About the Tariff

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Introduction

The purpose of the Integrated Sexual Health Tariff is to:


Background

The London Sexual Health Programme was concerned that Sexual and Reproductive Health clinics were not being adequately funded and there were disincentives to develop integrated services that bettered served patients and offered better public health outcomes. There was also concern that much of the complex GUM care undertaken was not being adequately funded. Furthermore, commissioners felt that they were commissioning services ‘blind’, with insufficient information being delivered and too late to impact their decisions.

Pathway Analytics was commissioned to support the London Sexual Health Programme develop a set of currencies and tariffs to promote the delivery of integrated sexual health care in London. 

The development of the Integrated Sexual Health Tariff was driven by four expert working groups drawn from sites across London.

  1. Clinical Working Group
  2. Commissioning Working Group
  3. Data Management Working Group
  4. Finance Working Group

Pathway Currencies and Tariffs

The model used to develop the price of care was a Time Driven Activity Based Cost model based on granular elements of care. These elements of care could then combined into bundles or 'Currencies'. The Currency describe the generic package of care delivered and each Currency has two prices known as 'Tariffs':

This approach was specifically endorsed by Price Waterhouse Coopers (PWC) in an overarching review of Payment by Results (PbR) development sites in 2008 as recommended best practice in designing tariffs. It has since been recommended as an approach to future PbR development by Monitor.


Pathways

Clinicians from the Clinical Working Group mapped over 140 care Pathways that describe, in detail the care and resources delivered in each element of care they undertake in their clinics. Many hours of clinicians’ time was used to develop and review these pathways that have been reviewed nationally and have the support of the professional bodies BASHH and The Faculty of Sexual and Reproductive Health. Subsequent changes in care Pathways due to a change in clinical practice can be rapidly implemented in the underlying Tariff charges.

pathway-cost-model

Pathways were developed that represented the care delivered either on a contact basis for care activity that is recorded visit by visit or on an episodic basis for care that is recorded only by diagnosis. For example the pathway for Management of reactive treponemal serology, covers the cost of treatment over multiple visits whereas the pathway for T6 Hepatitis Test, only covers the cost of the single visit when the test is conducted. This approach enables the linking of a Tariff payment to both activity codes and diagnosis codes as appropriate.

Managing 140 care pathways and their Primary and Additional Tariff prices, while not difficult for data collection systems, was considered to be too cumbersome for tariff purposes. It was decided to follow PbR guidance and bundle the Pathways into Currencies.

 pathway-example  pathway-example-detail

 

Detailed Pathway cost data is maintained in the Pathway Analytics Cost model and can be updated automatically when resource costs change.

Pathways are therefore bundled by weighted average into Currencies and a Currency factor is applied to accommodate for the number of times un-coded Pathways in that Currency are delivered. The data behind the Pathway weighting and Currency factoring was collected by a detailed patient-level data collection exercise from 12 representative pilot sites across London.

Pathways, Currencies and Tariffs are published and available for scrutiny and comment in the Pathway Analytics website www.pathwayanalytics.com. Comments on care Pathways are collated and reviewed regularly (now annually) by the responsible clinical working group and any changes are agreed an implemented as part of an agreed change management process.


What's Included and What's Excluded?

The Integrated Sexual Health Tariffs include all sexual health services provided by specialist sexual health service providers:

and exclude:


Resource Costs and Reference Costs

The Pathway costs and the Tariffs they drive have been designed to be setting independent and to account for the ‘ground-up’ cost of delivering the care described in the pathway. Therefore all the resource costs used to build them up have been stripped of Market Forces Factor and other location specific skews. Resources were costed from British National Formulary, suppliers in the South West of England and published Department of Health salary scales.

Clinical staff costs were calculated as a cost per minute of on clinical available time (defined as time available to deliver the care in the costed Pathways). Staff costs included on costs.

