Tariffs and Profitability for Gynaecological Oncology Services Rob Gornall Gynaecological Oncologist Gloucestershire Hospitals FT Who Cares?  Best practice comes first  Swings and roundabouts  It seems to get sorted so concentrate on important things I can influence/improve  Lets not draw attention to ourselves  BUT … Organisational and funding changes     Hospitals and FT in financial difficulty Ongoing shrinkage in budgets Evolution of Business Intelligence/PLICS data Service Line Reporting and position of gynaecological oncology within divisional structures  Business planning requirements for staff/workload expansion Specific difficulties  Likely never ‘profitable’  Recent surgical developments have been implemented by profession in unplanned way without sound national/local planning Notably Role out of radical laparoscopic surgery Radical debulking surgery for ovarian cancer What Services Constitute Gynaecological Oncology?     Tertiary referral surgical resection services Non surgical Oncology radiotherapy/chemotherapy Outpatient Services – follow up/combined clinics Nurse specialist activity Additional Related Activity      Radiology/Pathology Additional Surgical activity Complex benign gynaecology General Surgery colorectal, plastics etc Research Methods of commissioning  Local commissioning Diagnostic/Local Treatment block contracts  Specialised commissioning Case specific and national tariff based  Scope for local/regional negotiation  Individual tariff setting by some providers Current Issues  Limited data on the accurate cost of complex gynaecological oncology procedures Primary/Interval debulking procedures vary in extent  Widespread introduction of minimal access cancer surgery  Current gynae oncology and general gynaecological practice variability in UK How are tariffs calculated NHS PBR Annual Guide  2014 last year for DoH responsibility – responsibility of Commissioning board and Monitor  Based on underlying reference costs with 3 year time lag  Adjustments from tariff calculations only made for good reasons eg to avoid  national pricing anomalies  Perverse incentives What is the ‘standard’ tariff for an ovarian cancer debulking prodecure TAH BSO Omentectomy Peritoneal excision Q074 T361 MA06Z Spell income PLICS cost 3910 7559 Open major upper and lower genital tract procedures with malignancy With CC Additional 25% Ovarian cancer ‘mitigation’ Additional description Procedure Code HRG Description Ureterolysis Q074 LB07Z Ureter open procedure Additional Transverse description Colectomy Procedure Code FZ08B HRG Q074 Ureterolysis Complex large intestine procedure Ureter openwithout CC procedure Q074 LB07Z Anterior resection H334 Complex large Q074 ureterolysis intestine Modified posterior X143 procedure exenteration Without CC LB07Z FZ08B Ureter open procedure MA01Z Lower/Upper V complex procedures Right hemicolectomy appendix tumour FZ09A Proximal colon procedures with CC H071 Costs Additional procedure Spell income PLICS ureterolysis 5017 7718 Transverse colectomy 5870 8927 Anterior resection 5097 9653 Modified posterior exenteration 6144 8054 Right hemicolectomy 7188 4832 Cost estimate complications  Example Ovarian Malignancy complicated by enteric fistula/nephrostomy/TPN with extended stay Total inpatient Stay 120 days Income 27,159 Cost 51,217 For sample 10 case examined deficit 40K Tariffs for endometrial cancer Procedure Code HRG Description SPELL income TLH BSO Q074 Y752 Q221 MA08Z Upper genital tract laparoscopic procedures 2234 TAH BSO Q074 Q221 MA06Z Open major with malignancy 3489 TLH BSO pelvic and pa nodes omental biopsy Q074 Y752 Q221 T856 T364 T423 Z941 U212 Y973 MA06Z Upper genital tract laparoscopic procedures 2234 Tariffs for cervical cancer Procedure RH PLND Q071 T856 T866 LB07Z Ureter open procedure 4848 TLRH PLND Q071 Y752 T856 T866 MA08Z Upper 2234 Genital Tract Laparoscopic major procedure Short Term Options Marginal Gains Optimise use of: Outpatient tariffs Diagnostics Development of actual cost tariffs for extra contractual work Agreement of departmental Coding Policy Outpatient Tariff New Follow Up Gynae Onc 168 98 Gynae 140 89 Oncology 234 104 ‘Multiprofessional’ 270 140 Ways forward  Rectify anomalies in national grouping system  Recognition of extended surgical staging in payment schedule  Development of tariff uplift for good practice eg enhanced recovery/short stay laparoscopic hysterectomy procedures  New codes with enhanced tariff to reflect complexity of radical debulking surgery The way forward  More joined up thinking nationally on economic impact of prospective treatment changes and tariff review  Production of accurate costings on a national level for ovarian cancer surgery with reference to NICE guidance on initial surgical management  Working through BGCS commissioning subgroup and complex gynae CRG to approach Commissioning Board