creating an integrated health care system in greece: a primary care perspective

P1: IZO

Journal of Medical Systems [joms] pp1277-joms-490328 September 18, 2004 16:2 Style file version June 5th, 2002

Journal of Medical Systems, Vol. 28, No. 6, December 2004 ( C© 2004)

Creating an Integrated Health Care System in Greece:A Primary Care Perspective

K. Souliotis1,3 and C. Lionis2

Over the past few years Greece has undergone several endeavors, aimed at moderniz-ing and improving the national health care services. A Health Care Reform Act seekingquality improvement and coordination of outpatient and hospital services at the Re-gional level, through the enhancement of primary care, has been recently approved.This paper reports a proposal for integrated health system in the primary care sys-tem in Greece with a major focus on equity, quality, and outcomes. The equity andquality framework of this proposal will possess the main components focusing on theprovision of essential services, clinical, and organizational standards.

KEY WORDS: health policy; primary health care; integrated health care; personal doctor; Greece.

INTRODUCTION

Over the last few years, Greece has undergone several endeavors to modernizeand improve national health services. A Health Care Reform seeking quality im-provement and coordination of outpatient and hospital services at the regional level,through the enhancement of Primary Care (PC), has been recently approved.(1) Thislatest Health Act strives to improve the quality of care throughout the implemen-tation of Regional Health Systems (RHS). Although several endeavors were madeto develop an effective PC in Greece, there are still many concerns and it remainsa question whether the new Health Care Reform could possibly develop a unifiedframework accountable continually by all citizens in the near future.

The Greek Minister of Health and Welfare addressed an invitation to a smallgroup of experts and academics with the main task of the committee being to reviewthe situation and suggest effective changes in the current system. In the frameworkof this Committee, the two authors made a proposal, and part of this proposal wasinitially published in a Greek medical journal.(2)

1Ministry of Health and Welfare, National School of Public Health, Athens, Greece.2University of Crete, The Regional Health and Welfare System of Crete, Greece.3To whom correspondence should be addressed at 5, 28th October Street, 124 61, Haidari, Athens, Greece;e-mail: [email protected].

643

0148-5598/04/1200-0643/0 C© 2004 Springer Science+Business Media, Inc.

P1: IZO


644 Souliotis and Lionis

The present report outlines briefly the existing PHC situation in Greece and itsfunding framework, with the aim to illustrate to an international readership not onlystrengths and weaknesses, but to outline a theoretical model of an integrated healthsystem based on strategic alliances while attempting to develop an inexpensive pro-posal in improving the PC quality, and develop services with an explicit accountabilityto meeting the health needs of their local communities.

Primary Care in Greece: Infrastructure and Services

As far as public infrastructure is concerned, production and distribution of careare accomplished primarily via a “network” consisting of approximately 200 NationalHealth Service (NHS) health centers that are serving semiurban and rural areas, andapproximately 250 Social Security Institution (SSI) polyclinics mostly in urban areas.PC centers in rural areas are accountable for curative and preventive services for allpeople living in their catchment areas and they serve their visitors in both, health carecenter, a central station, that is staffed by GPs and internists, nurses, and lab assistants,and other health and administrative personnel, and satellite practice staffed by onephysician, usually a GP.

The SSI is the largest insurance organization in Greece and represents approxi-mately 55% of the insured population. It is considered that this informal “network” inmost cases enjoys a rational planning distribution, good density of medical personnel,and satisfactory technological level. The PC units of the SSI, cover the insured pop-ulation of the SSI for primary medical care and diagnostic services. They are staffedwith about 7500 doctors of almost all specialties, 4000 nurses, and other health carepersonnel. Most of the doctors are part-time salaried employees, who simultaneouslymaintain their private practices.(3)

That sector portion of the insured population belonging to the insurance fundswithout their own health services is covered by way of contracts with private schemesand private physicians, but without ensuring the adequacy and the quality of services,while insufficient provisions for prevention and health promotion and for posthos-pitalization care. Of course these conditions are also noted in the realm of publicproviders.

