Integrated Healthcare Systems for Family Physicians ผศ.นพ.บวรศม ลีระพันธ์
FM Academic Activities For Medical Residents28 October 2016
Pix source: Rattanaphibunkun C., Chantaragomol C, Wongsin A., PMAC 2016 Art Contest
Seminar Outline
Pix source: online.wsj.com
Q1: What do we know about
“PHC” in Thailand?
Q2: What do we know about “Healthcare
Systems”in Thailand?
Q3: What policies are needed for the future of PHC and
“Integrated Healthcare
Management”?
Q1: What do we know about PHC in Thailand?
(“Myths and Facts About PHC in Thailand”)
Pix source: online.wsj.com
What Do You Mean by “Primary Care”?
1. Basic medical services
2. Self-care, and health for all
3. First-contact, continuous, coordinated, and comprehensive care
4. Health promotion practices, and actions on social determinants of health
(=What a layman usually thinks of primary care)
(The Declaration of Alma-Ata 1978)
(Starfield 1992, 1998)
(Ottawa Charter 1986, The 66th World Health Assembly 2013)
Source: Stange KC. Barbara Starfield: Passage of the Pathfinder of Primary Care. The Annals of Family Medicine. 2011 July 1, 2011;9(4):292-6; Pix source: practiceimprovement.com.au;
Action on Social Determinants of Health
(การสร้างเสริมสุขภาพ)
Community-based Primary Healthcare
(การสาธารณสุขมูลฐาน)
Primary Care Medicine,Family Medicine
(เวชศาสตร์ปฐมภูม,ิ เวชศาสตร์ครอบครัว)
Basic Medical Care(บริการการแพทย์ระดบัพืDนฐาน)
• Health promotion practice at the population health level
• “Health in All Policies”
• Self-care• Community health worker• Community health volunteer• “Health for All”• First-contact care• Continuous care• Coordinated care• Comprehensive Care
•Health center (สอ./รพ.สต.)•OPD, physician office•Mobile medical units
What Do You Mean by “Primary Care”?
Community-basedPrimary Healthcare
Clinical Practicesat Primary Care
Level
“The Doughnut Hole” of Primary Care
• Primary care services in developed countries
• Medical facilities in urban settings• Medical facilities in private-sector
(without public health functions)
• Primary care services in developing countries
• Medical facilities in rural settings• Medical facilities in public-sector
(with public health functions)
ØWhat exactly policies & systems are we talking about?
“Primary” & “General”
Primary GeneralPrimary School
Primary Data
Primary Election
Primary Tumor
Primary Stage [of projects, etc]
Director-General
Attorney-General
Surgeon-General
General Hospital
General [Prayuth Chan-ocha]
Ø How do you feel about the “Primaries” and “Generals” listed above”?
Ø How’s about “Primary Healthcare” and “General Practitioner”?
Structure of Urban Health Services(City of Chanthaburi)
Pix source: สาํนกังานวจิยัและพฒันาระบบสุขภาพชุมชน (2555)
Structure of Urban Health Services(City of Chanthaburi)
Pix source: Office of Community Based Health Care Research and Development (2012)
Source: W. Simpson del.; E. Walker lith.; Day & Son, Lithrs. to the Queen.Pix source: http://en.wikipedia.org/wiki/History_of_hospitals#mediaviewer/File:Hospital_at_Scutari_2a.jpg
“Hospital at Scutari” - A ward of the hospital at Scutari where Florence Nightingale worked and helped to restructure the modern hospital
Disability-Adjusted Year Lost (2004)
InjuryNCD
Infection
0-45-1415-2930-4445-5960-6970-7980+0-45-1415-2930-4445-5960-6970-7980+
MalesFemales
1,600
1,400
1,200
1,000
800
600
400
200
0
SourSource: Adapted from: WHO (2008), http://www.who.int/healthinfo/global_burden_disease
FigureSource:InstituteforHealthcareImprovement(2012).PartneringinSelf-ManagementSupport:AToolkitforClinicians.
Institute for Healthcare Improvement Page 9 Partnering in Self-Management Support: A Toolkit for Clinicians
Collaborative Care: Cycle of Self-Management Support
Self-Management Supports
Primary Care vs. Palliative Care
“Palliative care is care provided based on patient & family needs & goals and independent of prognosis.”
Managing Long-Term Care
Source: Adapted from Feldman, Nadash & Gursen (2008)
1) Chronic Care
2) Palliative Care
3) Rehabilitative Services
• Activities of Daily Living (ADL)• Instrumental Activities of Daily Living (IADL)
4) Supportive services
• Care plans, appointment arrangement • Coordination between providers & patients-caregivers• Logistics and supply of necessities
5) Care Management
Hospital Care vs. Primary Care:Control Knobs Framework for Health Reform
Source: Adapted from Roberts et al. (2003).
Financing of Thai Healthcare SystemCSMBS SSS UCS Motor Vehicle
Victim Protection Law
Private Health Insurance
Feature State/Employer welfare
Compulsory heath insurance with state subsidies
State welfare Compulsory heath insurance for vehicleowners
Voluntary health insurance
Targeted groups of beneficiaries
Civil servants, state enterprise employees and dependents
Employees inprivate sector and temporary employees in public sector
Thai citizens without the coverage of CSMBS & SSS
Victims of vehicle accidents
General public
Source of financing
Govt. budget Tri-party (Employee, employer and govt. budget)
Govt. budget Vehicle owners Household
Method of payment to health facilities
Fee-for-service Capitation and Fee-for-service
Capitation and Fee-for-service
Fee-for-service Fee-for-service
Major problems Rapidly and constantly rising costs
Covering while being employed only
Inadequate budget
Redundant eligibility and slow disbursement
Redundant eligibility and slow disbursement
Source: Adapted from Wibulpolprasert et al. (2011). Thailand Health Profile 2008-2010.
