Συστήματα αποζημίωσης ιατρών της ΠΦΥ. Ποια είναι η βέλτιστη επιλογή;

Συστήματα Αποζημίωσης των Ιατρών της ΠΦΥ
Η Βέλτιστη Επιλογή;
Ευάγγελος Α. Φραγκούλης, MD, MSc
Γενικός/ Οικογενειακός Ιατρός
MSc Διοίκηση Μονάδων Υγείας
Αν. Αρχίατρος ΕΔΟΕΑΠ
Γ.Γ. Ελληνικής Ένωσης Γενικής Ιατρικής
Μέλος ΔΣ ΕΛΕΓΕΙΑ
18ο Πανελλήνιο Συνέδριο Management Υπηρεσιών Υγείας,
7-8 Οκτωβρίου 2016, Θεσσαλονίκη, Γ.Ν. Παπαγεωργίου

1
• Improve the experience of care
2
• Improve the health of the population
3
• Reduce per capita costs of healthcare
Health Affairs 27, no3 (2008):759-769

Greater care complexity
• Studies estimate that it would take 7.4 hours to deliver all
recommended preventive services and 10.6 hours per
working day to deliver all evidence-based care for chronic
conditions to a primary care panel.
• “These excessive demands contribute to long waiting times
and inadequate quality of care for patients.”
• Concern about one’s ability to manage complex, chronically
ill patients may contribute to driving career choice away
from primary care.
Kimberly et al, Am J Public Health. 2003 3
Østbye et al, Ann Fam Med. 2005
Bodenheimer T. N Engl J Med. 2006

“Today, 21st century medical technology is often delivered
with 19th century organization structures, management
practices, measurement methods, and payment models”
Michael Porter, Professor Harvard Business School
“If you run a company and you don’t know what your client
benefit and satisfaction levels are, there is no way you can
manage, but in healthcare we have done this over and
over”
Dr Fred van Eenennaam, Chairman of Value-Based Health
Care Europe
Business as usual is over!!!
Need a fundamental departure from the past,
a system with erratic quality and unsustainable costs!

Στοχεύοντας στην ενδυνάμωση της ΠΦΥ
Increase
funding for
primary care
Reform primary
care payment
methods
Shift care out of
the hospitals
Improve access
to primary care
Change the skill
mix
Economic crisis, health systems and health in Europe: impact and implications for policy.
WHO Europe/ European Observatory on Health Systems and Policies, 2014

Payment systems and incentives
Economic theory predicts that the payment method
generates a set of incentives that influence behavior-
agency theory
McGuire Thomas G (2000). Physician Agency. Handbook of Health Economics. A.J. Culyer and J. P. Newhouse.
‘the principal’
(government,
insurer or
medical group)
Payment
method
‘the agent’
(the physician)
specific
behaviors
Different payment methods therefore can be used to
incentivise and promote different health policy goals.

Fee-for-service
• Physicians are paid a fee for every unit of care they deliver
(e.g. visits, treatments, lab tests) according to a fixed price schedule
• financial risk is borne by the payer (patient, state or insurer).
Incentivized to provide more, not better, care.
Misaligned incentives created or exacerbated
unsustainable costs
Given the asymmetry of information risk for
supplier-induced demand
Reduce the number of referrals to specialists?
Limited incentives to promote preventive
activities, unless preventive interventions are
specifically paid for?
incentivise physicians to increase their
productivity and rewards the more productive
physicians when patients can choose between
physicians.
Peckham S, Gousia K. GP payment schemes review (2014).
Policy Research Unit in Commisioning and the Healthcare system

Salary
• Physicians are paid a fixed amount of money for a pre specified
amount of hours worked regardless of the number of patients
seen or the volume or costs of services provided.
Disincentivised to put effort into attracting
new patients and/or providing the right
amount of care.
Associated with reduced activity, increased
referrals to specialists and hospitals
Cream skimming of patients, concentrate on
patients who bring with them the lowest
demands.
NOTHING
Ιδανική μόνο για άγονες περιοχές
με μικρούς πληθυσμούς

Effect of the GP payment method
in population health
• data at municipality level in
Norway over 16 years.
• no effect on mortality of the
volume of GP supply (in
contrast with more previous
studies)
• but an effect of composition,
with more contracted GPs
reducing mortality,
• but no effect of more
employed GPs.
Aakvik, A. and T. H. Holmas (2006). "Access to primary health care and health outcomes: the relationships
between GP characteristics and mortality rates." J Health Econ 25(6): 1139-1153.
Employed
GPs
Contracted
GPs

