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A presentation I gave at the EGM of Ireland's National Association of General Practitioners. Shows progress in some areas of health; payments to GPs since 2002; and argues that general practice should embrace measures which show its value and contribution to healthcare.
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Health Reform, Efficiency and Quality- how far yet to go?Oliver O’[email protected]
National Association of General Practitioners ConferencePortlaoise, 20 July 2013
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Health Reform• It goes on and on, a never-ending river…• Is any country not engaged in health reform?• No one model, no one best system• Assess what we do and what is planned in Ireland
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Health Reform – main themes• What we do – activity and services by health staff• What we get – the patient experience• What we pay – public and private funding• How we pay – tax, private insurance, out of pocket• How we manage – health provider organisations• How we govern – public and private law oversight• How we perform – efficiency, outcomes
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Health Reform – priorities?• What we do• Move to more primary care: measures?• Waiting times and ED improvement by SDU• HSE Clinical programmes: a high clinical priority, leadership
• What we get• Free GP care – await new announcement – ‘free’ primary care• Equal access to all hospital care – awaits eventual UHI
• What we pay• Fiscal constraint. 20% cuts since 2008. No growth ahead.
• How we pay• Universal Health Insurance: ‘building blocks’ first. Long way off.• Money Follows the Patient hospital payments: in shadow 2014; full 2015?
• How we manage• No major changes
• How we govern• 6 Hospital groups, HSE re-organisation, ultimately insurer role
• How we perform• HealthStat development?• New measurements actually driving change? HSE KPIs?
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Health Reform – evaluation• Ultimately, all to lead to Universal Health Insurance• ‘Building blocks’ to be in place by 2015/16: a metaphor• Ultimate achievement: 2021 earliest (two terms of Government)
• Highly complex interrelated changes at every level• Payment systems• Role of hospitals• Role of primary care providers• Role of insurers• Role of State organisations and regulators• Service integration and competition• Public entitlements and contributions• C-O-S-T
• White Paper this year – but more like a series of documents? 5
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Health Reform – what about…• What we do• How we perform
i.e.
• Clinical effectiveness• Cost efficiency
delivering
• Best health status and outcomes at a reasonable cost 6
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The Money: Health Spending
• HSE €13.4bn net• Most on primary and community service
• Insurance €1.6bn• Most on secondary, hospital-based services
• Private, out of pocket est €2.5bn• Most on primary services, drugs, elective
• Total €17.5bn (est.)• Most on primary or non-hospital services• Do we get all we can for this?• What gets measured? Gets attention?
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HSE spending composition
HospitalsCommunity Services
PCRSChildren & Families
CorporatePensions
National Services (inc Amb)Population Health
Repayment scheme
0 1,000 2,000 3,000 4,000 5,000 6,000
Financial Allocations of HSE Gross Spend €14.16bn 2013
4,117
2,562
1,535
998
733
541
477400 392 114 77 72
HSE Financing by Care Group 2013AcutePCRSDisabilityFair Deal - Nursing HomeMental HealthChildren & familiesMulti-care groupPrimary CareOlder peopleSocial inclusionOtherPalliative care
• PCRS includes GP fees and practice supports
• Primary care includes some out of hours services 8
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Performance: life years
• Big increases at age 65+: most likely health service effect?• Even in the four years of last decade
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High relative to EU
• Not just because of Central and E European states• Higher than Germany, UK; lower than France, NL
Source: Dept of Health, Health Key Trends, 2012
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Measured improvements
• Deaths from diseases of circulatory system and heart down
Source: Dept of Health, Health Key Trends, 2012
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Cancer catch-up still needed
