Incorporating Patient Level Information Costing Systems in the UK - Literature review Example

Literature Review:

Why is the UK government modifying Payment by Results through introducing Patient Level Information Costing Systems?

Payment by Results (PbR)

Payment by Results is the method of paying the providers for the health services that they have delivered, based on the health interventions they have undertaken. It is basically a new method of paying for the health services, which is different from the traditional method of paying for the inputs of services delivered. Inputs of service relates to resources, equipment and infrastructure that are needed for treatment (Centre for Social Impact Bonds, 2016). PbR was designed for stimulating improvement in NHS performance. Under the PbR system, the commissioner will pay the national tariff for treatment of each patient by the service provider, hence creating a direct relationship between the amount of activity undertaken and the amount payable (Mannion, Marini and Street, 2008).

The PbR system is used in the healthcare sector of England. Mannion, Marini and Street (2008) commented that with the use of the PbR system, the commissioners pays the healthcare providers on the basis of each patient they have seen or treated. Density of healthcare needs refers to the seriousness of the patient and the intense level of care that the patient will require. PbR was announced in 2002 by the Department of Health to support the NHS (National Health Service) system for reimbursing the hospitals in England for carrying out their activities. According to Street and Maynard (2007), with the implementation of the PbR the hospitals receive a fixed payment under a national tariff system for the treatment of each patient. Gradually PbR was extended to mental health services, community services, ambulances and many other forms of healthcare service. Facing a fixed tariff many hospitals started cost-cutting and reduced the length of stay for the patients in order to accommodate more patients (Mannion, Marini and Street, 2008).

The fixed national tariff has been set based on the average cost incurred by providing a similar standard of treatment procedures, incorporating data from all the NHS hospitals (Department of Health, 2013b). These also include non-clinical costs, for example, food, cleaning and real estate. The price for this particular standard procedure is called reference cost. This cost is standardised across all the NHS sectors which is only adjusted due to market forces. The market forces may lead to deviate from these costs, where some unavoidable cost may have to be incurred (Department of Health, 2013b). This new form of reimbursement is a major change from the traditional system of negotiations that led to a ‘block contract’ with the allocation of resources based on the historical costs of the activities and expenditures (Department of Health, 2013b).

Mannion, Marini and Street (2008) further explains that under the PbR system, when the commissioner pays fixed national tariff for the treatment of each patient, it creates a direct relationship between the volume of activities undertaken for the treatment and the amount payable. PbR facilitates incentives for the hospitals for undertaking more activities, by which the hospitals can increase their revenues proportionately with the increase in the activities. When the national tariff exceeds the actual cost of treatment, the providers get an opportunity to earn an incentive. But now the tariff for treatment of every patient is set nationally based on the average cost of treatment prevailing in the country. This represents that the hospitals become aware in advance about the payment that they will receive with the increase in the activities (Street and Maynard, 2007).

The PbR system is based on Healthcare Resource Groups (HRGs) which reflect the complexity of treatment and associated resources. HRGs are used in NHS in the U.K., they are similar to the Diagnosis Related Groups (DRGs) used in other countries. The main difference between HRGs and DRGs is that while DRGs were based on major diagnostic categories that correspond to a single organ system, HRGs were more directly related to specialties. HRGs are a grouping of similar kind of treatments that requires same type and volume of healthcare resources (Health and Social Care Information Centre, 2016a). HRGs help an organisation to identify the activities related to the different types of patients they care for and the treatment they provide. At present HRGs are used for determining reimbursement for the services generated by the providers. It is used as a uniform unit of currency for supporting the healthcare commissioning system (Health and Social Care Information Centre, 2016a).

The latest version of HRGs that is HRG4 is being used by the NHS since 2007 and it is being implemented in the PbR since 2009. The main modification in the HRG4 was done to implement it in some new clinical areas, which can support the Department of Health policies and the PbR system. Some new and updated HRG groupings are included in the HRG4 that can accurately record all information regarding patient treatment to project current and future trends in healthcare services (Health and Social Care Information Centre, 2016b).

