A presentation I gave at the EGM of Ireland's National Association of General Practitioners. Shows progress in some areas of health; payments to GPs since 2002; and argues that general practice should embrace measures which show its value and contribution to healthcare.

1. Health
Reform, Efficiency
and Quality
- how far yet to go?
Oliver O’Connor
ooc@sky.com
www.oliveroconnor.co
National Association of General Practitioners Conference
Portlaoise, 20 July 2013
www.oliveroconnor.co
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2. Health Reform
• It goes on and on, a never-ending river…
• Is any country not engaged in health reform?
• No one model, no one best system
• Assess what we do and what is planned in Ireland
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3. Health Reform – main themes
• What we do – activity and services by health staff
• What we get – the patient experience
• What we pay – public and private funding
• How we pay – tax, private insurance, out of pocket
• How we manage – health provider organisations
• How we govern – public and private law oversight
• How we perform – efficiency, outcomes
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4. Health Reform – priorities?
• What we do
• Move to more primary care: measures?
• Waiting times and ED improvement by SDU
• HSE Clinical programmes: a high clinical priority, leadership
• What we get
• Free GP care – await new announcement – ‘free’ primary care
• Equal access to all hospital care – awaits eventual UHI
• What we pay
• Fiscal constraint. 20% cuts since 2008. No growth ahead.
• How we pay
• Universal Health Insurance: ‘building blocks’ first. Long way off.
• Money Follows the Patient hospital payments: in shadow 2014; full 2015?
• How we manage
• No major changes
• How we govern
• 6 Hospital groups, HSE re-organisation, ultimately insurer role
• How we perform
• HealthStat development?
• New measurements actually driving change? HSE KPIs?
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5. Health Reform – evaluation
• Ultimately, all to lead to Universal Health Insurance
• ‘Building blocks’ to be in place by 2015/16: a metaphor
• Ultimate achievement: 2021 earliest (two terms of Government)
• Highly complex interrelated changes at every level
• Payment systems
• Role of hospitals
• Role of primary care providers
• Role of insurers
• Role of State organisations and regulators
• Service integration and competition
• Public entitlements and contributions
• C-O-S-T
• White Paper this year – but more like a series of documents?
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6. Health Reform – what about…
• What we do
• How we perform
i.e.
• Clinical effectiveness
• Cost efficiency
delivering
• Best health status and outcomes at a reasonable cost
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7. The Money: Health Spending
• HSE €13.4bn net
• Most on primary and community service
• Insurance €1.6bn
• Most on secondary, hospital-based services
• Private, out of pocket est €2.5bn
• Most on primary services, drugs, elective
• Total €17.5bn (est.)
• Most on primary or non-hospital services
• Do we get all we can for this?
• What gets measured? Gets attention?
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8. HSE spending composition
0 1,000 2,000 3,000 4,000 5,000 6,000
Hospitals
Community Services
PCRS
Children & Families
Corporate
Pensions
National Services (inc Amb)
Population Health
Repayment scheme
Financial Allocations of HSE Gross Spend €14.16bn 2013
0
4,117
2,562
1,535
998
733
541
477
400 392
114 77 72
HSE Financing by Care Group 2013
Acute
PCRS
Disability
Fair Deal - Nursing Home
Mental Health
Children & families
Multi-care group
Primary Care
Older people
• PCRS includes GP fees and
practice supports
• Primary care includes some out
of hours services
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9. Performance: life years
• Big increases at age 65+: most likely health service effect?
• Even in the four years of last decade
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10. High relative to EU
• Not just because of Central and E European states
• Higher than Germany, UK; lower than France, NL
Source: Dept of
Health, Health Key
Trends, 2012
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11. Measured improvements
• Deaths from diseases of circulatory system and heart down
Source: Dept of
Health, Health Key
Trends, 2012
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12. Cancer catch-up still needed
• 5 year survival improving but behind wealthiest EU countries
Source: Dept of
Health, Health Key
Trends, 2012
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13. Child immunisation rates up
• Sustained progress over a decade
• Slight downward movement on meningococcal immunisations
in 2010-11
Source: Dept of
Health, Health Key
Trends, 2012
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14. More efficient? Yes, but…
• Spending back to 2007 levels but activity up
• Overall 10% cut in public non-capital spending since 2009
• Up to 20% cut in hospital budgets since 2008 (mostly staff costs)
• But inpatient discharges up 3%
• Day cases up 1.3%, continuing trend
• Average length of stay down 4% (still not best though)
• Staff cut by 10,000
• ‘Efficiency’ gains yes.
