Presented at the First Congress of Indonesian Health Economic Association - Bandung, 24th of January, 2014

1. Integrating Medical Education and Payfor-Performance in Primary Care:
An Option for National Health Coverage
Ahmad Fuady
Department of Community Medicine, Faculty
of Medicine, Universitas Indonesia
January 2014

2. 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?

3. (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.

4. 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.

5. 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

6. 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

7. Tools for assessment
•
•
•
•
Multisource feedback, triangulation
Mini-clinical evaluation exercise
Direct observation of procedural skills
Multiple assessment method, a portofolio
Goal
Miller, 2010

8. Integrating with Pay-for-Performance?
• Financial incentives  improvement of quality
and continuity of care
de Bruin, 2011; Campbell, 2007

9. 9
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.

10. 10
Pay for performance: rationale
1. 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

11. • Also, improvement on education?
• Tools for assessment and certification
Some indications, for a more effective system:
• Payment on the basis of scoring on processbased incentives.
• Blending of individual- and group-level
incentives.
• Mixed of absolute and relative performance
de Bruin, 2011

12. Conrad and Perry, 2010; de Bruin, 2011
Considerations

13. 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

14. 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.

15. Conclusions
• The integration of medical education and payfor-performance in primary care is feasible with
some limitations.
• Pilot project and good design of integration are
required.