Payment pilots in primary care group practices

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

Abstract

The current government has committed to the development of new practice structures in primary care which will give more emphasis to prevention and care coordination. The 2007 Social Security Financing Bill scheduled a period of five years from January 2008 for experimentation with supplementary or substitutive remuneration schemes to fee for service in primary care. Group practices will choose among different remuneration packages for providing specific healthcare services.

Purpose of health policy or idea

The objective of this experimentation is to find an effective way of funding group practice in primary care to help them to become an important mode of practice in France.

Compared with traditional (solo) general practice, group practice is considered a means of ensuring good quality healthcare services throughout the country whilst improving the efficiency of care provision and health professionals' working conditions.

Group practices offer also a better work-life balance between private and professional life especially for the youngest generations of general practitioners. Despite the existence of group practice on the territory for many years, their take off has been slow in France and there is still a dominance of solo practice. In 2002, less than 40 percent of the GPs worked in group practice and their distribution was very unequal over the territory.

Different primary care structures are created through different institutional frameworks and payment schemes. Multidisciplinary Health Houses (MHHs) refer to group practice structures in which self-employed medical and paramedical health professionals are united in a single, dedicated practice. Health Care Centres (HCCs) are multidisciplinary group practices, mainly oriented to primary care but they could include specialist services.

The activity of doctors and other healthcare professionals in the ambulatory sector is paid generally on an individual fee-for-service basis. In solo or multidisciplinary private group practices doctors directly receive the fee. In Health Care Centres, professionals are paid by salary, even if the main financial resources of the HCCs are based on fee-for-services for their medical activities. Thus the work in group is not particularly enhanced.

In this context, fee-for-service is perceived as a barrier for developing coordination and cooperation in group practices.

The PLFSS 2007 has underlined the importance of experimenting with new modes of remunerating health professionals working in group practice with the objective of transforming the existing skill-mix in primary care by introducing new remuneration models pooling human resources from different disciplines.

Primary care structures (MHHs and HCCs) aim to improve the management of chronic diseases and the effectiveness of the care delivery by shifting the focus from curative care for acute conditions towards preventive services and care coordination. They also improve accessibility (with longer opening hours), try to provide efficient cooperation between professionals (in particular between general practitioners and nurses) and comprehensive care supply.

The development of MHHs and more broadly team work in primary care setting is one of the main objectives declared by the government in order to achieve ambulatory, hospital and social care integration.

The Social Security Financing Bill of 2007 (article 44 of the PLFSS 2007) scheduled an experimentation of new financing schemes in six regions (Bourgogne, Bretagne, Franche- Comté, Ile de France, Lorraine, Rhône-Alpes) with 52 group practices eligible (27 HCCs, 21 MHHs, 4 networks) and 33 group practices effectively enrolled at this time on a voluntary basis (20 HCC, 10 MHH, 3 networks).

Four different options of financing are proposed to these structures:

Option 1: A global envelope (covering the cost for coordination) initially based on the size of GP's patient list and on the number of health care professionals. For the following years the global envelope will be adjusted on performance achievement.

Option 2: Specific (extra) payments for selected new services (such as counselling chronic patients) for which the amount is initially based on the number of patients included in the program.

Option 3: Specific (extra) payments for professional cooperation.

Option 4: Diagnostic related group payment.

In November 2009, only the first two options were sufficiently advanced.

The first option proposes to keep the fee-for-service payment for the doctors and other health professionals and supplement this with a global envelope which will cover all the charges related to the coordinated activity. The payment will depend on the achievement of the 14 outcomes related to quality of care, effective professional/care coordination and efficiency measured by 27 indicators such as the rate of breast cancer screening among women between 50 and 74 years of age or the rate of diabetic patients having three HbA1c measure per year, etc. These indicators are currently being validated by the French High Authority of Health, HAS.

There is also a specific budget, which is designed by regional health authorities for local health needs. For example health promotion actions toward children at school.

The second option provides specific funding for education of patients with chronic diseases. This is a fixed budget (adjusted with the volume of patient treated) for patients with selected chronic illnesses such as heart failure, COPD, diabetes, asthma. 

This option (funding) could be complementary to the first option. The primary care structures can choose one or the other option or both.

The options 3 and 4 are still being developed. 

Main points

Main objectives

The main objective is to improve the quality and efficiency of care provided in these structures by encouraging collaboration among health practitioners and better coordination of ambulatory, hospital and long term care; and to improve the attractiveness of primary care practice for professionals.

The aim is to find new flexible and simpler solutions, beyond the traditional fee-for-service system, to finance multidisciplinary health houses and health centres valuing clinical performance of practitioners (physicians, nurses, physical therapists), and their engagement in preventive care practices (chronic care, screenings, counselling to chronic patients).

Groups affected

General practitioners, nurses, physical therapists, specialists, Regional Health Agencies, National Sickness Fund, Government, patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

Group practice represents still a marginal form of organization in France despite the growing number of MHHs (180 new projects). Moreover, the way they are financed and function varies widely. Certain MHHs receive subsidies for investment and/or running costs from a variety of sources such as the European Union, the Government, National Health Insurance or regional funds. Others run entirely with private funding. HCCs receive subsidies from municipalities (one quarter of their budget on average).

Recently the 2007 Social Security Financing Bill underlined the importance of multidisciplinary health houses alongside the traditional health centres in the experimentation of new modes of remunerating health professionals.

