The Danish Structure Reform and the development of GP Services

Conference on Nordic Healthcare ReformsHelsinki, October 4th 2013

Kjeld Møller PedersenProfessor, health economics and health policy

University of Southern DenmarkAalborg Universitykmp@sam.sdu.dk

Outline

1. Primary care in context: the structural reform 2007

2. The primary care sector

3. General practice

Two structural reforms: 1970 and 2007

• 1970: local government reform• far reaching decentralization of responsibilites for many services, including health care

• Reduced the number of counties from 26 to 14• county taxes financed about 85% of health care expenditures

• Reduced number of municipalities from 1200+ to 275

• 2007: Structural reform • reduced the 14 counties to 5 regions

• abolished regional taxation. • regional health care financed through

• reduced the 275 municipalities to 98

The five regions and 98 municipalitiesA total of 5.4 million inhabitants

1.2 mill

1.2 mill

1.6 mill

0.6 mill

0.8 mill

The regions have the responsibility for

• An elected regional council of 42 members constitute the political dimension

•Health care (hospitals, GPs etc.)• operational • planning• BUT not overall financing

• the regions receive an annual block grant from central government

• Administer and allocate the block grant to the various health services

• Regional development • A few specialized social institutions, i.e. for autists or the blind

98 municipalitiesAverage size: + 50,000 inhabitants

•Health related responsibilities(=7% of the municipal budgets)

- dental care for children (< 18 years)- health visitors (small childern)- home nursing and home aid- nursing home- health promotion and prevention- rehabilitation- social psychiatry (housing & rehab.)- addiction (drugs/alcohol)

Municipalities in the region The Region

Municipality

Health CoordinationCommittee (11 politicians)

Contact Forum)

Health agreemtns

Municipal Co-financing of

Regional health services

The 2007 reform introduced more co-operation &co-ordination between municipalities and region

Region

FinancingPublic: (taxes or social insurance)

Private(out-of-pocket)

Manage-ment &owner-ship 100%

public100% private

100%

100%

(’free’ to user)PublichospitalsHomenursing

General practiceNon-profit hospitals

PharmaciesApprox. 50%

Adult dentalcare

Approx. 80%

Denmark

For-profithospital Approx. 60%

Ambulanceservices Approx. 80%

1. PATIENTS

Hospitals

2. Health sector

3. The 5 regions

109 billion DDK= 77.2% of total health

expenditures

State blockgrants

“revenues”

GPs

Office basedspecialists

3. 98 municipalities

10 Billions DDK*= 6.9% of total

health expenditures

Pharmacies(drugs)

Physiotherapists & Chiropractors

7%

1%

8%

3%

77%

2%

Co-payment:24 billions DDK. - = 16,8 % of total health expenditures

Nursing homes*

Municipal health services

Rehabilitation

Municipaldentistry109 bn. D

DK

(= € 14.5 bn)

24 bn. DDK(€ 3.2 bn)

10 billions DDK*

Total: 143 billions DDK. i 2012=(€ 19 billion, 11% of GDP)

•Exclusive ofexpenditures fornursing homes& home help

Adult dentists 1%

Central admini.expenditures

Free physiotherapy

Prevention & health promotion

Municipal taxes & state block grants

“revenues”

9%

20%

8%

21%

6%

29%Home nursing

The primary sector consists of

1.Private (self-employed) practitioners working on contract with the region: GPs, physiotherapists, dentists, chiropractors (and office based specialists, pharmacists)

• The GPs act as gatekeepers, referring patients to hospital, office based specialist treatment and some municipal services.

2. Municipal health services: Home (district) nurses, health visitors, home help, nursing homes dentists (children, teenagers).

The Primary Sector

Hospital

General practice

Municipality

Coordination and cooperation needed

source: Konkurrenceredegørelsen 2006

Regulation

Free establishment?(i.e. right to receive reimbursement from the region)

Free services?

Fixed prices?

Referral needed?

GPs Yes Yes - No

Ear/eye office based specialists

Yes Yes - No

Other office based specialists

Yes Yes - Yes

Psychologist Yes (no) No Yes Yes

Physiotherapist Yes (no) (No) Yes Yes

(adult) Dentist No No (yes) No

General practice: A corner stone of the Danish Health System

85-90% of the population is contact with a GP during a year

On average 7 – 8 contacts per year (consultation, telephone, home visit)

Facts about general practice• about 3,600 GPs

• growing percentage of females, today about 40%

• organized in about 2,100 practice units• app. 60% are solo practices, mainly in the Copenhagen area• app. 19% of the practices have two GPs• app. 11% of the practices have three GPs• app. 9% of the practices have four or more GPs

• Ancillary personnel: Nurses, medical secretaries (laboratory tech.)• on average 0.8 – 0.9 ancilliary personnel per GP

• Based on a list system, i.e. citizens choose a GP and gets on his/her list. Can be changed every three months

• average list size: app. 1600 persons

Geographical locations with general practice

Reasonable geographicspread

However, increasinglydifficult toget doctorsto settle down in”outlyingareas”

Placeringen af lægevagtskonsultationerne i Danmark, januar 2010.