• Hospitals and healthcare staff are doing more with fewer personnel
and at lower cost
• But our hospital costs per procedure are still high internationally
• Input-output or payment-activity measure not enough or not
appropriate
• Health outcomes?
• Too much activity?
• Still over-use of ED?
• Avoidable hospitalisation? etc. etc
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15. OECDdevelopingprice/volumecomparisons
OECD, Joint session of the meetings of
Health Accounts Experts and Health Data
Correspondents, 11 October 2012
“Explaining differences in hospital expenditure across OECD
countries: the role of price and volume measures “
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16. UK NHS unit costs lower
Notes: Recent efficiency gains in Ireland should have narrowed the gap
Casemix a post-hoc averaging of cost; not very precise
Patient level / procedure level costing needed
Exchange rate €1=£0.80
0
5,000
10,000
15,000
20,000
25,000
HIP REPLACEMENT + CCC HIP REPLACEMENT - CCC KNEE REPLACEMT +CSCC KNEE REPLACEMT -CSCC
€ Irish Casemix rates vs UK NHS Tariffs - selected orthopaedics
Ireland 2009
Ireland -10%
UK Average
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17. A look at GPs…
• Up 31% since 2002
• Numbers up 7.7% since 2008, though health spending down
10% and HSE staff cut 10,000
0
500
1000
1500
2000
2500
3000
2002 2003 2004 2005 2006 2007 2008 2009 2011 2012
No. GPs with GMS contract
Source: Dept of
Health, Health Key
Trends, 2012
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18. More GMS patients
• Up 58% since 2002
• Numbers up 37% since 2008
• April 2013 – up 4.3% on April 2012
• Plus 129,000 GP Visit Card patients
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Eligible GMS Medical Card Patient (m)
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19. Total GMS payments to GPs
$0
$100
$200
$300
$400
$500
$600
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
GP Allowances €m
GP Fees €m
• Payments up €201m, 71%, since 2002
• Up 1.7% since 2008 (down 3.4% since 2009)
• New FEMPI cut to make savings of €38m (7.9% - 7.5%? stated)
Source: HSE, PCRS
GMS income before variable and fixed costs of each practice
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€445m

20. Payments per GP
• Payment per GP up 31% since 2002
• Down 5.6% since 2008
• With new FEMPI cut, will be down 13.1% on 2008
GMS income before variable and fixed costs of each practice
Source: HSE, PCRS
$0
$20
$40
$60
$80
$100
$120
$140
$160
$180
$200
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
GMS Payments per GP (€000s)
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21. Payments per GMS patient
• Payment per eligible patient up 10% since 2002, down 26% since 2008
• With new FEMPI cut, will be down 33% since 2008
• A 33% efficiency gain? Pity we don’t also have output/outcomes data
• Free GP care for whole population would cost c.€600m more at this rate
• ESRI calculated non-medical card holder GP costs at c.€389-€479m, 2009
$0
$50
$100
$150
$200
$250
$300
$350
$400
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
GMS Payments per Medical Card Patient (€s)
Source: HSE, PCRS
GMS income before variable and fixed costs of each practice
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22. GMS Pharmacy payments
• Up 86% since 2002, down 5.2% since 2008
• With FEMPI cut €32m, will be down 12.7% since 2008
• But depends on volumes of prescriptions and pricing
• 1,690 GMS pharmacists 2011, up from 1,620 in 2008
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
GMS Pharmacy Fees and Mark-Up €m 2002-12
Sources: HSE, PCRS
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23. What do we get? What is
measured?
• Traditionally, basic activity/inputs
• # ‘contacts’: GP visits, out-of-hours consultations
• # people have medical cards etc
• # doctors work in teams
• What is paid to doctors
• Nothing that demonstrated the value of general practice
• Much more now measured in hospitals
• Some Primary Care Key Performance Indicators now in
place
• But do they demonstrate the value and outcomes of general
practice?