Reasons for introducing PbR

The PbR system was designed for achieving many major objectives of improving the healthcare system. This system could help to improve the service quality which could in turn increase efficiency and value for money. The commissioners and the providers can retain back some amount and re-invest the same for further improving the services. By involving more number of providers and increasing the level of competition, the funds can be allowed to flow to any provider either NHS or an independent service provider. By this the patients can be treated as fixed tariff prices and according to NHS standards. With the use of this system the providers can come up with innovations and better quality services, as rewards are given to those providers who attract more patients (Pate, 2009).

PbR was basically a very new model and a new method of healthcare which could be easily accessible by the people and this can lead the flow of funds to service providers who prefer to offer service in a non-traditional and community-based manner. It was aimed at reducing waiting times of the patients by rewarding the providers who provides better and more volume of healthcare services. PbR was intended to make the system more consistent and transparent by the implementation of fixed payments to the providers based on the size and complexity of activities (Department of Health, 2013b).

Pate (2009) also mentioned that there are many services and procedures which are not under the scope of PbR and the price of those are influenced by negotiations. Services which are not covered by PbR include community services, primary care services, ambulance services and mental health services. However, in 2008-09 initiative was taken to incorporate mental health and ambulance services under the scope of PbR, but the plan was postponed because it was realised that more work was needed for developing and improving the data quality which will impact the activities and their prices (Pate, 2009).

Problems facing PbR

Appleby et al (2012) stated that the introduction of PbR definitely made some positive impacts within the NHS in England, but presently the applied system is not fit for the current and future healthcare industry. Appleby et al (2012) also stated their opinions on three aspects that- i) if the present method of PbR still continues, then the cost data regulating the system have to be improved; ii) if the current form of PbR is not properly designed to support any large scale shifts in healthcare from hospitals to other settings and iii) because the hospitals receive incentives for maintaining their income, there is lack of flexibility in tariff fluctuations.

As said by Clist and Dercon (2014), PbR fails to support continuity and coordination of healthcare. It does not provide any payment related to costs of coordination within the NHS or other independent provider. Moreover, it does not offer a financial framework for supporting and incentivising new methods of delivering healthcare services to the people. In England, NHS emphasises on providing greater importance to the prevention of illness and developing integrated care for addressing the healthcare needs of the people. This requires the PbR system to rethink the incentive structure (Clist and Dercon, 2014).

As Webster (2014) remarks, there has been a lot of argument about the success and failure of the PbR system. People who believe in PbR argue that all commissioning should be based on outcomes and the process of rewarding the providers is effective. On the other hand, people who are against the PbR system argues that it is not possible to get the whole system work according to the rules of the PbR (Webster, 2014). They believe that the PbR system does not stimulates the best practice within the sector. It supports the providers to cream off the easily available profits and delay those service users or patients who are comparatively less profitable. Webster (2014) claims whether PbR can actually achieve anything new that the traditional commissioning methods could not achieve.

According to a study by Miraldo, Goddard and Smith (2006), the PbR system is exposed to high rate of manipulation and gaming by the service providers. This manipulation is often a result of information asymmetry and the structure of the coding system. Due to such information asymmetry, the providers will be available with more cost related information than the commissioners. Manipulating the system becomes more evident in those areas where incentives are linked. Miraldo, Goddard and Smith (2006) also indicated that the PbR system is not completely prospective, because in a fully prospective system after a patient is admitted in the hospital, the providers cannot influence the tariff that they receive. In the PbR system, the service providers can influence the tariff by a process called up-coding, by which they can charge extra than the amount of service they have provided. Up-coding is a fraudulent system of medical billing in which a patient was charged for expensive treatment which was not actually performed (Phillips and Cohen, 2016).

Miraldo, Goddard and Smith (2006) further pointed out that often many patients are given unnecessary diagnoses, which are not actually required for the treatment. The providers may often misclassify the patients into specialist HRGs like emergency or critical where the funding system is different and much improved. In many instances it has been found that the patients are discharged earlier than their actual stay so that they could be readmitted again and another payment could be received. On the contrary, many providers also manipulate and extend the stay of a patient so that more payment could be extracted from them.

