Transcript The benefits of primary care

Strengthening primary care in
weak primary care systems
Prof. Peter P. Groenewegen
NIVEL – Netherlands Institute for Health
Services research
Overview
• Strong primary care is …..
• The need to strengthen primary care
• How weak primary care systems
strengthen primary care
- Western Europe
- Eastern Europe
• Social Health Insurance systems, but
different conditions
Characteristics of strong primary
care
• A generalist approach
• The point of first contact with health care
• Context-oriented
• Continuity
• Comprehensiveness
• Co-ordination
Simple single indicator: gatekeeping GPs
Why we need to strengthen
primary care …
Demand side challenges
• Multiple health and social
problems
• Increasing and changing
health care needs
• Better educated, more
demanding patients
• People live longer, stay
longer at home
Supply side challenges
• Organization: teams,
networks, single practices
• Manpower: limited work
force, more part-time
work
• Incentives: regulation,
payment
• Shifts from hospital to
primary care
Multiple health and social problems
Effects of strong primary care
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•
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•
•
Better health outcomes
Good quality care
Lower costs
Better opportunities for cost containment
Better opportunities for monitoring health,
health care utilisation, quality, and
preparedness
Western Europe
Western European countries
with stronger and weaker
primary care
Stronger:
• UK
• Denmark
• Spain
• Netherlands
• Italy
• Finland
Weaker:
• Portugal
• Belgium
• Greece
• Germany
• Switzerland
• France
Weak primary care systems in
Western Europe
• (mainly) Bismarckian systems: Belgium,
France, Germany
• Small scale primary care, GP practices
• Strong emphasis on freedom of choice
• Demand channeling via co-payments
Organisation of primary care:
Transformation from cottage
industry to modern community
health service
Policy changes to strengthen
primary care
Weak incentives and voluntary basis
• Germany: GP model (‘Hausarztmodelle’)
• France: preferred doctor scheme (‘médecin
traitant’)
• Belgium: capitation (‘forfaitaire betaling’) and
medical file (‘globaal medisch dossier’)
Germany: GP model
(‘Hausarztmodelle’)
• Based on individual contracts between
insurers and GPs
• Patient list; referral system; patients may
switch once a year
• Appr. one fifth of publicly insured (2007)
• Incentive for patients: lower copayment
• Incentive for GPs: additional
reimbursement, registration fee
• Effects seem to be very small
France: preferred doctor scheme
(‘médecin traitant’)
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•
•
•
•
Patient list and personal medical record
Referral system
Covering appr. 80% of the French (2007)
Patient incentives: higher reimbursement
Doctor incentives: capitation for follow up
of certain chronic diseases; income loss
compensation for some specialties
• Little information about effects
Belgium: medical file
(‘globaal medisch dossier’)
• If patients choose to be
with one GP (or practice),
their GP can keep their
medical file
• Incentive for patients:
lower level of costsharing when they visit
the GP who keeps their
medical file
• Incentive for GPs: fixed
amount per year
Belgium: capitation
(‘forfaitaire betaling’)
• Capitation fee for listed patients
• Mainly with group practices and health
centres in more deprived areas
• 80 practices and 165.000 insured (2007)
• Incentive for patients: no cost-sharing
• Incentive for GPs: capitation
• Lower prescriptions, referrals and
hospitalisations, more prevention
Former communist countries
Point of departure: the health
care system under communism
• State funded, parallel systems
• Salaried employees, large policlinics,
specialist orientation, underdeveloped
primary care system
• No patient choice of provider
• Strong role of government, central
planning, command-and-control
Trends in health system change
in transitional countries:
• From state funding to Social Health
Insurance: back to Bismarck
• From state provision to privatisation
(especially primary care)
• From allocated care to more patient choice
• From centralised role of government to
shared power
Gatekeeping in former communist
countries
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•
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Primary care as starting point for reforms
Introduction of gatekeeping
Training of GPs
Retraining of district doctors,
paediatricians, gynaecologists
Former communist countries with
stronger and weaker primary care
Former Soviet Union – non EU
• Belarus – non gatekeeping
• Georgia - non gatekeeping
• Kazakstan - non gatekeeping
• Moldavia - non gatekeeping
• Ukraine - non gatekeeping
Current EU member states
• Bulgaria – gatekeeping
• Czech Rep. – direct access if costs paid
privately
• Estonia - gatekeeping
• Hungary - gatekeeping
• Latvia - gatekeeping
• Lithuania - gatekeeping
• Poland – direct access if costs paid
privately
• Romania - gatekeeping
• Slovakia – direct access if costs paid
privately
Training and retraining GPs in Lithuania:
activity (numbers, scale score)
1994
1994
district
district
therapists paediatricians
2004
retrained
district
therapists
2004
retrained
paediatricians
2004
newly
trained
GPs
Contacts
19,4
(office +
home visits)
20,8
28,4
30,1
23,4
Medical
technical
procedures
1,10
1,04
1,51
1,35
1,36
Management and
follow up of
disease
2,40
1,55
2,71
2,41
2,41
Training and retraining GPs in
Lithuania: prevention (%)
1994
1994
district
district
therapists paediatricians
2004
retrained
district
therapists
2004
retrained
paediatricians
2004
newly
trained
GPs
High blood
pressure
90,6%
24,1%
88,6%
83,7%
76,0%
Blood
cholesterol
39,4
8,6
42,0
40,8
22,7
Smoking
6,6
9,7
9,1
8,2
1,3
Alcohol
7,2
11,3
7,4
10,2
1,3
Some comparative elements
• Urgency of reform in transitional countries
• Past experience of low patient choice
versus strong ideology of patient choice
• (Ambulatory) medical specialist opposition
in Western European SHI systems
Upcoming policies and problems
Bismarckian systems
• Disease management
• Vertical systems
• Performance payment
-------------------------------Weak incentives
PD  list system 
GP model  individual
Transitional countries
• Patient choice
• Prevention
-------------------------Strong incentives
profiling  P4P
contracts  benchmarks
Unintended consequences of P4P?
Discussion
• Strengthening primary care: Important differences in
context and national strategies
• Weak incentives and voluntary basis: Is it enough?
• How to convince governments, doctors, insurance
organisations, patients of the urgency?
• How to balance paternalism and patient choice?
• EU-countries provide a laboratory for comparative
research