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Capgemini Europe

The United States is not alone in seeking better ways to deliver and finance health care.Experiences from other countries demonstrate some valuable lessons in how collaborationbetween payers and providers can improve the health system.

A New Financing System for Dutch Hospitals

The Dutch health care system is in flux. It is moving towards a more market-oriented and demand-driven approach. The central government is shifting responsibilities towards the health care providers and health insurance organizations. Self-regulation by the sector itself, based on market principles, will change the role of the government significantly. In this context, the government, with support of key stakeholders in the Dutch health care system, is introducing a new funding system for all Dutch hospitals, based on case mix. This project is referred to as the DTC (diagnosis treatment combination) project.¹ The DTC project represents the biggest change in the Dutch hospital industry ever. The system has been under development for the past 3.5 years and is still in process.

The DTC approach is based on the “care episode” for a health problem of a patient within a medical specialty. The DTC system provides a mechanism for funding the new “integrated medical specialist care facility.” All actors involved agreed on this new organizational model for health care delivery in Dutch hospitals. The DTC is the product delivered to a patient by a medical division, and includes both a fee for the clinicians as well as the costs of the hospital involved. Taking such an approach for defining hospital products is a very challenging process.²

Though similar to DRGs (diagnosis-related groups), DTCs are different. The price of the DTC is based on the hospital’s costs and the medical specialist’s workload. The prices of DTCs will in any event include the variable costs of the hospital (including medicinal products and aids prescribed to outpatients) and of medical specialist care. Health insurers and hospital and medical specialists will negotiate the volume, the price, and the content of the DTCs. A DTC is an episodebased registration, aimed to facilitate a fee-for-service system in the Netherlands. It is a registration of hospital products done by the physicians themselves using electronic patient filing systems. Intermediate hospital products delivered to the patient on behalf of the physician are charged to the DTC of the patient, which results in a billable file containing the whole care process. Costs are calculated to the intermediate products, leading to a cost price of a DTC. DTCs are defined by the different scientific organizations of the different medical specialties.³

Developing and Implementing a Case Mix System

The Dutch Ministry of Health contracted with Capgemini to develop the DTCs and manage their implementation. In order to achieve these objectives, Capgemini developed a DTC structure describing medical care in collaboration with 25 medical specialties (national scientific organizations) and 40 “frontrunner” hospitals. The former provided medical knowledge. The latter provided production and costing data. In addition, they tested coding principles.

Data generated by all Dutch hospitals are analyzed in a central data warehouse that is operated by Capgemini (including benchmark information from about 100 hospitals). Since 2000, DTC data has been supplied by initially 20, and later 40, frontrunner hospitals to a central, national data warehouse – Capgemini’s Central Data Analysis Environment. This includes outpatient consultations, nursing days, operations, diagnostic procedures, and laboratory investigations. In addition, all Dutch hospitals provided their DTC data (without underlying activities or costs).⁴

The cost of the DTC is built up of a specialty component and a hospital component. The specialty component is the fee includbased on workload, while the hospital component comprises the cost of hospital activities incurred by the DTC. An actual cost has been allocated by the hospital to each activity.

Medical physicians provided insight into the workload of the specialists in relation to DTCs. They developed broad estimates of the time taken by activities related to direct and indirect patient-related care per DTC. In order to validate these estimates, Capgemini carried out a large time and motion study. More than 2500 medical doctors in about 60 hospitals coded their activities by means of handheld computers. Additionally, physicians were surveyed regarding staffing, productivity, and working hours per week. The results of these studies were combined with the estimates to develop the DTCs.⁵

DTC: A Model for Collaboration

The DTC model is a case mix system in which the framework of the medical product to be supplied is determined by the medical specialist. When opening a DTC, the patient is coded in the first instance by and at the responsibility of the physician. By drawing up their own coding list, which is filled in identically by physicians throughout the country, better support for the system is created.