Due to information asymmetry another problem might arise which is directly related to the admission of patients. Often many providers deliberately want to admit “low severity patients” because treatment of such patients involves low costs whereas the amount that the providers receives in tariff remains fixed (Miraldo, Goddard and Smith, 2006). Presence of manipulation and clinical discretion can be a serious issue for the NHS organisations.

Need for change

A Five Year Forward View (5YFV) was outlined by the NHS England with the purpose of considering why the change is needed, what the change or the success may be like and how to achieve that success (NHS England, 2014). The 5YFV sets outs a clear vision about the contribution of the NHS and the other healthcare organisations towards the healthcare of the nation and transformation that is required to cope with the current and future changing needs of the patients. It also emphasises on the various care models that could help in the transformation by identifying the activities that are required at both local and national levels. It also helps in identifying the major areas where the transformation could be targeted and what benefits the patients and taxpayers can get from it (NHS England, 2014).

All the NHS organisations including NHS England and NHS Improvement have recognised from the 5YFV that the increasing demand for healthcare services will create a huge gap between the resources available and the patient needs of nearly 30 billion pounds by 2020 (NHS Improvement, 2016). Although the NHS budget has been increased, still the service providers have an objective of improving efficiency by 2% every year for the next five year to fulfil the gap. This target of improvement has been set by Cost Improvement Program (CIP), which is a measure undertaken by NHS trusts to increase efficiency and reduce expenditure. The CIP is not only directed towards the cost saving, but it also aims to improve patient satisfaction, care and safety. From the wider improvement perspectives of the NHS, improving the costing system is one major element (NHS Improvement, 2016).

The focus on costing in NHS and other healthcare organisations have been increasing since the last few decades and with this development of costing process has also improved. The local service providers are already upgrading their patient-level cost data for supporting the transformation. However, the clinicians and the managers need to be ensured that they can rely on the available cost data for taking significant decisions. As stated by Blunt and Bardsley (2012a), costing a DRG (Diagnosis Related Group) or HRG (Healthcare Resource Group) with accuracy will require information about the inputs that are received by the individual patients within a healthcare organisation. Although the NHS Costing Manual tries to provide a greater degree of consistency in generating cost information considering the reference cost, still some information are most likely inaccurate. The reference cost is used for calculating the national tariff and enhancing efficiency in benchmarking by using the Reference Cost Index. The Reference Cost Index or RCI is a measure of the relative cost difference between NHS trusts. It shows the actual cost of a trust’s provided services compared with the same services delivered at national average cost (Department of Health, 2013a).

Patient Level Information Costing Systems (PLICS)

With the problems facing the PbR system and increasing need for patient-level cost information, the UK government and the commissioners have now incorporated a new method of costing called Patient Level Information Costing System (PLICS). The PLICS system aims to replace the performance of the mandatory national tariff system in PbR which fails to reimburse individual patient cost. According to Mannion, Marini and Street (2008), the PbR system can only reimburse about 20 per cent of actual costs for only one in six patient cases and it has been found biased towards underfunding the most expensive cases. Hence, the PLICS system has been initiated by the UK government and the healthcare organisations in England to obtain individual patient level costing information (Ellwood, 2015).

PLICS are now increasingly being used in NHS hospitals (University of Bristol, 2015). On the word of Blunt and Bardsley (2012a) the main objective of implementing PLICS is to better understand the cost drivers, which facilitates the day-to-day management and enhances the service quality. NHS Improvement (2016) remarks that, PLICS which is also called clinical costing mainly focuses on tracing the resources utilised the patients for their diagnosis or treatment and hence, calculating the expenses on those resources by incorporating the actual costs incurred by the service provider. The implementation of the PLICS systems requires the providers to collect accurate cost data at every stage of a particular patient’s stay. This data should represent the ‘causality of costs’ in the hospitals locating the reasons for incurring the costs and its sources (NHS Improvement, 2016). The PLICS is basically IT software which is installed and supported by the service provider to derive cost at patient level. This cost is known as Patient-level costs or PLC and it is an output of the PLICS system. The process by which the service providers inputs the data in to the PLICS system is called Patient-level cost recording and the process by which the providers submits the data to the NHS Improvement on a national basis is called Patient-level cost collection (NHS Improvement, 2016).

