Tariffs and Profitability for Gynaecological Oncology Services Rob Gornall Gynaecological Oncologist

Tariffs and Profitability for
Gynaecological Oncology Services
Rob Gornall
Gynaecological Oncologist
Gloucestershire Hospitals FT
Who Cares?
 Best practice comes first
 Swings and roundabouts
 It seems to get sorted so concentrate on important
things I can influence/improve
 Lets not draw attention to ourselves
 BUT …
Organisational and funding changes




Hospitals and FT in financial difficulty
Ongoing shrinkage in budgets
Evolution of Business Intelligence/PLICS data
Service Line Reporting and position of gynaecological
oncology within divisional structures
 Business planning requirements for staff/workload
expansion
Specific difficulties
 Likely never ‘profitable’
 Recent surgical developments have been
implemented by profession in unplanned way without
sound national/local planning
Notably
Role out of radical laparoscopic surgery
Radical debulking surgery for ovarian cancer
What Services Constitute
Gynaecological Oncology?




Tertiary referral surgical resection services
Non surgical Oncology radiotherapy/chemotherapy
Outpatient Services – follow up/combined clinics
Nurse specialist activity
Additional Related Activity





Radiology/Pathology
Additional Surgical activity
Complex benign gynaecology
General Surgery colorectal, plastics etc
Research
Methods of commissioning
 Local commissioning
Diagnostic/Local Treatment block contracts
 Specialised commissioning
Case specific and national tariff based
 Scope for local/regional negotiation
 Individual tariff setting by some providers
Current Issues
 Limited data on the accurate cost of complex
gynaecological oncology procedures
Primary/Interval debulking procedures vary in
extent
 Widespread introduction of minimal access cancer
surgery
 Current gynae oncology and general gynaecological
practice variability in UK
How are tariffs calculated
NHS PBR Annual Guide
 2014 last year for DoH responsibility – responsibility of
Commissioning board and Monitor
 Based on underlying reference costs with 3 year time
lag
 Adjustments from tariff calculations only made for
good reasons eg to avoid
 national pricing anomalies
 Perverse incentives
What is the ‘standard’ tariff for an
ovarian cancer debulking prodecure
TAH BSO
Omentectomy
Peritoneal
excision
Q074
T361
MA06Z
Spell income
PLICS cost
3910
7559
Open major
upper and
lower genital
tract
procedures
with
malignancy
With CC
Additional
25%
Ovarian cancer ‘mitigation’
Additional
description
Procedure Code
HRG
Description
Ureterolysis
Q074
LB07Z
Ureter open
procedure
Additional
Transverse
description
Colectomy
Procedure Code FZ08B
HRG
Q074
Ureterolysis
Complex large
intestine
procedure
Ureter
openwithout
CC
procedure
Q074
LB07Z
Anterior resection H334
Complex large
Q074
ureterolysis
intestine
Modified
posterior X143
procedure
exenteration
Without CC
LB07Z
FZ08B
Ureter open
procedure
MA01Z
Lower/Upper V
complex
procedures
Right
hemicolectomy
appendix tumour
FZ09A
Proximal colon
procedures with CC
H071
Costs
Additional procedure
Spell income
PLICS
ureterolysis
5017
7718
Transverse colectomy
5870
8927
Anterior resection
5097
9653
Modified posterior
exenteration
6144
8054
Right hemicolectomy
7188
4832
Cost estimate complications
 Example
Ovarian Malignancy complicated by enteric
fistula/nephrostomy/TPN with extended stay
Total inpatient Stay 120 days
Income 27,159
Cost
51,217
For sample 10 case examined deficit 40K
Tariffs for endometrial cancer
Procedure
Code
HRG
Description
SPELL
income
TLH BSO
Q074 Y752
Q221
MA08Z
Upper
genital tract
laparoscopic
procedures
2234
TAH BSO
Q074 Q221
MA06Z
Open major
with
malignancy
3489
TLH BSO
pelvic and pa
nodes
omental
biopsy
Q074 Y752
Q221 T856
T364 T423
Z941 U212
Y973
MA06Z
Upper
genital tract
laparoscopic
procedures
2234
Tariffs for cervical cancer
Procedure
RH PLND
Q071 T856
T866
LB07Z
Ureter open
procedure
4848
TLRH PLND
Q071 Y752
T856 T866
MA08Z
Upper
2234
Genital Tract
Laparoscopic
major
procedure
Short Term Options
Marginal Gains
Optimise use of:
Outpatient tariffs
Diagnostics
Development of actual cost tariffs for extra contractual
work
Agreement of departmental Coding Policy
Outpatient Tariff
New
Follow Up
Gynae Onc
168
98
Gynae
140
89
Oncology
234
104
‘Multiprofessional’
270
140
Ways forward
 Rectify anomalies in national grouping system
 Recognition of extended surgical staging in payment
schedule
 Development of tariff uplift for good practice eg
enhanced recovery/short stay laparoscopic
hysterectomy procedures
 New codes with enhanced tariff to reflect complexity
of radical debulking surgery
The way forward
 More joined up thinking nationally on economic
impact of prospective treatment changes and tariff
review
 Production of accurate costings on a national level
for ovarian cancer surgery with reference to NICE
guidance on initial surgical management
 Working through BGCS commissioning subgroup and
complex gynae CRG to approach Commissioning
Board