Integrating Medical Education and Pay-for-Performance in Primary Care: An Option for National Health Coverage

Ahmad Fuady

Department of Community Medicine, Faculty of Medicine, Universitas Indonesia

January 2014

Background•The implementation of Jaminan Kesehatan

Nasional (JKN) in 2014 challenge to strengthen primary care; roles as gate keeper, quality and cost controller.

•Problems in primary-level care: poor quality, shortage and discrepancy of healthworkers.

•Medical Education Act of 2013: introducing the term of Dokter Layanan Primer (DLP) a better quality of primary care?

(1) DLP• Currently zero-state of DLP; how to produce? • Additional professional education • Shifting ‘general physician’ to DLP?

(2) Payment system in primary care• Capitation system; criticized for a low basis fare

per capita and its uncertain mechanism for promotion and prevention.

• Pay-for-performance (P4P) system; an option? ▫ Some limitations ▫ Assessment of performance for payment; combined

for medical training? ▫ Quite similar concept with workplace based

assessment.

Idea• Integrating postgraduate training with

workplace-based assessment and the P4P system

Financial incentive better education better quality of care efficiency ?

Aim•Exploring the feasibility for the integration

and its potential to support the national health coverage.

The DLP in Indonesian health system•Family physician vs general physician vs

DLP?•Leave the debate!

•Focusing on how to produce a better quality of primary-level physician▫Postgraduate, master program?▫Postgraduate, professional specialist training?▫Not a conventional strategy workplace-

based

Workplace based assessment on quality of practice and education

•Recent reforms: “the assessment of day-to-day practices undertaken in the working environment”.

•Evaluating performance in context, re-coupling teaching and testing, formative potential, and more valid assessment.

•For licensing

Swanwick, 2005; Miller, 2010

Tools for assessment

•Multisource feedback, triangulation•Mini-clinical evaluation exercise•Direct observation of procedural skills•Multiple assessment method, a portofolio

Goal

Miller, 2010

Integrating with Pay-for-Performance?•Financial incentives improvement of

quality and continuity of care

de Bruin, 2011; Campbell, 2007

Pay for performance

“Both economic theory and common sense support the notion that payment for health care should be determined, at least in part, based on meaningful indicators of quality or value.”

Rosenthal, 2007

Providing explicit financial incentives to care providers based on their scores on preset performance measures with the goal of improving the quality and efficiency of care.

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Pay for performance: rationale1. Deficiencies in the quality and efficiency of care;2. Improving performance ultimately requires

changes in the behavior of physicians;3. Providers are responsive to financial incentives;4. Base payment methods have disadvantages and do

not explicitly stimulate good performance;5. Performance measurements have become more

accurate and sophisticated.

Therefore, it seems natural to tie a portion of providers’ income to their performance

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•Also, improvement on education?•Tools for assessment and certification

Some indications, for a more effective system:•Payment on the basis of scoring on process-

based incentives. •Blending of individual- and group-level

incentives. •Mixed of absolute and relative performance

de Bruin, 2011

Considerations

Conrad and Perry, 2010; de Bruin, 2011

Limitations

•Not the solely assessment for postgraduate training.

•Mixed evidence on the P4P.•“Distortion effect”: discourage efforts on

aspects of healthcare performance not included and rewarded by the scheme, tunnel vision.

•Gaming, risk selection. •Better recording of care rather than better

care. Rosenthal and Frank, 2006; van Herck, 2010;Chen, 2011; Conrad and Perry, 2010; de Bruin, 2011

How to design: current proposal• Integration, as a part of training

assessment• Episode-based/bundled payment: rewarding

patient management and outcomes (rather than volume) across the entire continuum of care.

• Global capitation + performance incentives.• Preparing a massive number, qualified

assessors.

Conclusions

•The integration of medical education and pay-for-performance in primary care is feasible with some limitations.

•Pilot project and good design of integration are required.