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)

• 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

Access

Costs Quality

Background

• 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

• 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

Objectives

• To contribute to improving the knowledge regarding Primary Care in Europe:

exploring the relationships that could exist between Quality and Costs of different models and systems of organizing and delivering PC across Europe

• 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

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

CO

OR

DIN

AT

ION

W

P 1

DIS

SM

INA

TIO

N

W

P 8

To measure the health quality in PC

To measure costs in PC

ORGANIZATION OF PRIMARY CARE IN

EUROPE

REGULATION

FINANCING

PAYMENTORGANIZATION

ORGANIZATIONAL BEHAVIOUR

• Costs

• Quality:

Approach

Work package 2: Evaluation of PC models in

EuropeMethodological Approach of a Classification System of PC Models in Europe : Germany, Spain, Estonia, Finland, Hungary, Italia and Lithuania.

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

FINANCING Mixed model

(Hungary)

BISMARCK SS(Estonia, Germany,

Lithuania)

BEVERIDGE NHS(Finland, Italy,

Spain)

7% Uninsured

10,6% Private Insurance18,8% Double coverage

Expenditure in HCas GDP

10,5%

6,1% 6,6%

24%

Expenditure in PC

5,7%

16% Double coverage

Descriptive analysis (I)

• 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)

• 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)

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)

Range of services

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 PC3.Referral required from GP, mainly group-practices in PC

4.Health care centers5.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

Validation models of PC in Europe (24 countries EU )

COUNTRYGEOGRAPHICAL DISTRIBUTION

OF PRIMARY CARE SERVICES

National system

Regiona/local system

Multiple Insurers

Complementary & suplementary

Duplicative

ESTONIAFINLANDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

PROVISION SERVICES VOLUNTARY PRIVATE INSURANCE

Capitation SalaryFee for service

Out of pocket

ESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

COUNTRYPROFESSIONAL INCOME *

*Predominance

COUNTRYGATEKEEPING TO

SPECIALISTS TYPE OF

FACILITIES*

Public Solo practice Group practiceIntegrated

networkESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

TYPE OF PRACTICE*

* Predominance

COUNTRY

FORMAL QUALITY MANAGEMENT & IMPROVEMENT PROGRAMMES

CONTINUING CLINICAL EDUCATION

PROGRAMMES

LOCAL ADAPTATION OF

CLINICAL GUIDELINES

ESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

Framework for classification of health systems based on PCMultidimensional => more complex => more realistic

Healthcare services provision Basic coverageGate-keeping

Private insurances Professional payment

Type of facilities Type of practice

Conclusions

Work package 3&4: Costs of Primary Care Systems

4 clinical vignettes representing the main areas of activity of PC: Acute care Chronic care Health promotion Prevention (vaccination)

Methodology Micro-costing

Methodology Macro-costing

• Actual costs: Real not estimated• Usual accounting principles and practices• Indicated in the estimated overall budget

Incl

udes Personnel Costs

Durable EquipmentConsumables and supplies identifiable

Work package 5&6: Quality of Primary Care Systems

• 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

60 Quality Indicators (aprox) selected to measure Quality of PC in Europe

Methodology Quality Indicators

Population Survey:

A sample of 3.020 persons25-75 years old7 countries participating in the projectDomains:

Socio-demographicSatisfactionSelf-perceived healthUtilization of servicesPrevention and health promotion interventions

Methodology Quality at the Population Level

Professional survey:

Medical records: Diabetes and blood pressure high14 indicators Specific approach for extracting data in each country

(sample)

Methodology Quality at the Clinical Level

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