Major Mechanisms of Healthcare Financing
HealthcareRegulator(s)
2) Taxes Payers
4) Employer-
based private health
insurance
3) Individual private health
insurance
Hospitals
MedicalSpecialists
Generalists& PCPs
1) Out-of-pocket Payments
Ambulatory Facilities
Payment Mechanisms:Salary, Fee-for-Service,
Global Budget, Capitation, etc.
CGD (CSMBS),
NHSO (UCS)
Taxes Payers
Employer-based private health
insurance
Individual & Employer’s
private health insurance
(Voluntary)
Hospitals
MedicalSpecialists
Generalists& PCPs
Patients paying out-of-pocket
Ambulatory Facilities
Payment Mechanisms:Salary, Fee-for-Service,
Global Budget, Capitation, DRGs, etc.
Thai Healthcare Systems
Providers in Public & Private Sector
Commercial Insurance
Companies
Social Security
Office (SSS)
Motor vehicle’s owners (Mandatory by the Motor
Vehicle Victim Protection Law)
Pix source: www.noogenesis.com/pineapple/blind_men_elephant.html
Integrated Healthcare & Systems Thinking
John Godfrey Saxe's ( 1816-1887) version of the famous Indian legend
Pix source: www.simoncamilleri.com/the_truth_of_the_elephant/
Integrated Healthcare & Systems Thinking
Q3: What policies are needed for the future of PHC and
“Integrated Healthcare Management”?
Pix source: online.wsj.com
Major Issues in Thai Healthcare SystemsFrenk J,ChenL,Bhutta ZA,CohenJ,CrispN,EvansT,etal.Healthprofessionalsforanewcentury:transformingeducationtostrengthenhealthsystemsinaninterdependentworld.TheLancet.2010;376(9756):1923-58.
Major Issues in Thai Healthcare Systems
• Thailand 1970s – Rural Health (“PHC")• Thailand 2010s – ??
“Transformative education creates change agents.”
“But change agents create what?”
Rural vs. Urban
18,972,330(31.1%)
29,133,829(44.2%)
41,944,111(68.9%)
36,847,830(55.8%)
0%10%20%30%40%50%60%70%80%90%
100%
2543 2553
ประชากรในเขตเทศบาล ประชากรนอกเขตเทศบาล
Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาติ, accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html
Poor vs. Middle-class
Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาติ, accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html
Source: Macagba, R. L. (1985). Hospitals and Primary Health Care: An International Study from the International Hospital Federation. In M. Hardie (Ed.), World-wide survey on the Role of Hospitals in Primary Health Care. London: International Hospital Federation.
Features of Primary Care Providers
Focus Public Health Medicine &Public Health
Setting Rural Urban
Professional Perception
Generalist Specialist
Public Perception
Second-tier Doctors(“basic”)
Top-tier Doctors(“personal & exclusive”)
SystemDesign
MovingAssembly Lines
CustomizedServices Systems
Delivery of PHC Services
Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp
Structure & Organizations of primary care services • Patient Care Teams• PCUs/Clinics• Systems/Networks• Governance policies
Four Cardinal Functions of primary care services • First Contact/Access• Continuity• Coordination• Comprehensiveness
“Anatomy of Primary Care” “Physiology of Primary Care”
First Contact/Access
Continuity Coordination Comprehensiveness
• Cost sharing• Distance to PC
practice • Distribution of
PC physicians • List size • Home visits in
PC • Electronic access
• Computerization of the practice
• Patient habits with first contact visits/referrals
• Endurance of patient–provider relationship
• PC practice management
• Collaboration among practitioners
• Referral system• Shared care
arrangements
• Premises, equipment
• Medical procedures
• Preventive, rehabilitative, educational activities
• Disease management
• Community links• Technical skills
Desirable PHC Functions
Source: WHO/Europe (2010)
Ø Selected proxy measures from WHO/Europe’s Primary Care Evaluation Tool (PCET)
Dealing with Complexity in Healthcare Systems (UnitedHealth Group, USA)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010
Care Coordination Innovations(UnitedHealth Group, US)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010
Traditional Work Flow in Clinics(Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)
Redesign: Parallel Work Flow in Clinics(Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)
Pre-visit Work in Geriatric Care
Pix source: Harvard Vanguard Medical Associates & Institute of Healthcare Improvement (2010)
Care Coordination: EMR
Pix source: Bates et al. (2003). A Proposal for Electronic Medical Records in U.S. Primary Care
Building Blocks of PHC Systems:Research Needed
Pix source: WHO’s framework for action. (2007)
New financing?• OOP?• Co-payment?• Membership fee?
New informatics?• Mobile app?• Personal health
data portal?• Disadvantaged
population’s data
New organizational model?• Team based providers?• Linkage with hospital care?
New kinds of providers?• MDs vs. non-MDs• Professional Manager?• Career path? • Linkage with academia?
New kinds of products?• Life-style modifications? • Preventive medicine?• Outlets of hospital ‘s
labs & pharmacy?
New governance?• Focus on personal services
vs. on public health services• Market vs. Central-planning
• Clinical outcomes of population-health-integrated PCUs vs. individual-health-oriented PCUs
• Satisfaction of patients receiving care from PCUs located in urban community vs. from PCUs attached to hospitals
• Satisfaction of primary care providers working in differently organized PCUs
• Comparison of comprehensiveness of care delivered in differently organized PCUs
• Financial risks of differently organized PCUs • Appropriateness of office hours of urban PCUs• Effectiveness of P&P programs in urban communities
Considerations for Further Study
Source: Leerapan (2012). Primary Care Services in Urban Settings: Lessons from International Experiences.