Strengthening primary care in weak primary care systems

Prof. Peter P. GroenewegenNIVEL – 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

• 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’)

• 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 cost-sharing 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

• 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 district therapists

1994 district paedia-tricians

2004 retrained district therapists

2004 retrained paedia-tricians

2004

newly trained GPs

Contacts (office + home visits)

19,4 20,8 28,4 30,1 23,4

Medical technical procedures

1,10 1,04 1,51 1,35 1,36

Manage-ment and follow up of disease

2,40 1,55 2,71 2,41 2,41

Training and retraining GPs in Lithuania: prevention (%)1994 district therapists

1994 district paedia-tricians

2004 retrained district therapists

2004 retrained paedia-tricians

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