In the French healthcare system where fee-for-service is the major way of remuneration for structures or for physicians, nurses and physiotherapists in ambulatory sector, it is necessary to conceive a method of financing which will value clinical practice of group beside the incentives given for sharing administrative or structural costs. This juridical frame needs adaptations that will permit a new flexible scheme of payments for practitioners working as a group practice. Regional Health Authorities (created by the latest reform of regional health governance) will be in charge of defining a regional plan for ambulatory care and will be able to contract with multidisciplinary group practices. They will  be in charge of verifying the adequacy of projects taking into account specific healthcare needs in the territory concerned and approving the projects according to the law on new regional governance (21 July 2009).

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Health administrators, general practitioners, and some experts have strongly supported the pilot projects experimenting new methods of remuneration for group practices. The preliminary evaluation of Multidisciplinary Health Houses in two regions (Franche-Comté and Bourgogne), carried out at the request of national Sickness Fund,  has shown that the results in terms of accessibility, inter-professional cooperation and range of medical care services available in these structures were improved.

The purpose is to extend these experimentations to other regions in France, in remote rural areas and deprived suburbs.

Initiators of idea/main actors

• Government

• Providers

• Payers

Approach of idea

The approach of the idea is described as:
new: Providing specific funds for professionals is not a new strategy but financing them through the group practice is new.

Innovation or pilot project

Stakeholder positions

The experimentation initiated by the Government has been strongly supported by the GP unions. Position of National Sickness Fund appears to be neutral at the moment while there is a strong opposition from medical specialists, still anchored to a fee-for-service practice.

Actors and positions

Government
Government	very supportive		strongly opposed
Regional Health Authorities	very supportive		strongly opposed
Providers
Unions of General Practitioners	very supportive		strongly opposed
Unions of Specialists	very supportive		strongly opposed
Payers
National Sickness Fund	very supportive		strongly opposed

Influences in policy making and legislation

This experimentation is designed to be easily extended in other regions of France after the pilot project. It offers the possibility to group practices to handle for the first time a global budget for ambulatory care, without being dependent on short term experimental funds.

Actors and influence

Government
Government	very strong		none
Regional Health Authorities	very strong		none
Providers
Unions of General Practitioners	very strong		none
Unions of Specialists	very strong		none
Payers
National Sickness Fund	very strong		none

Positions and Influences at a glance

Monitoring and evaluation

The cost-effectiveness of these pilots (evolution of prescription drugs, expenditure on medication and complementary exams, emergency hospital visits, etc.) will be evaluated by different studies. A pilot group including all stakeholders (professionals, the National Sickness Fund and health administration) will supervise these studies.

Dimensions of evaluation

Process, Outcome, Structure

Results of evaluation

The evaluation of this experimentation is currently running by a multidisciplinary team of researchers in primary care (www.irdes.fr/EspaceRecherche/Partenariats/Prospere/index.htm). However, between 2007/2008 a study was carried out in two regions (Franche-Comté and Bourgogne) for evaluating the quality and efficiency of care in multidisciplinary health houses. This study was initiated by the Health insurance fund and conducted by IRDES, the regional unions of Insurance Funds and federations of Health Houses.

The results showed that these structures, compared with traditional general medical practice, present certain advantages: greater accessibility due to longer opening hours, efficient cooperation between professional and more extensive care supply. A specific analysis carried out among type 2 diabetes patients demonstrated that overall, they benefit from better follow-up care management when their GP practiced in a health house compared to those with a GP in a control zone. On average, the total expenditure and general medicine expenditures were 2 percent higher for those patients followed up in a health house, while pharmaceutical (-5%) and nursing care (-8%) expenditures were lower. However, there were wide variations between different structures both in terms of cost-efficiency and care quality. For example, in most structures the patient expenditures for prescribed drugs and nursing care were significantly lower (17 to 30%) compared with those patients in the control zone, but in a few others either there was no difference or the expenditures were actually higher.

The relation between efficiency, quality and modes of payment is not known.

Expected outcome

The pilot projects (experimentation) will help to achieve some rationalization in new ways of remuneration for group practices. However, it is not clear how and to what extent the results will help to standardise the remuneration for group practice in France. The Health Administration prioritized a bottom-up approach engaging health professionals working in group practice in the experimentation and thus accepted that the contracts vary locally. This compromise challenges the evaluation results. 

 

 

 

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

Le bilan des maisons et pôles de santé et les proposition pour leur déploiement: www.sante-jeunesse-sports.gouv.fr/IMG/pdf/rapport_maison_de_sante.pdf

PLFSS. Projet de loi de financement de la Sécurité sociale 2007. Available at www.securite-sociale.fr/chiffres/lfss/lfss2007/lfss2007.htm

Or, Zeynep. "Update on new regional health governance". Health Policy Monitor, October 2009. Available at www.hpm.org/survey/fr/a14/2

Les maisons de santé: une solution d'avenir? Société française de Santé Publique ,suppl n°4 Santé Publique , La Revue, 2009

Bourgueil et al. (2009)"An exploratory evaluation of Multidisciplinary Health Houses in Franche-Comté and Burgundy"Irdes, Questions d'économie de la santé n°147, Octobre www.irdes.fr/EspaceRecherche/Qes2009.html#n147 

Reform formerly reported in

Hospital payment reform Process Stages: Implementation

Author/s and/or contributors to this survey

Luciano Lorenza, Julien Mousques, Yann Bourgueil

The current government has committed to the development of new practice structures in primary care which will give more emphasis to prevention and care coordination.

The 2007 Social Security Financing Bill has scheduled a period of five years since January 2008 for experimentation with supplementary or substitutive remuneration schemes to fee for service in primary care. Group practices in six regions are asked to choose among different modes of remuneration packages for providing specific healthcare services.

Suggested citation for this online article

Luciano Lorenza, Julien Mousques, Yann Bourgueil. "Payment pilots in primary care group practices". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/fr/a15/2