The paradox between current models of Primary Care and evolving Evidence Based

Medicine concepts – International comparisons

William Behan

November 2014

National Primary Care Conference

Lyrath Estate, Kilkenny, Ireland

twitter@DrWilliamBehan

Health vs Healthcare Activity

WHO definition of HealthHealth is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1948)

Determinants of healthIncome and social status, Education, Gender,Physical environment, Social support, Genetics, Personal behaviour and coping, Health services - access and use of services that prevent and treat disease influences health

Health vs Healthcare Activity

Health industry related activities

Clinical: Acute and Chronic including long term care, Education, Research, Administrative, Pharma, Infrastructure Development, Insurance, Promotion/Public Relations, Legal (Defensive Medicine)

What does the payment model reward?

Marginal cost vs Marginal Benefit

Opportunity Cost: benefit, profit, or value of something that must be given up to acquire or achieve something else

Price vs Cost vs Value eg. Pandemic Influenza

Finite Budget – Good or Bad?

U.S. Hospital Administration Costs Exceed All Others by Far• 25 percent of total U.S. hospital spending = Administrative costs • Reducing U.S. spending for hospital administration to Scottish or

Canadian levels would have saved more than $150 billion in 2011

Monopolizing medicine: Why hospital consolidation may increase healthcare costs• Financial incentives in the current payment system: Same Doctor Visit,

Double the Cost: “Facility Fees”• Survey by American Medical Association: 58% of family physicians and

50% of internists are employees.Eg.: In 2011 Medicare spent €1.5 billion more on only two services alone: evaluation and management visits and ECHO fees due to changes alone

Professor Kaplan: Time-Driven Activity-Based Costing in Healthcare

Marc Jamoulle: Quaternary Prevention 1986Combine Narrative and Evidence Based Medicine

Marc Jamoulle: Quaternary Prevention 1986Combine Narrative and Evidence Based Medicine

Too Much Medicine Campaign, BMJ 2002 & 2013Highlight the threat to human health posed by over-diagnosis and the waste of resources on unnecessary care

Measuring Low-Value Care in Medicare JAMA 2014Australian Study:150 Potentially Low-Value Health Care Practices: Cervical & Prostate cancer screening in elderly. Back imaging for patients with low back painThe low-value services accounted for 0.6% to 2.7% of overall spending but these findings may be just the ‘tip of the ice berg’

General health checks don’t work Editorial: BMJ 2014;348:g3680

Screenings and Executive Physicals: Hazardous to Your Health JACC 2014

THE INVERSE CARE LAWJulian Tudor Hart 1971 Lancet• The availability of good medical care tends to vary inversely

with the need for it in the population served • Operates more completely where medical care is most

exposed to market forces, and less so where such exposure is reduced

• BMJ Editorial 2012: Doctor-patient relationship more adversely affected in deprived areas by the lack of time

Recent International Evidence Supporting Primary Care

2009 Annals of Family Medicine editorial; ‘The Paradox of Primary Care’

• “Different levels of analysis yield different views”• The Paradox of primary care is that primary care provides poorer quality

disease specific care but better overall patient outcomes and at lower costs compared to specialty care

2012 Barbara Starfields SESPAS ReportAdding 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%

2014 Annals Family Medicine editorial: ‘Health Is Primary: Family Medicine for America’s Health• 2007-11 Rhode Island increased primary care spending from

5.4% to 8.0%: 23% increase in primary care spending = 18% reduction in total spending:

• 15-fold return on investment. (Commonwealth Fund 6-fold)

BMJ 2014 Review 48 studies: • Seeing the same GP each time can reduce emergency

department attendance BMJ 2014;349:g4847

Recent International Evidence Supporting Primary Care

Small US Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions

Survey of 1,045 primary care practices found that:• Practices with three to nine physicians had 27 percent lower unnecessary

admission rates compared to larger practices• One or two doctor owned practices had 33% lower preventable hospital

admission rates than practices with 10 to 19 physicians• The largest practices had in place significantly more patient-centered

medical home processes which were not associated with lower rates of preventable hospital admissions

• Small practices have unmeasured characteristics that may contribute to their lower rates of preventable hospital admissions (Patient-staff relatnshp)

• Practices owned by physicians had significantly lower ambulatory care–sensitive admission rates than those owned by hospitals.

2001 Department of Health: Health strategy document ‘Primary Care; A New

Direction’ - 1978 Declaration of Alma Ata

2003 Brennan Report: health service administration & financial accountability

2003 the World Health Report “health systems with strong, integrated primary

care are associated with better outcomes probably because they provide for

more comprehensive, longitudinal and coordinated care”

2004 Irish College of General Practice attributes of primary care: personal, first

contact, continuous, comprehensive, co-ordinated, cost effective, high quality,

equitably distributed, community orientated & accountable (WONCA)

2014 – HSE/DoH ignores all recent evidence on what makes public health care

more equitable, cheaper and effective but refers to 1978 Alma Ata

Irish Health Policy Development Time Line

Quality of Healthcare in IrelandComparing the USA, UK and 17 Western countries' efficiency and effectiveness in reducing mortality 1979-2005: JRSM 2011First Ireland2nd UK17th USA

Perceived and reported access to the general practitioner: An international comparison of universal access and mixed private/public systemsK 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 ROISame 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%

Universal Health Insurance IrelandCosts?Cover current private budget = €5.5 billion + Excess administrative costs due to Kaplan style multipayer fee-per-item system: 10% €18.3 billion = €1.8 billionTotal = €7.3 billion

