Socioeconomic distribution of GP visits following patient choice reform and differences in reimbursement models: Evidence from Sweden

ObjectiveThis study aims to analyse changes in the socioeconomic distribution of GP visits following primary care patient choice reform, and to compare their magnitude and direction in pure capitation, versus capitation/activity-based mixed, provider reimbursement settings.MethodsWe compute absolute and relative concentration indices using total population registry data from three Swedish counties (N∼3.6 million) two years pre, to two years post, reform. We decompose the indices by the contribution of first, non-recurrent and recurrent visits, and compare their changes in the different provider reimbursement settings.ResultsIn all three counties, the number of visits increased for all population groups. Increases were larger, and distributional changes more pro-poor, in the county with mixed reimbursement. Visit increases were mostly driven by recurrent and, especially, non-recurrent, visits, which were increasingly pro-poor in all counties in absolute, but not in relative, terms. First visits either became decreasingly pro-poor, or did not change significantly. Exclusion of high users removed the pro-poor patterns in the two counties with pure capitation.ConclusionsThe reform led to increased access to GP visits, but implied small changes in their socioeconomic distribution. In combination with provider reimbursement models with incentives for higher visit volumes, changes were more pro-poor over time, but it is not clear whether this was at the expense of reduced visit length or content.     

The use of guidelines in the primary care management of hypertension and diabetes

Summary Objectives:The paper examines to what degree German primary care physicians know and work along the rules established in guidelines for arterial hypertension and diabetes mellitus.Methods:HYDRA is a 2-stage cross-sectional point prevalence study with 1912 participating primary care settings throughout Germany including 45125 patients. A pre-study questionnaire to assess doctors practice patterns was used. Subsequently doctors completed a structured clinical appraisal with a diagnostic workup and characterization of the current treatments provided. All patients filled out a questionnaire.Results:Pre-study results show that only every second primary care physician manages the patients according to established guidelines. Further, physicians estimated their own work as problematic and not always successful. Guideline-oriented doctors were more likely to report hypertension and diabetes treatment patterns that also match guidelines recommendations.Conclusions:The study shows a considerable degree of dissatisfaction with the quality of their work among primary care physicians. Guideline-oriented doctors however reveal more frequently formally adequate management characteristics. This encouraging aspect suggests the need of more successful implementation of medical guidelines in order to achieve improved evidence-based medicine and better patient-oriented health care.

     

The high-cost,type 2 diabetes mellitus patient: an analysis of managed care administrative data

Background

Type 2 diabetes mellitus (T2DM) affects 25.8 million individuals in the United States and exerts a substantial economic burden on patients, health care systems, and society. Few studies have categorized costs and resource use at the patient level. The goals of this study were to assess predictors of being a high-cost (HC) patient and compare HC T2DM patients with not high-cost (NHC) T2DM patients.

Methods

Using managed care administrative claims data, patients with two or more T2DM diagnoses between 2005 and 2010 were selected. Patients were followed for 1 year after their first observed T2DM diagnosis; patients not continuously enrolled during this period were excluded from the study. Study measures included annual health care expenditures by component (i.e., inpatient, outpatient, pharmacy, total). Patients accruing total costs in the top 10% of the overall cost distribution (i.e., patients with costs > $20,528) were classified as HC a priori; all other patients were considered NHC. To assess predictors of being HC, a logistic regression model was estimated, accounting for demographics; underlying comorbidity burden (using the Charlson Comorbidity Index [CCI] score); diagnoses of renal impairment, obesity, or hypertension; and receipt of insulin, oral antidiabetics only, or no antidiabetics.

Results

A total of 1,720,041 patients met the inclusion criteria; 172,004 were HC. The mean (SD) CCI score for HC patients was 4.3 (3.0) versus 2.1 (1.7) for NHC patients. Mean (SD; upper 95% confidence interval-lower 95% confidence interval) annual per-patient costs were $56,468 ($65,604; $56,778-$56,157) among HC patients and $4,674 ($4,504; $4,695-$4,652) among NHC patients. Inpatient care and pharmacy costs were higher for HC patients than for NHC patients. The strongest predictor of being an HC patient was having a CCI score of 2 or greater (odds ratio [OR] = 4.896), followed by a diagnosis of obesity (OR = 2.106), renal impairment (OR = 2.368), and insulin use (OR = 2.098).