Fast åben i hele vagttiden

Fast åben i dele af vagttiden

Kun åben efter aftale

Out-of-hours Services (4. p.m. to 8 a.m week-days, weekends and holiday)

Open throuhout

Part time open

Open after booking

• Organized by GPs on a rotating basis• January 1st 2014 the Capital Regions opts out of this system

• Often located at a hospital – but run independent of hospital

• Issues: Triage by nurses? Coordination/integration with hospital acute/emergency admission

Services:• telephone consultation

• visit, practice location (but based on prior telephone contact)

• home visit (prior telephone contact).

GPs/FamilyPracticeself-

referral referral

required

Office basedspecialists

Hospitals

Universityhospitals

referral

required

Community health centers – home nursing – health visitors

Municipalities

The referral chain: Offer (adequate) treatment at the lowest specialized level

- save specialized health care facilities for the complicated cases

Should/can handle Should/can handle 85-90% of all cases 10-15% of all cases

Pharmacies

prescriptions

GPs/Family Physicians as gatekeepers

GPs/FamilyPractice

self-

referral

• Do not necessarily require ’sophisticated’ facilities

• Well trained nurses can reduce the workload of the GPs

• issue of the size of the ’list’, e.g. number of persons attached to a particular GP

• Recruitment and retention of GPs always a challenge – as is remuneration/pay

DENMARK• 2200 practice units• 1.7 GPs per unit• 1.5 nurses/secretaries• average list size: 1561• +40 million contacts /year• referral rate to more specialized care 10-20%• mix of per capita & fee-for-service (35/65)• average GP income higher than hospital consultants

19

Payment model for general practice1. General model: Mixture of per capita and fee-for-service

• Per capita app. 30% of total remuneration

• Capitation is the payment of a given amount of money to doctors for each patient registered with them (the list), in return for a commitment that they will respond to the care needs of their patients over a period of time (normally a year)

• The present system has been in place for more than 50 years (apart from Copenhagen where GPs until

early 1990ies were paid entirely by capitation)

• Concern about too big fee-for-service component

20

General practitioners (cont.)

2. No cap on total amount of remuneration• However, ’benchmarking’ is used as a dialogue

instrument• age- and sex adjusted prescription expenditures at least once a year

3. Experiment with annual payment for a disease specific ’package’.

• For diabetes. Package includes annual status, control visits, reporting of quality indicators etc. • Voluntary; annual amount: 1100 Dkr. (160 €)

4. Numerous regional add-ons to the nationally negotiated contract (a document of 230 pages) to reflect regional needs and priorities• Typically paid by an hourly rate

November 2008212 pages

The latest government review

The role of general practice in the health sector of the future

Chapters on:1.Future tasks, e.g. chronic care, coherent patient pathways …

2.Acute care, e.g. day-time, night, week-ends, holidays

3.Capacity and geograhical coverage the GPs (GP shortage)

4.Coordination and collaboration with hospitals and municipalities

5.Diagnosing and referral 6. Quality, IT and postgraduate education

7.Reimbursement system (Payment of GPs)

Reasonably balanced

The Danish Healthcare Quality ProgrammeThe Danish Healthcare Quality Programme, DDKM, is an accreditation system. The programme serves as a method to generate continuous and persistent quality development across the entire healthcare sector in Denmark.

The Danish Healthcare Quality Programme provides accreditation standards of good quality – along with methods to measure and control this quality.

General practice will undergo accreditation process

The system has been pilot tested in 26 general practices. Reportfrom September 2012

Draft document, accreditation standards

4 groups of standards:

External survey every 3rd year

Patient pathwayAccessibilityDiagnosingReferralVulnerable groupsCoordination

Patient empowerment & info.Involvement of patients/relatives

Patient safety

Recent developments in the GP-sector

Report from the Auditor General

Report on activities and expenditures in the practice sector

Critical about • documentation of expenditure control• lack of transparency• lack of quality information

The 2010 contract between GPs and Danish Regions

• a total of 202 pages• ’covers everything’:

• tariffs• provider number/licens• control/quality • planning• conflict resolution• etc.

Usually based on a principleof ’mutual veto’, i.e. changes required agreementbetween the two parties

Change of the health lawlate June 2013

Radically changed the rules of the game.

• tipped the power balance towards Danish Regions

• changed planning authority

• abolished the mutual veto. Danish Regions have the final say

• more transparency, e.g. information about quality• expenditure control

Moved severalcontractelementsinto legislation