Original Title: Procedimientos de financiación en atención primaria adecuados a recursos y eficiencia, mediante adjusted clinical groups (ACG)

Authors' objectives: 1) Calculate the magnitude and variability of the disease burden, expressed in extended diagnostic conglomerates and need for care due to comorbidity, expressed in aggregate diagnostic groups. 2) Obtain the mean relative weights of the cost of care for each one of the Adjusted Clinical Groups (ACG). 3) Calculate efficiency rates and resource utilisation bands through the standardisation of ACG case-mix. 4) Explore patterns of pharmacy expenditure by means of demographic data, of the use of resources and of the pharmaceutical expenditure associated with these. 5) Set up a general index to evaluate efficiency in the budgetary distribution of resources according to Primary Care Units and Regions.

Authors' results and conclusions: 1. During the year 2009, the number of people who did not use primary care services amounted to 51,161 children and 598,492 adults, representing, overall, 28.26% of the population. 80% of diagnoses are condensed into 11 of the 27 largest medical conglomerates, corresponding to prevention activities, symptoms and general signs, ORL, skeletal muscle apparatus, cardiovascular, skin, respiratory, gastrointestinal and hepatic, general surgery, neurology and ophthalmology. 2. The average relative weights of the ACG, compared to the American figures, presented an adjusted determination coefficient R2 = 0.46. 3. The 2,298,754 patients studied generated 10,157,636 visits, 390,700 radiological studies, 1,726,457 analyses, 967,885 referrals to specialised care. 1.35% of patients attended have high or very high expected costs. 4. Pharmaceutical expenditure, generated by primary care prescribers follows the reverse gradient to social deprivation. 5. The General Efficiency index includes, in one-year periods, the structure/process/result-on-health parameters and allows the Primary Care Units to be differentiated according to efficiency, allowing an improvement in the future budgetary adjustment. CONCLUSIONS In our environment, the ACG system provided sufficient information to group together the patients of the population of the Basque Autonomous Community according to their clinical-epidemiological status, their need for care and the use of resources. The correlation of the North American and Basque average weights is only moderate as this does not integrate hospital expenditure variables. The adjustment of pharmacy expenditure should consider the social deprivation variable. Lastly, the integration of ACG information for a general evaluation of the level of efficiency of Primary Care Units and health region, and to consider this as a budgetary distribution element, is feasible.

Authors' recommendations: The use of ACG for capitated payment as a contributory method in the health financing of primary care must also include information and costs of the area of specialised care. Specifically, it is proposed to include information relating to emergency treatment and hospital admissions and pharmaceutical expenditure, and reference services (monographic and tertiary hospitals)

Authors' methods: 1) Population-based retrospective transversal study, based on the computerised medical records of patients attended to in primary health care centres, of the Basque Health System/Osakidetza, during the period 2005-2009. The records were drawn up in accordance with CIE-9-MC, and by means of the ACG System® application, version 6.0, with the following results: a. Magnitude and variability of the population health burden according to health regions, expressed in Expanded Diagnosis Cluster (EDC and MEDC), and by means of the morbidity ratio between observed and expected rates. b. Need for care, through the measurement of comorbidity, expressed in the number of Aggregated Diagnostic Groups. 2) Calculation of the average relative weights of the cost of care through iso-consumptions, Adjusted Clinical Groups (ACG), and their adjustment. Later, their correlation with the American weights was calculated. 3) Identification of expected costs in 5 resource utilisation bands by means of ACG iso-consumptions. 4) From a sample of individuals and of the following variables: socio-economic deprivation rates, consumption of resources in primary care (consultations, referrals to specialised care, laboratory and radiology usage and pharmaceutical prescription data) and in specialised care (first referrals to specialised care, and hospital admissions during the year), a regression model was made from which a formula which simulated the expenditure in pharmaceutical prescriptions, based on these variables, was obtained. 5) Construction of a theoretical model to evaluate the level of efficiency in the distribution of resources, called the General Efficiency index. This model includes structural variables (personnel costs budget and general expenditure), process variables (efficiency indices in the resources used in the calculation of the ACG) and result variables (evaluation results of a battery of clinical indicators used in paediatrics and general medicine).

Project Status: Completed

Year Published: 2011

URL for published report: https://www.euskadi.eus/contenidos/informacion/2012_osteba_publicacion/es_def/adjuntos/D-12-02_WEB%20_%20procedimientos%20de%20financiaci%C3%B3n.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government