Capitation
• a fixed, up-front rate per person enrolled in their list regardless of the type and amount of
services used
• Can be risk-adjusted in order to account for differences in the age and health distribution of
the patient population across physicians
Incentivise cost containment and under-
provision of services (even below the clinically
necessary levels)
shift more care to specialist and hospital
services in order to minimize their effort while
still retaining the capitation fee. Gatekeeper
role of GP?
Incentivise patient selection, avoiding those
with high levels of needs - ‘cream skimming’,
esp. when the payment is not risk-adjusted
Promotes preventive work since under
capitation physicians would like to preserve
their patients’ health status to avoid future
costly treatments.
Panel of patients. Accountability and
responsibility for a defined practice
population. Essential for Continuity of Care and
Care Coordination

Pay for Performance (P4P)
• financial incentives for reaching targets on predefined
performance measures
• providers are responsive to financial incentives
• commonest payment methods not designed to
stimulate good performance and separately creates
incentives for undesired behavior
• The main goal of P4P is to improve patient outcomes
while mitigating unintended consequences
• Contributing to better prevention and disease
management/ including efficiency measures, could also
mitigate cost growth

P4P
• Designing a fair and effective P4P program is a complex undertaking. This
complexity and the limited effectiveness thus far cast serious doubt on whether
P4P can be cost effective.
• Performance payments themselves, data collection and validation, payment
calculation involve significant transaction costs.
• Evaluations of P4P programs should assess the impact on quality but also include
comprehensive cost analyses. However, a recent review identified only nine
economic evaluations of P4P programs and concluded that current evidence is
insufficient to support P4P cost-effectiveness.
• P4P may be able to mitigate cost growth through better prevention and disease
management and through inclusion of efficiency measures.
• Empirical research investigating the influence of specific design choices and
contextual factors is needed to enable fine tuning of P4P programs tailored to the
setting of implementation.
Eijkenaar F. Key issues in the design of pay for performance programs. Eur J Health Econ (2013) 14:117–131.

Arguments against P4P
• based on flawed evidence
• has not led to real improvements in care or outcomes
• leads to worse unincentivised care and widen inequalities
• unintended consequences of gaming, overtreatment and a
focus on pharmaceutical rather than psychosocial care will
result
• emphasizing ‘vertical’ disease management rather than
horizontally-integrated holistic care it is not patient centred
• de-professionalizes doctors
• not a good use of resources
Siriwardena N (2010). Should the Quality and Outcomes Framework be abolished? No

Goals of Payment Reform Models
Schneider E et al. Payment Reform. Analysis of Models and Performance Measurement Implications. RAND
Health Quarterly, 2011; 1(1):3

Blended payment methods
• Pure payment methods combined into more complex
payment methods to have a more desirable mix of
incentives, avoiding some of the adverse incentives of
simple payment methods.
• even the most sophisticated blended payment methods
cannot fully eradicate incentives to over-treat or under-
treat patients
• complex payment methods may create their own set of
perverse incentives (e.g. gaming the system)
Simoens, S. and A. Giuffrida (2004). "The impact of physician payment methods on raising the efficiency of
the healthcare system: an international comparison." Appl Health Econ Health Policy 3(1): 39-46

• Value = Health outcomes achieved per dollar spent
• What matters for the patients
• Unites the interests of all actors of the system
If value improves, patients, payers, providers, and suppliers can all
benefit/ improved sustainability of the system

The Value agenda
• a supply-driven health care system organized around what
physicians do 
a patient-centered system organized around what patients need
• volume and profitability of services provided (physician visits,
hospitalizations, procedures, and tests) 
patient outcomes achieved
More care and more expensive care is not necessarily better care…
• Restructuring how health care delivery is organized, measured, and
reimbursed.
M. Porter, T. Lee. The Strategy That Will Fix Health Care. Harvard Business Review. Oct 2013

Μετατόπιση του ενδιαφέροντος-
ευθυγράμμιση των κινήτρων
Όγκος
υπηρεσιών
Αξία
υπηρεσιών
it is patient health results that matter,
not the volume of services delivered
Η αποζημίωση κατά πράξη αντιστρατεύεται την παραγωγή
αξίας (προκλητή ζήτηση υπηρεσιών).
Η παραγωγή αξίας για τους ασθενείς θα πρέπει να καθορίζει
τις ανταμοιβές όλων των άλλων παικτών του συστήματος.

