Activity Based Funding Maternity Services “A Divisional Perspective” Susan Gannon: Divisional Director Women’s & Children’s Services Western Health The Health Reform Agreement Commonwealth State National Funding Pool Comprising of individual state accounts State Managed Fund Local Health Networks Health Services Hospitals Footer Text Hospitals 2 At a Local Level Local Health Networks Health Services Hospital Hospital Emergency Services Medical Services Surgical Services Women’s & Children’s Services Hospital Cardiac & Crit Care Services Subacute & Mental Health Services Maternity Services Footer Text 3 Allocation of Funds • Based on last years activity • Separations • Activity Based Funding Target (WIES & VACS) to be (NWAU) • Predicted growth Footer Text 4 Overall Benefits of ABF • Allows for the capture of consistent information on activity and costs • Provides benchmarking to manage variations in costs and practices leading to greater efficiencies • Demonstrates the relationship between services provided and the funds allocated • Does it lead to rewarding good practice to improve quality and safety? Or • How could it ? Footer Text 5 Midwifery Services How does it differ from other Acute Services? • All care can be delivered in the community (unless clinically indicated) • There is a need to provide a seamless service between acute settings and the community for our families • Maternity Services are not bound by walls of a hospital • How do we ensure women are receiving continuity of care when transferred from one health service to another, from one provider to another or from the community to the hospital? • Does activity based funding allow for this integration of care providers? • Is activity based funding determining care models ? • However, having a national system there is an opportunity for greater analysis, benchmarking and review Footer Text 6 Pricing Footer Text 7 Case Review: Sunshine Hospital How activity based funding influences revenue or How care models influence revenue Footer Text 8 2011/12 Weights Recorded Victoria Vaginal Birth Caesarean Birth Hospital Average weight per separation Hospital Average weight per separation Statewide 0.712227041 Statewide 1.644287182 Sunshine Hospital 0.694995617 Sunshine Hospital 1.566685753 Hospital 2 * 0.724676193 Hospital 2 * 1.747877531 Hospital 3 * 0.779579016 Hospital 3 * 1.767439283 Hospital 4 * 0.777130196 Hospital 4 * 1.78840064 Hospital 5 0.716397075 Hospital 5 1.590204876 Hospital 6 0.706511144 Hospital 6 1.574610222 Hospital 7 0.682114562 Hospital 7 1.578055219 Hospital 8 0.663772999 Hospital 8 1.553209695 Hospital 9 0.686268887 Hospital 9 1.553209695 Hospital 10 0.714724493 Hospital 10 1.578055219 Hospital 11 0.634895777 Hospital 11 1.564562543 Hospital 12 0.720412852 Hospital 12 1.590603446 Hospital 13 0.632127027 Hospital 13 1.574860218 Footer Text 9 Why is the alarming for Sunshine Hospital? • Decreased revenue • Low socioeconomic demographic • High refugee area • Increasing complexity of clients • High BMI numbers Footer Text 10 Why lower weights? High Cost Weights • Models of Care • • • • Midwifery Group Practice Home Birth Program Efficient Early Discharge program Over 70 % Midwifery lead care • Ambulatory Management Low Cost Weights • Inefficient Coding Footer Text 11 Western Health Maternity Model of Care Private Midwifery • 49 Community Clinics • Integrated models with local councils • Western Collaborative Footer Text 12 Sunshine Hospital • 1,080 Women per year in Midwifery Group Practice which includes homebirth • 76% women in a midwifery care model • Close to 600 births per obstetrician Footer Text 13 Pregnancy Care Lead Pregnancy % Sunshine Care Provider % Statewide % Public Hospitals % Private Hospitals Obstetrician 9.3 55.0 36.4 99.2 Midwife 76.3 25.7 36.2 0.0 GP 12.6 17.5 24.9 0.2 None 0.2 1.0 1.2 0.0 The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) 2009 Data Set Footer Text 14 Intrapartum Care Lead Intrapartum Care Provider % Sunshine % Statewide % Public Hospitals % Private Hospitals Obstetrician 30.5 62.9 48.2 98.3 Midwife 68.8 28.0 39.0 1.4 GP 0.1 8.5 12.0 0.2 None 0.6 0.5 0.6 0.1 The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) 2009 Data Set Footer Text 15 2012/13 Weights (Victoria) DRG Same Day Inlier Average LOS Vaginal uncomplicated 0.4586 0.8478 2.4 Vaginal Complications 0.5042 0.9568 2.7 Vaginal Catastrophic 0.5590 1.269 3.8 DRG Same Day Inlier Average LOS Caesarean Delivery 1.0737 1.7826 3.9 Caesarean