News / Online only: PBR road test begins

In a letter accompanying the road test, NHS deputy chief executive David Flory said the Department intends to expand PBR into mental health and introduce a mandatory paediatric diabetes pathway best practice tariff, together with mandatory tariffs for a number of direct access diagnostic tests. The latter would help support choice and unbundling of care pathways.

However, the Department’s proposed approach has been modified in two areas following feedback from the sense check in the autumn. The year of care tariff for cystic fibrosis will be phased in by transitioning from local to national prices in 2012/13, with a view to introducing a national mandated tariff in 2013/14. The transitional year would allow further work between commissioners and providers and on issues associated with shared care outside specialist centres and GP prescribing of specialist drugs.

The second modification is a reduction in the number of conditions covered by the new best practice tariff promoting the management of emergency conditions on a same day basis. Mr Flory said this change had been made to retain clinical buy-in and create a solid base for future expansion in this area.

For the first time, the Department has published post-discharge tariffs – for cardiac and pulmonary, and hip and knee replacement rehabilitation. These will be mandatory where acute and community services are integrated in one trust.

As in previous years, there are amendments to some draft prices following concerns they risk introducing perverse clinical incentives.

The road test will run until 20 January and the final PBR package for 2012/13 is due to be published in mid February.

Areas highlighted in the package include:

Business rules

The Department reiterated it would retain the 30% marginal rate for emergency admissions above threshold and non-payment for avoidable emergency readmissions.

Local clinical reviews will inform decisions over non-payment of emergency readmissions. Details will be provided following the completion of pilots. Mr Flory stressed commissioners must be transparent over how unpaid funds are used to support post discharge and reablement services.

Price adjustments under tariff flexibilities rules will be limited to where contractually-agreed patient exclusion criteria exist. Commissioners must notify their strategic health authority before implementing any adjustment.

Tariff

Tariff prices have been adjusted by -1.5% – national efficiency requirement (-4%) plus pay and price inflation (2.2%) plus best practice tariff efficiencies (0.3%).

Proposed CNST contributions rises have been applied directly to the relevant tariff prices.

No fundamental changes to tariff structure, though prices for a small number of healthcare resource groups (HRGs) have been set at the same level across all settings, or across day case and outpatient procedures.

There will be an increase in the number of HRGs with a mandatory outpatient procedure tariff. There is also a small increase in the number of HRGs with a mandatory tariff.

A shadow maternity pathway payment system will be made available in the new year. The intention is to mandate its use in 2013/14.

The specialist top-ups are: children (50%); spinal surgery (32%); neurosciences (28%); and orthopaedic (24%). Only the orthopaedic top-up will have no restriction on eligibility. Cochlear implants have been removed from eligibility for the children’s top-up.

The approach to reimbursement of long stays introduced in 2011/12 will continue – a five-day trim point ‘floor’ and standardising the long-stay payment at HRG chapter level.

The threshold percentages for the short-stay emergency tariff remain unchanged.

Exclusions have been reviewed and updated.

The fourth edition on ICD-10 codes will be implemented from April 2012 and built into the local payment 2012/13 grouper. However, for the 2012/13 local payment grouper, the HRG structure will be retained where practicable in order to reflect the base design used to collect the 2009/10 reference costs.

Best practice tariffs

Existing best practice tariffs (BPTs) are being rolled forward in 2012/13, including the adult renal dialysis BPT where the transition to a mandatory tariff will be completed in 2012/13.

BPTs for fragility hip fracture, stroke and paediatric diabetes are revised. For fragility hip fracture and stroke the payment differential between best practice and non-best practice approaches has been increased by 50%. In fragility hip fracture the best practice criteria will include cognitive impairment testing for dementia. A mandatory pathway tariff will be introduced for paediatric diabetes.

BPTs will be extended in a number of areas – interventional radiology; same day emergency care in a number of scenarios, including cellulitis and asthma; day cases, including some tonsillectomy and septoplasty HRGs; and home haemodialysis and assisted automated peritoneal dialysis. In addition, there will be BPTs for three outpatient procedures – diagnostic cystoscopy, diagnostic hysteroscopy and hysteroscopic sterilisation.

BPTs will be introduced to reward providers that meet quality criteria in major trauma services. These will be provided on a per-patient basis and through an additional payment.

Expanding the scope of PBR

Post discharge tariffs will be introduced for cardiac, pulmonary, hip and knee replacement rehabilitation. They will be mandatory where acute and community services have been merged into one trust.

The transition to a mandatory adult renal tariff will be completed.

Mandatory tariffs will be introduced for direct access diagnostic tests, including diagnostic imaging; respiratory tests for simple airflow and bronchodilator studies; and flexible sigmoidoscopy.

The care cluster currency for mental health will be mandated with local prices.

National currencies for chemotherapy and external beam radiology will be mandated, while the Department will also publish non-mandatory prices for these services.

There will be a phased introduction of a year of care tariff for cystic fibrosis by transitioning from local to national prices in 2012/13.

A national mandatory currency for ambulance services, with local prices, will be introduced.

Currencies for eight community services will be introduced as part of the any qualified provider programme. These are: musculoskeletal services for back and neck pain; adult hearing services; continence; diagnostic tests closer to home; children’s wheelchair services; podiatry; venous leg ulcer and wound dressing; and primary care psychological therapies for adults.

Non-mandatory currencies for smoking cessation will also be published.