclinics
• poor quality of medical care

• premedical, qualified medical care,
• examining patients for detecting ailments at an
  early stage,
• appointment for hospitalization,
• chronically ill patients for preventive medical
  examination,
• rehabilitation treatment,
• provision of medicines.

assigned population using PHC
Expanding functions of PHC
Solutions
Complex capitation standard rate

• making requirements for doctor and SMW training
  stricter
• SMW status reinforcement
• extending the staff size of SMW and keeping the
  relation between them in balance
• improving the level of doctor and SMW training
• improving the level and the quality of care
  workers and psychologists work
• increasing payments by integrating
  differentiated payment for doctors and SMW work
  for expanding their functions and achieving
  targeted results

• decreasing the number of common chronic
  manageable diseases (CMD) at PHC level
• systematic, explanatory, promotion work with
  population on disease prevention and forming
  healthy lifestyle
• transferring focus from ill patients onto
  protection of healthy population
• delegation of powers from dedicated expert to
  the specialists of PHC
• expanding SMW powers and independence
• strengthening social orientation of PHC

assigned population using PHC, primarily with
preventive purposes
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Pilot studies results

• on the example of pilot MO municipal polyclinic
  ?8 of ?stana general practitioners actual
  salary rose 2.2 times, therapists 2.0 times and
  pediatrists 1.6 times, nurses actual salary
  rose 2.3 times therapist nurses 2.1 times
  pediatrists nurses 1.6 times

MP ?8 General practice General practice General practice Therapy Therapy Therapy Pediatrics Pediatrics Pediatrics
Salary calculations Base salary Additional salary Total Base salary Additional salary Total Base salary Additional salary Total
Doctor 85000 102330 187330 80000 85850 165850 80000 52180 132180
Nurse 65000 87280 152280 60000 68680 128680 60000 37060 97060
on the example of pilot MO Taiynshyn CRH, NKR
general practitioners actual salary rose 2.9
times, therapists 2.5 times and pediatrists
2.3 times, nurses actual salary rose 3 times
therapist nurses 2.4 times pediatrists nurses
2.5 times (CCSR equals to 1221,12)
General practice General practice General practice Therapy Therapy Therapy Pediatrics Pediatrics Pediatrics
Salary calculations Actual (without AGC) With AGC (CCSR 1196,98) With AGC (CCSR 1221,12) Actual (without AGC) With AGC (CCSR 1196,98) With AGC (CCSR 1221,12) Actual (without AGC) With AGC (CCSR 1196,98) With AGC (CCSR 1221,12)
Doctor 110428 166122 328922 110428 143095 283328 110428 130461 258313
Nurse 70941 109775 217354 70941 87224 172704 70941 91468 181106
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CCSR fund distribution (on the example of MP ?8)

• 491890 tenge one divisions salary fund per
  month (1 doctor 2-3 SMW), consists of
• 215000 base actual salary (as of today on
  actual basis)
• 276890 additional actual salary (per 1 doctor
  and 2 SMW)
• () For reaching lowest acceptable level of
  indicators
• (-) In case of not reaching or partially reaching
  lowest acceptable level of indicators, financial
  means are redirected to divisions with better
  results (of lowest acceptable level)

Additional salary fund 276890 KZT 56 Base
salary fund 215000 KZT 44
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Expenses structure (on the example of pilot
organization municipal polyclinic ?8, Astana)
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Relation between PHC/CDPexpenses on the example
of pilot MO MP ?8 of Astana
Additional 95 tenge per one assigned person per
month
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Differentiation of PHC and CDP services, included
to CCR (896 KZT)

• PHC 55 services
• (596 KZT)
• Doctor admissions
• General clinic examinations
• Biochemical examinations
• ECG
• Bacteriologic examinations
• Immunoprophylaxis
• Procedures and operations

• CDP all the other services including high-cost
  services (300 KZT)
• Specialized doctors admissions
• Extended biochemical examinations
• Radiologic examinations
• Ultrasound
• Function studies
• Procedures and operations
• Primary surgical treatment of wounds, cast
  application/removal

• High-cost services (are limited by the local
  executive bodies) for certain population classes
• PCR, angiography, PET, CT, medicogenetic
  examinations and others in accordance with the
  GVFMC

