Ομιλία – Παρουσίαση: Αθανάσιος Λοπατατζίδης, Group Commercial Executive Director, AFFIDEA Τίτλος παρουσίασης: «Καινοτόμες μέθοδοι αποζημίωσης ΠΦΥ με βάση την αξία»

1. Καινοτόμες μέθοδοι αποζημίωσης
ΠΦΥ με βάση την αξία
Athanasios Lopatatzidis
Group Executive Commercial Director,
Affidea

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Structure of the presentation
1. Set the scenes:
• Burden of disease across EU
• Competition trends
• Health services transformation
2. Assessing modern needs
3. Direction to go forward: innovative
examples
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Spend versus Results
• Spending up, impact to mortality & disease mostly flat

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The burden of disease

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How did we get here?
13.7% 27.9% Obesity~0% 5%
• Move (Exercise) Less
• TV & Video Games
• Sedentary jobs
• Diet
• Sugar
• Corn Syrup
• Processed food
• Growing Disparities
• Income
• Zip Code

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The burden of disease
Probability of dying prematurely from non-communicable diseases

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Rising Risk
• Based on Behaviors
Health & Healthy Behaviors
0 1 2 3 4-5
52% 10% 3%
24%11%
87% Unhealthy Lifestyle 3% Healthy Lifestyle
Healthy Behaviors
 Non-smoker
 Active lifestyle
 Normal body fat
*Mayo Clinic
 Healthy diet
 Moderate/
Non-drinker

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Where is the spend?
• Behaviors Drive Health
Illness we Treat
Unhealthy Behavior

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VH I health insurance prices to
increase by up to 6%
Company says rising cost of claims left it with no
alternative to pushing up prices
Conor Pope Wed, Mar 30, 2016, 17:49
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The Err Is Human: Building a Safer Health Care System
American Institute of Medicine, 1999
Equivalent to three jumbo jets crashing every other day; statistics widely reported by the
media
44,000 to 98,000 Americans
dying due to medical errors each year

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Assessing modern
needs
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Reimbursement of outpatient healthcare services will be transformed
from a payor led “disease treatment”, to a patient centric “health
maintenance” model
Today 2025+
Treatment centric model
Activity reimbursement (fee-for-service)
Patient centric care coordinated by
outpatient provider networks
Value based reimbursement
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FFS Tied to Quality: At least a portion of payments vary based on the quality or efficiency of health care delivery (e.g.
Hospital VBP, Physician Value-Based Modifier)
Alternative Payment Models: Some or all payment linked to effective management of a population or episode of care
(e.g. ACOs, medical homes, bundled payment)
All
Medicare
FFS
FFS Linked
to Quality
Alternative
Payment
Models
2016
All
Medicare
FFS
FFS Linked
to Quality
Alternative
Payment
Models
2018
HHS Sets Targets Linking Payments to Performance
Nearly half of all fee-for-service payments will be made under alternative payment models
by 2018
Source: Prof. Mossialos, LSE

16. Health technology, digitalization and
wellness aspirations are changing the
traditional role of insurers
Predict,
5%
Predict,
9%
Predict,
22%
Diagnose,
15%
Diagnose,
19%
50%
40%
Diagnose,
27%
30%
Treat, 70%
Treat,
60%
80%
70%
Treat, 35%
Monitor,
10%
Monitor,
12%
Monitor,
16%
0%
10%
20%
60%
90%
100%
2012 2018 2025
Reactive nature of healthcare changing
Risk mitigation to
manage rising
healthcare costs
Europe
Provider Networks 66%
Plan Changes 66%
Cost Sharing 52%
Service Limits 38%

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Single contracts
Payer-to-provider contracts remain the norm,
structured service by service
Money that follows organisations
Which makes collaboration hard
Payment tied to activity
About half of hospital reimbursement is via a tariff
system
Block contracts are usually based on historic and
projected activity
Understanding costs at the provider
level
Usually procedure based, so do not capture total
costs across the pathway
Accountability for organisational
performance
CEOs and boards held to account for the
performance of their individual organisations
Collaborations between providers
Integrated provision will require increasingly
sophisticated provider-to-provider contracting
Money that follows people/patients
For which collaboration is usually required
Payment tied to patients
Payment linked to quality and cost for a specified
population
Or payment linked to quality and cost for a specified
patient group (e.g. cancer patients)
Understanding costs at person level
An understanding of the total costs across sectors and
providers at the patient level
Accountability for patient and
population outcomes
Health leaders held to account for the healthy of their
populations and systems
And will define the travel towards population health management
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Today 2025+
Source: Prof. Mossialos, LSE

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Direction to move
forward
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“2.12 million or 46 per cent of
the population in Ireland
have private health
insurance and of these 2.12
m, approx. 1.1 m are
members of the first and
originally state-created
health insurance VHI.
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Shoulder concept study will maximize the value of Employee
Benefit Programs by appropriate, evidence-based, cost-
effective care
Employee
benefit
program
Visit outpatient
care physician
Perform
voluntary MRI
Visit surgical
orthopedic
team
Receive
treatment
Receive
physiotherapy
Feedback – Care Coordination
Individuals with
high incidence of
shoulder disorders
(forestry workers,
carpenters, heavy
weight movers,
car / homecare
workers,
aluminium
smelters etc.)
• Intake by web
and phone
using clinical
decision
support
• Perform clinical
review by nurse
/ physician
In the presence of significant
evidence of malfunction on the
voluntary MRI:
 Perform a surgical procedure
 Follow up recovery & monitor
clinical & financial outcomes
“Improving efficiency and reducing costs associated with hospital care while at the same time
maintaining excellent clinical quality, convenience and moving care ‘closer to home’.”
• Set up solutions to monitor outcome and cost per injury &
specialist
• Constant data-driven feedback and development
• Removal of suppliers with poor outcomes of high total costs
• Development and implementation of physiotherapy app
Day Care
Provider
Payor

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Care Coordination
• Medical Consultations
• Home care visits
• Diagnostic Imaging
• Lab exams
• Dental care
• Physio
Patient Satisfaction Survey
show Affidea’s net improvement
in quality & efficiency:
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30
%
64
%
Yes
(Clients)
Yes
(Insurance Agents)
Affidea improved service
quality & efficiency?