Strengthening primary care in weak primary care systems

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Strengthening primary care in weak primary care systems Prof. Peter P. Groenewegen NIVEL – Netherlands Institute for Health Services research

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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 - PowerPoint PPT Presentation

Transcript of Strengthening primary care in weak primary care systems

Page 1: Strengthening primary care in weak primary care systems

Strengthening primary care in weak primary care systems

Prof. Peter P. GroenewegenNIVEL – Netherlands Institute for Health

Services research

Page 2: Strengthening primary care in weak primary care systems

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

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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

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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

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Multiple health and social problems

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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

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Western Europe

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Western European countries with stronger and weaker

primary care

Stronger:• UK• Denmark• Spain• Netherlands• Italy• Finland

Weaker:• Portugal• Belgium• Greece• Germany• Switzerland• France

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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

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Organisation of primary care:Transformation from cottage

industry to modern community health service

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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’)

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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

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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

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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

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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

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Former communist countries

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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

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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

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Gatekeeping in former communist countries

• Primary care as starting point for reforms• Introduction of gatekeeping• Training of GPs • Retraining of district doctors,

paediatricians, gynaecologists

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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

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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

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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

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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

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Upcoming policies and problems

Bismarckian systems• Disease management• Vertical systems• Performance payment--------------------------------Weak incentivesPD list system GP model individual

Transitional countries• Patient choice• Prevention

--------------------------Strong incentivesprofiling P4Pcontracts benchmarks

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Unintended consequences of P4P?

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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

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