1. EUprimecare: Quality and Costs of Primary Care in Europe September 2012, Gothenburg (Sweden) European Forum Primary Care Grant Agreement no. 241595 Dr. Antonio Sarría-Santamera (ISCIII) Sonia García (ISCIII) Eleonora Corsalini (UB)

2. The goals of any healthcare system: Deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources AccessCostsQuality Background

3. The Tallin Charter Strengthening of health systems to improve people's health but keeping equity. Primary Care Basic structure of health system Eliminating health disparities Background

4. Common framework to describe Primary Care models in the EU is not available Not yet developed a trans-national consensus on how to define quality of Primary Care Cost of Primary Care are not well identified in national accounting systems Background

5. Objectives

6. Institute of Health Carlos III. ISCIII. Spain Universität Bielefeld. UNIBI. Germany University of Tartu. UTartu. Estonia National Institute for Strategic Health Research. ESKI. Hungary Országos Alapellátási Intezet. OALI. Hungary Institute for health and Welfare. THL. Finland Kaunas University of Medicine. KMU. Lithuania Universitá Commerciale Luigi Bocconi. UB. Italy Partners

7. Conceptual structure Identify a methodology to measure the PC quality WP 5 & 6 Identify a methodology to measure costs in PC WP 3 & 4 WP 7 WP2 Evaluation of PC models COORDINATION WP 1 DISSMINATION WP 8 To measure the health quality in PC To measure costs in PC ORGANIZATION OF PRIMARY CARE IN EUROPE REGULATIONFINANCINGPAYMENTORGANIZATION ORGANIZATIONAL BEHAVIOUR

8. Approach

9. Work package 2: Evaluation of PC models in Europe Work package 2: Evaluation of PC models in Europe Methodological Approach of a Classification System of PC Models in Europe : Germany, Spain, Estonia, Finland, Hungary, Italia and Lithuania.

10. WP2: Methodology 1.Literature review Structure or process of PC in Europe Control knobs: financing, regulation, payment, organization, and organizational behavior 2.Selection of indicators => template design: 1.5 variables (Control knobs) to optimize healthcare systems results: 2.Range of services 3.Descriptive Analysis & Principal Component Analysis

11. FINANCING Mixed model (Hungary) BISMARCK SS (Estonia, Germany, Lithuania) BEVERIDGE NHS (Finland, Italy, Spain) 7% Uninsured 10,6% Private Insurance 18,8% Double coverage Expenditure in HC as GDP 10,5% 6,1%6,6% 24% Expenditure in PC 5,7% 16% Double coverage Descriptive analysis (I)

12. Formal mechanisms to guarantee accessibility, equity and quality of healthcare Gate-keeping systems, except in Germany Facilities: Mostly public: Finland, Spain, Hungary and Lithuania Totally private: Germany, Estonia and Italy Clinical practice: Integrated network: Finland and Spain Solo and group practices: Germany, Estonia, Italy, Lithuania, Hungary REGULATION ORGANIZATION Descriptive analysis (II)

13. Process to monitoring and improving the quality of medical practice: Quality management systems measuring clinical and no clinical quality indicators Clinical practices guidelines Continuing education ORGANIZATIONAL BEHAVIOUR Descriptive analysis (III)

14.  Provision of services through national/regional/local health systems (Yes/No)  Private voluntary health insurance (Yes/No)  Geographical distribution of PC services (Yes/No)  Professional income (Capitation/Salary/Fee for service/Out of pocket)  Gatekeeping for specialist (Yes/No)  Type of facilities (Public/private)  Type of clinical practice (Solo practice/Group practice/ Network)  Improvement programs & Quality management systems (Yes/No)  Continuing clinical education program (Yes/No)  Local adaptation of clinical practice guideline (Yes/No) Financing Regulation Organization Payment Organizational behavior Quantitative analysis (PCA)

15. Range of services

16. Results of Qualitative analysis Based on a functional perspective, allowed to proposing 5 models: 1.Direct access to specialist 2.Referral required from GP, mainly solo-practices in PC 3.Referral required from GP, mainly group-practices in PC 4.Health care centers 5.Polyclinics Based on a functional perspective, allowed to proposing 5 functional models: Model 1: Direct access to any GP or specialist (Germany) Model 2: Referral required from GP, mainly solo-practices in PC (Hungary, Italy) Model 3: Referral required from GP, mainly group-practices in PC (Estonia, Lithuania) Model 4: GPs working mainly in health care centres (Finland, Spain) Model 5: Polyclinics (Shemasko). Not necessarily GPs at all Results

19. * *Predominance

22. Framework for classification of health systems based on PC Multidimensional => more complex => more realistic Healthcare services provision Basic coverage Gate-keeping Private insurances Professional payment Type of facilities Type of practice Conclusions

23. Work package 3&4: Costs of Primary Care Systems

24. Methodology Micro-costing

25. Methodology Macro-costing Actual costs: Real not estimated Usual accounting principles and practices Indicated in the estimated overall budget

26. Work package 5&6: Quality of Primary Care Systems

27. Focus Group Discussion : Patients (n= 53) Primary care professionals (n= 64) 7 countries: Estonia, Finland, Germany, Hungary, Italy, Lithuania, Spain. Helped to understand the views about quality in the different partner countries and to set a list of quality criteria. Non-clinical indicators for each criteria were identified from the literature review and prioritized by scoring according to importance and measurability. Methodology Quality Indicators

29. Methodology Quality at the Population Level

30. Methodology Quality at the Clinical Level