1. Strengthening primary care in weak primary care systems Prof. Peter P. Groenewegen NIVEL – Netherlands Institute for Health Services research

2. 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

3. 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

4. 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

5. Multiple health and social problems

6. 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

7. Western Europe

8. Western European countries with stronger and weaker primary care Stronger: UK Denmark Spain Netherlands Italy Finland Weaker: Portugal Belgium Greece Germany Switzerland France

9. 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

10. Organisation of primary care: Transformation from cottage industry to modern community health service

11. 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’)

12. 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

13. 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

14. 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

15. 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

16. Former communist countries

17. 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

18. 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

19. Gatekeeping in former communist countries Primary care as starting point for reforms Introduction of gatekeeping Training of GPs Retraining of district doctors, paediatricians, gynaecologists

20. 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

21. 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) 19,420,828,430,123,4 Medical technical procedures 1,101,041,511,351,36 Manage- ment and follow up of disease 2,401,552,712,41

22. 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 39,48,642,040,822,7 Smoking6,69,79,18,21,3 Alcohol7,211,37,410,21,3

23. 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

24. Upcoming policies and problems Bismarckian systems Disease management Vertical systems Performance payment -------------------------------- Weak incentives PD  list system  GP model  individual Transitional countries Patient choice Prevention -------------------------- Strong incentives profiling  P4P contracts  benchmarks

25. Unintended consequences of P4P?

26. 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