• 5 year survival improving but behind wealthiest EU countries
Source: Dept of Health, Health Key Trends, 2012
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Child immunisation rates up
• Sustained progress over a decade• Slight downward movement on meningococcal immunisations
in 2010-11
Source: Dept of Health, Health Key Trends, 2012
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More efficient? Yes, but…• Spending back to 2007 levels but activity up• Overall 10% cut in public non-capital spending since 2009
• Up to 20% cut in hospital budgets since 2008 (mostly staff costs)• But inpatient discharges up 3%• Day cases up 1.3%, continuing trend• Average length of stay down 4% (still not best though)
• Staff cut by 10,000• ‘Efficiency’ gains yes.• Hospitals and healthcare staff are doing more with fewer personnel and at
lower cost• But our hospital costs per procedure are still high internationally
• Input-output or payment-activity measure not enough or not appropriate• Health outcomes?• Too much activity?• Still over-use of ED?• Avoidable hospitalisation? etc. etc
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OECD developing price/volume comparisons
OECD, Joint session of the meetings of Health Accounts Experts and Health Data Correspondents, 11 October 2012
“Explaining differences in hospital expenditure across OECD countries: the role of price and volume measures “
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UK NHS unit costs lower
Notes: Recent efficiency gains in Ireland should have narrowed the gapCasemix a post-hoc averaging of cost; not very precisePatient level / procedure level costing neededExchange rate €1=£0.80
HIP REPLACEMENT + CCC HIP REPLACEMENT - CCC KNEE REPLACEMT +CSCC KNEE REPLACEMT -CSCC0
5,000
10,000
15,000
20,000
25,000
Irish Casemix rates vs UK NHS Tariffs - selected orthopaedics
Ireland 2009Ireland -10%UK Average
€
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A look at GPs…
• Up 31% since 2002• Numbers up 7.7% since 2008, though health spending down
10% and HSE staff cut 10,000
2002 2003 2004 2005 2006 2007 2008 2009 2011 20120
500
1000
1500
2000
2500
3000
No. GPs with GMS contract
Source: Dept of Health, Health Key Trends, 2012
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More GMS patients
• Up 58% since 2002• Numbers up 37% since 2008• April 2013 – up 4.3% on April 2012• Plus 129,000 GP Visit Card patients
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Eligible GMS Medical Card Patient (m)
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Total GMS payments to GPs
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012$0
$100
$200
$300
$400
$500
$600
GP Allowances €mGP Fees €m
• Payments up €201m, 71%, since 2002• Up 1.7% since 2008 (down 3.4% since 2009)• New FEMPI cut to make savings of €38m (7.9% - 7.5%? stated)
Source: HSE, PCRS
GMS income before variable and fixed costs of each practice
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€445m
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Payments per GP
• Payment per GP up 31% since 2002• Down 5.6% since 2008• With new FEMPI cut, will be down 13.1% on 2008
GMS income before variable and fixed costs of each practice
Source: HSE, PCRS
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012$0
$20
$40
$60
$80
$100
$120
$140
$160
$180
$200
GMS Payments per GP (€000s)
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Payments per GMS patient
• Payment per eligible patient up 10% since 2002, down 26% since 2008• With new FEMPI cut, will be down 33% since 2008• A 33% efficiency gain? Pity we don’t also have output/outcomes data• Free GP care for whole population would cost c.€600m more at this rate• ESRI calculated non-medical card holder GP costs at c.€389-€479m, 2009
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012$0
$50
$100
$150
$200
$250
$300
$350
$400
GMS Payments per Medical Card Patient (€s)
Source: HSE, PCRS
GMS income before variable and fixed costs of each practice
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GMS Pharmacy payments
• Up 86% since 2002, down 5.2% since 2008• With FEMPI cut €32m, will be down 12.7% since 2008• But depends on volumes of prescriptions and pricing• 1,690 GMS pharmacists 2011, up from 1,620 in 2008
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
GMS Pharmacy Fees and Mark-Up €m 2002-12
Sources: HSE, PCRS
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What do we get? What is measured?
