Financial Crisis and Primary Care in Greece : now more than ever

Financial Crisis and Primary Carein Greece : now more than ever

EFPC Conference, Istanbul Turkey, September 10, 2013

Pavlos N. Theodorakis,MD, MSc, DipLSHTM, PhD,

Chairman, PHC-SC,General Practitioner,

WHO National Counterpart for Mental Health

Health In Action: PHC - SC

Primary Health Care Providers in Greece

2

PUBLIC AND PRIVATE PHC RESOURCES

Technical Assessment Report: Primary Health Care

Rural Health Centers 207Rural District Surgeries 1.578Outpatient Clinics of Public Hospitals 138EOPYY Units (Former IKA) 326Private Diagnostic Centers 4.500Municipal Surgeries 80NHS Physicians 23.500EOPYY Physicians (Former IKA) 11.500Private Physicians 25.500Private Dentists 12.586Pharmacies 12.500

PHC PROFILE

• Most extensive and medically staffed PHC network in the world with regard to the population size

• 4,2 visits/ year/ person in PHC in Greece• 4,4 visits/ year/ person in PHC (OECD, 2009)• elderly (up to 6) and women (up to 5).• 80% visited a doctor, at least once, last year. • >40 million visits during last year.


Large number of physicians – the highest among countries of the OECD and as a result emphasis in

medicalization

www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm

http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm


Inhabitants per Physician (Private & Public Sector)


THE WHOLE COUNTRY

EAST AND WEST MAKEDONIACENTRAL MAKEDONIA

WEST MAKEDONIA THESSALY

HPEIROSIONION

WEST CREECESTEREA ELLADA

ATTIKIPELOPONNHSOUNORTH AEGEANSOUTH AEGEAN

CRETE

175

206144

206189

159183

221221

149371

241267

149



Inhabitants per Specialty (Private & Public Sector)


PHYSICIAN

BIO-PATHOLOGY

CARDIOLOGIST

PEDIATRICIAN

OBSTETRICIAN

OPHTHALMOLOGIST

ORTHOPEDIC

DERMATOLOGIST

OTOLARIGOLOGIST

PULMONOLOGIST

PSYCHIATRIST

SURGEON

RADIOLOGIST

OUROLOGIST

NEUROLOGIST

GASTROENDEROLOST

ENDOCRINOLOGIST

1.5313.889

3.7653.417

4.871

5.9785.106

11.3878.943

8.566

8.7714.895

5.70811.111

10.194

18.15121.912



Generalists V Specialists

Cost Containment Measures in PHC

• 5 euros fee when attending outpatients dpts of General Hospitals (including paediatric, university and specialised ones) (emergency cases excluded)

• 0-25% co-payments for medication • 15% flat co-payments for diagnostic tests when private

sector is chosen• Free of fee access for preventive activities and

participation in mass-screening programmes


Strong primary care systems

Source: Kringos et al, 2012


“A Future for Primary Care for the Greek Population”

AthensJanuary, 8, 9 and 10, 2012

Experts: Prof Peter Groenewegen, Nivel Institute, Netherlands

Prof Arnoldas Jurgutis, University of Klaipeda, Lithuania


TFGR of the EC, in cooperation with domain leader Germany and the Greek MoH (PHC-SC)


http://www.biomedcentral.com/1471-2296/11/81/figure/

Governance (I)

• Unclear distribution of responsibilities between national government and district and local authorities (centralization-decentralization), health insurance funds and NHS, public and private sector.

• No broadly supported vision of primary care, priority setting, financing, supply planning and management, service provision or quality monitoring.


Governance (II)

• No explicit governmental policy to regulate the distribution of primary care providers and facilities more evenly.

• The delivery of integrated primary care is an issue that needs extensive efforts.

• Low level of development of ICT solutions.• Lack of use of results of empirical research by

policy makers.


Economic conditions for PC

• Low payment for GPs (compared to other specialists and compared to other countries),mainly in salaried service, but also self-employed on fee-for-service basis (potential problem of incentives).

• Large share of private spending and under the table payments (less strong in PC than in hospital care).

• Gaps in available equipment especially in rural areas.


Workforce development

• Unbalanced, lack of GPs and nurses in primary care.• Training of GPs heavily focused on hospital care. • No clear job/task description for GPs and other PC

providers.• No policy in health education to redress the balance

between generalists and specialists and to increase the attractiveness of residency training in family medicine.

• Lack of proper attitudes and public health management competences for the managers of primary health care institutions.


Access

• Low use of appointment systems (in rural areas), telephone and email consultations.

• Patient satisfaction with the ease to reach and gain access to general practitioners was relatively low (2007).