Conclusions

High-cost T2DM patients accrue approximately $52,000 more in total annual health care costs than not high-cost T2DM patients. Patients were significantly more likely to be high-cost if they had comorbid conditions, a diagnosis of obesity, or used insulin.     

Cost analysis as a management tool for improving the efficiency of primary care: some examples from Java.

Health programs in developing countries increasingly face limited or even reduced budgets. More and better services might be produced from these resources by improving efficiency through better management and program design. Cost analysis at individual health units can help identify sources of inefficiency, and provide guidance to managers as to where they can achieve important gains in productivity. This paper presents several examples from health centers and sub-centers in rural Java. Indonesia, showing how inefficiencies in staffing patterns, personnel management, and drug management can affect cost-efficiency. Routine analysis of cost data could provide the basis for management incentives to local health units to increase both outputs and quality of care.     

An extension in eligibility for free primary care and avoidable hospitalisations: a natural experiment

In the Republic of Ireland, approximately 30 per cent of the population ('medical card patients') are entitled to free GP services. Eligibility is determined primarily on the basis of an income means test. The remaining 70 per cent of the population ('private patients') must pay the full cost of GP consultations. In July 2001, eligibility for a medical card was extended to all those over 70 years of age, regardless of income. This extension in eligibility provides a natural experiment whereby we can examine the influence of access to free GP services on avoidable hospitalisations. Avoidable hospitalisations are those that are potentially avoidable with timely and effective access to primary care services or that can be treated more appropriately in a primary care setting. Using hospital discharge data for the period 1999-2004, the purpose of this paper is to test the proposition that enhanced access to GP services for the over 70s after July 2001 led to a decline in avoidable hospitalisations among this group. The results indicate that while avoidable hospitalisations for the over 70s did decline after 2001, they also fell for the under 70s, meaning that a significant difference-in-difference effect could not be identified.     

Are Japanese people satisfied with their health care system and services? Empirical evidence from survey data

Background

Japan’s universal health care system provides many advantages for its users, including affordable health coverage with free and equal access to medical institutions. However, the Japanese population’s satisfaction with the health care system is among the lowest internationally. This paper investigates the extent and determinants of satisfaction toward Japan’s health care system and services, and compares the results with those of eleven other high-income countries.

The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.     

Management of cardiovascular risk factors in people with diabetes in primary care: cross-sectional study

OBJECTIVES: Cardiovascular disease is the major cause of morbidity and mortality in people with diabetes. The management of cardiovascular risk factors in people with diabetes in primary care was compared with National Institute of Clinical Excellence guidelines. DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188 patients, participating in the Kent, Surrey and Sussex Primary Care Research Network. Primary outcomes were process of care measures. METHODS: Analysis of general practice computer data on the management of 5980 patients with diabetes, of whom 86% were aged 45 years and over. RESULTS: The prevalence of diabetes was 2.0% in women and 2.6% in men, much lower than the estimated expected prevalence of 4.8% for women and 3.3% in men. Blood pressure was well recorded (96% in both sexes), cholesterol levels less well (79% of women, 84% of men). Hypertension (78% of women, 72% of men) was common. Twenty-one percent of women and 16% of men had a blood pressure above 160/100 mmHg, suggesting under use of antihypertensive therapy. Cholesterol levels were >or=5 mmol/l in 46% of women and 38% of men. Lipid-lowering drugs were prescribed in 38% of women and men. Aspirin was prescribed in 38% of women and 40% of men. CONCLUSIONS: There is an under-diagnosis of diabetes and an under-treatment of blood pressure and blood cholesterol, more marked in women than in men. There is scope for improved management within general practice, including addressing sex inequalities.     

Billing system and health care utilization: Evidence from Thailand

We examined the role of billing processes in health care utilization by exploiting a shift in provider payment from fee-for-service reimbursement towards fee-for-service direct disbursement for outpatient services in Thailand. Specifically, prior to October 2006, affected patients had to pay the full cost of outpatient treatment and subsequently received reimbursement; thereafter, these payments can be sent directly to the providers, without patients having to pay anything upfront. By using nationally representative micro-data and a difference-in-difference methodology, we show that the direct disbursement policy leads to an increase in outpatient utilization among the sick. This non-price change has long-lasting impacts and particularly increases the health care utilization of sick individuals who are living in rural areas, are less educated and earn low incomes. These findings suggest that direct disbursement helps to increase liquidity constraint individuals’ health care utilization. The results emphasize the effectiveness of behavioural interventions in health policy making.     