Measuring value in health care
Michael Porter, 2007

Building an enabling
Information Technology Platform
• Χρήση της τεχνολογίας πληροφορίας (ΙΤ) με τρόπο που να κινητοποιεί την αναδόμηση του
συστήματος παροχής υπηρεσιών και την μέτρηση των αποτελεσμάτων
• Επικεντρώνεται στους ασθενείς. Το σύστημα ακολουθεί τους ασθενείς στις διαφορετικές
υπηρεσίες, δομές και χρόνους ενός πλήρους κύκλου φροντίδας
• Χρησιμοποιεί κοινούς κώδικες πληροφοριών. Οι πληροφορίες μπορούν να αναζητηθούν,
ανταλλαχθούν, ερμηνευτούν από όλα τα μέρη του συστήματος.
• Ενσωματώνει κάθε είδους πληροφορία για τον ασθενή (εικόνες, εργαστηριακά αποτελέσματα,
παραπομπές και κάθε άλλο στοιχείο που βοηθά στην πρόσληψη μιας συνολικής εικόνας για τον
ασθενή).
• Ο ιατρικός φάκελος είναι προσπελάσιμος σε όποιον συμμετέχει στη φροντίδα του ασθενούς.
• Ενσωματώνει ειδικά εξειδικευμένα πρότυπα για κάθε νόσημα.
• Διευκολύνει την εξαγωγή δεδομένων. Τα δεδομένα είναι απαραίτητα για τη μέτρηση των
αποτελεσμάτων υγείας, του κόστους που ακολουθεί τον ασθενή, τον έλεγχο των παραγόντων
κινδύνου .
Μ. Porter, 2011

Measure Outcomes and Cost for Every Patient
Μέτρηση, Αναφορά και Σύγκριση των Αποτελεσμάτων 
Βελτίωση των Αποτελεσμάτων και Ελάττωση Κόστους

Core GMS contract
1
• a ‘global sum’ calculated according to the ‘Carr-Hill
formula’, which takes into account patient numbers
(capitation) alongside adjustment factors for age,
deprivation, burden of disease etc;
2
• pay for performance, known as the ‘Quality and
Outcomes Framework’ (QOF), which provides incentive
payments for reaching a number of disease-based targets
(approx. 20% of practice income)
3
• ‘enhanced service’ payments

Quality and Outcomes Framework
(QOFs/ UK 2004)
Μέχρι και 25% αύξηση της αμοιβής κάθε ιατρείου στη
βάση 5 ομάδων παραμέτρων- ανάπτυξη από το NICE:
• 80 κλινικές παράμετροι (65.5% συνολικής επίδοσης)
• 43 οργανωτικές παράμετροι (18.1%)
• 4 παράμετροι σχετικές με την εμπειρία ασθενών
(10.8%)
• 8 παράμετροι σχετικά με υπηρεσίες πρόληψης και
προαγωγής υγείας (3.6%)
• παροχή ολιστικής φροντίδας(2%)

Quality targets for general practice in Scotland are to be scrapped in a move labelled ‘bold’ and
‘positive’ by the BMA
BMA Scotland GPs committee chair Alan McDevitt said: ‘The removal of the QOF system is a
significant step towards our vision for the future of general practice in Scotland.
‘This bold move is part of the reinvigoration of general practice in Scotland. It will have a positive
effect on practices, by reducing workload and bureaucracy, allowing GPs to focus on the complex
care needs of their patients.’

electronic Clinical Quality Measures
(eCQMs)

• Communication with health care professionals
• Access to care and information
• Customer service
• Coordination of care
The Centers for Medicare & Medicaid Services (CMS) sponsors the national
implementation of the survey, sets the policies for survey administration, analyzes
the data, and publishes the results in private and public reports (including Web sites
such as HospitalCompare and PhysicianCompare).
also uses the survey scores along with other quality measures to help determine
payment incentives that reward high-performing health care providers.

