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Performance payment for Family Doctors - follow up

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
Agris Koppel, Ain Aaviksoo, Gerli Paat
Health Policy Issues: 
Reform formerly reported in: 
Performance payment for Family Doctors
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein ja nein nein


In January 2006 a new payment policy for family physicians based on performance indicators was launched. 49% of family doctors have registered for monitoring of mostly prevention-oriented performance indicators during 2006 and are eligible for a bonus payment in 2007 if meeting the targets. There has been a remarkable increase (30-41%) in the number of prophylactic visits to family doctors during the first quarter of 2006, which is promising for the success of the whole policy.

Neue Entwicklungen

The main purpose of the idea is to promote individual family physicians to achieve preset service targets by rewarding bonus payments. It is the joint initiative of the Estonian National Health Insurance Fund (EHIF) and the Estonian Family Physicians' Association, the direct result of three years of discussions over opportunities and principles to increase family doctors' revenues. Implementation is carried out through a government-approved regulation on payment principles for primary healthcare (so called "price-list"); funding and technical administering is the responsibility of EHIF using its routine payment procedures.

The indicators for bonus payments are designed for measurement of the daily performance of family physicians and are prescribed in their working instructions set by Ministry of Social Affairs. The performance is evaluated in the three main areas: 1) activities toward prevention of diseases, 2) monitoring of chronically ill, 3) the effectiveness of treatment. According to current policy, the priority areas are vaccination coverage, screening procedures and chronic disease monitoring. Main target groups are children (0-18 years, for vaccination and regular check-ups), 31-50 and 51-65 years old population. Priority areas are vaccination, measurement of blood lipid and glucose levels, mammography (45-59 year old women), II type diabetes and high blood pressure patients; family doctors also have to perform certain simple surgical procedures and monitor normal pregnancy.

Family physicians are expected to receive up to 4000 EEK (255 EUR) monthly on top of their usual per capita payment for meeting the performance indicators. Expected outcomes of the policy are improved quality and effectiveness of preventive services, as well as better monitoring of chronic diseases. Specific outcome indicators have not yet been defined, but the aim is to reduce morbidity and hospitalisation rates. For family doctors the goal is to improve the motivation of better performing physicians.


Characteristics of this policy

Innovationsgrad traditionell recht innovativ innovativ
Kontroversität unumstritten unumstritten kontrovers
Strukturelle Wirkung marginal recht fundamental fundamental
Medienpräsenz sehr gering gering sehr hoch
Übertragbarkeit sehr systemabhängig recht systemabhängig systemneutral
current current   previous previous

All stakeholders are so far supportive towards the idea. The policy is innovative to the extent that it has not been implemented in too many countries so far, but even more due to its universal application to all family physicians. It would be the first real step towards outcome-based payment in Estonia, which makes its potential impact to the system remarkable. Public visibility is low or neutral; it depends on individual family physicians.


Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein ja nein nein

Initiators of idea/main actors

  • Regierung: Description of actors and their positions
  • Leistungserbringer: Description of actors and their positions
  • Kostenträger: Description of actors and their Influence

Stakeholder positions

Family doctors have been the initiators of the idea from the very beginning. However, the current plan is far from sufficient in the opinion of leaders of the professional society, as the financial reward for improved performance barely covers the costs that it imposes on doctors. Yet, as the principle is supported by family physicians, the official policy is to get the new policy running and then develop it further after first results are available.

The Ministry of Social Affairs (MoSA) has prepared the draft amendment to the Government Regulation showing also its relative commitment to the policy. The regulation is to be passed any time soon, as the first period of monitoring the performance is scheduled to start in January 2006, and first bonus payments in 2007 will be based on the results from the previous year. Still, implementation has been postponed already about a year due to reshuffled financial priorities toward hospital doctors' salaries in 2005. This shows that the policy is important but not the highest priority for the government if other stakeholders will make their case stronger than family physicians. The Health Insurance Fund (EHIF) supervisory board officially approved the policy in May 2005, but can only implement it after the Government Regulation is passed. As the policy is planned theoretically, but not with clear quantitative benchmarks, one can read some hesitation of EHIF from the financial impact that the policy will have - this has been acknowledged by all members. It seems that the payer (EHIF) relies more on professionalism than on financial motivation of family doctors in successful implementation of the policy. The first year is clearly seen as a pilot (though implemented throughout the country).
There is no formal policy paper regarding the bonus payment to family doctors. Main documents to refer to are the decision of the EHIF supervisory board and draft Government Regulation.