A series of Standard Staff Blends have been used in many pathways to recognise the fact that senior staff are required to be present in clinics but there maybe insufficient patient volume to utilise them efficiently ie in the pathway pricing we account for the fact a Doctor likely to take a blood sample, a job a nurse might expect to do.

PWA Staff Blend

Use of significant capital equipment was costed on a case-by-case basis, usually allowing for discounted full life cost per minute of use.
Overheads were estimated at 30% of total costs and distributed by applying them to clinical staff costs.

This data is collated in Pathway Analytics Cost Model toolkit that allows for easy management and update of resources costs as they change.

 


Currencies

Since not all pathways matched activity codes in the SRHAD and GUMCAD reports and some activities could not be uniquely identified by a single code which could trigger double accounting, it was decided that a Currency should only be paid for once in each patient visit and that an allowance should be factored to cover several un-coded activities which may also have been delivered.

Currencies were developed based on the following guidance:


Tariffs

  2015 Tariff

Currency

 Primary  Additional 
STI Intervention C  £281.15  £267.13
SRH Complex  £213.76  £187.16
Medical Gynaecology  £148.00  £131.92
LARC Procedure £139.91 £120.55
Psycho Sex / Counselling £126.45 £116.19
STI Intervention B £113.09 £81.78
T5 HSV Test £83.40 £76.30
T4 Full Screen £81.79 £56.31
TT 3 Site Chlamydia & Gonorrhoea Test £70.12 £70.12
T6 Hepatitis Test £67.48 £60.61
T3 Chlamydia, Gonorrhoea & Syphilis Tests  £60.58 £42.51
SRH Standard £58.08 £31.11
HIV Test £53.11 £28.36
T2 Chlamydia & Gonorrhoea Test £48.57 £30.51
STI Intervention A £27.98 £20.31
Ultrasound £29.05 £29.05
TS Microscopy £14.48 £14.48

 

The Primary tariff is used for the most expensive currency in a patient episode, the Additional tariff is used for all the others.  The Additional tariff represents the charge for the marginal activity or extra unique activity if the care pathway is delivered alongside another.

The tariff price represents the cost of delivering the complete episode of care represented by that currency, in the case of the three STI Interventions the episodes usually take place over a number of visits, the remaining currencies are largely contact-based.  Please refer to the existing guidance about when an episode is considered closed and when a new or recurring episode can be established.


Tariff Calculation

The tariff prices are calculated by the following process:

Pricing up the representative care pathways, we have currently over 100 care pathways described in detail, agreed by clinicians across England and by the appropriate professional bodies.  All pathways describe a 'contact' patient episode with the exception of the three STI Intervention currencies that represent a complete episode of care according the recognised best practice.  The STI Test pathways are designed  to cost the care up to the point of patient notification of a negative diagnosis and assume that only a certain proportion of patients receive a negative diagnosis.  The cost of positive diagnosis including the patient and partner notification costs are captured in the diagnosis pathways contained in the three STI Intervention currencies.

The pathways are then grouped into currencies that are clinically meaningful and where possible similarly priced.

The currency price is deduced by the weighted average price of the collection of pathways in each currency, the weightings being taken from a study detailed activity data taken from nine pilot sites across London.

Each currency is then subjected to a factor that represents the average number of times a pathway from that currency is triggered in a patient episode.  As each currency can only be triggered once in any patient episode, it is necessary to estimate the average number of pathways that are represented.  This is necessary because it is not possible to uniquely identify each instance of each and every pathway from within the patient level activity data so there is a need to make an estimation.  For example, a currency tariff might be factored by 1.5 indicating that on average 1.5 of the pathways from that currency are consumed in the average patient episode. 

The final currency price is then reduced by 1.5% cost saving measure implemented in 2012 by the Department of Health.


Invalid Currency Combinations

It became apparent that there were emerging a number of Currency combinations that were double accounting for the same care. Where for example two Currencies would be triggered for the same care or two currencies would be mutually exclusive. In such cases the Grouper implements a rule set to let one of the Currencies remain extant to remove the other. For example where a Tariff for a T4 and a T2 Currency are triggered the T4 (Full Screen Incl HIV antibody Test) include the Chlamydia and Gonorrhoea Test represented by the T2 and therefore the T2 is ignored. This process is automatically implemented in the Integrated Sexual Health Grouper.