Who Pays?Ireland population: 4.6 millionNon-payers, current medical card patients: 1.92 millionNext 30% “nominal payment”: 1.38 millionBalance population to pay approx. €6 billion: 1.3 million= €4,600 per man, woman or child or €18,400 per family

Leadership skills

• Integrity/Fairness/Honesty

• Technical Competence/Understand program,

• True engagement with team (Arnstein’s Ladder)

• Vision/Creativity/Initiative => Proactive>Reactive

• Ability to Delegate

• Communicate: both transmitting and receiving information

• Commitment/Enthusiastic

• Open to Change

• Motivate/Team Builder/Enable members of group to grow

3.1 3.42.5

0

0.5

1

1.5

2

2.5

3

3.5

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K Lynchpredicted

figure

Gov. SurveyGMS 2 weekrecollection

Gov. SurveyPrivate 2

weekrecollection

UKQRESEARCH

Audit

IMJ GMSAudit

IMJ PrivateAudit

Lifeways2006 GMSUnder 5s

Audit

Lifeways2006 Private

Under 5sAudit

Under 6s attendance rate:Minister Kathleen Lynch Figures

3.1 3.42.5

6.5

0

1

2

3

4

5

6

7

K Lynchpredicted

figure

Gov. SurveyGMS 2 weekrecollection

Gov. SurveyPrivate 2

weekrecollection

UKQRESEARCHAudit Under

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IMJ GMSAudit Under

6s

IMJ PrivateAudit Under

6s

Lifeways2006 GMSUnder 5s

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Lifeways2006 Private

Under 5sAudit

Under 6s attendance rate: UK figures

3.1 3.42.5

6.5 6.6

5.1

0

1

2

3

4

5

6

7

K Lynchpredicted

figure

Gov. SurveyGMS 2 weekrecollection

Gov. SurveyPrivate 2

weekrecollection

UKQRESEARCHAudit Under

6s

IMJ GMSAudit Under

6s

IMJ PrivateAudit Under

6s

Lifeways2006 GMSUnder 5s

Audit

Lifeways2006 Private

Under 5sAudit

Under 6s attendance rate: NUIG figures

3.1 3.42.5

6.55.8

2.7

6.6

5.1

0

1

2

3

4

5

6

7

K Lynchpredicted

figure

Gov. SurveyGMS 2 weekrecollection

Gov. SurveyPrivate 2

weekrecollection

UKQRESEARCHAudit Under

6s

IMJ GMSAudit Under

6s

IMJ PrivateAudit Under

6s

Lifeways2006 GMSUnder 5s

Audit

Lifeways2006 Private

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Under 6s attendance rate: 2014 IMJ

What figures do you believe?

Individual Performance and Burnout• Satisfying work provides autonomy, complexity, and a

connection between effort and reward - Malcolm Gladwell• Should there be a relationship between the added value an

individual brings to an enterprise and remuneration?

Burnout• Cognitive, emotional and physical intensity of job (Good features also)• Patients poor access to resources/being deprived of their entitlements• Lack of association between national policy and best evidence based

practice• Politics/public service unions driving health care policy• Clinical leaders having to cede all authority to administrators• Lack of association between health care inputs and outputs

Burnout• Regulatory bodies confusing bureaucratic achievements/ adherence

with hospital based protocols with good primary care• Good work is penalised (particularly in US)• Unnecessary administration/bureaucratic barriers to fair payment• Hostile media• General Practice exposed to much greater financial cuts than public

service• Media/corporate healthcare influences on patients causing

inappropriate scaremongering.• Patients unrealistic perceptions• Constant weight of personal responsibility and public accountability• Dealing with uncertainty

Affect of Stress or Burnout on Performance: Science; 2013Being 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 alcoholicAnnals of Family Medicine; 2014Care of the Patient Requires Care of the Provider: The Triple Aim—enhancing patient experience, improving population health, and reducing costsBurnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs Burnout thus imperils the Triple Aim

The paradox between current models of Primary Care and evolving Evidence Based Medicine concepts US Model• Healthcare run by corporations• Total health spend: 16.2% GDP• 4% total health spend on general practice• Fee-per-item with heavy emphasis on administration not true outcomes• Focus on commoditising and fragmenting care• Activity generation is promoted by hospitals buying up primary care• Medicare / Health Maintenance Organisations policies promotes this by

paying more to GPs attached to hospitals• Outcomes: Profit• Most inefficient in the OECD

The paradox between current models of Primary Care and evolving Evidence Based Medicine concepts UK Model• Universal Entitlement• Total health spend: 8.9% GDP• 8% public spend or 7% total health spend on general practice• Very big GP practices – less continuity of care• Capitation payments > Fee-per-item• Focus political agenda primary care on consumer wants > needs• Massive burden of clinical & social care as well as administrative

activity• Rewarding easily measured outputs rather then true outcomes• High death rates

The paradox between current models of Primary Care and evolving Evidence Based Medicine concepts Irish Model• Oldest, Poorest & Sickest have Full Entitlement – Most Equitable• Total health spend: 8.5% GDP• 3.2% HSE spend or 2.5% total health spend is on GP• Possible total spend including private income 3.8% (Gov. data)• Smaller GP owned practices: more accessible, flexible,

innovative, personalised service & more continuity of care• GMS Capitation payments > Fee-per-item/Private Fee-per-item• General Practice is focused on consumer needs > wants• Massive drive to corporatise, increase bureaucracy, commoditise

and fragment care, removing clinicians from policy decisions

The paradox between current models of Primary Care and evolving Evidence Based Medicine

concepts – International comparisons

What Works WellSmall, 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 WorkLarge, 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

William Behan

twitter@DrWilliamBehan