Determinants of the choice of GP practice registration in England: Evidence from a discrete choice experiment

There have been growing concerns that general practitioner (GP) services in England, which are based on registration with a single practice located near the patient's home, are not sufficiently convenient for patients. To inform the decision as to whether to change registration rules allowing patients to register ‘out-of-area’ and to estimate the demand for this wider choice, we undertook a discrete choice experiment with 1706 respondents. Latent class models were used to analyse preferences for GP practice registration comparing preferences for neighbourhood and non-neighbourhood practices. We find that there is some appetite for registering outside the neighbourhood, but this preference is not uniformly shared across the population. Specifically individuals who are less mobile (e.g. older people and those with caring responsibilities), or satisfied with their local practice are less likely to be interested in registering at a practice outside their neighbourhood. Overall, people feel most strongly about obtaining an appointment with a GP as quickly as possible. Respondents regarded weekend opening as less important than other factors, and particularly less important than extended practice opening hours from Monday to Friday. Assuming a constant demand for GP services, a policy encouraging GP practices to extend their opening hours during the week is likely to decrease the average patient waiting time for an appointment and is likely to be preferred by patients.     

Management of diabetes in primary care: A structured-care approach

Background: In the Irish Midland Health Service Executive (HSE) Diabetes Structured Care Project, additional resources were targeted at general practice in the absence of a local hospital-based specialized diabetes unit. Objective: We assessed the performance of the Midland HSE Diabetes Structured Care programme in 2003, bench-marked against Primary Care Trust (PCT) data from the 2003/2004 National Diabetes Audit for England. Methods: Data on 947 patients (72% of eligible patients) from all 20 general practices participating in the structured-care programme were collected retrospectively over a 12-month period. The data included demographic and clinical variables as well as key process-of-care and intermediate outcome indicators used in the National Diabetes Audit for England. Results: The level of recording of process-of-care measures was near or above the upper quartile for PCTs in England. The proportion of patients with HbA_1c concentrations at target levels (<6.5%) in the Midlands HSE project (26.8%) was virtually identical to the upper quartile level for PCTs in England (27.4%). The proportion of patients reaching target total cholesterol levels (<5.0 mmol/l) (54.6%) was close to the mean for PCTs in England (56.6%), and performance with regard to target blood pressure levels was equally poor in both the Midlands HSE (18.0%) and in PCTs in England (20.8%).

Conclusion: Primary-care-led structured care, with relatively limited but well-focused investment, can achieve quality of care for patients with diabetes, comparable to international best practice.     

Effectiveness of pro-active organizational models in primary care for diabetes patients

BackgroundDemographic changes and chronicity are posing new challenges to health care systems. Our study aimed to examine how effectively the three different types of proactive primary care models adopted by three different regional health care systems in Italy were improving the quality of diabetes management by general practitioners.MethodsA coordinated Italian nationwide project to compare systematically the new proactive organizational models implemented at regional and local level (the MEDINA Project) involved several regions and their local health units (LHUs). A quasi-experimental study was conducted on a large dataset obtained by processing administrative databases. A combined indicator was developed to assess the quality of care delivered by primary care physicians, based on adherence to recommendations concerning patient monitoring and treatment.ResultThe study concerned 602 Italian general practitioners (GPs), 174 of them female, who were caring for a total of 753,366 patients (47,575 of them diabetic). Analyzing a total score, representing global adherence to a quality management of patients with diabetes, confirmed that GPs who had adopted the new model of care for their diabetic patients obtained better results than those who had not, so the new policy was generally effective.ConclusionOur study showed that introducing new, proactive primary care models could sustain efforts made around the world to guarantee good-quality chronic disease management in the primary care setting.     

The excess health care costs of KardioPro,an integrated care program for coronary heart disease prevention

Coronary heart disease (CHD) is a major cause of death and important driver of health care costs. Recent German health care reforms have promoted integrated care contracts allowing statutory health insurance providers more room to organize health care provision. One provider offers KardioPro, an integrated primary care-based CHD prevention program. As insurance providers should be aware of the financial consequences when developing optional programs, this study aims to analyze the costs associated with KardioPro participation. 13,264 KardioPro participants were compared with a propensity score-matched control group. Post-enrollment health care costs were calculated based on routine data over a follow-up period of up to 4 years. For those people who incurred costs, KardioPro participation was significantly associated with increased physician costs (by 33%), reduced hospital costs (by 19%), and reduced pharmaceutical costs (by 16%). Overall costs were increased by 4%, but this was not significant. Total excess costs per observation year were €131 per person (95% confidence interval: [€−36.5; €296]). Overall, KardioPro likely affected treatment as the program increased costs of physician services and reduced costs of hospital services. Further effects of substituting potential inpatient care with increased outpatient care might become fully apparent only over a longer time horizon.     