The analysis of currency combinations shows that most patient visits trigger one or two currencies with an average tariff of £68.66 to £126.41


Market Forces Factor

Each provider has a Market Forces Factor (MFF) (for example 1.123456) that is applied to national PbR tariff charges it raises to allow for local costs that differ from the reference costs used to generate the national tariff.

The tariff charged raised by each patient visit is factored by the providers’ MFF in place in the month that care was delivered. A commissioner will therefore pay a different amount for the same care delivered by different providers. This process is automatically implemented in the Integrated Sexual Health Grouper and therefore all the charges delivered by the Grouper include the appropriate MFF.

PBR Guidance and MFF:
https://www.gov.uk/government/publications/payment-by-results-pbr-operational-guidance-and-tariffs


Primary and Additional Tariffs

As mentioned previously, each Pathway and each Currency has two Tariff prices Primary and Additional. The Additional Tariff represents the marginal cost of delivering an element of care in that currency alongside an element of care in another, more expensive currency.

In practice, this is implemented by identifying all the currencies triggered in each individual patient visit and applying the Primary Tariff of the most expensive and the Additional Tariff to all the remainder. This method prevents the double accounting of activities such as ‘Register, meet and greet’ every time a different currency is triggered in the same visit. This process is automatically implemented in the Integrated Sexual Health Grouper.


Responsible Commissioner

As part of the GUMCAD and SRHAD report, Providers are required to submit to the responsible commissioner, based on guidance published by the DH.  The Integrated Sexual Health Grouper uses this data to allocate the Tariff charges associated to each patient visit to an individual commissioner.

Output from the Grouper showing charges to be raised to a commissioner by different providers:

distribution of charges


Data Management

A critical element to implementing a successful tariff is an authoritative measurement mechanism for triggering payments. Care providers were already suffering under a data reporting burden that was not designed to directly benefit either their service or service commissioning. Commissioners would typically receive a summary sheet stating the number of patients seen for various high-level descriptions of care some time after year-end.

process-summary

Data collection is one half of the data management process and, in most cases, this is managed by a patient level data collection system deployed down to each clinic and used by clinicians during the patient consultation. The second part is the data reporting for tariff and this is usually done by a data manager who is often also an administrator or clinician. So any additional burden in this area would need to be minimised.


Integrated Sexual Health Report

One of the guiding principles in implementing the Integrated Sexual Health Tariff was to promote integrated services. To do this effectively it was important to collate together both datasets (GUMCAD and SRHAD) for both types of care, GU and Sexual and Reproductive Health. However, GUMCAD has been developed for epidemiological purposes to monitor prevalence of disease and is therefore episode based while SRHAD is designed to monitor care activity and is contact based. In a GUMCAD report the patient’s test date is used as the central record for an episode and the diagnosis is ‘attached’ to the test – there is actually no reportable record of care delivered (apart from a few anomalous care codes). Where as the SRHAD records the care activity delivered in each visit.

It was therefore decided by the Data Management Working Group that a patient visit would be uniquely identified in both GUMCAD and SRHAD by the Clinic ID, Patient ID and Attendance Date. That means it would be assumed any patient attending the same clinic on the same date would have had only one visit. It also assumes that both data collection systems in an integrated clinic use the same Patient ID and Clinic ID, which they are required to do anyway. By making these assumptions we have been able to create an Integrated Sexual Health Tariff Dataset which is based entirely on SRHAD and GUMCAD. It does require an additional field to identify Level 1 and 2 GUM clinics, this needs to be done because they use a slightly different set of diagnosis codes with the suffix ‘M’ to denote ‘medication given’.

By adopting this integrated dataset approach, double accounting of tariffs triggered in different reporting systems for the same care is prevented and a truly integrated Tariff supports integrated care delivery.


