1. 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)

2. Health care budget
Sagatavots Veselības ministrijā
29/11/2018

3. 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

4. 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

5. 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

6. Distribution of Income of GP by Payment Methods in Year 2009

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

8. 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

9. 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

10. 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.

11. 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

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

13. 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

14. 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

15. The National Health Service Latvia
31 k-3 Cesu Street
Riga, Latvia, LV-1012
Aigars Miezitis
ImPrim Project

16. 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).

17. 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?

18. 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%)

19. Standards How do we measure this??
SFAM.Q - Diabetes
Standards
How do we measure this??
Check up 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

20. Quality work from GPs’ perspective

21. The APO audit method

22. 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