1. How incentives work The Catalan single purchaser integrated care experience: evaluation results Improving primary care in Europe and the US: Towards patient-centered, proactive and coordinated systems of care The Rockefeller Foundation Bellagio Study and Conference Center, Italy April 2 to 6, 2008 Josep M. Argimon

2. Framework Context:  Chronic disease management Goals:  Promote cooperation among providers  Facilitate the integration process of a fragmented health system Means:  Provider payment mechanisms: Capitation

3. Purchasing 1.0: competition System:  Per health services lines since early 90’ Primary Care Specialized Care Adjusted capitation Activity adjusted by complexity INCENTIVES Cost- consciousness Purchaser- provider split Clarity of rules (contracts) Poor incentives for coordination Sum-zero game No risk sharing

4. Capitation pilot Context:  (2001) 5 pilots to test capitation as contract base for integrated services Goals:  To improve healthcare equity, continuity and efficiency through the promotion of territorial alliances among providers Method:  Average per capita expenditure adjusted by “need” proxies

5. Purchasing 2.0: coopetition System:  Integrated health services for a defined population Primary Care Specialized Care INCENTIVES Strong incentives for coordination Risk sharing Cost- consciousness Purchaser- provider split Identity risks Adjusted per capita expenditure

6. Evaluation

7. Quantitative study:  Chronic conditions selected: heart failure, COPD.... Qualitative study (2005):  Semi-structured interviews to managers and health professionals  Narrative analysis Results:  Great variability of perceptions and facts  Good alternative to resource allocation  More dialogue and increased trust and transparency.  A service quality improvement tool.  Lack of knowledge in the base line

8. Conclusions Qualitative study:  Payment mechanisms need to be paired with purchaser’s policy making capacity.  Integrated networks perform better when cost, benefits and risks are shared.  Creating a culture of trust and cooperation needs time  Managers and professionals need to be involved

9. Thank you