AIGARS MIEZITIS 4 September 2012 Instruments for Improving Financial Provisions for Primary Health Care Services AIGARS MIEZITIS 4 September 2012 eu.baltic.net Part-financed by the European Union (European Regional Development Fund and European Neighbourhood and Partnership Instrument)

Health care budget Sagatavots Veselības ministrijā 29/11/2018

Health Care Reform COLLAPSE Basic Care for all (bread & H2O) Limited Access More Access COLLAPSE Basic Care for all (bread & H2O) More care for some; same care for most (moving on) Limited Funding As before, but this is a build slide COLLAPSE: my sense is that with only cost containment and no changes in access, there will be political outcry and the system will suffer with less service and many fewer providers Back to the 90s; refers to the recent times with predominant fee for service care; many hope for this scenario but there is now a moral imperative and too much pressure on costs to allow a return to this scenario Basic care; “Bread & Water”; with tightly restricted funding plus more access, this at best can only be a basic package and rationing of health care is a possibility Utopia; self evident description but very hard to get there and may not be possible on an immediate basis but perhaps with a more controlled stepwise plan some close might emerge More for some; same for most, aka, “moving on”; this is the great compromise; everyone gets something desired but no stakeholder is completely satisfied Back to the 90s Utopia Robust Funding Clyde Yancy, MD Baylor Heart and Vascular Center

Expectations Purchaser Provider Control of the costs Allocate resources Transparent Pay for performance Good quality Increased production Flexible Cost efficient Provider Cover the costs Fairly and predictable Transparent Long term conditions Incentives

Problems identified 2009 (I) The payments are not based on quality A large number of people who are exempt from paying patient fees The proportion of the public health care budget resources allocated for inpatient care is too high Insufficient availability of PHC Insufficient number of nurses in proportion to the numbers of doctors and patients Insufficient use of e-health solutions in health care resource planning

Distribution of Income of GP by Payment Methods in Year 2009

Proposed Approach to QBS Objective is to increase Value = outcomes relative to costs

Redistribution of financial flow inside health care system 2009 2011 Outpatient care 24.0 30.0 Inpatient care 40.7 Reimbursement of pharmaceuticals 12.4 12.0 Emergency Health Care 4.0 5.0 Health promotion 1.3 2.6 Other (education, capital investments, international obligations, administrative costs) 17.6 20.4 8

Aims of Quality Bonus system in Latvia for PHC To strength organization of PHC practice To increase accessibility of GP To promote the GP active involvement in disease prevention To ensure more effective management of patients with chronic diseases To tackle the spread of infectious diseases To motivate GP-s to provide broad range of health services to patients

Approach taken in Great Britain –Quality and Outcomes Framework Quality and Outcomes Framework was introduced in Egland in 2004. It incentivises family doctors (FD) to improve their services to patients, including improved clinical care and better outcomes. It is a way how to reward family doctor practices (NOT individual FD) for meeting higher standards in quality of care. QOF operates through a system of points which are awarded for levels of achievement against set criteria and for which FD receive financial reward.

Approach taken in Estonia Quality Bonus System which is paid once a year retrospectively; The aim of the QBS is to promote active involvement of family doctors in disease prevention, tackle the spread of infectious diseases, ensure more effective chronic disease management in the community and to provide a broad range of health services. There are three main indicator domains: Prevention Chronic disease management Additional skills from family doctor

Introduction of new payment model in Latvia Capitation Quality Bonus System (QBS), open to family doctors on a voluntary basis

Indicator Groups Prevention Chronic conditions eg check-up, vaccination, screening Chronic conditions eg diabetes, hypertension Increase of cost efficiency of Health Care system Increase Minor surgery, pregnancy care, Reduce referrals, hospitalization rate Organization Support of use IT solutions OUTCOMES Look in ore detail after lunch COSTS 13

Principles of a QBS Voluntary scheme with status as a ‘measure of excellence’ Criteria for entry into scheme A single scheme applying only to family doctors Indicators within control or influence of the family doctor Audit trail Targets have to be ‘absolute’ not comparative Target ranges based on evidence No ‘exception reporting’ of what is achievable for the upper bound, and what is currently achieved to set the lower bound. 14 14

The National Health Service Latvia 31 k-3 Cesu Street Riga, Latvia, LV-1012 Aigars Miezitis ImPrim Project Aigars.miezitis@vmnvd.gov.lv

Criteria What’s important for a good Quality of Care? SFAM.Q - Diabetes Criteria What’s important for a good Quality of Care? 1. A healthy life-style Normal weight Physical activity Smokefree 2. B-glucose control 3. BP control 4. Hyperlipidemi therapy 5. Regular fundus control 6. Regular check up of feet 7. Regular control of microalbuminuria 8. Patients self-management and knowledge about their disease (co-production).

Indicators How do we measure quality of care?? SFAM.Q - Diabetes Indicators How do we measure quality of care?? 1. Proportions of patients with data on BMI, Physical activity and Smoking habits 2. Proportion of pat.s with data on HbA1C and Proportion of pat.s w HbA1C <6,5 3. Proportion of pat.s w BP ≤130/80 4. Proportion f pat.s w T-Chol check last 2 ys And proportion of those with <5,0 5-7. Proportion of patients having made a check up of fundus, feet, Microalbuminuria and 8. Is there an individual plan for this patient?

Standards What goals do we have?? SFAM.Q - Diabetes Standards What goals do we have?? 1. Proportions of patients with data on BMI (90%), Physical activity (70%) and Smoking habits (90%) and <20% smokers 2. Proportion of pat.s with data on HbA1C (90%) and Proportion of pat.s w HbA1C <6,5 (70%) 3. Proportion of pat.s w BP ≤130/80 (50%) 4. Proportion f pat.s w T-Chol check last 2 ys (65%) And proportion of those with <5,0 (30%) 5-7. Proportion of patients having made a check up of fundus, (100%) feet, (100%) Microalbuminuria (70%) and 8. Is there an individual plan for this patient? (50%)

Standards How do we measure this?? SFAM.Q - Diabetes Standards How do we measure this?? Check up 10-20 records for patients with diabetes per doctor and make your notes If you want to make it more easy start with HbA1C, T-Chol, fundus controls, control of feet, proportion of patients w BP <130/80 and the use of an individual treatment programme

Quality work from GPs’ perspective

The APO audit method

The APO audit method Diabetes audit in Sothern Sweden: Physicians and nurses in PHC and Secondary Care Patients, 3 groups: Children. Adults - Type 1 and Type 2 Barbara Starfield, ACG Case Mix: Case Mix Audit. Physicians and patients