This document discusses healthcare funding and general practice in Ireland. It begins by outlining the "Triple Aim" of enhancing patient experience, improving population health, and reducing costs. It then discusses how burnout among providers can undermine this aim and proposes a "Quadruple Aim" of also caring for providers. The document presents international evidence that increased primary care and general practice is associated with better outcomes and lower costs. It also shows data on accessibility of care in Ireland and trends in healthcare spending.
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Republic of Ireland Faculty RCGP Winter meeting December 2017 William Behan
1. Healthcare and Funding General Practice
The Republic of Ireland Faculty of the Royal College of General Practitioners
Winter Meeting December 2017
William Behan
twitter@DrWilliamBehan
slideshare DrWilliamBehan
2. The Triple Aim
• Enhancing patient experience
• Improving population health
• Reducing costs
W Behan December 2017
3. Quadruple Aim: Care of the Patient Requires Care of
the Provider
The Triple Aim
• Enhancing patient experience
• Improving population health
• Reducing costs
• Burnout is associated with lower patient satisfaction,
reduced health outcomes and it may increase costs
• Burnout thus imperils the Triple Aim
W Behan December 2017
4. International Evidence Supporting GP Provided Primary Care
2012 Barbara Starfields SESPAS Report
Adding one more one primary care physician per 10,000 population REDUCES
• Death rates from 2% to 6%, particularly reducing health inequality
• Inpatient admissions by 6%
• Outpatient visits by 5%
• Emergency room visits by 10% and
• Surgeries by over 7%
BMJ 2014 Review 48 studies:
• Seeing the same GP each time can reduce emergency department
attendance BMJ 2014;349:g4847
W Behan December 2017
5. • 2007-11 Rhode Island increased primary care spending
from 5.4% to 8.0%: 2.6% change in total spending = 18%
reduction in total spending: 7-fold return on
investment. (some cost transfer)
• Commonwealth Fund 6-fold
• Oregon 2016: Every $1 spend in P.C. = $13 savings
(€240m/3 years and increasing year on year)
International Evidence Supporting Value of Primary Care
2015 Irish Health Spend on 24/7 Clinical GP: €734m/€19.9b = 3.7%
UK Health Spend on 12/24 General Practice: £10b/£144b = 7%
W Behan December 2017
7. Accessibility of general practice care in Ireland
What proportion of all patients cannot see a GP/get medical care
due to cost?
• 2006 EJGP: 26% “had a medical problem in the previous year but
had not consulted the doctor because of cost”
• EU-SILC 2003-2015: <4% (2.6% in 2015) “Needed a medical
examination or treatment but did not receive it in the last 12
months”
• Growing Up in Ireland: 0.2% “Of 3.9% who required but did not
receive medical attention only 0.2% stated it was because they
“Couldn’t afford to pay””
W Behan December 2017
8. Perceived and reported access to the general practitioner: An
international comparison of universal access and mixed
private/public systems
K Galway, A Murphy, A Kelly, A Gilliland, AW Murphy, D O'Reilly, T O’Dowd, C O'Neill, E Shryane, K Steel, G Bury
Ir Med J. 2007 Jun;100(6):494-7
How quickly do you get to see
a PARTICULAR doctor? n (%)
Country NI ROI
Same day 12.7% 40.1%
Next day 18.4% 32.5%
2 working days 19.0% 13.6%
3+ working days 45.0% 8.1%
Health and Social Services for Older People
HeSSOP II 2004 (Aged 65+; n=1,000)
25% were with their GPs for between ten and nineteen years
41% were with their GP for more than twenty years
9. Why is Primary Care/General Practice Such Good Value?
2009 Annals of Family Medicine editorial;
• ‘The Paradox of Primary Care/General Practice’:
primary care provides better overall patient outcomes
and at lower costs compared to specialty care
W Behan December 2017
10. CONCEPT OF HIGH vs LOW VALUE/HARMFUL HEALTHCARE
• Marc Jamoulle: Quaternary Prevention 1986
• Too Much Medicine Campaign (BMJ)
• Choosing Wisely (AIBM Foundation)
• Less is More (JAMA Int Med)
• General health checks don’t work Editorial:
BMJ 2014;348:g3680
• UK National Screening Committee Recommendations
• Inverse Benefit Law
Why is Primary Care/General Practice Such Good Value?