Συνεργασία- Διασύνδεση- Συντονισμός
Ομάδες Υγείας

Διασύνδεση ΠΦΥ με Εξειδικευμένη Φροντίδα
• The ideal combination of primary and specialty care will vary by patients’
subgroup/ medical condition/ individual patients across time.
• A joint team, organized around meeting the needs of patients.
Shared goal of improving outcomes and efficiency for their common patient.
• Systematic efforts to share protocols, define handoffs, and build personal
relationships.
• Access to the same clinical information system, consistent outcomes data
routinely collected and shared.
• Bundled payment systems that reimburse primary care and specialty clinicians as
a group for a given patient increases the likelihood that they will collaborate.
Porter et al. Redesigning Primary Care: A Strategic Vision To Improve Value By Organizing
Around Patients' Needs . Health Affairs, 32, no.3 (2013):516-525

Accountable Care Organizations (ACOs)
• Coordinated delivery systems that reward providers
who deliver lower-cost, higher-quality care for a given
population of patients.
• A typical ACO would include a hospital, primary care
clinicians, specialists and other health professionals.
• The idea is that the more providers collaborate, and
are rewarded for improving the health of a group of
patients, the better and more cost-effective our
health system will be.

Primary Care Doctor Pay Surpasses
$250K/y
as doctors are increasingly paid via
value-based care models that
emphasize quality, better
outcomes and keeping their
patients healthy.
“As we shift toward value-based
payment, practices will continue to
look to primary care and non-
physician providers to lead efforts
to improve patient experiences
and the quality of care they
provide,”
“Practices are giving primary care
physicians significant new
responsibility for coordinating care
among specialists, managing
patient medications and helping
patients and caregivers manage
chronic conditions.”Forbes, May 29, 2016

Νέο σύστημα εξωνοσοκομειακής φροντίδας
βασισμένο στο μοντέλο της Πορτογαλίας
• καθολική πρόσβαση και την ισότιμη φροντίδα των πολιτών
στο σύστημα Υγείας
• Κάθε οικογενειακός γιατρός έχει "χρεωμένα" περίπου 2.000
άτομα. Εχει ευθύνη για τον εμβολιασμό, τους προληπτικούς
ελέγχους, τα περιοδικά "τσεκάπ", την αγωγή Υγείας, την
παρακολούθηση χρονίων νοσημάτων και φυσικά την
παραπομπή σε άλλα επίπεδα του συστήματος
• Θα τηρούνται οδηγίες και πρωτόκολλα, ώστε να έχουμε πιο
τεκμηριωμένη άσκηση της Ιατρικής, χωρίς προκλητή ζήτηση και
περιττές παρεμβάσεις. Θα υπάρχουν υγειονομικοί δείκτες που
πρέπει να παρακολουθούνται. Για παράδειγμα, οι πάσχοντες
από διαβήτη θα πρέπει να είναι σωστά ρυθμισμένοι και με
βάση τον δείκτη αυτό, θα αξιολογούνται γιατροί και μονάδα.
Πρόκειται για ένα "συμβόλαιο" υποχρεώσεων, το οποίο θα
τηρείται ώστε να διασφαλίζεται ότι παρέχεται τεκμηριωμένη
φροντίδα Υγείας και μετρήσιμη απόδοση του συστήματος

Νέο σύστημα εξωνοσοκομειακής φροντίδας
βασισμένο στο μοντέλο της Πορτογαλίας
Τρεις στόχοι
• η καθολική κάλυψη του μόνιμου πληθυσμού
• η ισότιμη πρόσβαση, ανεξαρτήτως εισοδήματος και
περιοχής
• και η οικονομική προστασία, δηλαδή δωρεάν
υπηρεσίες υγείας.
Οι γιατροί που θα απασχοληθούν στα ιατρεία γειτονιάς
θα είναι πλήρους και αποκλειστικής απασχόλησης –
δηλαδή δεν θα μπορούν να έχουν δικό τους ιατρείο-
με τριετή σύμβαση και με μηνιαίο μισθό 1.800
ευρώ καθαρά.
Πρωτοβάθμια υγεία: Μειώνονται οι ιδιώτες με σύμβαση, έρχονται οι
οικογενειακοί γιατροί , Ειρήνη Ανδρουλάκη, cnn.gr 5/10/2016

Είναι έτσι το πορτογαλικό μοντέλο;

alexandre.lourenco@icloud.com
1,8x
Portuguese experience
capitation formulas, performance links &
payment modalities
Alexandre Lourenço
9th October 2014

1,8x
Contracting environment, process and interactions
Monitoring &
Evaluation
Services
Design
Provision
of care
Providers
identification
Health needs
assessment
General
Principles
National Audit Office, 2010

1,8x
Health Care Professional Remuneration
Salary
Capitation
Fee for service
P4P
Other components
Fixed salary
Warranty of minimum earnings
Minimum number of adjusted patients
Other activities

