Manises PPP - Private Healthcare Australia

Manises PPP
Sydney
Nov 2010
Index
1
PPP Overview in Spain
2 What is Manises
3 Manises Key Management Model
4 In Short
5 Discussion
2
1. PPP
Overview
in Spain
3
Sanitas: who we are
100% owned by BUPA (since 1989)
More than 50 years of operations in Spain
Integrated Healthcare Group:
• PMI: number two operator in Spain
• Hospital Group: Integrated network of 60 centres (Hospitals,
Multispecialty and dental)
• Care Homes: number two operator in Spain
Also operating in other Health services like Wellbeing,
aesthetics..
4
Spanish National Health System
100% financed out of general tax
Governance is decentralized through local
healthcare management organisations in
each of the 17 Regions
Universal healthcare free of charge
Benefits include:
• Primary healthcare
• Specialised healthcare, including outpatient and inpatient care
• 60% of the price of prescription drugs (some have full
coverage)
Gatekeeper model
5
Private Participation in the Public Health System
Health System
Insurer
Private
Provider
Public
Private
Public
Contracts
Muface
Mugeju
Isfas
Collaborating
entities
(BBVA, SCH,
CAM)
NHS
PFI
Infrastructure
PPP
Health care
Provision +
infraestucture
6
•Designs
Construction
Financing &
Operations
•NHS carries out
the clinical
services
•Payment Fee
• PFI & Clinical
payment
• Capitative
payment
Evolution Public – Private Colaboration Model
+
Intermediate Care
Construction
Equipment
Maintenance
Baix de
Llobregat
+
Services
No clinical
Majadahonda
S. Sebastian de
los Reyes
+
High Tech
Burgos
+
Specialized
Medical Care
Valdemoro
Torrejon
+
Primary Care
Elche
Alzira
7
Manises
PPP – Why for NHS
Control health
care costs by
transferring risk to
a more efficient
private provider
Allows making
important
investments in
infrastructures
and defer its
payments
Flexibility &
Innovation
Capacity
Easy check of
the quality
standards
Generate
savings for the
regions
8
PPP – Why for Sanitas
Strenghten our
healthcare
market position
Participation in
an emerging
market in Spain,
where our
competitors
(Adeslas, Asisa..)
are
Help to counter
the impact that
any possible
improvement of
the NHS would
have on the PMI
business
Attractive
financial returns
expected, non
cyclical incomes
& flows
9
2. What is
Manises
10
Valencia Health System: Our customer
In the Valencia Community there
are 23 health departments, 5 of
them are working as PPP
The Manises Department is
functionally dependent on the local
health government
We are part of the NHS
11
Our Health Department
Riba-Roja
Turia
(17.266)
• We cover an area of 20
Manises
(19.952)
Cheste
(8.320)
villages
• We give assistance through:
• 20 Primary Health
Centres
• 2 Specialised Health
Centres
El Carmen 3.319
Xiperets 6.867
Riba-Roja
Chiva TuriaLogorilla
(17.266)
Quart de
Buñol
(10.857)
(1.421)
Poblet
10.709
Alborache CheCalicanto Logorilla
Manises
Aldaia
(23.973)
(19.952)
(57)
(812)
(1.421)
ste
(25.171)
El Carmen
Chiva (10.857)
Quart de Poblet
Yatova
(8.3Pecheriza
3.319
Barrio
Calicanto (57)
Aldaiadel(23.973)
20)
(1.713)
Xiperets 6.867
Pecheriza (266)(266)
(25.171)
Cristo
6.749
Barrio del
Godelleta
Cristo 6.749
Godelleta (2.582)
(2.582)
Turis
Buñol
Macastre
10.709
(5.474)
Alborache (812)
(938)
• We give medical assistance to nearly 200.000 people
• First hospital resulting from a concession model in an urban area. Only 8 km.