Severe 1.2588 2.1297 4.9 Caesarean Catastrophic 1.0355 2.8535 7.2 1 = $4,270 Footer Text 16 What does this mean in $$ terms ? DRG Same Day Inlier $ Difference Vaginal uncomplicated 0.4586 0.8478 $1,665 Vaginal Complications 0.5042 0.9568 $1,696 Vaginal Catastrophic 0.5590 1.269 $2,776 DRG Same Day Inlier $ Difference Caesarean Delivery 1.0737 1.7826 $3,330 Caesarean Severe 1.2588 2.1297 $3,928 Caesarean Catastrophic 1.0355 2.8535 $7,891 Footer Text 17 Vaginal Birth Exercise • 5,000 births • Caesarean rate of 28% • 3,600 Vaginal Deliveries • 50% were same day • Revenue $3,457 800 as apposed to $6,454,800 • Saving or a loss of $2,997,000 • Footer Text Saving or loss perspective will depend on efficiency of service in the initial phase 18 Midwifery Group Practice (MGP) Births MGP EFT EFT Reduction EFT Gap Bed Stock 270 6 0.69 5.31 0 540 12 8.4 3.56 4 810 18 19.94 +1.95 8 + 1 Birth 1080 24 23.95 0.05 12 + 1 Birth The staffing to delivery the model is still required therefore the staffing costs remain unchanged with the reduced weights for decreased LOS therefore less revenue for Maternity Service Footer Text 19 Health Round Table Data Vaginal Birth • For complicated vaginal deliveries 4% decrease in LOS • For women with co-morbidities 14% decrease in LOS • Normal vaginal Delivery 16% shorter LOS • 35% of women discharged before midday compared to state average 28% • Sunshine saves 500 bed days more each year than the Victorian average • Emergency readmission rate is 66% lower than the Victorian average Footer Text 20 Health Round Table Data Caesarean • 19% shorter than state average • 51% discharged before midday compared to 37% • Readmission rate 3% lower • Save 700 bed days Footer Text 21 Ambulatory Care • Pregnancy Day Stay Units • • • Iron Infusions CTG Monitoring AFI’s Does it lead to rewarding good practice to improve quality and safety? • Breastfeeding Centres • Admission Criteria of 4 hours with observation • $177 as an outpatient • $460 as an day admission Footer Text 22 Coding • Raising the weights to gain increased funding • • • • • Co-morbidities Complications NWAU Aboriginal & Torres Straight Islanders NWAU Remote adjustments Note that the unqualified baby is as a package with the mother • Accurate data recording and collecting and timely • Audit • Medical, midwifery and clerical education Footer Text 23 2012/13 Weights (Victoria) DRG Same Day Inlier Average LOS Vaginal uncomplicated 0.4586 0.8478 2.4 Vaginal Complications 0.5042 0.9568 2.7 Vaginal Catastrophic 0.5590 1.269 3.8 DRG Same Day Inlier Average LOS Caesarean Delivery 1.0737 1.7826 3.9 Caesarean Severe 1.2588 2.1297 4.9 Caesarean Catastrophic 1.0355 2.8535 7.2 1 = $4,270 Footer Text 24 National Approach • Will allow for analysis between like services • Allows for a greater voice in funding to promote women centred care • Will demonstrate inefficiencies in care • The question not yet answered is it the right funding model for a service which should move between primary and acute care streams • From a Western Health perspective, does it allow for the model of care that is integrating services for Western Region of Victoria ? Or could it stifle innovation? Footer Text 25 United Kingdom Maternity Services Pathway Payment System • • • Supported by the Royal College of Midwives, Royal college of Obstetricians and Gynaecology April 2013 Single payment approach where the lead maternity provider is responsible for providing care or payment if transfer is required • • • • Footer Text Standard Care Intermediate Intensive The system is to promote a culture based on normality to support providers that attract women to chose normality rather than intervention 26 Footer Text 27 This is Our Quantum Leap: Breaking down boundaries Maximising funding streams • 4 Acute sites providing maternity care • Medicare Locals • Local Government • Universities • DoH • Multiple Community Services Mothers and Babies of the West Footer Text 28 The Western Collaborative Strategic Plan Does ABF lead to rewarding good practice to improve quality and safety in Maternity? Collaborative Models of Care Community Integration . Mothers & Babies of the West 2012 - 2022 Consumer centred, safe and accessible How does ABF promote: • Continuity of care models • Integration of care streams • Lower LOS • Decreased caesarean section rate • Increased breastfeeding rates • Improved mortality & morbidity rates services Footer Text 29 Let the debate/discussion begin ! What are your thoughts?