Blunt and Bardsley (2012b) indicated that any organisation that wants to become more efficient needs a thorough understanding of its costs and income. By the implementation of the patient-level costing, the healthcare service providers can analyse their costs in a more sophisticated way. Even if patient-level costing is much developed in some countries, in NHS it is still growing. This system has been encouraged by the Department of Health as a device to locate efficiency savings, where about 20 billion pounds of savings have been identified by 2014 (Blunt and Bardsley, 2012b).

Recently, NHS has reorganized the monitoring of their financial information, by incorporating income and expenditure streams at every organisation level. This has been done to identify the amount of payment flowing from each individual patient (Adil and Chambers, 2012). The hospitals knows how much have been spent on their services, but it becomes difficult for them to break down those aggregate figures for estimating the relative costs of each services (Blunt and Bardsley, 2012b). For looking into the details of the costs a lot of approximations are done which places the validity of the cost information system into question. The PLICS system aims to overcome this problem by utilising much more detailed information about the cost related to each patient. According to the Department of Health (2013), it is not mandatory to use the PLICS in the NHS organisations, but it is recommended to implement it so that the NHS organisations can completely understand and develop their business to create a benchmark of healthcare service for the healthcare organisations across the world.

According to a survey done by the Chartered Institute of Management Accountants (2010), only 17 per cent of 53 NHS organisations that have responded to the survey implemented the PLICS system. However, this number increased to 29 per cent from the responds of the Foundation Trusts (Chartered Institute of Management Accountants, 2010). According to another recent survey done by the Department of Health, 75 out of 155 acute NHS organisations (48 per cent) had employed the PLICS system and more 26 per cent were planning to implement the system in their organisations (Department of Health, 2013a). The maximum number of PLICS implemented was in the South East Coast Strategic Health Authority area which was recorded at 100 per cent. This amount is followed by London Strategic Health Authority area at 73 per cent and the East of England Strategic Health Authority area at 67 per cent (Blunt and Bardsley, 2012a).

Patient-level Costing in a Multi-speciality Hospital

Every hospital has their own way of recording cost information of the patients and getting accurate cost information is most important. The hospitals need to understand the involvement of cost in every function and every activity that it undertakes. According to Chartered Institute of Management Accountants (2014), many NHS organisations have come up with a new system of financial control and financial performance monitoring called Service Line Reporting (SLR). The main concept behind SLR is that each service line like orthopaedics, paediatrics or endocrinology, is handled as a separate business unit and is managed by a single clinician. The SLR system generates data from a large number of clinical and financial sources for improving cost transparency within the hospital. This also represents the profitability of a particular service line and helps in managing performance effectively (Chartered Institute of Management Accountants, 2014).

Engagement of doctors and hospital staffs in the total costing procedure is an important aspect that helps the management in identifying cost related to each patient. Based on an article by The King’s Fund (2012), hospitals with more clinician and staff engagement can enhance experiences for the patients and can achieve better outcomes. Lack of clinical engagement can result in inappropriate costing and the hospitals may have to incur huge loss for this reason. Blackpool, Fylde and Wyre Hospital Trusts experienced huge financial crisis with an estimated deficit of 21 million pounds in 2006. The main reason for this was lack of clinical engagement and high costs (The King’s Fund, 2012).

As per the NHS Improvement (2016) costing transformation programme, the implementation of Patient-level costing system have helped many hospitals in identifying income and expenditure related data of each patients and in the process they can measure the profitability related to each service line. For example, York Teaching Hospital of NHS Foundation Trust has identified 160,000 pounds additional income by reviewing its breast surgery procedure (NHS Improvement, 2016). The trust has set up a process called ‘deep dive’, where the income and expenditure data can be generated from the patient-level costing system. This has also helped them to identify areas of improvement and this process was further extended to all specialties across the trust (NHS Improvement, 2016).

