The Solution to Bending the Irish Healthcare Value Curve Is General Practice - The evidence supporting continuity of care from a personal GP team as opposed to a corporate primary care organisation

1. The Value Of General Practice Led
Primary Care.
Does GP Autonomy, Mastery and
Satisfaction Matter?
William Behan
October 2017
twitter@DrWilliamBehan
slideshare DrWilliamBehan

2. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

3. The Triple Aim
• Enhancing patient experience
• Improving population health
• Reducing costs
W Behan ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

4. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

5. Affect of Stress or Burnout on Performance:
Science; 2013
Being preoccupied with money problems affects attention
= 13 IQ points loss on formal cognitive assessment
= losing a night's sleep
= difference in IQ between a person who is a normal adult
versus a chronic alcoholic
W Behan ICGP October 2017
Should GPs be minded?
Motivation = Autonomy, Mastery & Satisfaction

6. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

7. 100%
73%
67%
0%
20%
40%
60%
80%
100%
120%
RelativePreventable
AdmissionRate
10 or more GPs 3 to 9 GPs 1 or 2 GPs
Small US Primary Care Physician Practices Have Low Rates
of Preventable Hospital Admissions
Survey of 1,045 primary care practices found that:
W Behan ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

8. • 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
Irish Health Spend on 24/7 General Practice: €734m/€19.9b = 3.7%
UK Health Spend on 12/24 General Practice: £10b/£144b = 7%
Motivation = Autonomy, Mastery & Satisfaction

9. 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)
• Longitudinal relationship between GP and patient
results in reduced asymmetry of information and
alignment of goals
• Accessibility to senior decision maker
Motivation = Autonomy, Mastery & Satisfaction

10. GP
GP Practice Receptionist
GP Practice Nurse
GP Practice Manager
Pubic Health Nurse
Social Worker
Physiotherapist
Pharmacist
Community Psychiatrist Psychologist
Speech Therapist
Occupational Therapist
PATIENT
System (HSE) Centred Primary Care Teams
HSE Manager
W Behan ICGP October 2017

11. GP
GP Practice Receptionist
GP Practice Nurse/Assistant
GP Practice Manager
Pubic Health Nurse
Social Worker
Physiotherapist
Pharmacist
Community Psychiatrist
Psychologist
Speech Therapist
Occupational Therapist
PATIENT
Patient Centred General Practice Teams
HSE Manager
W Behan ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

12. 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
Motivation = Autonomy, Mastery & Satisfaction

13. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

14. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

15. Marc Jamoulle: Quaternary Prevention 1986
Combine Narrative and Evidence Based Medicine
W Behan ICGP October 2017

16. W Behan ICGP October 2017

17. Surrogate/direct measurements of Irish general
practice care
• HeSSOP 2 (2004) High levels of GMS & Private patient satisfaction
w access & quality of care (95%). High levels of continuity of care
W Behan ICGP October 2017
• Low rate of undiagnosed diabetes
• Audit Report of the Midland Diabetes Structured Care
Programme: 3,700 patients/20 practices; 80% reduction in DM
complications
• 60% UK ED attendance rate/capita
Motivation = Autonomy, Mastery & Satisfaction

18. Surrogate/direct measurements of Irish general
practice value
EARLI Pilot Study: Blueprint for Primary Care (MPCC)
Emergency Admission Likelihood Index
• GP / Public Health Nurse / Community Services
• 50% reduction admissions in 21 Very High Risk
• 30% reduction admissions in 55 High Risk
• Extended nationally: potential to save €60-€108m annually
Warfarin Clinic (MPPC)
• 264 Patients
• 3 minute 4 step process vs HSE 13 step process
• 69% TTR
• 70% Satisfaction 10/10 W Behan ICGP October 2017

19. 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
W Behan ICGP October 2017

20. Accessibility of general practice care in Ireland
W Behan ICGP October 2017
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””

21. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

22. 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?
W Behan ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

23. Basic Terminology
• Price
• Cost
• Value
• Opportunity Cost
(€ Inputs)
(Outputs)
W Behan ICGP October 2017
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
=

24. 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 ICGP October 2017Motivation = Autonomy, Mastery & Satisfaction

25. 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 W Behan ICGP October 2017
OECD Self-Employed GPs Income per Average Wage

26. The Paradox between current models of Primary
Care and evolving Evidence of Value
What Works Well
Small, motivated, well resourced GP led surgeries with good
administrative, nursing & I.T. focusing on personalised patient care >
disease care being paid on a predominantly capitation basis
What Does Not Work
Large, over-resourced, highly bureaucratic, corporate primary care
centres with good administrative and I.T. support where individual
clinicians focus on administering fragments of care rather than whole
patient outcomes being paid on a commoditised, fee-per-item basis
GP Autonomy, Mastery and Satisfaction Matter
W Behan ICGP October 2017

27. The Solution to Bending the Irish Healthcare Value Curve
Is General Practice
• Corporatizing healthcare results in a highly bureaucratic, commoditized and
fragmented “market-based” environment which increases cost and reduces
value due to the asymmetry of information that exists between healthcare
provider and both purchaser and recipient. It also reduces the alignment
between both patients and populations with the health system goals
• Continuity of care from self-employed family physicians who are allowed the
autonomy to provide patient centred care is the most effective way to deal
with medical complexity and uncertainty; reduce healthcare inequity,
unnecessary healthcare activity, total healthcare costs and population deaths.
• The well-proven value of continuity of personalized care and superior medical
professionalism in patient and population outcomes is never monetized
twitter@DrWilliamBehan www.slideshare.net/DrWilliamBehan
ICGP October 2017