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24. HSE Key Performance Indicators
• In National Service Plan and Monthly Performance Reports
Supplementary Documents
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25. HSE - 7 KPIs in Primary Care
• Number of PCTs implementing the National Integrated Care Package for
Diabetes
• Number of Health & Social Care Networks in development
• Percentage of Operational Areas with community representation for Primary
Care Team and Network development
• No. of contacts with GP Out of Hours
• Primary Care Physiotherapy:
• no. of patients for whom a referral was received
• no. of patients seen for a first time assessment
• no. of face to face contacts / visits / appointments
• Primary Care Occupational therapy:
• no. of clients who received a direct service
• no. of clients for whom a referral was received
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26. 7 Main KPIs in Primary Care
• Orthodontics:
• no. of patients on the assessment waiting list
• waiting time from referral to assessment
• Number of patients on the treatment waiting list - Grade 4
• Waiting time from assessment to commencement of treatment – Grade 4
• Number of patients on the treatment waiting list - Grade 5
• Waiting time from assessment to commencement of treatment – Grade 5
• Number of patients receiving active treatment
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27. A data desert
• What do these KPIs tell us about, and help deliver from, General
Practice?
• Certain levels of team-organisation
• Activity levels out of hours
• …
• Clinical effectiveness of general practice?
• Cost efficiency / value for money of general practice?
• Evidence of best practice in action and for development?
• Nothing on effectiveness or value of General Practice
• Should other existing KPIs be associated directly with General Practice
• E.g. child and adult immunisation rates?
• A lot more to do
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28. OECD: can GPs help more?
• Indicators relating to long term conditions ‘which should be fully
managed in the community’ (hospital admissions rates can show
+/- performance of primary care)
• Asthma admissions
• Diabetes – incl. avoidable limb amputations
• Influenza Vaccinations for 65+, link to COPD Admissions rates
• Ireland: some of these are in HSE Acute Services KPIs, but not in
primary care
• Mental health indicators ?
• Data capture: e.g. Danish General Practice Database
• Information on 30 areas of general practice, made available to all
practices
• Depression, COPD, heart disease, diabetes, childhood and adult
vaccination, contraception etc
• Enables identification of patients being sub-optimally treated
• Comparisons with other practices
• Patient monitoring of own data
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29. Selected indicators - COPD
Source: OECD
Health at a Glance
2011
• Ireland worst on admission rate; could do much better on vaccinations
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30. Selected indicators - Diabetes
• Ireland good on prevalence and on admissions; could be better
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31. Asthma prevalence and
admissions
• As quoted in the HSE KPI metadata for Acute Hospitals
• Ireland could do better for women at the same prevalence rate
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32. Recommendations for
Denmark’s primary care
Source: OECD REVIEWS OF HEALTH CARE QUALITY: DENMARK, April 2013
• Setting a national vision for how the primary care sector should deliver seamless
and co-ordinated care, especially in light of increasing burden of long-term
conditions and a faster through-put in specialist care
• Bringing about a more transparent, formalised and verifiableprogramme of
continual professional development for all primary care practitioners, supported by
national standards, guidelines and time-limited financial incentives.
• Rewarding quality and continuity of the care that GPs provide, such as through
sharing of useful local experiences of successful integrated care
models, encouragement of group-based practice models, and piloting of advanced
nursing roles.
• Developing quality mechanisms – such as clinical guidelines and standards –
centered around patients with multiple chronic conditions and long-term care
needs, and the co-ordinating role of the general practitioner.
• Strengthening the information infrastructure underpinning quality in primary
care, for example by establishing a quality register for chronic care based in
primary care and by making better use of the DAK-E data capture system.
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33. Conclusions
• Seek to demonstrate not just assert effectiveness and efficiency of
General Practice
• Demand measurement, even when it shows under-performance
• Seek out and implement meaningful performance indicators for
General Practice on clinical quality and cost efficiency
• Avoid subsuming indicators into acute care or other areas of health
management
• Embrace ex-ante cost-effectiveness assessments
• Embrace new technologies and change in practice management
and clinical care
• Help move cost-reduction agenda to cost-effectiveness agenda
• Don’t just seek more inputs (more GPs, more money for GPs), but
more cost- and clinically-effective investment
• Expect HSE / insurers to be more demanding and discerning
purchasers of care – meet the challenge head on
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