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.
ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE SYSTEM.pptx
Â
National Association of GPs Presentation 20 July 2013
1. Health
Reform, Efficiency
and Quality
- how far yet to go?
Oliver OâConnor
ooc@sky.com
www.oliveroconnor.co
National Association of General Practitioners Conference
Portlaoise, 20 July 2013
www.oliveroconnor.co
1
2. Health Reform
⢠It goes on and on, a never-ending riverâŚ
⢠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
www.oliveroconnor.co
2
3. Health Reform â main themes
⢠What we do â activity and services by health staff
⢠What we get â the patient experience
⢠What we pay â public and private funding
⢠How we pay â tax, private insurance, out of pocket
⢠How we manage â health provider organisations
⢠How we govern â public and private law oversight
⢠How we perform â efficiency, outcomes
www.oliveroconnor.co
3
4. Health Reform â 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 â await new announcement â âfreeâ primary care
⢠Equal access to all hospital care â awaits eventual UHI
⢠What we pay
⢠Fiscal constraint. 20% cuts since 2008. No growth ahead.
⢠How we pay
⢠Universal Health Insurance: âbuilding blocksâ 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?
www.oliveroconnor.co
4
5. Health Reform â evaluation
⢠Ultimately, all to lead to Universal Health Insurance
⢠âBuilding blocksâ 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 â but more like a series of documents?
www.oliveroconnor.co
5
6. Health Reform â what aboutâŚ
⢠What we do
⢠How we perform
i.e.
⢠Clinical effectiveness
⢠Cost efficiency
delivering
⢠Best health status and outcomes at a reasonable cost
www.oliveroconnor.co
6
7. The Money: Health Spending
⢠HSE âŹ13.4bn net
⢠Most on primary and community service
⢠Insurance âŹ1.6bn
⢠Most on secondary, hospital-based services
⢠Private, out of pocket est âŹ2.5bn
⢠Most on primary services, drugs, elective
⢠Total âŹ17.5bn (est.)
⢠Most on primary or non-hospital services
⢠Do we get all we can for this?
⢠What gets measured? Gets attention?
www.oliveroconnor.co
7
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 âŹ14.16bn 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
www.oliveroconnor.co
8
9. Performance: life years
⢠Big increases at age 65+: most likely health service effect?
⢠Even in the four years of last decade
www.oliveroconnor.co
9
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
www.oliveroconnor.co
10
11. Measured improvements
⢠Deaths from diseases of circulatory system and heart down
Source: Dept of
Health, Health Key
Trends, 2012
www.oliveroconnor.co
11
12. Cancer catch-up still needed
⢠5 year survival improving but behind wealthiest EU countries
Source: Dept of
Health, Health Key
Trends, 2012
www.oliveroconnor.co
12
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
www.oliveroconnor.co
13
14. More efficient? Yes, butâŚ
⢠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
⢠âEfficiencyâ 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
www.oliveroconnor.co
14
15. OECDdevelopingprice/volumecomparisons
OECD, Joint session of the meetings of
Health Accounts Experts and Health Data
Correspondents, 11 October 2012
âExplaining differences in hospital expenditure across OECD
countries: the role of price and volume measures â
www.oliveroconnor.co
15
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 âŹ1=ÂŁ0.80
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
www.oliveroconnor.co
16
17. A look at GPsâŚ
⢠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
www.oliveroconnor.co
17
18. More GMS patients
⢠Up 58% since 2002
⢠Numbers up 37% since 2008
⢠April 2013 â 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)
www.oliveroconnor.co
18
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 âŹm
GP Fees âŹm
⢠Payments up âŹ201m, 71%, since 2002
⢠Up 1.7% since 2008 (down 3.4% since 2009)
⢠New FEMPI cut to make savings of âŹ38m (7.9% - 7.5%? stated)
Source: HSE, PCRS
GMS income before variable and fixed costs of each practice
www.oliveroconnor.co
19
âŹ445m
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 (âŹ000s)
www.oliveroconnor.co
20
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 donât also have output/outcomes data
⢠Free GP care for whole population would cost c.âŹ600m more at this rate
⢠ESRI calculated non-medical card holder GP costs at c.âŹ389-âŹ479m, 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 (âŹs)
Source: HSE, PCRS
GMS income before variable and fixed costs of each practice
www.oliveroconnor.co
21
22. GMS Pharmacy payments
⢠Up 86% since 2002, down 5.2% since 2008
⢠With FEMPI cut âŹ32m, 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 âŹm 2002-12
Sources: HSE, PCRS
www.oliveroconnor.co
22
23. What do we get? What is
measured?
⢠Traditionally, basic activity/inputs
⢠# âcontactsâ: 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?
www.oliveroconnor.co
23
24. HSE Key Performance Indicators
⢠In National Service Plan and Monthly Performance Reports
Supplementary Documents
www.oliveroconnor.co
24
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
www.oliveroconnor.co
25
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 â Grade 4
⢠Number of patients on the treatment waiting list - Grade 5
⢠Waiting time from assessment to commencement of treatment â Grade 5
⢠Number of patients receiving active treatment
www.oliveroconnor.co
26
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
⢠âŚ
⢠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
www.oliveroconnor.co
27
28. OECD: can GPs help more?
⢠Indicators relating to long term conditions âwhich should be fully
managed in the communityâ (hospital admissions rates can show
+/- performance of primary care)
⢠Asthma admissions
⢠Diabetes â 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
www.oliveroconnor.co
28
29. Selected indicators - COPD
Source: OECD
Health at a Glance
2011
⢠Ireland worst on admission rate; could do much better on vaccinations
www.oliveroconnor.co
29
30. Selected indicators - Diabetes
⢠Ireland good on prevalence and on admissions; could be better
www.oliveroconnor.co
30
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
www.oliveroconnor.co
31
32. Recommendations for
Denmarkâs 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 â such as clinical guidelines and standards â
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.
www.oliveroconnor.co
32
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
⢠Donât 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 â meet the challenge head on
www.oliveroconnor.co
33