This gap in state production of PC services is due not only to a lack of fundsas to their limited temporal availability to the public. This fact together with thepossibility of public funding by way of contracts with the various insurance fundsresulted in pronounced investment activity by the private sector in outpatient carethrough the establishment of private diagnostic centers, now numbering over 400throughout Greece.(4)

Primary Care in Greece: The Existing Funding Framework

The funding framework governing the functioning of the health sector in Greeceover the last years has been characterized by a continual increase in health expen-diture. Recent research, show that total health expenditure in Greece reached 9.1%of GDP in 2000, of which 42% was private spending.(5) Indeed, given the limitedacceptance by the public insurance coverage through private health schemes, the

P1: IZO


Creating an Integrated Health Care System in Greece 645

greatest share of funding is related to out of pocket payments that burden personaland family income.(4,5) According to recent estimates the average amount spent byhouseholds in Greece on a yearly basis for PHC services, whether supplementary orin addition to their insurance coverage, is 2.45 million euros, or approximately 28%of the total (public and private) expenditures for health.(5)

The above factors exist as part of the wider environment in which funding bysocial insurance has been limited over the last years, resulting in that it is now con-sidered to be inadequate to completely cover the population’s needs. In addition,the ability of the state budget to subsidize reform endeavors in the health sectoris considered to be limited. Also, the continuation—or the result—of recent years’policies which were fashioned in the environment of the fiscal limitations imposedby the country’s efforts at joining the Economic and Monetary Union.

Primary Care in Greece: Some Achievements and Concerns

Regarding the provision of PC in Greece the current situation has been ana-lyzed in a number of reports that have brought attention to the factors that define itnegatively. These include, inter alia:(6−8)

• The exclusive involvement of General/Family Physicians (G/F) and primary-care physicians in curative activities and their absorption in dispensing ofprescriptions

• The failure of these practitioners to use clinical guidelines and other standardsfor best practice

• Their small contribution to providing home care• The lack of experience from community based programs and interventions

aimed at diseases’ prevention and health promotion• Their failure to diagnose mental disorders and other illnesses

On the other hand it appears that the GPs and PC physicians are capable inmanaging effectively some clinical and health-related conditions and specifically:

(a) Use suitable instruments in assessing for diagnosing dementia(9,10) and dep-ression,(9) and making early diagnosis of treatable conditions and diseases

(b) Assess the vaccination coverage of schoolchildren and high-risk individuals,and administrate these vaccinations(11,12)

(c) Follow practical guidelines for diagnosing bronchial asthma and hepatitisC,(13) and effectively use these guidelines in the therapeutic management oftheir patients

(d) Carry screening programs for specific chronic diseases and follow-up high-risk groups

(e) Manage emergency cases and deal effectively with most of these.(14)

Several suggestions for the further development of General/Family Medicineand PC in Greece have been recently outlined.

P1: IZO



A Debate for a Unified Primary Care System

The discussion about an intergrated PC system is not new, but currently animportant debate has evolved, with a focus on the quality improvement of PC services.

SSI’s existing structures in urban centers, which in many political and scientificapproaches are treated negatively regarding reform endeavors, could be the founda-tion upon which to construct a new PC system. In line with this reasoning proposalswere presented for the development of an administratively and organically unifiedsystem for providing PC, with the basic precondition that the SSI structures relin-quish their autonomy and become part of the National Health System. This proposalis supplemented by indication of the need to create a unified funding base as theprerequisite for the reasonable utilization of available funds.

The first criticism to be made of the above positions is that the subordination—atleast in the first phase—of SSI’s structures to the NHS, may create problems rang-ing from the establishment of ownership framework and use of production means,to the regulation of physicians’ employment status, in addition, the administrativecost of the transition is expected to be high. Beyond this, it is extremely uncertainwhether such a primarily administrative intervention in the system will produce tan-gible results in terms of adequacy and quality of services that could be perceived bythe users in the short term. As far as pooling of resources under one administrativeentity is concerned, the effectiveness of the intervention as outlined using the ratio-nale of high degree of representation and creation of surpluses in negotiations withproducers, is controlled given that entities such as SSI already have a high degree ofrepresentation, which within the existing institutional framework (pre-establishedprices and products) does not allow for contractual grounds as a foundation fornegotiation.