away from Valencia
• Doors opened on May 7 , 2009
• In May 2010, 44.200 persons added from Mislata
th
12
Our Health Department
A new department created from three different ones
CE Aldaia
20 CS
Manises
Hospital
Military
Hospital
CE
Mislata
Competitive Environment - The Major public hospitals are in the
catchment area
Hospital
La Fe
Hospital
General
Hospital
Peset
Hospital
Clínico
Hospital
Arnau
13
Our Stakeholders
BUPA
Bancaja
CAM
50 %
50 %
Ribera
Salud
Sanitas
40 %
60 %
Especializada y
l’Horta Manises
Government, Mayors and Community Association’s satisfaction is one of our goals
We collaborate with them to provide the best medical care
We develop health programmes together
The quality of our assistance is one of their objectives
14
Manises Hospital
Resources
221 Single
rooms
32
Outpatient
hospital
Examination
rooms
10
Large
multipurpose
operating
rooms
6
Dilation
rooms
24
Post-surgical
posts
2
Delivery
rooms
53
Consultation
rooms
10
Intensive
care rooms
16
18
Dialysis
stations
Military Hospital
Resources
137
Beds
2
Large
multipurpose
operating
rooms
12
Outpatient
hospital
Examination
rooms
28
Consultation
rooms
17
3. Manises
Key
Management
Model
18
Manises Management Model
STRATEGIC PLAN
What do we want
to achieve?
High level of Satisfaction & Clinical Safety
Efficiency: Scorecards
OPERATING AND
ORGANISATIONAL MODEL
How do we operate?
RESOURCES (HUMAN, SYSTEMS,
INFRASTRUCTURE, EQUIPMENT)
What resources are available?
Clinical & Quality Governance
SH Model
Strategic Premises
Business Case
HR: FTE + Remuneration Model
Services, Technology & Infrastructure
The structure of the management model is the key to managing a new business
19
Business case: P&L
P&L
Profit &
Loss
(M. €)
Total
revenues
Operating
costs
EBITDA
EBIT
2009
2010
2011
2012
2013
2014
43,7
108,7
125,5
131,5
137,3
143,4
50,5
94,5
107,4
111,3
115,3
119,4
-6,9
-11,9
14,2
5,8
18,0
8,7
20,2
10,4
22,0
12,0
24,0
13,7
Profit & Loss Account (M. €)
300
250
200
150
100
50
2009
2010
2011
2012
2013
2014
2015
2016
Total Revenues
2017
2018
2019
2020
2021
EBIT
20
2022
2023
2024
Business Case: Capex & Return Analysis
CAPEX
Capex
(M. €)
Manises
Hospital
Military
Hospital &
Manises
Total
investment
Construction
Phase
Total Reinvestment
Total
Capex
101,8
46,5
148,3
15,1
15,1
61,7
163,4
101,8
IRR: 12,3 %
21
Revenue Structure
Capitation Revenue: 116,7 M.€ (192.329 inhabitants x 607,14€)
Revenue Positive Intercentres invoicing: Activity from non capitative population
Other customers: Traffic Accidents Insurers, Mutual Insurers…
Complementary revenue: Parking, Vending machines, TV, etc…
12%
85%
22
PPP´s: Valencia and Madrid models
Valencia
Contract length
Services
included
• 15 years, extendable an additional 5 years by
mutual consent, beginning once the hospital is
operational
•
•
•
•
Primary care
Outpatient and inpatient specialised care
A&E
Pharmaceutical management across all
centres managed (but only responsible for
cost of inpatient pharmaceuticals)
• Addiction rehabilitation and family planning
• 30 years beginning with the signing of the
contract, therefore including the
construction period (~21 months)
• Outpatient and inpatient specialised care
• A&E
• Pharmaceuticals provided with inpatient care
• Does not include the cost of prosthesis,
ambulance or oxygen therapy
•
•
•
•
•
•
•
• All statutory personnel currently working in
primary health centres included in the health
area continue to be employees of the state,
although managed by the company responsible
for the health area
• All hospital personnel are
employees of the company
responsible for managing the
health area
Services
explicitly
excluded
Personnel
Madrid
primary care
organ transplants
ambulance services
oxygen therapy
addiction rehabilitation
family planning services
pharmaceuticals
23
PPP´s: Valencia and Madrid models (II)
Valencia
Subcontracting
Construction
period
• Cannot subcontract medical services
• Cannot subcontract medical services
