Fundamental primary care reform

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

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Abstract

In April 2008 a primary health care development plan was released after two years of debates and preparation. The plan covers the years of 2007-2015 and foresees organising primary care services (integrated with some specialist and social care) in health centres which are built around a group of family doctors while part of the central purchasing role and regional responsibility for providing primary care services will be delegated to the new regional units.

Purpose of health policy or idea

Main objectives of the development plan are described as ensuring fair and good access, quality and efficiency of primary health care services. The goal is further described by using three WHO measures for health systems: good health outcomes, customer satisfaction and protection from financial risks.

Main points

Main objectives

• Access
• Quality
• Effectiveness
• Fairness

Type of incentives

It is an ambitious, comprehensive and long-term reform plan where all potential levers (financing, payment, regulations, organisation and behaviour) for steering are to be used.

Groups affected

As the policy will fundamentally re-shape primary care organisation and financing principles, a broad range of professionals will be affected, including family doctors and primary care nurses,, the plan will also affect other specialists working at the primary care level (e.g. physiotherapists, pharmacists, occupational health physicians, social workers etc). The policy has a remarkable effect on patients, but also on the Health Insurance Fund.

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

Political and economic background

The reform of primary care began in 1991 with the aim of developing a family medicine centred PHC system and establishing family medicine as a medical specialty. In 1992, respecialization courses for family practitioners started in the University of Tartu. In 1993, family medicine was designated and recognized as a medical specialty. By the end of 2001, 557 family doctors had a diploma in family medicine, and by 2003, the number of family doctors was ca 800, sufficient to cover most of the population.

In 1998, reforms introduced a new legal status for family doctors (as independent contractors) and a change of the payment system from fee-for-service to a mix of capitation, fee-for-service and additional allowances. The new system was intended to support the family doctors' gate-keeping role and ensure continuity of care.

The Estonian network of family medicine covers the whole country and provides good geographical accessibility. Patients consider the family medicine service quality to be good - 91% of the population has expressed their satisfaction. Family medicine is guaranteed to those who have health insurance but those without do not have an equal access. The number of prophylactic visits to family doctors is increasing from year to year, both with respect to the patients in the practice list and per practitioner.

In 2007 a performance payment system for family doctors was introduced (see HPM report 9/2007 and 6/2005). Expected outcomes of the policy are improved quality and effectiveness of preventive services, as well as better monitoring of chronic diseases. Currently, 61% of family doctors have joined with the system and are eligible for bonus payments. However the feedback from practitioners is mixed as the introduction of the system has increased the workload of the family doctors and the financial gain is relatively small.

A serious issue on the level of primary health care is the absence of a sole institution which is responsible for the planning, organization, and supervision of primary medical care. As a result, the responsibilities are dispersed among several institutions; there exists an ambiguity about the co-ordination of actions and allocation of resources. The responsibilities are shared with the County Government, EHIF, Health Care Board and MoSA.

The Health Service Organization Act set the legal form for practising as family doctor. According to this act, family doctors are private owners and may practise as private entrepreneurs or found companies providing PHC. The latter may merge only with other companies providing PHC, and may not be partners or shareholders of companies providing specialised medical care. As a result of a 2008 amendment of the Health Service Organization Act, the local government can act as a partner and shareholder of a company providing PHC. The range of activity of family doctors is defined by law as providing PHC, nursing care, social services, and teaching and scientific research in health care. Nursing care has been included since January 2008 with the aim to expand the activities preformed by the PHC team.

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

The development of the concept of primary care started in 2006. The feeling was that primary health care is defined too narrowly and that there is poor integration with social and specialist care. A broad working group summoned by the Ministry of Social Affairs has been discussing the draft document for over a year. Yet, it has been difficult to reach consensus and get the policy formally accepted. At the current stage the purpose has been to define primary care and develop a concept for it that assures the increasing role of primary care in the improvement of population health.

 Approach of idea

Independent providers will continue providing a wide range of services (including social, mental and occupational health and nursing services on top of family medicine) in the current form of operation (single, group or polyclinic type practices).

Two new institutional forms will be established. First, health centres (46-184 for the country) are the primary entry point for citizens. These centres will be formed around current family physician practices with adjacent services. The centres will take up territorial responsibility for a wide range of services. The policy supports the idea that health centres will share resources and work in close cooperation with current small general hospitals.

The second new institution will be a regional coordinating unit at county (15) level (average size 40 000 inhabitants) plus two more for the largest cities Tallinn and Tartu. Coordinating units will bear full territorial responsibility to provide all services as defined necessary at primary care level. They will contract the health centres or directly individual service providers. Legal essence of these regional coordinating units has not been clearly defined. Multiple legal forms ranging from a single cooperative business entity to voluntary network of independent providers is articulated in the draft policy paper.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

• MoSA
• Association of Family doctors
• Health Insurance Fund
• Emergency services doctors
• Hospitals

Stakeholder positions are difficult to describe, as systematic analysis is not available. The strategy development process has been relatively long (over 2 years), but has mostly taken place within a dedicated working group. Broader debate has started only recently. Most spokespersons have supported the strategy, because otherwise there wouldn't be any plan. Real attitudes will probably be revealed once the implementation process starts.

