1. –www.hospice.rowww.hospice.ro Using Costing as a Tool for Advancing Palliative Care in Romania Daniela Mosoiu, MD, PhD Malina Dumitrescu Hospice Casa Sperantei, Brasov, Romania

2. –www.hospice.rowww.hospice.ro Situation Analysis Understanding the model of the Health Care System History and achievements of palliative care in Romania Needs vs. achievements Funding mechanism for palliative care

3. Brief review of PC in Romania Romanian Health care system – Bismarck model  Tax collection (employee + employer)  Population served: insured, special categories, emergencies  Service packages provided  Providers contracted  Annual review of “Frame Contract” and its regulations  Joint roles: Ministry of Health, House of Health Insurances, College of Physicians –www.hospice.rowww.hospice.ro

4. –www.hospice.rowww.hospice.ro History of palliative care in Romania 1990’s – landmark in PC development in RO 1992 – Hospice Casa Sperantei founded in Brasov 1997 – Palliative Care Education Centre in Brasov 1998 – National Palliative Care Organization 1999 – P.C. subspecialty acknowledged 2001 – Oral morphine available for pain control 2002 – First Inpatient Hospice unit opened in Brasov 2003 – Hospice Casa Sperantei = Beacon of excellence 2005 - 2007 – Opioids Law and Norms passed

5. –www.hospice.rowww.hospice.ro 2005 – P.C. commission set up in the Min.of Health (MoH) 2005 – Hospice Casa Sperantei = coordinator of the P.C. education as subspecialty in Romania 2005 – P.C. in inpatient units introduced in the Frame- Contract of the House of Health Insurances (HoHI) 2007 – First public reimbursement of the HoHI for P.C. admissions in Inpatient Units 2007-2008 public awareness campaign and national survey 2007 – First inpatient unit in public hospital History of palliative care in Romania

6. –www.hospice.rowww.hospice.ro 2007 – National Coalition of P.C. providers 2008 – Partnership between MoH, Hospice and the National Coalition of Cancer Patients Association 2008 – start of Health Budget Monitoring costing project 2010 – Home-based Palliative Care services acknowledged 2009 – curricula for nurses in basic training 2010 – first Master program in PC (Brasov Medical Faculty) 2011 – 5 medical faculties in Romania introduce palliative care in the basic studies curricula History of palliative care in Romania

7. PC need in Romania Estimated need for PC: about 170,000 persons/year  In 2009: 31 PC providers → 46 services: –21 inpatient units –15 home-based units –3 day centres4003 persons –4 outpatient clincisreceived PC –3 hospital teams –www.hospice.rowww.hospice.ro

8. –www.hospice.rowww.hospice.ro Models of care Home care: NGO sector 15 In patient units: Public sector: 8 Acute hospital wards: 7 Chronic hospitals: 1 NGO: 10 Private sector: 3 Out patient clinics: 2 Day centers: 3 Mobile Hospital teams:3

9. PC need and services –www.hospice.rowww.hospice.ro

10. –www.hospice.rowww.hospice.ro Financing Sources for Palliative Care in Romania Ministry of Finances Community External Sources Ministry of Health Ministry of Labour Min. of Public Admin. Health Insurance Inpatient Unit Home care Mobile Hospital Team Outpatient Clinic Private services Public services Day centre

11. –www.hospice.rowww.hospice.ro Why Hospice Casa Sperantei ? Reference center for country and region Previous impact at policy level – Partnership with MoH – Success in triggering the new law of opioids National coordination role in other arias (education program for PC competence, coalition or PC provioders, awareness campaign) National sustainable development strategy for 60% PC needs coverage by 2020

12. –www.hospice.rowww.hospice.ro Aim of costing project To facilitate the inclusion of palliative care services in the public funding scheme, by providing research-based cost data

13. –www.hospice.rowww.hospice.ro Method Surveys on allocation/expenditure and cost/patient Ministry of Health District Insurance Houses Health Boards Palliative care providers Minimum standards and unit cost Palliative care homebased services Palliative Care Inpatient units Costing frameworks Palliative care homebased services Palliative Care Inpatient units Dissemination of result at policy maker level

14. –www.hospice.rowww.hospice.ro Survey of authorities (FOIA Law 544/2001) Allocation/Expenditure 2008 on PC List of authorized providers PC providers 2008 Nr palliative care beds Nr patients admitted 2008 Average cost/patient Staff Drugs & medical supplies Food and hotel Administrative & Others

15. –www.hospice.rowww.hospice.ro Survey of providers

16. –www.hospice.rowww.hospice.ro Results discrepancy of data from differ. authorities confusion general home care and PC Database with providersNo identifiable budget line at MoHSources of funding range from 90-410/bed/day Allocation/bed/day /patient/day (some districts) /patient/admission (most districts) Expenditure Expenditure for public PC providers not traceable just for private providers Structure of cost

17. –www.hospice.rowww.hospice.ro Expenditure per patient per day

18. –www.hospice.rowww.hospice.ro Data pointed out: Inconsistency of recording Unclear criteria in allocation Lack of control of use of public money Impossibility to base cost calculation on collected data Consistent contribution of private funds