W Behan December 2017
11.
12. Marc Jamoulle: Quaternary Prevention 1986
Combine Narrative and Evidence Based Medicine
W Behan ICGP October 2017
13. Difference between GP and hospital care
• “The role of the GP is to tolerate uncertainty, explore
probability and marginalise danger.
Specialists aim to reduce uncertainty, explore
possibility & marginalise error.” (Marinker)
• Disease specialist vs holistic generalist perspective
“(Partialist vs Totalist”)
• Longitudinal relationship between GP and patient
results in reduced asymmetry of information and
alignment of goals
W Behan December 2017
14. Difference between General Practice & Primary Care
• True teams (Prof Michael West)
• Arnsteins Ladder of Engagement
• Patient Centred > System Centred
• Accessibility to senior(decision making), holistic
clinician
W Behan December 2017
15. Individual Performance
Malcolm Gladwell: Satisfying work
• Should there be a relationship between the added value an
individual brings to an enterprise and remuneration?
• Autonomy, Mastery and Purpose (Personal Satisfaction)
– Dan Pink: The puzzle of motivation
• Rewards only work in a narrow band of circumstances
• If/Then Rewards often destroy creativity
• Secret to high performance is to tap into a persons
intrinsic drive
W Behan December 2017
16. Value of Lollipops
(a.) If Then
(b.) If
(c.) If
Then (b.) is better value than (a.)
Then (c.) is better value than (a.)
W Behan December 2017
17. 2009 Pandemic Influenza A (H1N1) Immunisation Costs/Value
• 10% of population considered high risk expected to provide 90%
deaths
• Public Immunisation Clinic €34/vaccine
• General Practice est. €8.50/vaccine administered to mostly high risk
• Economic benefits of reducing Influenza in community not
considered for this analysis
Similar Reduction
in Community Deaths
GP
Vaccinating 1 high risk
patient @ €8.50
HSE
Vaccinating 100 low risk
patients @ €3,400
18. Basic Terminology
• Price
• Cost
• Value
• Opportunity Cost
(€ Inputs)
(Outputs)
Outcomes
Cost
• Fixed/Variable.
• Health Sector, Patient & Family, Society, Productivity Losses
= € given/expected for goods/services
= resources consumed a/w supplying a service
= (Total)
Benefit given up in order to take
another course of action
=
19. Health Outcomes that matter to a Patients Condition
Total Costs of delivering the Outcomes
Cycle of
Care
Value
Prof Michael Porter/Robert Kaplan
How do we define value?
=
Total
Health
Value
=
Total Health outcomes that matter to Patients
Total Patient, Environmental
Costs of delivering those Outcomes
Health System &
Surrogate Outcomes
W Behan December 2017
20. Concepts generally considered when paying for health
Is it a standard business?
• Role of a business is to maximise profit
• Income – Expenditure = Profit
How services are paid for
Who pays
Purchaser, supplier, user of service influences on activity
Moral Hazards
Monopoly/Monopsony issues
W Behan December 2017
21. Concepts generally NOT considered when paying
for health
Cognitive vs Procedural Care
Total Outcomes. Including indirect costs/benefits
(Very complex)
• What surrogate outcomes could be considered?
