APPENDIX C
MTG POLICY PAPER ON PAYMENT BY RESULTS
Ensuring Appropriate HRG Tariffs—It will
be essential to ensure that HRG Tariffs accurately reflect the
care actually being provided. Inappropriate payment can discourage
hospitals from using highly innovative and effective technologies
that can help save lives and improve quality of life. This may
jeopardise patient access to such technologies and adversely affect
the research and development efforts of manufacturers seeking
new and improved breakthrough technologies. Payment rates should
also distinguish key therapies within specific payment levels,
rather than including clinically and economically dissimilar therapies
in the same payment groups. The MTG was supportive of the DoH's
consultation with all stakeholders to ensure that consideration
of national tariff rates is conducted appropriately under the
HRG system. The casemix activity of hospitals needs to be monitored
to asses the impact of PbR. It is possible, for example, that
the system will discourage complex angioplasty in favour of coronary
artery bypass surgery due to the inflexibility of a fixed tariff.
Ensuring Sufficiently Specific HRGs—As
the HRG system is phased in over the next few years, it is important
that there be sufficiently specific HRGs to capture the breadth
and complexity of the vast array of procedures used throughout
the NHS.
Generating Robust Hospital Data—Robust
data will be critical to the success of the HRG payment system.
It is essential that a mechanism is in place for generating valid
data and utilising this data as early in the evolution of the
HRG payment system. This will aid HRG policymaking and ultimately
result in more appropriate payment rates. Hospital understanding
and accurate use of codes is essential to ensure the collection
of robust data.
Ensuring Rapid Adoption of New Innovations—A
consequence of HRG-like payment systems is that they can be slow
to react to new and innovative medical technologies, especially
those that are substantially different from items already being
used in hospitals. This can have a detrimental impact on patient
access to medical technology. MTG welcomes the apparent flexibility
of the "pass through" system described in the technical
guidance, but fears that in practice its use maybe seen as cumbersome
and time consuming by PCTs and providers alike. Its use needs
to be assessed and technologies having particular problems may
need to be supported by specific guidance from the centre.
Making HRG Assignments Regularly and Appropriately—Newly
marketed and existing medical technologies should be assigned
expeditiously to appropriately paying HRGs from the time of their
introduction based on valid data submitted by manufacturers. Clear
criteria for determining and correcting the inadequacy of payment
of an existing HRG should be developed as part of this process.
Anticipate Transition Costs to Ensure Continuation
of Patient Care—As the HRG system is implemented over the
next few years, policymakers should realise that even the best
planning cannot fully predict the costs and challenges of transitioning
an entire health care system to HRGs. While the MTG stands firmly
behind the objectives of the PBR effort, efficiencies from this
system will not occur immediately and the costs of adoption may
be substantial. We call upon the Government to ensure that adequate
resources are provided to support the transition to HRG payment.
Changing the method of payment in this way alters
the commissioning incentives for Trusts; this should mostly benefit
patients, as it should ensure that they are treated on the basis
of need. However, the system could create incentives for Trusts
to discontinue treatments they would otherwise have used—not
on the basis of effectiveness or cost-effectiveness, but because
the tariff is inappropriate. For example, there are variations
in the calculation of outpatient costs, and this may act as a
disincentive to providing treatments in outpatients, especially
when the tariff for inpatient care is higher; this could have
negative impact on patient throughput and access to less-invasive
technologies that could be used in the outpatient setting. It
will be a significant challenge to tackle these problems without
adding to the complexity of the system.
The system should not introduce new sources
of delay because hospitals do not have payment levels that are
sufficient for certain therapies. In addition, the impact of HRG
payment on hospital waiting times should be carefully monitored
and understood. Where hospitals are given a low incentive to use
certain technologies because of low payments, waiting times could
worsen for key procedures.
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