Reimbursement Flashcards
What is a hospital?
HC institution providing patient treatment with specialised staff and equipment
How has uncertainty affected HC investments?
It is a rapidly changing environment with a lot of uncertainty
Investment is the primary driver in HC startup world
There is an unclear reimbursement landscape in the future
Unclear is the new normal, so we have to invest
What is redefining the reimbursement environment?
Blending between digital and medical.
Crossover between medical outcomes, economics, and increasingly informed population
What are recent hospitals changes in various countries’=
Holland - strongly community based, moving away from hospitals
Korea - validate hospitals, build very large new ones
UK - strongly GP based
How are healthcare providers paid?
They are paid by insurance / government payers through reimbursement of medical services and goods
This means they first provide the medical services, then they file for reimbursement
Common misunderstandings about reimbursement
Regulatory approval does not mean you will get reimbursed
If medical devices are not classed as such, you cannot apply for reimbursement
Changes in the healthcare environment - Drivers
Impact of austerity
Older population
Different clinical condition types and their impact
Response to drivers of change in HC environment
Move to LOWEST COST MODEL
This involves managing patients in the community
What is the technology response to these drivers?
Move to HC apps and AI (this especially is fundamental for the future)
What is AI’s place in reimbursement?
AI was not included when they created/redesigned the system to approach these drivers.
AI is not included in reimbursement systems, so there is no way for those who create it to be reimbursed
- no funds have been set aside for AI > these resources are therefore not commonly employed and are cut out the market e.g. app to manage diabetes
Healthcare system types
Free market (insurance based) - US
Bismark (competing social funds) - France, Germany
Hybrid (private insurance for high earners, social for all others)- Japan, Holland
Beveridge (free at point of care, social based) - UK, It, Port, Spain, Scandinavia
Ex- Semashko restructured beveridge/bismark) - Russia
Who came up with Value Based Healthcare Reimbursement?
Michael Porter
What is Value Based Healthcare Reimbursement?
The future of reimbursement will be based on the value created by the product and the ability to demonstrate that value
How are reimbursement systems changing?
Slow to change
Now beginning to embrace new technology
What is basic structure of UK health system
Gov DoH
NHS England
CCG
NHS trusts, Ambulance Services, Mental Health, GP
How do codes in the healthcare system work?
Each intervention or procedure is covered by a code
This code informs the CCG what the intervention is and what the billing tariff id
What are Healthcare Related Groups?
Grouping of all the codes of everything used (both interventional and diagnostic)
This forms the basis of hospital reimbursement
What are the 2 types of codes used?
Operation: OPCD
Diagnosic: ICD10
How can hospitals save money?
They are allocated income to complete each operation/procedure
If they are able to reduce costs or redefine services to do the procedure for less, they save money
What is an example of redefining services?
Moving patients around the bed to avoid bed sore formation
How does the coding system differ in the US
They have three different types of coding
Categories I - III
What is the main difference with healthcare service provision in the US?
The doctors have a fee for service, so they receive payment for delivering the service
What are the three biggest healthcare markets in the world?
US
Japan
EU
Give an example of value based reimbursement
A wound dressing for DFU can be more expensive than one for VU, as VU has higher cost to society
What is value in value proposition?
Health outcomes that matter to patients
/
costs of delivering that outcome
Essentially considers what the best outcome for the patient is, and how much that will cost
What is the central goal in healthcare for value based healthcare?
Value for the patient is the central goal
Not volume, cost containment of meeting medical parameters
What does Value Based Health Care act as?
Fundamental driving force between:
- adoption of services,
- fees for services
- design for medical products
Explain QALY
Quality Adjusted Life Years 1 QALY = 1 year in perfect health 0.5 = bedridden 0= death Negative = worse than death
How could you reduce costs in medical care?
- Reduce stay in hospital
- Manufacture cheaper products
- Change clinical pathway
What was Eykonia
Takes 3D images of wounds to document their progress
Received a lot of angel investment as it was starting off
It failed because nurses have low prescribing power, and it is unnecessarily expensive for something you can do with a ruler
Now re-adapted for gaming and 3D imaging.
To achieve reimbursement you must demonstrate:
- Clinical Trial Design
- Regulatory Path
- Health economics
