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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