Patient-level Costing in Cancer Specialist Hospital

An article in British Journal of Cancer (2015) stated that the cost of cancer treatment is much different and of considerable significance in the international healthcare sector. The initial treatment period of the cancer patients, rehabilitation process and follow-up after a cancer diagnosis incurs huge costs in every healthcare organisation including NHS. Classification and projection of these costs along with other relevant outcomes plays an important role in planning healthcare budget and designing services aiming at enhanced efficiency.

The methods used by many hospitals in United Kingdom either fails to record local variations or incurs a heavy burden on data collection. This is due to absence of in depth databases. The cost and income data relating to individual patient cases are calculated by using a national tariff (British Journal of Cancer, 2015). PLICS are developed in many cancer hospitals in order to improve the accuracy and standardise the costing methods using this national tariff. Patient-level costing systems offer new opportunities for calculating the total hospital-based cost of care. By accurately recording the patient-level variations, these hospitals can improve their current costing methods (British Journal of Cancer, 2015).

The major issue in cancer hospitals is to identify the activities and cost relating to chemotherapy. A lot of adjustments and modifications need to take place in order to produce accurate chemotherapy costs and activity details. If chemotherapy is recorded within the cancer hospital’s PLICS system then those details will be easily accessible (British Journal of Cancer, 2015). An in-depth understanding is required of how activities and costs in different departments of the hospital are linked and what manual adjustments are necessary to generate costs for reference cost reporting.

According to Department of Health (2012), some cancer hospitals may need to make adjustments to confirm that costs and activities are accurately allocated to the correct patient. For example, a particular patient’s chemotherapy delivery may be recorded under appropriate reference cost workbook. Now depending on the information system and the patient records, the hospital might conduct a manual checking for tracing activities to that patient. This will require details about the patient case and types of tests done on the patient.

In a recent case mentioned in NHS Improvement (2016), an NHS organisation successfully recovered the investment in its costing by reviewing its cancer drugs. In this case the income received by the organisation did not match with the cost of care of the patient and thus, used the dashboard to investigate what led to the mismatch. The clinical director of haematology department identified that for a particular cancer patient the cost of care were considerably higher than the income received against it. He found that the patient had been treated with a particular drug which had a high cost associated with it. The identification of that particular oncology drug which was driving the higher cost led to the investigation of whether the cost information was accurate and if by any means that cost could be recovered or reduced. The head of the costing department immediately contacted the head of contracting and commissioning to locate why the organisation received no income for that high cost drug. With the assistance from the pharmacy manager, they discovered that the drug was entitled for reimbursement from the Cancer Drugs Fund (CDF), but unfortunately it had not been labelled in the pharmacy system, hence no income was received for that drug.

The team immediately reviewed all the CDF drugs and discovered that there are many other drugs which are eligible for reimbursement but had not been labelled. The system was rectified and the organisation now reviews the CDF drugs list on a regular basis. This process change increased income for that organisation by 90,000 pounds that year. Such review process and consistent approach support’s every healthcare organisation’s financial sustainability and also enhances patient services (NHS Improvement, 2016).

Rising Trend of PLICS Implementation

PLICS which basically is an IT system, combines activity-based financial and operational data to calculate costs related to individual patients. According to a survey by Llewellyn et al (2016), the utilisation of the PLICS system was investigated which was followed by few case studies for analysing the current and potential users. The aim of the survey was to evaluate the use of PLICS in four areas- better resource allocation, cost improvement, clinical engagement and understanding clinical variation. It emphasises on developing the whole NHS economy rather than the individual organisations where PLICS are applied (Llewellyn et al, 2016)

Ellwood et al (2015) explains that the patient-level costs helps in identifying variations and reducing waste. Most of these organisations are evaluating the individual level patient costs against the national tariff and they also compare the costs across and within the specialities. They engage the clinicians with cost data as they are involved in decision-making regarding the utilisation of the resources. The organisations set a benchmark using their cost data relating to patient-level activities against national or local treatment conventions (Realcom, 2016). PLICS have also been used by many organisations in redesigning services and moving services to another care setting, thereby reducing redundant interventions and referrals (University of Bristol, 2015). The data obtained from the PLICS are recorded into national databases and as in 2013 about 74 per cent of organisations employed PLICS for providing reference cost data (Llewellyn et al, 2015).