Actors and positions

Description of actors and their positions
Ministry of Social Affairssehr unterstützendunterstützend stark dagegen
Family doctorssehr unterstützendsehr unterstützend stark dagegen
Health Insurance Fundsehr unterstützendsehr unterstützend stark dagegen
current current   previous previous

Influences in policy making and legislation

The policy can be implemented through the Government Regulation that will introduce new "health service" - bonus payment for successful provision of preventive and chronic care monitoring tasks. The need for the Regulation arises from the fact that EHIF has no legal mandate to differentiating payment by quality, which is defined only through a certification process of providers and professionals by the Health Care Board. Practically EHIF can only decide upon reimbursing or not for a service in the "price-list", but can not apply a differentiated price, bonus payments or penalties for better or worse performance.
Draft amendment to the regulation is ready since February 2005.

Actors and influence

Description of actors and their influence

Ministry of Social Affairssehr großsehr groß kein
Family doctorssehr großgroß kein
Health Insurance Fundsehr großsehr groß kein
current current   previous previous
Family doctorsHealth Insurance FundMinistry of Social Affairs

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Main actors for the implementation are government, EHIF and family doctors. Indirectly the patients also have a role in the success or failure of the policy, but the assumption is that they are nevertheless eager to visit their doctor, be it for free vaccination, screening or chronic disease monitoring. Family physicians have to provide electronic reports about the achievement of performance indicators to EHIF once per year. It basically includes information on the subset of target group patients in the list and services provided to them. EHIF will then check the reports against its database of reimbursement claims that is generated dynamically on a monthly basis. Thus, both family physicians and EHIF must have appropriate IT-systems in place to monitor the performance. EHIF has openly stated that it needs to upgrade the information system to be able to implement the policy accordingly. All family doctors are using individual health information systems and forward reimbursement claims electronically since 1998. All upgrades, though, are on their responsibility and cost.

Monitoring and evaluation

EHIF would like to monitor the process, so it is likely that the evaluation process with appropriate indicators will be initiated. EHIF started to pay bonuses for the family physicians since July 2007 according to their performance based on the prevention of diseases, monitoring of the chronically ill and on the effectiveness of treatment. 500 physicians out of 800 applied for the performance payments based on the results from 2006. The total cost for EHIF for the year 2006 is expected to reach 8,2 mil. EEK (52 300EUR). The maximum payment for a family physician on top of the other performance related bonuses is 4000 EEK (255 EUR) per month. This year, only 9 physicians received the maximum amount and 21 physicians 80% (3200 EEK). In 2007, the number of family physicians who applied for the performance payments has decreased to 453 with 49 new entrants but also 96 physicians quit. The new data about the coverage of the services included in the list of performance indicators compared to all physicians show that there are several, but minor differences. For example, the vaccination of infants - 80% (78% for the whole group), medical examination of infants - 95% (94%), pre-school examination - 76% (65%). The coverage was the same in the case of SHV prevention (96%), PAP (52%) and MAM (56%). Also, the patients with II type diabetes (33%) and hypertonia arterialis (29%) share the same coverage rate.

Expected outcome

The policy is expected to prompt individual family physicians to achieve preset service targets by rewarding bonus payments. The overall goal is to improve coverage of preventive services to general population and monitoring of chronic diseases and reduce respective morbidity and hospitalisation rates. The policy has principal support of all stakeholders (doctors, government and insurance fund), but the final outcome is somewhat vague - no clear indicators for success or failure except the performance indicators per se. Family doctors expressed their scepticism towards the low financial input - both because of low reward and the lack of fee-for-service approach, which they would prefer. There is no baseline information regarding the current level of objectives of the policy under discussion. Hopefully there will be developed some measurable outcome targets, as EHIF has expressed its practical interest in it. It is unlikely that the policy will achieve major impact through its current implementation plan. Both the ability of family physicians to reach the benchmarks and their motivation to do so might be the obstacle, at least for the first year. An important outcome could be the first summary of the situation, i.e. a baseline description, and a better targeted and rewarded policy amendment after the first year pilot.

Impact of this policy

Qualität kaum Einfluss neutral starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering neutral sehr hoch
current current   previous previous

At the current phase it is difficult to judge upon the real impact of the policy. The implementation has not started yet, and the outcome indicators haven't been defined as of today.


Sources of Information

Estonian Health Insurance Fund annual report

Reform formerly reported in

Performance payment for Family Doctors
Process Stages: Umsetzung

Author/s and/or contributors to this survey

Agris Koppel, Ain Aaviksoo, Gerli Paat

Empfohlene Zitierweise für diesen Online-Artikel:

Agris Koppel, Ain Aaviksoo, Gerli Paat. "Performance payment for Family Doctors - follow up". Health Policy Monitor, 12/10/2007. Available at