• 25 months from signing of contract
• 18 months from issuance of planning permit
Capita established by CAV
Bidders define:
• A capita payment to cover medical services
provided
• A fixed fee to cover the cost of the construction
and maintenance of the infrastructure
• Incentive for reducing pharmaceutical´s
• Commercial activities (parking,
restaurant, flower shop)
• Commercial activities (parking,
restaurant, flower shop)
• Maximum of 85% of list price for incoming
activity, could be reduced in the bid terms
presented
• 100% of list price for all services provided
to health area residents outside of
managed centres (except excluded
services)
• 90% of list price for incoming activity
• 100% of list price for all services
provided to health area residents
outside of managed centres (except
excluded services)
Payment
Other revenue
streams
Inter-centre
costs
Madrid
24
PPP´s: Valencia and Madrid models (III)
Valencia
Price increase
mechanism
Return on
investment
Madrid
• Annual increase based upon the lower of:
• growth of Valencian government health
budget
• average growth national health budget
• 85% of inflation growth in hospital
spend in the Community of Madrid
• Capped at 7.5% for medical
services
• No Cap
Negative intercentres charges
If our protected population receives health services by other health departments, we would
have to take up the following costs:
The negative Intercentres invoicing can come from:
Patients who decide to be assisted by specialists of other public hospitals
•
Patient’s choice
•
Waiting list
Patients with pathologies not included in the Service Portfolio of Manises Hospital
This is not the case in primary care
It is being more difficult to reduce the negative Intercentres than other
concessions
Our population transferred from other nearby hospitals, which are still functioning, and one of
which is the largest hospital in the Valencia Region.
On the other hand, we have more capacity to generate positive intercentres
than other concessions in the near future
We are around a densely populated area, nearly 1,5 million people
26
Scorecards
MANISES
HOSPITAL
Ratio of day patient surgery
Ratio of cesarians
HEALTHCARE EFFICIENCY Ratio of surgical difficulty
RATIOS
Average Stay
Ratio of reentries
A&E pressure
Consultation occupancy ratio
OCCUPATIONAL RATIOS
MANAGEMENT RATIOS
Theater occupancy ratio
Hospitalisation occupancy ratio
ICU occupancy
NICU occupancyAppointment ratio
Appointment occupancy ratio
Total productivity ratio
Doctor productivity ratio
Absenteeism ratio
FTE
Medical cost ratio
Property cost x m2
% Specialities with consultation waiting list higher than 30 days
Specialities with surgeries waiting list higher than 60 days higher
than 15%
OTHERS
Portfolio of services
Total complaints
% of clinical complaints/total
% of A&E complaints/total
% of complanints per patients attended
AC
2010 YTD Q1
2009 YTD Q4
DEV
52%
56%
-7,1%
16,00%
3,80%
4,2
5,10%
80,00%
56,00%
50,00%
76,00%
75,30%
35,50%
109%
2,39
5
2,70%
675
14,70%
47,3
17,00%
3,70%
4,3
4,70%
76%
44,71
31,12%
91%
74,78%
25,43%
106,00%
2,19
4,54
2,50%
633
0,148
55,8
-5,9%
2,7%
-2,3%
8,5%
5,3%
-98,7%
60,7%
-16,5%
0,7%
39,6%
2,7%
9,1%
10,1%
8,0%
6,6%
-0,7%
-15,2%
10,80%
15,90%
-32,1%
38%
35,89%
5,9%
40
61,6
0,092
0,358
39
65
0,0998
0,3742
2,6%
-5,2%
-7,8%
-4,3%
0,0023
0,0027
-14,8%
Headcount May 2010
700
600
500
400
300
200
100
0
Employees
Civil Servants
28
4. In short
29
In Short
1. We provide healthcare to nearly 200.000 inhabitants
2. Long term partnership with Public health system ensuring :
- Efficiency
- Innovation
- High Quality Standards
3. Much more than a hospital:
- 20 Primary centres
- 2 Speciality Centres
- Manises Hospital
- Intermediate Care Hospital
4. Great opportunity to develop and improve our hospital management
model
5. Diversify Sanitas’ operations
6. Counter the impact of NHS on our PMI business
7. Attractive financial returns expected
30
5. Discussion
31
Manises PPP
Sydney
Nov 2010