Pay for Performance – Pay for Performance – a critical assessmenta critical assessment (using recent Estonian experience)(using recent Estonian experience)

“Improving primary care in Europe and the US: Towards patient-centered, proactive and coordinated systems of care”

April 3, 2008

Ain Aaviksoo, MD MPHPRAXIS – Center for Policy Studies

Why?Why?

• Encourage most rapid feasible performance improvement by all providers.

• Support innovation and constructive change throughout the health care system.

• Promote better outcomes of care, especially through coordination of care across provider settings and time.

IOM. Rewarding provider performance: aligning incentives in Medicare. (2006)

• Motivate family physicians to actively engage in disease prevention and monitoring of chronic patients, and to provide the insured with a broad health service (monitoring of pregnant women, perform minor surgeries, etc.).

Estonian Health Insurance Fund Annual Report 2006

The Context (Estonia)The Context (Estonia)

• Area 45 000 sqkm

• ~1.4M inhabitants

• GDP per capita 12 300 EUR (2006)

• Health expenditure per capita 496 EUR; 5% of GDP (2006)

• Single public Health Insurance Fund (85% of public and 63% of total HC costs)

• ~800 family doctors practicing as private entepreneurs (61% in solo practices)

Map source: www.parks.it

High penetration of ICT in High penetration of ICT in primary careprimary care

Source: Development of the information society in Estonia as mirrored in European surveys in 2003. Estonian Informatics Centre. Data from „eEurope+ Health Survey”, June 2003. http://www.ria.ee/atp/?id=762 (Accessed January 12, 2006)

Everything grows ... Everything grows ... and some grow even moreand some grow even more

The case of Estonia (timeline)The case of Estonia (timeline)

2002 Family Doctors’ Association started accreditation

2003 no payment differentiation by accreditation possible

2005 concept for P4P agreed between family doctors and Health Insurance Fund (based on NHS example)

2006 first year of reporting on performance

2007 first payment according to results from 2006 (max 8% of annual revenues);second year of reporting; adjustment of criteria

How does P4P work in Estonia?How does P4P work in Estonia?

Results from 2006Results from 2006

CRITICAL ANALYSISCRITICAL ANALYSIS

Organisation mattersOrganisation matters

Solo practice (N=35)

Group practice (N=65)

Polyclinic type practice(N=13)

Total sample (N=113)

Proportion of bonus payment

recipients66% 52% 85% 60%

Proportion of higher bonus

payment recipients

4% 24% 0% 13%

Bonus payment by capital area family physicians in 2006Bonus payment by capital area family physicians in 2006

Confounders and facilitatorsConfounders and facilitators

• Introduction of the P4P parallel to robust growth of overall healthcare and primary care budget

• Initiative of family doctors’ leaders to praise the colleagues who do good job

• Universal ICT backup

ChallengesChallenges

• Decreasing participation trend plus differentiation(?) by performance

• Financial reward very small

• Future improvements of the programme planned “carefully” and resistance is growing

• Integration of overall health care system is rather poor

ObservationsObservations

• Large scale implementation of P4P: USA, UK, Estonia

• Ideas evolving in most countries• Actively promoted by the World Bank

(P. Schneider. “Provider Payment Reforms: Lessons from Europe and America for South Eastern Europe”. WB Policy Note. October 2007)

International comparisonInternational comparisonLessons learnt (by P Schneider) “Trial” in Estonia

Cost and administrative burden are key barriers Relatively low (ICT already implemented), but

still the issue causing most resistance

Careful monitoring needed to avoid unexpected

side effects

Ongoing; some independent analysis and

evaluation embedded

Incremental introduction to reduce risks Easy to start, but missing the final (even if

temporary) goal

Public information to put pressure Results publicly available; local media covers

extensively

Supporting wider health strategy necessary Health insurance fund leadership is there, but

general health policy is too scattered

Performance effect is probably relatively small Initial results vary promising among those who

participated voluntarily. Overall effect – too

close to call …

Back to basicsBack to basics

Adapted from M Roberts et al. “Getting health reforms right”. OUP 2004POLITICAL DECISIONS

Risks & recommendationsRisks & recommendations

• Feasibility of implementation

• Sufficiency of reward

• Precision/predictability of outcomes

• Adequacy of the tool for given goalES Fisher, NEJM Nov 2006