1,8x
Salary
Capitation
Fee for service
P4P
Other components
Other activities

1,8x
68

1,8x
69

1,8xDiagnostics
Pharmaceutical consumption
Clinical profile
Age
Gender
Demographic Characteristics
Individual risk

1,8xDiabetes type 2
High blood pressure
Clinical profile
67 years old
Man
Demographic Characteristics
Individual risk
4,3

1,8x
Salary
Capitation
Fee for service
P4P
Minimum number of adjusted patients
1550 patients* or 1917 adjusted
patients
* It is in discussion a minimum number of 1900 patients or 2350
adjusted patients.
Increased number of adjusted patients
equivalent to increased earnings
Other components
Age Adjusted patient
0-6 1,5
65-74 2,0
>74 2,5
Other activities

1,8x
Salary
Capitation
Fee for service
P4P
Only for MD - Home care
€/per visit
Maximum of 20 visits/month
Other components
Other activities

1,8x
Salary
Capitation
Fee for service
P4P
P4P to the all unit
Set of 22 contracted indicators select from a
national set of more than 100 indicators
Other components
Number Level Type Wheitgh
2 National Access 7,5%
7 National Clinical Performance 26,0%
2 National Efficiency 24,0%
1 National Perceived quality 5,0%
4 Regional Any 15,0%
2 Sector Any 7,5%
2 Local Any 15,0%
Targets defined by national heath objectives, good practices,
resources available and historical data
Other activities

1,8x
National set of indicators select for the period
2014-2016
Utilization rate of medical consultations in the last 3 years
Rate nursing home visits per 1,000 patients
Proportion of pregnant women with adequate follow-up
Proportion of women in reproductive age with appropriate monitoring in family planning
Proportion of Infants within the first year of life with adequate follow-up
Proportion of seniors without prescription anxiolytics, sedatives and hypnotics
Proportion of patients with more than 13 years old characterized with smoking habits in the last three years
Proportion of hypertensive patients older than 65 years old with controlled blood pressure
Proportion of controlled diabetics
Proportion of patients satisfied
Pharmaceuticals expediture per user
Ancillary exams expenditure per user

1,8x
Salary
Capitation
Fee for service
P4P
Supplement Coordination
Supplement Training (interns)
Other components
Other activities

1,8x
Salary
Capitation
Fee for service
P4P
Activities outside the basket of services:
e.g. Smoke cessation
Other components
Other activities

1,8x

1,8x
Ποσοστό γυναικών 26-65 ετών
που έχει υποβληθεί σε παπ-τεστ
την τελευταία τριετία

Poor performance in cancer screening

1,8x
Proportion of hypertensive patients
with controlled blood pressure
35.4
52.6
64.0
45.3
37.8
53.8
65.2
48.0
UCSP-M USF-A USF-B Todas ARS | Todas
UF-M
2012
2013

Φαρμακευτική δαπάνη

From Non-System
to System
Swenson, Stephen MD, et al. Cottage Industry to Postindustrial Care –
The Revolution in Healthcare Delivery. NEJM, January 20, 2010
Κατεστραμμένο, αναποτελεσματικό σύστημα
Κατακερματισμένη, επεισοδιακή, χαοτική
μη συντονισμένη φροντίδα
Πάροχοι απομονωμένοι
Μοντέλο οικιακής βιοτεχνίας
Πολλαπλά σημεία εισόδου
Πολλαπλά μονοπάτια φροντίδας
Διαφορές σε αποτελέσματα
Αδυναμία σύναψης μακρόχρονης σχέσης,
Διάχυση ευθύνης
Αποζημίωση για την όγκο-ποσότητα υπηρεσιών
Ολιστική, συντονισμένη φροντίδα
Συνέχεια φροντίδας- μακρόχρονη σχέση
συνεργασίας με ασθενή
Συνεργασία- διασύνδεση ιατρών, επαγγελματιών
υγείας, υπηρεσιών, δομών
Κοινός στόχος η βελτίωση της υγείας του ασθενούς
και του πληθυσμού
Ευθυγράμμιση των κινήτρων των παικτών-
αποζημίωση παρόχων βάση της αξίας που παράγουν
Μέτρηση- καταγραφή-δημοσιοποίηση
αποτελεσμάτων υγείας και κόστους για κάθε ασθενή
Ενσωμάτωση υψηλής τεχνολογίας
Διαφάνεια των αποτελεσμάτων

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