Why should the Dutch medical specialists develop their own coding list when well-known international classifications already exist? Most classifications used in hospitals are not geared to the specific day-to-day practice of the medical physician. Too few of their own medical activities are identifiable in these classifications. The classifications are too extensive. A specialty often covers only a limited part of the classification. In addition, the degree of detailing of the code is frequently not geared to the specific situation. For example, classification of certain urologic tumors cannot be shown and the structure of the classification is often not practical.⁶

The DTC system is thus a collaborative approach, requiring active involvement of the medical specialists. It thereby introduces the most recent clinical insights and consensus. Intensive involvement of the medical specialists means, for example, that the care products, which are finely attuned to each specialty, are clearly identifiable from a medical point of view. It helps ensure that care institutions and health insurers can process the system administratively. It also helps ensure that the system is dynamic, and that the different variables can be redefined. In the future, it will be possible to anticipate new developments within the medical discipline very quickly.

Achievements to Date

In 2004, health insurers begin paying hospitals and medical specialists on the basis of DTCs. Initially, 10 percent of a hospital’s budget can be negotiated. On a go-forward basis, all negotiations between health insurers and hospitals, as well as contracting for care (purchasing), will increasingly be based on DTCs.

All Dutch hospitals now have an increased understanding of case mix. Hospitals, medical specialists, and health insurers also have an increased understanding of costs. Until now, this information was not available, since there was no incentive to calculate real costs.

So far, the Dutch Ministry of Health has developed the following:

• A DTC product list for all specialties;
• Groups of DTCs to facilitate negotiations (higher level);
• Costs of each DTC as they occur in the front-runner hospitals; and
• The workload of the medical specialist for each DTC and, on the basis of the hourly remuneration, the costs of the medical specialist care for each DTC.

The government’s objectives in moving toward DTCs were to better allocate resources, coordinate supply of and demand for care, control internal business processes, and gain more insight into quality. Anticipated results included better capacity planning, shorter waiting lists, faster processing times, correct pricing, and greater price awareness amongst all concerned. The government and the other parties are expecting such a system to create a situation in which hospitals are assured of a break-even payment, specialists receive pay according to the work they do, and health insurers obtain value for money.

Mobile Health Care “Caremore+” Benefits Nurses and Patients in the Netherlands

Sensire is a home care organization in the Netherlands. A few years ago, Sensire’s staff was faced with several problems including waiting lists, administrative pressures, a staffing shortage, and high turnover. These problems were caused by incomplete client/patient information, data communication problems, and difficulties in locating staff for replacement and/or support.

Sensire was formed in 1993 after a merger between a number of organizations in the field of home health care and social work in the east region of the Netherlands. With a budget of about †120 million and a client base of 130,000 visits per year, Sensire spends over 4 million hours per year on care. Its mission is to support people needing home health care so they can be independent despite possible existing medical conditions. Sensire employs about 6500 people.

In 2001, Sensire started a pilot research project to evaluate the impact of using an advanced mobile Internet solution for health care givers in the field. Capgemini, together with the Mobile Technology Lab from Telecom Media Networks, developed a mobile Internet prototype under the name of “Caremore.”

In this pilot, Capgemini designed, developed, and implemented a wireless application protocol (WAP)-enabled application that was stored in a handheld PDA/mobile phone device that connected to the GPRS network. Forty-five district nurses were connected via GPRS mobile devices.

This system enables easy registration of patient demographics, treatment information, and access to employee work schedules. Specific benefits include the following:

• Nurses are better informed and can communicate with each other in real time;
• Patients don’t need to repeat their medical history each time a new nurse arrives for a visit;
• Patient demographic information is kept up to date; and
• Nurses no longer need to drive back and forth to obtain patient records.

In addition, the mobile solution eliminates the need to store patient information directly on the handset. This helps ensure security of private information.

Further Developments

Several studies carried out at home care organizations pointed out that implementing the Caremore concept would improve business effectiveness. The studies showed reduced errors, enhanced quality of data, and decreased technological redundancy. Employees experienced improved data exchange, better access and communications, a greater sense of safety during the evening, reduced travel time, and better morale. Financial projections showed a substantial, swift return on investment.

The pilot study results and actual experience led to a more improved comprehensive approach, “Caremore+”. Caremore+ helps to integrate fragmented processes and systems by using a middleware solution to interact between the front and back office. Capgemini partnered with Mobile Communication in Home Care (MCH+) to develop the “Care+Central” planning and registration solution for the home care market.

