University of Groningen
The Tripartite insurance model (TIM)
van der Pol, Simon; Dik, Jan-Willem H; Glasner, Corinna; Postma, Maarten J; Sinha, Bhanu;
Friedrich, Alex W
Published in:
Clinical Microbiology and Infection
DOI:
10.1016/j.cmi.2021.01.019
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van der Pol, S., Dik, J-W. H., Glasner, C., Postma, M. J., Sinha, B., & Friedrich, A. W. (2021). The Tripartite
insurance model (TIM): A financial incentive to prevent outbreaks of infections due to multi-drug resistant
microorganisms in hospitals. Clinical Microbiology and Infection, 27(5), 665-667.
https://doi.org/10.1016/j.cmi.2021.01.019
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Commentary
The tripartite insurance model (TIM): a
financial incentive to prevent
outbreaks of infections due to multidrug-resistant microorganisms in
hospitals
Simon van der Pol
1,*, Jan-Willem H. Dik
2,3, Corinna Glasner
2, Maarten J. Postma
1,4,
Bhanu Sinha
2, Alex W. Friedrich
21)University of Groningen, University Medical Centre Groningen, Department of Health Sciences, Groningen, the Netherlands
2)University of Groningen, University Medical Centre Groningen, Department of Medical Microbiology and Infection Control, Groningen, the Netherlands 3)National Health Care Institute, Diemen, the Netherlands
4)University of Groningen, Department of Economics, Econometrics and Finance, Groningen, the Netherlands
a r t i c l e i n f o
Article history:
Received 28 August 2020 Received in revised form 15 January 2021 Accepted 19 January 2021 Available online 30 January 2021 Editor: E.J. Kuipers
Keywords:
Antimicrobial resistance Diagnostics
Financial incentives Insurance model
Multidrug-resistant organism outbreaks
a b s t r a c t
Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) constitute a major challenge worldwide, but care providers are often not sufficiently incentivized to implement recom-mended infection prevention measures to prevent the spread of such infections. We propose a new approach which creates incentives for hospitals, external laboratories and insurers to collaborate on preventing MDRO outbreaks by testing more and implementing infection prevention measures. This tripartite insurance model (TIM) redistributes the costs of preventing and combating MDRO outbreaks in a way that all parties benefit from reducing the number of outbreaks. Simon van der Pol, Clin Microbiol Infect 2021;27:665
© 2021 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases. This is an open access article under the CC BY license (http://creativecommons.org/ licenses/by/4.0/).
Introduction
Healthcare-associated infections (HAIs), especially those caused by microorganisms resistant to antimicrobials, constitute a major challenge for medicine worldwide. The worldwide in-crease in multidrug-resistant microorganisms (MDROs) makes
HAIs increasingly difficult to control, treat and cure. This causes a
major rise in morbidity, mortality and healthcare costs [1,2]. In
2015 alone, an estimated 33 110 deaths were caused by HAIs
with MDROs in Europe [2]. The occurrence and spread of MDROs
vary between countries in Europe [3]. For example, in
Scandi-navian countries and the Netherlands, 1e2% of invasive Staphy-lococcus aureus isolates are resistant to methicillin (MRSA). In contrast, neighbouring countries such as Belgium, Germany and the United Kingdom record MRSA rates of 10e15%, while in some
countries in southern Europe 30% or more of invasive isolates are MRSA [3].
Although many countries have implemented extensive mea-sures to prevent the occurrence and spread of MDROs in recent years, levels of antimicrobial resistance (AMR) are predicted to rise
[1]. One reason for this may be a lack of economic incentives to
prevent AMR, further complicated by the fact that the impact of
AMR is difficult to quantify in economic terms [4]. The parties who
may benefit from preventing AMR are not the parties that make the
investments, complicating collaboration. We hypothesize that it is necessary to change the system by introducing not only medical but also economic incentives to reduce AMR. We propose a model of insurance against MDRO outbreaks that will incentivize infection prevention measures within the hospital, and with that, reduce the occurrence and spread of MDROs and hence MDRO outbreaks.
* Corresponding author. Simon van der Pol, UMCG, Sector F, afdeling Gezondheidswetenschappen, Simon van der Pol (FA10), Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
E-mail address:s.van.der.pol@umcg.nl(S. van der Pol).