As a continuation of the above speculations, it is noted that the final form of anyreform proposal is called upon to answer the following questions:

• Is it possible to apply an integrated system for PC?• What is the number of general practitioners and other primary care physi-

cians required to serve the needs of such a system, and what is the timeframerequired to produce this number?

• Is it possible to develop a legislative base based on the personal physician,and what is the adequate package of services to be provided to the insuredpopulation and individuals it is obliged to cover?

• To what extent an ideological and domain consensus is required before anyintervention?

The above issues require investigation and clarification before any interventionis attempted. At the center of speculation is the question of how much the prospectof administrative reorganization is the only path for PC health reform in Greece, andto what degree it can be guaranteed that the quality of care offered will be better“the day after.”

P1: IZO



CREATING AN INTEGRATED HEALTH SYSTEM IN THE GREEKPRIMARY CARE

The basic presupposition in the proposal creation of an integrated health systemin PHC in Greece is that the State is required to be the guarantor of an adequate pack-age of health services, while also ensuring their continuation in terms of follow-up.

On the other hand, this choice has an ideological and technical foundation re-garding administrative intervention that is the unification goal of health services,beyond the fact that it meets political, social, and economic obstacles, not offeringreason based on the criteria of equity, effectiveness, and efficiency.

The system suggested in the context of the present proposal must satisfy theprinciples set out below:(2,15,16)

(a) Continuity of care, allowing for the management of acute and chronic healthproblems by the same physician or health team across time

(b) Integrated and coordinated care that is management of the most commondiseases and health problems as well as major risk factors, in the patient’sown social, cultural, and psychological environment, through the intersec-tional collaboration meeting the patient’s care needs at local level.

(c) Patient, and their families, focused care coordinated with appropriate refer-ral and movement of patients through the system.

In such a system the role of the personal physician is also considered to be acentralized one. The personal physician must be defined by his duties that are hisobligations to provide the adequate health-care package to all of the system’s ben-eficiaries, including management of the most common diseases in the community,the major risk factors, immunizations, and services involving social care and reha-bilitation. This personal physician can preferably be specialized in General/FamilyMedicine, or failing this, another clinical specialty enabling him to fulfill his duties aspreviously outlined. Intensive training in the use of clinical protocols and basic skillsforeseen by the adequate health care package must be carried out prior to his inte-gration into the system. The time required to complete such an accelerated trainingprogram is estimated at one (1) month. Intensive on-the-job training following hisemployment should also be provided.(17)

The referral process is a central point in the system we propose to examine.The personal physician should be the one to assume the responsibility for referringpatients to other specialists or other health services. It is proposed that in the firstphase bypassing the procedures should not involve patient participation in cost, butrather should be the opportunity to promote the expediency and usefulness of thepersonal physician as an institution.

Another new element of the proposed systems is the introduction of auditingof the personal physician’s clinical effectiveness. Several methods could be used inmeasuring the personal doctor’s clinical effectiveness mainly through the establish-ment of a contract with binding provisions concerning the package of care offered(Table I).

It is emphasized that without ensuring such a “package” of services that clearlyinclude management of major risk factors and clinical assessment of the health status

P1: IZO



Table I. Package of Services to Be Offered by the Personal Physician to Each User of the System

1. Management of the most common diseases and health problems faced in PC based on the localepidemiological model including Arterial Hypertension, non-insulin-dependent Diabetes, BronchialAsthma, Chronic Obstructive Pulmonary Disease, Cardiac Insufficiency, Coronary Disease,Degenerative Bone Disease, Osteoporosis, infections common in the community, senility, majordepressions.

2. Management of major risk factors such as smoking, lipid disorders, obesity.3. Vaccination of children and adults.4. The early diagnosis of specific types of cancer, such as cancers of the breast, cervix, prostate,

and colon.5. Health-status evaluation (including cognitive and emotional disorders) in the elderly and in

patients with chronic diseases and disabilities.6. Developmental follow-up of infants and children, prenatal care.7. Treatment of minor trauma and injuries, performance of minor surgery, and provision of First

Aid, including basic cardiopulmonary resuscitation (CPR).8. Performance of a minimum number of diagnostic and therapeutic procedures in the clinic.9. Performance of a minimum number of diagnostic and therapeutic procedures in the patient’s home.

of the system’s users—in cases where documentation exists for effective action andintervention—not only is the concept of complete and total coverage of the popula-tion nullified, but in addition estimating the cost of transition becomes exceptionallydifficult.