The Caremore+ concept is built on the following structure:

• A layer of mobile solutions of a diverse range of suppliers, such as PDAs and mobile digital assistants (MDAs), to provide home care employees with operational or enterprise data;
• A top layer of a planning, registration, and information application, named Care+Central, from MCH+;
• A middle layer (middleware solution, for example, MS Biztalk) for interfacing the environment (e.g., present applications); and
• A lower layer, already existing at the home care organization, containing the home care information system, financial, logistic, human resource management, and other applications.

Hereward Burgers, CEO of MCH+, comments: “Care+Central is powered by a number of extensive functional modules. The planning module, which is key to the homecare business process, is made online at the office on a desktop PC. The valid planning is instantaneously visible on the homecare worker’s PDA; anytime, anyplace, and without delay. Care+ware, the mobile module, provides the home care worker a user-friendly overview with her schedule of visits to clients and other relevant data. During their rounds, home care employees can register their activities with only one tap on the screen and also access the relevant mobile electronic health record with another tap. In addition, planning and time registration are interactive and offer tracking and tracing of health care employees. Furthermore, all common activities (such as meetings and other activities that cannot be invoiced) can be registered using Care+ware. In conclusion, Care+ware offers a communication module incorporating voice, SMS, and email.”

Implementations

Care+Central’s planning and registration functions have been implemented at two sites in the Netherlands. It has been used to administratively support the primary care processes, giving all nurses continuous access to all the information they require to perform their duties. The application speeds information transfer between the organization’s management and the employees. The application also provides the information in a more flexible form, and gives employees more freedom to communicate from any location and at any time.

The benefits include:

• Interactive and flexible planning;
• Integrated time registration;
• More efficient business processes;
• Friendly user interface; and
• Fast, safe, and reliable data transfer and processing.

Vision of a Near Future

Home care organizations need to improve their customer service. IT solutions and CRM systems are playing an increasingly important role in the front office environment. Front office employees will be supported more effectively by modern IT tools, so that they are better able to help customers, both in selecting a range of services and in making use of the various services available.

The amount of time spent on administration will be reduced to the absolute minimum. Delays within the care process (waiting for the results of tests and examinations) will be eradicated by information processing technology. Capacity planning will take place efficiently, flexibly, and automatically. Planning will have become a fully integrated task within organizations and the care continuum.

The itinerant nature of home care will be fully supported by mobile applications. Registration will take place right at the source using mobile communication via the Internet, general pocket radio service (GPRS), universal mobile telecommunications system (UMTS), etc. It will be possible to transmit video images of the client via the Internet, allowing remote monitoring and remote consultation. Physicians will be able to remotely access medical records at high speed and thus offer support to home care staff. The service offered to the patient will be professional and totally appropriate. It will be possible to view data in an integrated way, resulting in more efficient management of home care organizations. The effects of the changing environment will be more visible and it will become easier to anticipate changes. In short, IT solutions will be applied in a more strategic way.

This article is a compilation of a series of conference proceedings on the Dutch DTCs. The first paper was presented at the Annual Conference of Patient Classification Systems Europe, in Brugge, Belgium in October 2002. The others were presented at the Annual Conference of Patient Classification Systems Europe in Washington, D.C., U.S., in October 2003.

1 Casemix in the Netherlands, by Jacob Hofdijk (Hiscom) and Corinne Tutein Nolthenius (Capgemini).

2 Casemix in the Netherlands, by Jacob Hofdijk (Hiscom) and Corinne Tutein Nolthenius (Capgemini).

3 Implementing a new episode-based, fee-for-service casemix system: Analysis and results, by Joost Zuurbier (Q-consult) and Henk Bakker (Capgemini).

4 Role of the medical specialists in the Definition of DBCs in the Netherlands, by Mathee Swenne-van Ingen (Prismant), Ed Bruijnes (Gooi Noord Hospital), Henk Bakker (Capgemini).

5 Role of the medical specialists in the Definition of DBCs in the Netherlands, by Mathee Swenne-van Ingen (Prismant), Ed Bruijnes (Gooi Noord Hospital), Henk Bakker (Capgemini).

6 Role of the Medical Specialist in the Definition of DBCs in the Netherlands, by Mathee Swenne-van Ingen (Prismant), Ed Bruijnes (Gooi Noord Hospital), Henk Bakker (Capgemini).