The Danish Structure Reform and the development of GP Services


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THL Vaikuttajaseminaari 3.-4.10.2013, Kjeld Møller Pedersen

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The Danish Structure Reform and the development of GP Services

  1. 1. The Danish Structure Reform and the development of GP Services Conference on Nordic Healthcare Reforms Helsinki, October 4th 2013 Kjeld Møller Pedersen Professor, health economics and health policy University of Southern Denmark Aalborg University
  2. 2. Outline 1. Primary care in context: the structural reform 2007 2. The primary care sector 3. General practice
  3. 3. 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
  4. 4. The five regions and 98 municipalities A total of 5.4 million inhabitants 1.2 mill 1.2 mill 1.6 mill 0.6 mill 0.8 mill
  5. 5. 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
  6. 6. 98 municipalities Average 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)
  7. 7. Municipalities in the region The Region Municipality Health Coordination Committee (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
  8. 8. Financing Public: (taxes or social insurance) Private (out-of-pocket) Manage- ment & owner- ship 100% public 100% private 100% 100% (’free’ to user) Public hospitals Home nursing General practice Non-profit hospitals Pharmacies Approx. 50% Adult dental care Approx. 80% Denmark For-profit hospital Approx. 60% Ambulance services Approx. 80%
  9. 9. 1. PATIENTS Hospitals 2. Health sector 3. The 5 regions 109 billion DDK = 77.2% of total health expenditures State block grants “revenues” GPs Office based specialists 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 Municipal dentistry109 bn. DDK (= € 14.5 bn) 24 bn. DDK (€ 3.2 bn) 10 billions DDK* Total: 143 billions DDK. i 2012 =(€ 19 billion, 11% of GDP) •Exclusive of expenditures for nursing 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
  10. 10. 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
  11. 11. Hospital General practice Municipality Coordination and cooperation needed
  12. 12. 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
  13. 13. 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)
  14. 14. 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
  15. 15. Geographical locations with general practice Reasonable geographic spread However, increasingly difficult to get doctors to settle down in ”outlying areas”
  16. 16. 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).
  17. 17. GPs/ Family Practiceself- referral referral required Office based specialists Hospitals University hospitals 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
  18. 18. GPs/Family Physicians as gatekeepers GPs/ Family Practice 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
  19. 19. 19 Payment model for general practice 1. 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. 20. 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
  21. 21. November 2008 212 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
  22. 22. The Danish Healthcare Quality Programme The 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. Report from September 2012
  23. 23. Draft document, accreditation standards 4 groups of standards: External survey every 3rd year Patient pathway Accessibility Diagnosing Referral Vulnerable groups Coordination Patient empowerment Involvement of patients/rela Patient safety
  24. 24. Recent developments in the GP-sector
  25. 25. 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
  26. 26. 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 principle of ’mutual veto’, i.e. changes required agreement between the two parties Change of the health law late 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 several contract elements into legislation