• Creeping administrative burden
W Behan December 2017
22. OECD (2017), Health spending (indicator). doi: 10.1787/8643de7e-en (Accessed on 24 November 2017)
27. 2009 2010 2011 2012 2013 2014 09-'14
Department of Health Figures
(€millions)
-20.0 -38.0 -84.7 -84.7 -104.7 -121.7 -454.0
True Figures (€millions) -50.5 -75.4 -142.3 -162.4 -197.4 -219.8 -969.5
-1200.0
-1000.0
-800.0
-600.0
-400.0
-200.0
0.0
€millions
Official and Real Figures: Annual and Cumulative Fee
Cuts to Irish General Practice 2009 - 2014
Department of Health Figures (€millions) True Figures (€millions)
29. 27817
24,069
33,856
34,193
43,891
26,697
37,329
46,920
57,555
58,128
74,615
63,459
0
10000
20000
30000
40000
50000
60000
70000
80000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
€
GP Secretarial subsidy (per year) — 3 or
more years' experience IN 2008
Salary CLERICAL OFFICER GRADE III -
YEAR 3 IN 2008
Salary GRADE IV (CLERICAL) YEAR 3 IN
2008
Salary Grade 3 year 3 in 2008 -> Grade 4
in 2013
Total Cost: CLERICAL OFFICER GRADE III -
YEAR 3 IN 2008
Total Cost: GRADE IV (CLERICAL) YEAR 3
IN 2008
Total Cost: CLERICAL OFFICER GRADE III -
YEAR 3 IN 2008,PROMOTED IN 2013
ROI Faculty RCGP Winter Meeting
W Behan December 2017
Effect of cuts on Pre-Tax, Post Pension Income
General Practitioners vs. HSE Admin Staff c Increments and Promotions
TOTAL COST
A Pay Mid point of pay range using formula above
B Direct Salary Cost Pay + Employers PRSI
C Total Salary Cost B + Imputed pensions cost (typically
25% of A)
D Total Staff Cost C + 40% of A in respect of ‘overheads’
Pension Levy February 2009
30. -40.0%
-30.0%
-20.0%
-10.0%
0.0%
10.0%
20.0%
2008 2009 2010 2011 2012 2013 2014
Changes in Resourcing of Irish Health Service Staff
(2015 VdeG Slide)
Pay and Pensions per HSE staff member
Pay & Pension per HSE Manager/Administrator
GMS Payments per patient
OECD Calculation GP Income (2013 & '14 Incorporate FEMPI 2013)
W Behan December 2017
31. 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2007 2008 2009 2010 2011# 2012## 2013 2014 2015
Austria Belgium Canada France Germany
Luxembourg Netherlands United Kingdom Ireland
Lower earning self-employed GPs are forced into employee status by Revenue
Self-employed GPs cannot get assistants/locums: Working more hours
# Change in Irish methodology of calculating GP income
## 2nd Change in Irish methodology of calculating Irish GP income
OECD Self-Employed GPs Income per Average Wage
W Behan December 2017
32. €-
€20,000
€40,000
€60,000
€80,000
€100,000
€120,000
€140,000
€160,000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Axis Title
Comparison of GP Personal Income vs HSE Lower
Management Incomes 2008-2017
OECD Self Employed GP Pre-Pension OECD Self Employed GP Post-Pension/Income protection
LOCAL HEALTH OFFICE MANAGER (HSE) HSE Grade 8
HSE Grade 8 promoted to LHO Manager in 2012
W Behan December 2017
39. 0.0
1.0
2.0
3.0
4.0
5.0
6.0
0 1 2 3 4 5 6 7 8 9 10 & 11 12 & 13 14-16 17-49 50+
EstimatedConsultations
Recorded Consultations
Comparison of true attendance to recollected
attendance
Est. GP consultations Recorded GP consultations Recorded GP + Nurse consultations
16 Surgeries; 873 Adults
Medical Card 57.7%; GPVC 10.1%
A Grace, W Behan, P Smyth.
HSE Trinity GPTS 2016
W Behan December 2017
40. 45.0
46.0
47.0
48.0
49.0
50.0
51.0
52.0
53.0
54.0
55.0
0 1 2 3 4 5 6 7 8 9 10 & 11 12 & 13 14-16 17-49 50+
EstimatedConsultations
Recorded Consultations
Comparison of true attendance to recollected
attendance
Est. GP consultations Recorded GP consultations Recorded GP + Nurse consultations
W Behan December 2017
41. 0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
55.0
0 1 2 3 4 5 6 7 8 9 10 & 11 12 & 13 14-16 17-49 50+
EstimatedConsultations
Recorded Consultations
Comparison of true attendance to recollected
attendance
Est. GP consultations Recorded GP consultations Recorded GP + Nurse consultations
Estimated visits to the GP: 4.1 per year
Actual GP visits: 5.4
Practice Nurse estimated visits: 1.2
Actual Practice Nurse visits: 1.6
Actual GP + Nurse: 5.7
W Behan December 2017