• Regional differences in access due to low number of GPs, vacancies.

• Cost sharing for prescription drugs. • Lack of information on actual consultation rates.


Comprehensiveness

• Often very small role of GPs, limited to prescribing and referring.

• Rural health centres have some role (though limited)in prevention.

• Lacking a clear community orientation.• Private practices (often single handed) mainly focus on

the patients visiting practice.• Sometimes lack of crucial equipment.


Continuity

• Personal continuity is a problem due to the fragmented health care system.

• Referral letters are not common. • Only occasionally primary care practices receive

information within 24 hours about contacts of patients with out-of-hours services.

• No information found about communication of specialists with general practitioners after the completion of an episode of treatment.


Coordination

• No referral system.

• Health centres provide opportunities for coordination within PC.

• No information about actual coordination.


Quality

• No information about quality of care in PC.

• Some private practices and diagnostic centres have more advanced quality assurance systems.


Efficiency

• Not enough information to assess efficiency.

• Health care institutions measure quantity of services (visits, laboratory tests etc.),but not how these service contribute to improvement of population health.


Equity

• There are clear and increasing inequities in health care in Greece.

• These inequities relate to health status, socio-economic status and place of living.


Recommendation (1)

• The MoH should develop a clear vision on strengthening primary care with GPs/FPs as core profession.

• Stakeholders (including patients) should be actively involved in vision development.

• A national PHC development strategy should be adopted by the MoH and possibly by Parliament.


Recommendation (2i)

• Access to primary care should be with the lowest possible cost-sharing from private or under the table payments. This is possible in a system of stepped access through mandatory referrals to specialist and hospital care and diagnostic services.

• Introduction of a referral system requires that the links between PHC and specialist and hospital care will be redefined.


Recommendation (2ii)

• Patients should be on the list of specific physicians (personal list system).

• The community orientation of PHC should be developed through relations with preventive services, community care and primary level mental health care.


Recommendation (3i)

• Funding of primary care should be geared to population needs through an adequate resource allocation formula.

• Payment of primary care physicians should take the form of a mix of capitation, fee-for-services and/or bonuses for specific targets.



• The level of payment of primary care professionals should be in line with their increased responsibilities.

• Those primary care professionals with a specific primary care education, such as GPs, should receive specific incentives.


Recommendation (4)

• Steps should be taken to split the purchaser and provider functions in health care.

• Contracts between purchasers and primary care providers should be based on the same principles and conditions for all primary care providers.

• Primary care organizations should be able to make their own choices in using their budget.


Recommendation (5)

• Primary care physicians should develop clinical guidelines in cooperation with other stakeholders.

• The development of a system of quality indicators is strongly recommended.

• Quality indicators should be part of quality improvement cycles at different levels.


Recommendation (6)

• Continuity of care should be facilitated by well-developed medical records.

• A possibility is to build on the e-prescribing

system.


Recommendation (7)

• Primary care professionals should have clear job descriptions that guide:

- educational requirements - contracts

- inform patients on what they can expect from primary care providers.


Recommendation (8i)

• An assessment of training needs for primary health care doctors and nurses working recently in practice is recommended

• Short training courses to obtain core competences, required by job description, should be developed and implemented.



• Policies for education and training of health professionals should address the misbalance between generalists and specialists and serve to increase the number of students in residency of family medicine.


Recommendation (8iii)

• Courses in primary health care and family medicine should be included in the undergraduate curriculum of medical and nursing education.

• Curriculum of the family medicine residency should be reviewed and adapted so that obtained competences are relevant to primary health care practice.


Recommendation (9)

• A referral system and personal list system should as far as possible be reconciled with freedom of choice for patients of their preferred primary health care provider.


Recommendation (10)

• Implementation of a comprehensive PHC system could begin in a small number of selected pilot areas.

• Pilot areas could be asked to participate on a voluntary basis, with clear requirements and conditions for participation, and in a transparent selection procedure.


Recommendation (11)

• The advantages of a strong primary care system for an equitable and sustainable health care system should be communicated to the wider public.

• A mass media strategy should be elaborated.


Recommendation (12)

• In the whole process of reorganizing primary care, independent monitoring and evaluation are extremely important.

• This requires an investment in collecting and analyzing information.


Thank you for your attention!

EFPC Conference, Istanbul Turkey, September 10, 2013

Pavlos N. Theodorakis,MD, MSc, DipLSHTM, PhD,

Chairman, PHC-SC,General Practitioner,

WHO National Counterpart for Mental Health


Documents

Financial Crisis and Primary Care in Greece : now more than ever