Emphasis should also be made of mechanisms that ought to be created by thesystem in order to support existing knowledge and guide the customary practice ofthe personal physicians and other health workers in the PC sector, with guidelinesand evidence-based information, contributing to the effective and efficient use of re-sources. Agreements that will serve the needs of health-care personnel, developmentof electronic and other guides that will govern diagnosis, therapy, and dispensing ofprescriptions, availability of on-line support mechanisms, auditing compliance as wellas evaluating the effectiveness of these interventions, are among the prime elementsthat should form part of a total PC system.

Reference to the role and function of nursing personnel in the community isessential and must follow European models. We are proposing to assign concrete rolesto nurses who will assist personal physicians, and especially in home-care activities.

In addition, this functional reorganization of PC in Greece demands a series ofsupportive interventions, such as:

(a) Establishing the required infrastructure for providing the system with thenecessary information regarding the evolution of the health-status model ofthe population and maintenance of medical records

(b) Extending the working hours of the facilities and organizing specialtieswithin the framework of coordinated networking among the various fa-cilities as well as in relation to hospital inpatient care

(c) Introducing a mixed compensation system (salary and per-capita remunera-tion) that will be common to all PHC units physicians regardless of specialty

(d) Certifying providers of services, in both the public and the privatesector

P1: IZO



DISCUSSION

Our proposal seems to be coming timely. A health care reform is in progress,the legislative framework seems to be efficient in General Practice/Family Medicine,although they are still seeking recognition within the Greek context. It introducesa new technique for public management, enriching the function of the PC healthsector with institutional adjustments, ensuring the clear limits of the various actors’responsibilities. The advantage of this contractual reasoning lies in the fact that itseparates administrative from functional responsibility in the system and in additionis by nature dynamic, which contributes to the ability taking advantage of all existingstructures.

It is profound that our proposal’s main endeavor is to see a model of integrateddelivery systems to be implemented in primary care in Greece. An interest in theconcept of integrated or organized delivery system has been seen in USA at thebeginning of the last decade,(18,19) with the goal and objective of a coordinated cost-effective care to be achieved. Vertical integration in our proposed model implies thecoordination in capacities or infrastructure (equipment, supplies, human resources,high technology) and the process of care (clinical protocols, medical audit, assessmentof quality assurance) in order to achieve the best care at the personal level.

Thus, we expect to provide the Regional Health and Welfare System with a morepluralistic character, enriching the mixture of provided care with services extendingbeyond the traditional curative approach including services of disease preventionand health promotion, and management of major risk factors. In addition, the cen-tral coordination of the system and the central role of the personal physician areexpected to restore continuity of care, introducing barriers to the system not basedon a rationale of limitation (gate-keeping), but rather on improvement of existingstructures and conditions under which health care is provided.

Thus, at the implementation level, the proposal resembles the model of HealthMaintenance Organizations in the USA, through the “exploitation” and improve-ment of SSI services in urban centers, taking advantage of private infrastructureand the formation of a functional framework for the health care market based on acomplex of contracts and agreements.(20,21)

Our approach presents some similarities with the American definition, offeredby the Institute of Medicine, defining PHC as “the provision of integrated, acces-sible health care services, by clinicians who are accountable for addressing a largemajority of personal health care needs, developing a sustained partnership with pa-tients, and practicing in the context of family and community.”(22) Thus, the Greekproposal meets the integrated dimension of the primary care services provision sinceit discusses the concepts of comprehensiveness, coordination, and continuity. It alsodefines the role of personal doctor who will be accountable for addressing a rangeof health services according to the identified needs, within the community or locallevel.