19. –www.hospice.rowww.hospice.ro Standards for PC Developed with the National PC Coalition Provided information for the costing framework Staff ratio, case load Contact time with patient/ discipline Staff qualification Staff costs Minimal equipment, office requirements

20. Physicians (1,5 full-time equivalent per 10 beds) Nurses and nurse assistants (14-18 full-time equivalent per 10 beds, 1 nurse per 3-5 beds and 1 nurse assistant per 5-7 beds, all per 8 hours shift) Psychologist (0,5 full-time equivalent per 10 beds) Other specialized personnel (4 full-time equivalent, including part-time for social worker, therapist, cleric, pharmacist, pharmacist assistant and others) Auxiliary personnel (1 full-time medical secretary)

21. –www.hospice.rowww.hospice.ro Unit Cost Inpatient Per patient/bed Home care Per visit Per episode of care

22. –www.hospice.rowww.hospice.ro Costing frameworks International expert Tested/adjusted local economist Comprising – Running costs – Sett up costs For home care and inpatient services

23. –www.hospice.rowww.hospice.ro Use of costing frameworks allow the provider to present realistic budgets for quality PC services avoid the discrepancies between costs reported by various providers give a clearer picture to and financing bodies about the comparative costs based on common calculation increase understanding of the home based PC services and development costs

24. –www.hospice.rowww.hospice.ro The costs structure Staff costs Direct costs (other than staff) Indirect costs Capital costs for service start-up

25. –www.hospice.rowww.hospice.ro Costing process

26. –www.hospice.rowww.hospice.ro Costing: Home-based PC

27. –www.hospice.rowww.hospice.ro Monthly Staff Costs/patient Homecare

28. –www.hospice.rowww.hospice.ro Costing: PC inpatient units

29. –www.hospice.rowww.hospice.ro Monthly Staff Costs/patient In-patient Unit

30. –www.hospice.rowww.hospice.ro Comparative cost analysis 448 € vs 1500 €

31. –www.hospice.rowww.hospice.ro Start-up costs for Inpatient vs HC

32. Preapring advocacy –www.hospice.rowww.hospice.ro CURE ≠ CARE Difference: Costs Benefits –OUTCOMES –Life saving, –Disease curing –Quality in –End-of-Life Care

33. HOW to convince? “Why spend on a new service?” “NO money is cheaper than SOME money” “They are dying anyway” → PERSONAL EXPERIENCE (… feelings…) → COST EFFECTIVENESS (… financials…) What is cost-effectiveness”? NOT: to spend lessget best quality YES: to spend wiselyfor as many beneficiaries… with existing resources –www.hospice.rowww.hospice.ro Preapring advocacy

34. –www.hospice.rowww.hospice.ro Advocacy methods 1. Creating networks of direct supporters Involved PC coalition: send letters to local HoHI and MPs Letter from local HoHI in Brasov to the National HoHI to support the change PC commission in the MS contacted national HoHI Contact MPs from all parties for support Supporter beneficiar IP in CNAS ??? 2. Proving service and education replication model supporters who know from inside what PC means

35. –www.hospice.rowww.hospice.ro Direct communication Conference at the Parliament Meeting at the National HoHI to present results of costing 3. Public awareness Press conference Results presented in conferences and Materials provided to Local Health Boards and local HoHI and to providers Advocacy methods

36. Advocating for a change Short term results:  Developing funding mechanisms for existing services  Base reimbursement on realistic costs Medium/long term expected results:  Influence general legal framework to include PC in the public health system  Improved funding for PC services  Provide annual budgetary allocation for PC services  Increased coverage with PC services –www.hospice.rowww.hospice.ro

37. –Advocating for a change 2. Medium/long term results  Influence general legal framework to include PC in the public health system  Amendments submitted to the Parliament for Health Law No.95/2006 in June 2010 (resolution pending)  Amendments to ministerial Orders submitted in 2009:  Authorization of service providers  Staff ratio for PC in Inpatient units  Human resources education (pre- and post-graduate)  Evaluation and monitoring of quality in PC services –www.hospice.rowww.hospice.ro

38. –New challenges: Home-based PC (= preferred setting for patients):  Restrictive and bureaucratic procedure to access home care  Resticttive access by type of disease (only cancer and HIV/AIDS)  Restrictied access of providers to contract services (insufficient legal regulations for providers’ authorization  Insufficient funding dedicated to Home-based PC Inpatient PC services:  Lowest qualification of PC inpatient units, resulting in poor funding –www.hospice.rowww.hospice.ro

39. –New challenges: Outpatient PC:  Define outpatient services for PC  Evaluate costs in outpatient PC services Hospital Mobile PC teams:  Evaluate costs after a 2-year pilot project  Define hospital teams input  Submit results and advocate to include hospital teams –www.hospice.rowww.hospice.ro

40. –Conclusions  Identify barriers and opportunities  Act collectively rather that individually  Monitor the change  Share the experience –www.hospice.rowww.hospice.ro