Payment by results could hamper best practice
Payment by results (PBR), the system by which hospital care is paid for in England, is influencing the way in which hospitals treat patients, according to speakers at a Pharmaceutical
Marketing Society meeting held in London last week.
Noel Staunton, pharmaceutical consultant, 3i Consultancy, suggested that
the way the national tariff operates (see Panel) could encourage hospitals
to admit patients for lengths of time that might not be in their best
interests. For example, for coronary obstructive pulmonary disease, a
hospital will gain maximum profitability if a patient is admitted for
two days and one second, he said. This way, the hospital qualifies for
the full tariff rate (as opposed to the lower short-stay rate applied
for admissions of less than two days) but gets paid the same amount as
it would if the patient stayed for the maximum allowed under the tariff
of 25 days.
How PBR works
Payment by results (PBR) is a copy of a US system and is a way
of paying for hospital care in England that was introduced in April
2004. A national tariff specifies what primary care trusts
must
pay hospitals for everything that happens to an individual
patient while in hospital.
The PBR system, in contrast to the old system of block contracts
in which PCTs paid for whole populations irrespective of the
number of admissions or length of stay, allows money to be
disinvested from
secondary care and stimulates prescribing in primary care. |
Chris Doyle, managing director of marketing consultancy firm
Brand New Concepts, demonstrated that similar pressures exist in accident
and emergency
departments. He said that between 2005–06 and 2006–07 there
was an increase of 18 to 20 per cent in short stays in hospital following
admission via accident and emergency. This, he suggested, could be because
the tariff specifies that hospitals are paid a standard accident and
emergency attendance fee of £73. However, if patients are admitted
for one day under the “sprains, strains and minor open wounds” code,
the hospital receives £569. “PBR is driving hospitals to
do things differently but
… I don’t know if it is driving them the
right way,” he said.
PBR systems can also threaten secondary care prescribing of expensive
drugs, said Mr Staunton. He explained that this has happened in Germany,
where there is a tendency to use cheaper drugs because, unless the drug
reduces length of stay, the hospital earns the same amount regardless
of which drug it uses. “I am sure that the individual consultant
will do what is best for the patient, but they will be under the financial
hammer,” he said. Some expensive drugs are included in a PBR exclusion
list, which means they are not reimbursed by the national tariff. It
is therefore possible for the hospital to ask for extra funding for the
drug from the PCT, Mr Staunton explained.
Both speakers agreed that the opportunity to manipulate the PBR system
in this way should cease in two years’ time when reliable data
have been generated and the national tariff adjusted accordingly. |
The
Pharmaceutical Journal
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