• Traditionally, basic activity/inputs • # ‘contacts’: GP visits, out-of-hours consultations• # people have medical cards etc• # doctors work in teams• What is paid to doctors• Nothing that demonstrated the value of general practice
• Much more now measured in hospitals • Some Primary Care Key Performance Indicators now in
place• But do they demonstrate the value and outcomes of general
practice? 23
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HSE Key Performance Indicators• In National Service Plan and Monthly Performance Reports
Supplementary Documents
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HSE - 7 KPIs in Primary Care
• Number of PCTs implementing the National Integrated Care Package for Diabetes
• Number of Health & Social Care Networks in development• Percentage of Operational Areas with community representation for Primary
Care Team and Network development• No. of contacts with GP Out of Hours• Primary Care Physiotherapy: • no. of patients for whom a referral was received• no. of patients seen for a first time assessment• no. of face to face contacts / visits / appointments
• Primary Care Occupational therapy: • no. of clients who received a direct service • no. of clients for whom a referral was received
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7 Main KPIs in Primary Care• Orthodontics: • no. of patients on the assessment waiting list • waiting time from referral to assessment• Number of patients on the treatment waiting list - Grade 4• Waiting time from assessment to commencement of treatment – Grade 4• Number of patients on the treatment waiting list - Grade 5• Waiting time from assessment to commencement of treatment – Grade 5• Number of patients receiving active treatment
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A data desert• What do these KPIs tell us about, and help deliver from,
General Practice?• Certain levels of team-organisation• Activity levels out of hours• …• Clinical effectiveness of general practice?• Cost efficiency / value for money of general practice?• Evidence of best practice in action and for development?• Nothing on effectiveness or value of General Practice
• Should other existing KPIs be associated directly with General Practice• E.g. child and adult immunisation rates?
• A lot more to do 27
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OECD: can GPs help more?• Indicators relating to long term conditions ‘which should be fully
managed in the community’ (hospital admissions rates can show +/- performance of primary care)• Asthma admissions• Diabetes – incl. avoidable limb amputations• Influenza Vaccinations for 65+, link to COPD Admissions rates• Ireland: some of these are in HSE Acute Services KPIs, but not in
primary care• Mental health indicators ?
• Data capture: e.g. Danish General Practice Database• Information on 30 areas of general practice, made available to all
practices• Depression, COPD, heart disease, diabetes, childhood and adult
vaccination, contraception etc• Enables identification of patients being sub-optimally treated• Comparisons with other practices• Patient monitoring of own data
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Selected indicators - COPD
Source: OECD Health at a Glance 2011
• Ireland worst on admission rate; could do much better on vaccinations
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Selected indicators - Diabetes
• Ireland good on prevalence and on admissions; could be better
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Asthma prevalence and admissions
• As quoted in the HSE KPI metadata for Acute Hospitals
• Ireland could do better for women at the same prevalence rate
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Recommendations for Denmark’s primary care
Source: OECD REVIEWS OF HEALTH CARE QUALITY: DENMARK, April 2013
• Setting a national vision for how the primary care sector should deliver seamless and co-ordinated care, especially in light of increasing burden of long-term conditions and a faster through-put in specialist care
• Bringing about a more transparent, formalised and verifiable programme of continual professional development for all primary care practitioners, supported by national standards, guidelines and time-limited financial incentives.
• Rewarding quality and continuity of the care that GPs provide, such as through sharing of useful local experiences of successful integrated care models, encouragement of group-based practice models, and piloting of advanced nursing roles.
• Developing quality mechanisms – such as clinical guidelines and standards – centered around patients with multiple chronic conditions and long-term care needs, and the co-ordinating role of the general practitioner.
• Strengthening the information infrastructure underpinning quality in primary care, for example by establishing a quality register for chronic care based in primary care and by making better use of the DAK-E data capture system.
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Conclusions• Seek to demonstrate not just assert effectiveness and efficiency of
General Practice• Demand measurement, even when it shows under-performance• Seek out and implement meaningful performance indicators for
General Practice on clinical quality and cost efficiency• Avoid subsuming indicators into acute care or other areas of health
management• Embrace ex-ante cost-effectiveness assessments• Embrace new technologies and change in practice management and
clinical care• Help move cost-reduction agenda to cost-effectiveness agenda• Don’t just seek more inputs (more GPs, more money for GPs), but
more cost- and clinically-effective investment• Expect HSE / insurers to be more demanding and discerning
purchasers of care – meet the challenge head on33