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PHC volume within the GVFMC
Service name For healthy persons For patients with acute forms of chronic diseases For children under 18 For pregnant women
Prevention Carrying out activities on health protection and promotion, informing population on healthy lifestyle, healthy nutrition, planning family Carrying out activities on health protection and promotion, informing population on healthy lifestyle, healthy nutrition, planning family Carrying out activities on health protection and promotion, informing population on healthy lifestyle, healthy nutrition, planning family Carrying out activities on health protection and promotion, informing population on healthy lifestyle, healthy nutrition, planning family
Prevention Teaching sanitary-hygienic skills of teeth and mucous tunic of mouth care Teaching sanitary-hygienic skills of teeth and mucous tunic of mouth care Teaching sanitary-hygienic skills of teeth and mucous tunic of mouth care Teaching sanitary-hygienic skills of teeth and mucous tunic of mouth care
Prevention Preventive medical surveys of targeted population groups in accordance with the order set by the authorized body Preventive medical surveys of targeted population groups in accordance with the order set by the authorized body Preventive medical surveys of targeted population groups in accordance with the order set by the authorized body Preventive medical surveys of targeted population groups in accordance with the order set by the authorized body
Prevention Doing preventive injections against infections and infestations, according to the National Calendar of Immunization Doing preventive injections against infections and infestations, according to the National Calendar of Immunization Doing preventive injections against infections and infestations, according to the National Calendar of Immunization
Prevention Children, including infants nursing Nursing of the pregnant
Prevention Sanitary and anti-epidemic (preventive) activities in sites of contagious diseases Sanitary and anti-epidemic (preventive) activities in sites of contagious diseases Sanitary and anti-epidemic (preventive) activities in sites of contagious diseases Sanitary and anti-epidemic (preventive) activities in sites of contagious diseases
Prevention Teaching patients and their family members to self-control, self, and mutual care Teaching patients and their family members to self-control, self, and mutual care Teaching patients and their family members to self-control, self, and mutual care Teaching patients and their family members to self-control, self, and mutual care
Prevention Trainings in prophylactic rooms, health promotion schools. Trainings in prophylactic rooms, health promotion schools. Trainings in prophylactic rooms, health promotion schools.
Prevention Telephone consultation of people, taking part in ailments management program (AMP) Telephone consultation of people, taking part in ailments management program (AMP) Telephone consultation of people, taking part in ailments management program (AMP)
Prevention Sociomedical and psychological services on prescription. Sociomedical and psychological services on prescription. Sociomedical and psychological services on prescription.
Prevention Primary prevention Dispensary admission and case follow-up. Primary and secondary prevention of illnesses for dispensary cases. Dispensary admission and case follow-up. Primary and secondary prevention of illnesses for dispensary cases. Dispensary admission and case follow-up. Primary and secondary prevention of illnesses for dispensary cases.
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PHC volume within the GVFMC
Service name For healthy persons For patients with acute forms of chronic diseases For children under 18 For pregnant women
Diagnostics Admission and consultation Admission and service at home Admission and service at home Admission and service at home
Diagnostics Laboratory and diagnostic examinations with PHC specialist referral at hand Laboratory and diagnostic examinations with PHC specialist referral at hand Laboratory and diagnostic examinations with PHC specialist referral at hand Laboratory and diagnostic examinations with PHC specialist referral at hand
Diagnostics General blood and urine test General blood and urine test General blood and urine test General blood and urine test
Diagnostics Vaginal smear microscopy Vaginal smear microscopy and vagina sanitation
Diagnostics Sputum analysis for TB detection (smear microscopy) Sputum analysis for TB detection (smear microscopy) Sputum analysis for TB detection (smear microscopy) Sputum analysis for TB detection (smear microscopy)
Diagnostics HIV-infection and Wassermann reaction blood sampling HIV-infection and Wassermann reaction blood sampling HIV-infection and Wassermann reaction blood sampling HIV-infection and Wassermann reaction blood sampling
Diagnostics Microreaction, statoscopy Microreaction, statoscopy Microreaction, statoscopy Microreaction, statoscopy
Diagnostics Material sampling for microbiologic examinations Material sampling for microbiologic examinations Material sampling for microbiologic examinations
Diagnostics Biochemical examinations blood clotting time, bleeding time, bile pigments in urine, cholesterol, tryglycerides, blood sugar (express-methods with test system usage ) Biochemical examinations blood clotting time, bleeding time, bile pigments in urine, cholesterol, tryglycerides, blood sugar (express-methods with test system usage ) Biochemical examinations blood clotting time, bleeding time, bile pigments in urine, cholesterol, tryglycerides, blood sugar (express-methods with test system usage )
Diagnostics Electrocardiogram Electrocardiogram Electrocardiogram
Diagnostics Fluorography Fluorography Fluorography from 15 years
Treatment First aid when necessary First aid when necessary First aid when necessary First aid when necessary
Treatment Medication treatment prescription intravenous, intramuscular, hypodermic injection on prescription immobilization (application of gauze bandage casts, splints) on prescription Medication treatment prescription intravenous, intramuscular, hypodermic injection on prescription immobilization (application of gauze bandage casts, splints) on prescription Medication treatment prescription intravenous, intramuscular, hypodermic injection on prescription immobilization (application of gauze bandage casts, splints) on prescription Medication treatment prescription intravenous, intramuscular, hypodermic injection on prescription immobilization (application of gauze bandage casts, splints) on prescription
Treatment Paid medical services are rendered when PHC is done on patients initiative, as well as without PHC specialists referrals, basing on the agreement, concluded between the patient and the healthcare subject Paid medical services are rendered when PHC is done on patients initiative, as well as without PHC specialists referrals, basing on the agreement, concluded between the patient and the healthcare subject Paid medical services are rendered when PHC is done on patients initiative, as well as without PHC specialists referrals, basing on the agreement, concluded between the patient and the healthcare subject Paid medical services are rendered when PHC is done on patients initiative, as well as without PHC specialists referrals, basing on the agreement, concluded between the patient and the healthcare subject
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Expected results

• Expanding PHC availability by private PHC
  organizations network expansion, as well as on
  the base of PPP
• Increasing the number of finished cases of visits
  for medical care at PHC level (not lesser than
  70)
• Provision of PHC development priority
• Transfer of focus from hospital care onto
  outpatient services

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• Thank you for your attention!