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The current situation
Outbreaks during which MDROs spread quickly through
hos-pitals are a majorfinancial risk; a study in a Dutch academic
hos-pital estimated an average cost ofV546 per infected patient per
outbreak day [5]. To prevent MDRO outbreaks and limit the further
spread of MDROs, there is a need for an integrated stewardship approach comprising antimicrobial therapy, infection prevention
and diagnostics to effectively combat AMR [6]. Core to this is an
innovative approach for infection management, which closely links diagnostics and therapy to provide optimal diagnostics and treat-ment targeted to individual patients [6]. Additionally, screening for MDROs is important to identify patients that require additional precautions.
Key to such a screening approach is an adequate testing ca-pacity, low barriers for clinicians to perform these tests, and microbiological advice to interpret the test results. In some healthcare systems, incentives seem to have developed to save costs by reducing tests in hospitals. For example, there may be an incentive not to screen patients when high AMR levels are publicly reported, since positive tests would possibly drive patients to competing hospitals when seeking care. Furthermore, if tests are outsourced, hospitals often pay per diagnostic test performed, and
the benefits from the economies of scale initially flow back to
external microbiological laboratories. For external microbiological laboratories that are being contracted by healthcare providers, MDRO outbreaks can lead to an increase in the number of diag-nostic tests and therefore, albeit not actively desired, to positive financial effects. In consequence, the incentive to reduce the number of outbreaks could be solely medical and jeopardized by the underlying misdirecting economic incentive.
The tripartite insurance model (TIM)
Most current economic constructs are production-driven and not able to support adequate preventive policies, complicating approaches to further AMR reduction [7]. Therefore, there is a clear need to develop a model in which clinicians and hospital man-agement are not only driven by medical necessity but also by financial incentives to counteract AMR. We propose an insurance
model which enables the redistribution of the various financial
flows of MDRO preventive policies, tests and outbreaks [5]. The
model considers three parties: the hospital and an external labo-ratory, as previously mentioned, and a new stakeholder, a casualty insurer. This is a conceptual model which can be tailored to different healthcare systems, with the requirement that the parties act independently. In the TIM, we do not discern between public or private funding. Health insurers are not included in the model; we expect their role to remain unchanged (i.e. reimbursing costs of care for individual patients).
Within the TIM, we differentiate between two different types of costs: constant costs and outbreak costs. Constant costs need to be paid regardless of an MDRO outbreak, and include insurance pre-miums, the contract with the microbiological laboratory, hospital staff costs (e.g. hiring a full-time infection prevention specialist), and infection prevention measures. Outbreak costs include addi-tional diagnostics, cleaning, personnel (hours spent on outbreaks by hospital staff and productivity losses of infected staff), patient isolation and opportunity costs due to closed beds (i.e. missed
revenue) [5]. Key in an insurance model is to transfer risks from a
risk-averting party (in this case a hospital) to a party more willing to take on these risks (an insurer) [8]. Additionally, as it is unlikely that all hospitals signing up for the TIM will suffer an outbreak
simultaneously, the financial risks related to outbreaks are
distributed more evenly, i.e., the risks are pooled [8].
The hospital would negotiate a lump sum contract with an external laboratory to provide routine tests tailored to the needs of the hospital. In the case of an outbreak, all additional tests are covered by this contract. This will give the laboratory an incentive to aid in the prevention of outbreaks: for example by educating hospital staff on infection prevention strategies. In consequence, the laboratory will have a strong incentive to reduce costs and time to result of a diagnostic test which will encourage cost-effective diagnostic procedures.
The hospital also has a contract with the insurer covering the missed revenue of closed beds and cleaning costs caused by an
outbreak [9]. The insurance premium will be determined based on
the number of beds, bed occupancy, and risk-modifying factors. Risk-increasing factors include the prevalence of MDROs within the hospitals and the healthcare region, effective nursing-staff-to-patient ratio, the number and size of previous outbreaks within the hospital, and a lack of action after admission screenings. Risk-reducing factors include a high annual number of screened pa-tients, an active stewardship programme, and a high compliance
with hand hygiene and other infection prevention guidelines [10].
In general, a bonus/malus seems critical: hospitals which perform well and effectively reduce AMR levels and the number of out-breaks will have lower premiums than hospitals with many outbreaks.