Tariff Local Codes

From 1 April 2015, with the implementation of GUMCADv2 and the SRHAD update, local codes are no longer necessary.

One of the key benefits in implementing a tariff was the need for better and more reliable commissioning data based on the statutory returns service providers are required to make to the HPA and DH Information Centre known as GUMCAD and SRHAD respectively. By supplementing these returns with a limited number of Tariff ‘Local Codes’ it is possible to identify nearly all the care activity delivered by service providers (that care not identified was accounted for in the Currency factor described earlier). The ‘Local Codes’ were developed by the Data Management Working Group and de-conflicted with the HPA and DH Information Centre. Service providers were therefore required to implement 9 ‘Local Codes’ in their data collection systems. Where necessary, the IT Systems providers supported the implementation of these local codes.

We estimate that about 85% of Tariff charges are triggered by data taken directly from statutory reports already in place.

Integrated Sexual Health Tariff Local Codes

Behavioural Guidance V7.4pdf (this guidance is now depricated)

SHHAPT (GUMCAD) Codes

Tariff Payment Triggers

With an integrated data report in place it is possible to create payment triggers based on an activity code profile that represents the Pathway description in each Currency. In some cases these Payment Trigger Profiles are simple for example a T2 code triggers a T2 Chlamydia & Gonorrhoea Test Currency and equivalent payment. In other cases they become extremely complex. These profiles are implemented in the Integrated Sexual Health Grouper.

Example of a complex payment trigger:

currency-combinations

Each set of payment triggers associated with each Currency Tariff 


Implementation

The principles for implementation are:

There are two technical stages in implementing the Integrated Sexual Health Tariff experienced by a service provider:

Preparation

1. Brief clinicians - on the use of local codes and refresh their coding guidance.
2. PLICS - set-up local codes on patient level information collection systems
3. Subscribe - to the Integrated Sexual Health Tariff Grouper

Reporting

4. Collate - six weeks after month end collate patient level data in GUMCAD and SHRAD reports
5. Prepare Tariff Dataset from your PLICS reports.
6. Calculate - upload data to the Integrated Sexual Health Tariff Grouper, validate and Submit

The Grouper returns a detailed report of the charges being raised to each commissioner from each provider.
Once these are in place, it is possible to run the Integrated Sexual Health Tariff in Shadow over a period of time to identify it’s clinical, financial and technical impact before a decision is made to migrate contracts to Tariff charging. The migration process is then a procedural one to raise the appropriate commissioning notices with providers and then start to charge using the Integrated Tariff. During the shadow process commissioners can review the Tariff data and Shadow charges raised.

Provider data managers are supported in the implementation process through a series of Workshops and online support. If necessary this can be augmented with desktop sharing sessions. On the whole, response from providers has been positive that once they have successfully uploaded data once, subsequent uploads are easy. However, the process does highlight any data collection issues they may have that were not previously evident. It does usually take three months for a provider to bring their clinical data collection process up the desired standard. This should have the added benefit of improving the HPA’s GUMCAD data.


Financial Impact Assessment

Region by region, financial impact assessments have been carried out to identify the financial impact to both providers and commissioners. The financial impact assessment for London was carried out by the Finance Working Group and chaired by a Director of Finance. On the whole, there is a general saving to commissioners of between 5% to 25% within each region. The variance within region can be considerably higher.

Case mix does not appear to significantly disadvantage providers.

fia-case-mix

These financial impacts are before any change in behaviour adopted by Providers as a result of the Tariff. The Tariff has been designed to encourage the integration of services and a patient-centric approach to care delivery.

The risks to a provider or commissioner gaining or loosing are:

The impact of cross charging and de-hosting makes a consistent gain of 2% to 5% for commissioners.


Governance

A Steering Group managed the governance, with representation from all the major London and national stakeholders, including HPA, BASHH, Faculty of Sexual and Reproductive Health and DH PbR.

The issues that would need to be resolved were:

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