Benefits of PLICS over PbR

Appleby et al (2012) emphasised the main challenges towards the healthcare system in future. These challenges include negligence in prevention of health issues, increasing demand by the ageing population, increasing frequency of long-term health conditions, huge variations in quality of healthcare services with indications that it could be improved by the application of more systematic practices and an increasing dependence on hospitals relating to underdevelopment of community services and primary care units. Appleby et al (2012) also indicated that considering this situation, the main issue is which payment system can effectively support the NHS organisations to fight against these challenges. Although the PbR system provides incentives for improving efficiency in service delivery, this system is lacking in the way that the service providers only respond to the prices they face and also the PbR system has limited scope (Appleby et al, 2012). The PbR system also put the hospital finance under pressure (Appleby et al, 2012).

On the other hand, Blunt and Bardsley (2012a) identified that PLICS is a much wider and in-depth scope in calculating individual patient-level cost by incorporating all the activities connected to a particular patient. The PLICS system incorporates all costs incurred including depreciation and fixed costs which do not change with the change in the activities. Blunt and Bardsley (2012a) states that in 2009, the Department of Health depicted five major benefits of implementing a PLICS system, which are as follows:

i) This system helps an organisation to get a transparent picture of their income and costs at every level of service on a monthly or quarterly basis.

ii) It helps in evaluating cost variations and improving clinical involvement and ownership relating to cost information. This helps in comparison against inside teams as well as outside peer groups.

iii) It helps in identifying any future change needed in the classification and grouping of patients under similar types of activities and costs.

iv) The most significant benefit of PLICS over the PbR system is that the national PbR tariff has failed in reimbursing individual patient costs. This represents the advantage of PLICS cost data in informing funding policy for payment.

v) The PLICS system generates valuable data that can be discussed with the commissioners for improvement.

Blunt and Bardsley (2012a), also indicated that in spite of these benefits, the implementation of the PLICS system represents a huge shift in the costing methodology and it will require the support of many previous systems. Moreover, the cost of implementing the system is huge and it varies from one organisation to another. In another article by Blunt and Bardsley (2012b) mentioned an example that in 2009, one NHS trust implemented the PLICS system and they estimated the cost of investment in software, hardware and training to be around 250,000 pounds to 500,000 pounds including additional expense in maintenance, on-going support and licence fee. This definitely is a significant investment but not that huge comparing to the income of the NHS acute organisations (NHS, 2014).

If the PLICS is implemented effectively it can provide a vast range of useful and accurate data on cost per patient against income (Ellwood, 2015). The benefits of PLICS are not limited to detailed analysis of costs only. It is also used for enhancing more accurate budget projections and to implement changes in certain patient groups (Blunt and Bardsley, 2012a). This could be used both as an instrument for improving efficiency in those services and also for understanding the full costs of care for individual patients.

Blunt and Bardsley (2012b) indicated that if the information from the PLICS system can be generated more frequently like on a daily or weekly basis, the costs could be easily exposed to the surveillance methods that are applied for monitoring. This will help to intervene immediately in a service, if costs are found to be consistently deviating from the expected value. The introduction of PLICS will depict that the service providers have a very detailed and advanced understanding of their costs, to which the commissioners do not have guaranteed access. This may create information asymmetry which can have a negative impact on the efficiency of the healthcare sector (Blunt and Bardsley, 2012b). However, to avoid this, the policy-makers could implement some sort of mandatory cost-information sharing model between all the providers and commissioners. In this way, PLICS could be an effective tool for all healthcare organisations. It can provide a vast range of accurate data on proportion of expenditure and profitability against income.

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