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 incentivesPD list system GP model individual

Transitional countries• Patient choice• Prevention

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