The terms “personal physician” or “personal care” are not unknown in therelevant literature. Recent publications document the value of the personal rela-tionship between doctor and patient, along with the role of the personal physician,which is considered important in treating most of the health problems for which the

P1: IZO



patient visits the doctor.(23) Such physicians may be effective for patients with minoror acute problems when a quick access is required. Of course this reference concernsthe British Health System, a system that emphasizes clinical management, a frame-work that includes all measures for improving quality of care, as well as improvingeffectiveness. Our approach is not far from the new definition of General Prac-tice/Family Medicine and core competences of General Practitioners that WONCAEurope has recently advocated.(24)

Strengthening of support mechanisms contributes to rational use of resourcesand improvement of the system’s effectiveness, while indicators’ measure for control-ling clinical effectiveness (medical audit) are also expected to contribute to this end.The British experience in PHC change can highlight a series of measures supportingthe everyday tasks of General Physicians, especially with the adoption of guidelinesbut also rapidly available information in newly published documentation. Thus, theNational Health System, has established a Centre for Reviews and Dissemination, atthe University of York and a recent bulletin of Effectiveness Matters provides a guideon how to search available resources on evidence of clinical effectiveness.(25) An ini-tiative has also been undertaken in Crete, Greece, where the Regional Health andWelfare Authorities in collaboration with the Clinic of Social and Family Medicinehave developed a website that provides immediate information regarding practicalguidance in the areas of general medical consensus results or systematic review ofthe literature (www.cgrg.gr). The methods that these authorities are using in orderto measure clinical effectiveness in primary care have been recently discussed in anInternational Conference at Catvat, Croatia.(26)

The formation of a flexible compensation system provides additional motivationfor increased productivity and controlling the facilities’ “clients”— without, however,voiding the right of free choice—and on the other hand contributes to controllingcosts for care since it allows gradual application of global budgets.

In conclusion, the choice of functional intervention in the provision of PHCappears to combine the following advantages:

i It constitutes a realistic solution applicable in the medium term.ii It utilizes the existing infrastructure and thus avoids wasting resources in order

to create new structures or make transition to a new framework (overviewedby the Ministry of Health). In addition, maintaining the funding apparatusand strengthening the viewpoint of the buyer (the insurance funds), ensuresthe greatest possible social consensus, avoiding upheavals with uncertain out-comes. The same is foreseen in the case of physicians who are already manningthe existing structures.

iii Ensures improvements in the quality of services by way of procedures thatguarantee universal acceptance, whereas in addition it introduces into thesystem the concept of the personal physician which on the one hand has beenthe goal of health policy for a number of years, and on the other hand is anadditional—after central administration—potential guarantor of the adequacyof provided services.

iv It can be a first stage, a precursor of a major administrative innovation in thesystem—if its advisability is confirmed—which in accordance with the relevant

P1: IZO



proposals foresees development of a unified system in the areas of both fundingand provision of services.

In conclusion, the proposed approach seems to be suitable for the developmentof a proper network that will offer a full continuum of care and minimize serviceduplication.

ACKNOWLEDGMENTS

We are grateful to the former Minister of Health and Welfare, Professor CostasStefanis, for inspiring and encouraging us to bring all these ideas to a paper.

REFERENCES

1. Lionis, Ch., and Mercouris, M.-P., Views on today’s situation in primary health care and proposalsfor its improvement. Prim. Health Care 12:7–9, 2000 (in Greek).

2. Souliotis, K., and Lionis, C., Functional reconstruction for the primary health care : A proposal forthe rise of the impassable. Arch. Hellenic Med. 20(5):466–476, 2003 (in Greek).

3. Ministry of Health and Welfare of Greece, Health, Health Care and Welfare in Greece, Athens, Greece,2003.

4. Souliotis, K., The Role of the Private Sector in the Greek Health Care System, Papazisis, Athens,Greece, 2000 (in Greek).

5. Souliotis, K., Analysis of health expenditure in Greece 1989–2000. Methodological clarifications anddiscoveries regarding the health care system. In Kyriopoulos, K, and Souliotis, K. (eds.), HealthExpenditures in Greece. Methodological Problems in Measurement and Consequencies for HealthPolicies, Papazisis, Athens, Greece, 2002 (in Greek).

6. Kyriopoulos, J., Georgoussi, E., Andrioti, D., Boerma, W., and Mercouris, M. P., The involvement ofGeneral-Medicine physicians in Preventive Medicine. Prim. Health Care 7:21–28, 1995 (in Greek).

