Innovations in Paying GPs Towards a Three-level European model? Experience from European countries (England, France, Germany, the Netherlands and Sweden) Prof. Dr. med. Reinhard Busse, MPH Department of Health Care Management/ WHO Collaborating Centre for Health Systems, Research and Management, Berlin University of Technology & European Observatory on Health Systems and Policies
Introduction Provider payment mechanisms are key to the performance of any health system, and the demands placed on them are high: Allocate resources fairly among different providers of care Motivate actors within the system to be productive Account for patients needs (= ensure equitable access) and expectations Incentivize using effective and appropriate services as well as contributing to good outcomes Be administratively easy and contribute to an overall efficient health system. Aiming to overcome the limitations of traditional provider payment mechanisms, European countries have developed a range of innovative approaches to provider payment. How do they work? Do they work can they square the circle?
Introduction Basic forms of physician payment mechanisms and their expected incentives in regard to selected objectives Productivity and number of services Patient needs and expectations (risk acceptance) Appropriateness and adherence to evidence-based medicine (quality of processes) Quality of outcomes Administrative simplicity and ease of costcontainment + (+) ( ) ( ) Capitation [if not properly riskadjusted]/(+) (+) O (+)/( ) Salary ( ) O O O +
Introduction Basic forms of physician payment mechanisms and their expected incentives in regard to selected objectives Productivity and number of services Patient needs and expectations (risk acceptance) Appropriateness and adherence to evidence-based medicine (quality of processes) Two observations stand out: Quality of outcomes Administrative simplicity and ease of costcontainment + (+) ( ) ( ) 1) basically all payment mechanisms provide conflicting incentives for production of services and costcontainment (an unsurprising but politically worrisome observation); and Capitation [if not properly riskadjusted]/(+) (+) O (+)/( ) Salary ( ) O O O + 2) none provide positive incentives for producing high quality outcomes.
Framework Conceptual framework for analyzing provider payment systems narrow Scope of payment (What services are included?) broad too generous Patients Patient characteristics: -Physicians: capitation Capitation -Hospitals: Pure DRGs C Cq Quality coarse Fairness of payment too small (not costcovering) A F characteristics: -Physicians: Providers Salary -Hospitals: Fixed Budget salary E G Information used to determine payment D B Service characteristics: -Physicians: Fee-for-service -Hospitals: Fee-for-service Bq Services Fee-for-service Fineness of payment categories fine
Payment and sector of care France Germany Netherlands England Sweden (since 2009) Sweden (before 2009) Primary care Officebased GPs GPs in outpatient dep ts Ambulatory secondary care (Primarily) Officebased specialists Outpatient departments: hospital-based specialists Inpatient care Hospitals
Traditional forms of paying GPs (until early 2000s) France Germany Netherlands England Sweden PHI: (regionally capped) Capitation Salary SHI: Capitation
The apparent answer: Blended payment but maybeyouareasconfusedasi am whatitis Basically, I see two variants 1. using different forms of payment on different levels, e.g. payer all physicians in one area or in one institution vs. institution individual physicians 2. combining different forms of payment on one level (and there could be a combination of the two)
Main reforms in GP payment England2004: new GP contract introduces (1) opt-out or for enhanced services and (2) quality bonus for reaching targets ( quality and outcomes framework ) France: on top of (1) small lump sums for coordinating chronically ill patients (ADL; 2004) and (2) quality bonus for reaching targets or above-average improvement (2009) Germany2002: GPs are paid small lump sums for activities under disease management programmes; 2009: (1) capitation payments physicians associations based on actual need (actually utilisation) and (2) separation of basic and additional services with separate caps ensuring full payments for services within caps Netherlands2006: merger of SHI and PHI leads to new GP payment system consisting of capitation plus fee-per-visit Sweden2007: starting in Halland county, a move towards additional private office-based GPs competing with public health centers necessitates money-follows-patient payments
Germany the ambulatory care sector ca. 135.000 physicians, of which 120.000 self-employed ca. 73.000 single-handed practices (78%) ca. 73.000 physicians (55%) ca. 19.000 group practices (20%) ca. 45.000 physicians (40%) Mandatory membership in 16 regional associations ca. 1.500 health centers (2%) ca. 6.000 physicians (5%)