Finally, the external laboratory is contracted by the insurer to audit the hospital regarding the implementation of infection
pre-vention measures, which in turn influences the insurance premium
paid by the hospital. This integral collaboration between the hos-pital and laboratory regarding infection control is already imple-mented in some countries (e.g. The Netherlands): it stimulates the transfer of knowledge and improves the use of diagnostics for clinical and preventive purposes. Additionally, the risks for the insurer will be reduced, as the outbreak risk decreases.
In the TIM, outbreak costs are for the most part covered by the insurance and for a lesser part by the laboratory, which has to pay for additional tests. As more tests would increase costs of the lab-oratory but not the income, the lablab-oratory has a clear incentive to reduce its operating costs related to performing the tests, as well as to help the healthcare provider to control the spread of AMR and
prevent outbreaks. The hospital has an additionalfinancial
incen-tive not to run the risk of an increase in the insurance premium due to outbreaks caused by AMR. Finally, the insurer's profits increase if AMR is reduced and outbreaks are prevented, as the insurer will continue to receive premiums but does not need to reimburse as many outbreak costs. This preventive-economic approach changes the incentives on all three stakeholder sites towards the main in-terest of the patient.
Next steps
Before implementing the TIM, key questions remain to be answered, some of which have been raised in a stakeholder meeting where all three parties were represented. We believe it is vital to assess the hospital management's willingness to pay for this proposed system: what percentage of the hotel costs would they be willing to spend on insurance premiums? Additionally, a major hurdle is to convince insurers that this is a vital business model, especially since there are currently no sound and complete data to support this system. Risk models need to be developed to predict hospital outbreaks, to be used as a basis for the insurance premium calculation. Current projections of the prevalence of MDROs show
an increasing trend [1], which can lead insurers to conclude that
risks are too difficult to curtail. To critically assess the investments required to implement the TIM, we believe it is vital to apply a broad societal perspective, where not only the direct effects on
S. van der Pol et al. / Clinical Microbiology and Infection 27 (2021) 665e667 666
hospital outbreaks are included but also delays in care due to these outbreaks, the long-term loss of effective antibiotics due to AMR [1], and increased morbidity and mortality [2]. Whether these
long-term benefits outweigh the short-term investmentsdsuch as
implementation costs and, potentially, increased spending on diagnostic tests for the hospitaldremains to be investigated further. An implementation trial in several hospitals, combined with health-economic analyses, would be important to assess the incremental value of the TIM for the health system and its feasi-bility from an insurer's perspective. Although we focused on hos-pitals in this commentary, it may also be possible to include other inpatient facilities such as nursing homes in the model.
Author contributions
JWHD, BS and AWF: conceptualization. SvdP and JWHD: inves-tigation. CG, MJP and AWF: resources. SvdP and JWHD: writing original draft. CG, MJP, BS and AWF: writingdreview and editing. MJP and AWF: supervision. CG: project administration. AWF: funding acquisition.
Transparency declaration
Professor Dr Postma reports grants and personal fees from various pharmaceutical industries, all outside the submitted work. He holds stocks in Ingress Health and Pharmacoeconomics Advice Groningen (PAG Ltd) and is advisor to Asc Academics, all pharma-coeconomic consultancy companies. Mr Van der Pol, Dr Dik, Dr Glasner and Professor Dr Sinha and Professor Dr Friedrich have nothing to disclose. This study was supported by the INTERREG VA
(122084) funded project health-i-care (http://www.health-i-care.
eu), part of a DutcheGerman cross-border network supported by
the European Commission, the Dutch Ministry of Economics, the Ministry of Economy, Innovation, Digitalisation and Energy of the German Federal State of North Rhine-Westphalia, the Ministry for National and European Affairs and Regional Development of Lower Saxony and the Dutch Provinces Drenthe, Flevoland, Frysl^an, Gel-derland, Groningen, Noord-Brabant and Overijssel. This research was also supported by the INTERREG VA (202085) funded project
EurHealth-1Health (http://www.eurhealth1health.eu), part of a
DutcheGerman cross-border network supported by the European
Commission, the Dutch Ministry of Health, Welfare and Sport, the Ministry of Economy, Innovation, Digitalisation and Energy of the German Federal State of North Rhine-Westphalia and the Ministry for National and European Affairs and Regional Development of Lower Saxony.
Acknowledgements
We thank the following persons for their input in the context of a stakeholder meeting: Sophie Dannenfeld, Jacob Dijkstra and Ruud Koning.
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