MoSA  as the initiator of the policy is very satisfied with the results so far. MoSA is responsible for development and implementation of the co-oordination system (incl change in regulations).

EHIF, the main source of financing, is very interested in the reform of primary care. However, they do not really support this particular strategy, which according to EHIFis not fully worked out.

The association of Family doctors is also an important stakeholder group, but their position is not yet fully formed. Leading professionals are fairly supportive, but it may be because they bear part of the responsibility for the delayed process. It seems like there is no broad consensus. Main concerns are the financing of the strategy and the looming lack of personnel to implement it.

Patients have not been involved, as the Ministry of Social Affairs expects no big changes to happen for them. This is also partly due to fact that the Estonian Patient Advocacy Association is lacking the capacity to participate in this kind of policy development process. It has declared its main strategic role in "locating and highlighting the issues and problems in health service through patients complaints and informing service provider and legislative organs."

Actors and positions

Regierung
Minister of Social Affairs	sehr unterstützend		stark dagegen
Leistungserbringer
Association of Family doctors	sehr unterstützend		stark dagegen
Emergency services doctors	sehr unterstützend		stark dagegen
Hospitals	sehr unterstützend		stark dagegen
Kostenträger
Health Insurance Fund	sehr unterstützend		stark dagegen

Influences in policy making and legislation

Primary health care is currently defined as primary medical care with services rendered by family doctors and nurses. There are laid down general requirements for accessibility and quality of primary medical care and it is prohibited for primary care institutions to provide other services than primary care. In 2007 a change in law was passed which allowed local government units to become an owner of the provider of primary medical care. This change is expected to tighten the links of medical care services with other social services which are financed from the budgets of local governments.

Actors and influence

Regierung
Minister of Social Affairs	sehr groß		kein
Leistungserbringer
Association of Family doctors	sehr groß		kein
Emergency services doctors	sehr groß		kein
Hospitals	sehr groß		kein
Kostenträger
Health Insurance Fund	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

Currently the proposal is in a draft status. Once adopted by the MoSA, it is expected that some feasibility studies and legal audit will be conducted within 2008. First implementation acts are expected in 2009.

In the concept the organisation is described as follows: local co-ordination centres with territorial responsibilities are introduced. The main task of these centres is to assure a balanced development of the health services, their accessibility and quality.

Independent providers of health care services are expected to collaborate. The collaboration or even mergers should be undertaken only on a voluntary basis by agreements on partnership or formation of new legal entities.

According to the plan, primary health care services are accessible to patients close to their place of residence by the year of 2015 provided by the family doctor and his team and with the collaboration of other health care services providers in the network.

Monitoring and evaluation

There has not yet been a decision on details of the evaluation process. The general indicators for monitoring of the policy are as follows.

General indicators:

• The number of patients switching their family doctor will decrease to 9% in 2015 (in 2006 it was 11%)
• In the year 2015 93% of the population are still fairly satisfied or very satisfied with their family doctor

Accessibility indicators:

• The share of patients admitted to the reception on the first day (with acute illness) is still 42% in 2015.
• The share of patients admitted to the reception in 3 days is 90% (80% in 2006).
• In 2015 the share of population without access to general medical care is 0% (5% in 2006)

Quality indicators:

• The number and percentage of cases handled by the expert committee on the quality of health care will remain unchanged by 2015 or decreases compared to 2006 (17%)
• The number and percentage of negative cases identified by the expert committee on the quality of health care will remain unchanged by 2015 or decreases compared to 2006 (31%)

Efficiency indicators:

• The share of patients directed to the medical specialist by family physicians is 10%.
• The average number of visits per patient (3,6) will remain the same in year 2015 compared to 2006.
• The share of primary health care financing will increase to 13% by 2015 (7,5% of the total costs to health care).
• The eHealth project is implemented in primary health care services.

Expected outcome

Impact of this policy

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

If the strategy will be implemented as foreseen, the impact will be fundamental. So far primary health care in Estonia has been seen as mostly the activity of family physicians. Formally networking of primary care with other services will be a remarkable change. The designers of the plan see the gratest challenge in maintaing access to services at the current (2006) level if small health centers are favored.

Similar to hospital reforms the plan depends on good investment and financing. While hospital reform was supported by a generous 15% annual increase in the Health Insurance Fund Budget since 2001, it is still lacking investments of 1.5 times of the Health Insurance Fund annual budget and olny a fifth of that amount is contributed by the state. The looming economic slowdown will not be favourable to any big reform plans in healthcare, and so far hospitals have been able to position themselves better than other providers.

Thus, currently experts consider an implementation of the current draft plan in near future to be unlikely. However, minor changes toward the expected goal will probably take place. This may change if the economic situation dramatically improves and the political will to implement this reform becomes stronger.

References

Author/s and/or contributors to this survey

Aaviksoo, Ain and Gerli Paat

Empfohlene Zitierweise für diesen Online-Artikel:

Aaviksoo, Ain and Gerli Paat. "Fundamental primary care reform". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/ee/a11/4