Germany 2-step payment of physicians Sickness fund X Sickness fund Y Sickness fund Z Capitation based on previous year s utilisation, increase factor, adjustments Physicians association (KV) GP budget (ca. 1/3) Specialists budget (ca. 2/3) up to specialty-specific case-volume age-based caps (RLV) for basic and groups of special services GP 1 GP 2 GP 3 Spec1 Spec2 Spec3
Physician payment (with innovations) GPs Capitation/ lump sum England France Germany Netherlands for enhancedservices (if contracted with PCT) per patient for essential services; fixed allowance for costs related to setting up or maintaining practices for self-employed GPs Lump sum for managementof patients with long-termdiseases (ADL) and involvementin provider network for self-employed GPs up to case-volume agebased caps (CVAPC) Lump sum for involvement in Disease ManagementPrograms (DMP) Consultation fees per year and registered patient Quality-related adjustments Salary Specialists QOF; new P4P contracts for GPs For individual contracts for practice improvement GPs working in hospitals,in service of a GP practice or PCT For workin private practice (i.e., not within NHS) GPsworking in hospitals, in service of a GP or in health centers and preventive and social services For self-employed specialists (including specialists practicing in private for profit clinics) -- As a pilot model GPs working in hospitals, in service of a GP or in health care centers for self-employed specialists up to casevolume age-based caps (CVAPC) GPs working in service of a GP practice or in primary care centers 75% of specialists (i.e., working independently in hospitals) as part of DBC payment Capitation -- -- -- -- Quality-related adjustments Salary New contracts for specialists; Clinical Excellence Awards Physicians workingunder the NHS contract -- -- -- Specialists working in hospitals Specialistsworking in hospitals 25% of specialists working in hospitals
Physician payment (with innovations) 2 GPs in Swedish counties/regions Halland Stockholm Västmanland Region Skåne Västra Götalandsregionen Different feeper visit for registered patients and for other patients Fee per visit for all patients (and reduced payments above a volume-ceiling for registered patients) Different fee per visit for registered patients and for other patients Fee per visit for notregistered patients Fee per visit for not - registered patients Capitation for registered patients basedon four age-groups for registered patients based on three agegroups for registered patients based on four agegroups for registered patients based on classification of diagnoses (80%) and socio-economic indicators (20%). Flat fee for drug prescription based on age and sex for registered patients based on age and sex (50%) and classificationof diagnoses (50%).Possible additional flat fee based on socioeconomic indicators & geographical location Qualityrelated adjustments Lump-sum penalty payment if noncompliance with drug recommendations Increase or decrease of total payment up to 3% depending on performance, incl. drug recommendations Bonuspayment up to 2% of total payment depending on performance Bonuspayment up to 2% of total payment depending on performance Bonuspayment up to 3% of total payment depending on performance Salary GPs working in hospitals, in service of a GP practice or in health care centers
Payment components in GP care France Germany Netherlands England Sweden Objective: appropriateness & outcomes Quality payment CAPI bonus QOF bonus Bonus and/or Malus Objective: productivity & patient needs Objective: admin. simplicity & costcontainment (& geogr. equity) Extra service payment Basic service payment ADL payment DMP payment with caps per service type RLV (capped ) (per visit & outof-hours) Capitation ( enhanced services ) Capitation (per visit) Capitation
Determination of capitation payments England: sex and 7 age bands = 14 categories (1.0 = males 5-14 8.9 females 85+) plusadjustments for long-term illness and standardised mortality ratio plus adjustment for cost (GP, staff, land, buildings) Germany: based on actual utilisation in previous year Netherlands: 3 age bands plus deprivation in area = 6 categories Sweden: several age bands and/or morbidity factors (plus socio-economic factors)
Percentage of total payment per component (estimates) France Germany Netherlands England Sweden Objective: appropriateness & outcomes 5% 25-30% max. +/- 3% Objective: productivity & patient needs 1% 95% <5% 30% 40-45% <10% 10-20% (Stockholm 60%) Objective: admin. simplicity & costcontainment (& geogr. equity) 60-70% 55-60% 65% 80-90% (Stockholm 40%)
Conclusions For GP payment, countries are moving toward a European model consisting of: (1) Capitation (inscription)/ capped (visittriggered) to pay for providing basic services; (2) special lump sums for specific patient groups (if capitation is not sufficiently risk-adjusted) + for (potentially) underprovided services and/or requiring special expertise or technology; (3) quality-related bonus (or malus) for (not) reaching certain targets. 60% 20-30% 10-20%