7. Georgoussi, E., Andrioti, D., Kyriopoulos, J., Boerma, W., and Mercouris, P. M. The characteristicsof General-Medicine physicians’ services in Greece, in comparison with other European countries.Prim. Health Care 4:193–202, 1999 (in Greek).

8. Lionis, Ch., and Kyriopoulos, J., Primary health care and General Medicine: The safety valve for highquality in health care. Prim. Health Care 12:167–168, 2000 (in Greek).

9. Arguriadou, S., Melissaropoulou, H., Krania, E., Karagiannidou, A., Vlachonikolis, J., and Lionis,C., Dementia and depression: Two frequent disorders of the aged in primary health care in Greece.Fam. Pract. 18:87–91, 2001.

10. Lionis, C., Tzagournissakis, M., Iatraki, E., Kozyraki, M., Antonakis, N., and Plaitakis, A., Are primarycare physicians able to assess dementia? An estimation of their capacity after a short-term trainingprogram in rural Crete. Am. J. Geriatr. Psychiatry 9:3, 2001.

11. Lionis, C., Chatziarsenis, M., Antonakis, N., Gianoulis, Y., and Fioretos, M., Assessment of vaccinecoverage of school children in three primary health care areas in rural Crete, Greece. Fam. Pract.15:443–448, 1998.

12. Chatziarsenis, M., Miyakis, S., Faresjo, T., Fioretos, M., Vlachonicolis, J., Trell, E., and Lionis, C.,Is there room for General Practice in penitentiary institutions: Screening and vaccinating high riskgroups against hepatitis. Fam. Pract. 16:366–368, 1999.

13. Lionis, C., Frangoulis, E., Skliros, S., Alexandrakis, G., and Kouroumalis, E., How Greek GPs managehepatitis C infected patients: Experiences gained from a primary health care district in rural Crete.Aust. J. Fam. Phys. 28:207, 1999.

14. Evrenidou, K., Mylonakis, M., Mittas, E., Vlachonikolis, I., and Lionis, C., Visits to a General Prac-titioner in a tourist area of Crete during one night. Medicine 78:261–265, 2000 (in Greek).

15. Kyriopoulos, J., Lionis, C., Dimoliatis, G., Mercouris, M. P., Economou, C., Tsakos, G., and Philalithis,A., Primary health care as the foundation of health reform. Prim. Health Care 12:169–188, 2000 (inGreek).

16. Lionis, C., The draft law in primary health care—A challenge in health care reform. Prim. HealthCare 14:11–12, 2002 (in Greek).

P1: IZO



17. Lionis, C., and Mercouris, M.-P., General/Family Medicine at the crossroads: Necessary prerequisitesfor its establishment in Greece. Prim. Health Care 13:8–9, 2001 (in Greek).

18. Anderson, S. T., How healthcare organization can achieve true integration. Health Finance Manage.52:31–34, 1998.

19. Devers, K. J., Mitchell, J. B., and Erickson, K. L., Implementing organized delivery systems: Anintegration score card. Health Care Manage. Rev. 19:7–20, 1994.

20. Luft, H. S., Health Maintenance Organizations: Dimensions and Performance, Wiley, New York, 1981.21. Luft, H. S., Translating the U.S. HMO experience to other health systems. Health Aff. 10:172–186,

1991.22. Donaldson, M., Yordy, K., and Vanselow, N. (eds.), Institute of Medicine: Defining primary care: An

interim report, National Academy Press, Washington, DC, 1994, p. 16.23. Kearly, K., Freeman, G., and Heatth, A., An exploration of the value of the personal doctor–patient

relationship in General Practice. Br. J. Gen. Pract. 51:712–718, 2001.24. WONCA Europe,The European Definition of General Practice/Family Medicine, WONCA Europe,

2002, (www.medisin.ntnu.no/wonca).25. NHS Centre for Reviews and Dissemination, the University of York, Assessing the evidence on

clinical effectiveness. Effectiveness Matters 5:1–7, 2001 (http://www.york.ac.uk)26. Lionis, C., Seeking the clinical effectiveness in primary care within the regional health system in

Greece. In The Abstract Book, in the 6th International Conference Biotechnology and Public Health,Catvat, Croatia, October 10, 2003.

creating an integrated health care system in greece: a primary care perspective

Documents