Rebalancing health systems toward community-based care: The role of subsectoral politics

There has been increased policy discourse urging a “rebalancing” of health systems from institutionally-based to community-based approaches. This paper offers an analysis of the subsectoral dynamics that condition opportunities to strengthen community-based care relative to acute care. We report on the results of a policy study in Ontario, Canada that explored factors impacting on the capacity to expand community-based care. In so doing, we highlight the challenges associated with the community subsector’s ability to develop ‘critical’ status and challenge the dominance of the acute subsector. We conclude that attempts to rebalance health systems toward community-based care should begin by understanding that health care is not a monolithic policy sector, but rather a collection of proximate policy sub-sectors, inclusive of community care, acute care, and institutional care, each with their own internal characteristics and dynamics that impact sectoral directions.     

Uncontrolled diabetes and health care utilisation: panel data evidence from Spain

Despite size and relevance of uncontrolled diabetes, robust evidence on its effects on health care utilisation is very limited, especially among European countries. We employed longitudinal administrative data from Spain (2004–2010) to explore the relationship between uncontrolled type 2 diabetes and health care utilisation. We used a biomarker (glycated haemoglobin, HbA1c) to detect the presence of uncontrolled diabetes and explore its effects on both primary and secondary health care. We estimated a range of panel count data models, including negative binomials with random effects, dynamic and hurdle specifications to account for unobserved heterogeneity, previous utilisation and selection. We found uncontrolled diabetes in between 27 and 30% of patients of both genders. Our estimates suggested that although women appeared to systematically consume more health care compared to men, their consumption levels did not seem to be influenced by uncontrolled diabetes. Conversely, among men uncontrolled diabetes increased the average number of GP visits per year by between 3 and 3.4%, specialist visits by 5.3–6.1%, depending on specifications, and also extended annual hospital length of stay by 15%. We also found some evidence of heterogeneity in utilisation based on the level of uncontrolled diabetes among male individuals. Overall, our results suggested the need for different diabetes management plans depending on gender and levels of glycaemic control.     

The relationship between rates of hospitalization for ambulatory care sensitive conditions and local access to primary healthcare in Manitoba First Nations communities: Results from the Innovation in Community-based Primary Healthcare Supporting Transformation in the Health of First Nations in Manitoba (iPHIT) study

ObjectivesThe objective of this study was to assess the performance of models of primary healthcare (PHC) delivered in First Nation and adjacent communities in Manitoba, using hospitalization rates for ambulatory care sensitive conditions (ACSC) as the primary outcome.MethodsWe used generalized estimating equation logistic regression on administrative claims data for 63 First Nations communities from Manitoba (1986–2016) comprising 140,111 people, housed at the Manitoba Centre for Health Policy. We controlled for age, sex, and socio-economic status to describe the relationship between hospitalization rates for ACSC and models of PHC in First Nation communities.ResultsHospitalization rates for acute, chronic, vaccine-preventable, and mental health-related ACSCs have decreased over time in First Nation communities, yet remain significantly higher in First Nations and remote non-First Nations communities as compared with other Manitobans. When comparing different models of care, hospitalization rates were historically higher in communities served by health centres/offices, whether or not supplemented by itinerant medical services. These rates have significantly declined over the past two decades.ConclusionLocal access to a broader complement of PHC services is associated with lower rates of avoidable hospitalization in First Nation communities. The lack of these services in many First Nation communities demonstrates the failure of the current Canadian healthcare system to meet the need of First Nation peoples. Improving access to PHC in all 63 First Nation communities can be expected to result in a reduction in ACSC hospitalization rates and reduce healthcare cost.     

中国农村基本卫生保健工作发展与思考

目的：了解我国农村地区基本卫生保健工作的现状,以及在新世纪第一个十年中取得的成绩和存在的问题,为进一步推进农村基本卫生保健工作提出有针对性的政策建议。方法：按照分层抽样的方法,在全国选择400个县级行政单位,收集当地农村基本卫生保健工作的相关数据。结果与发现：（1）农村基本卫生保健工作得到政府重视,但财政保障仍不足;（2）乡村两级医疗卫生服务体系建设仍需不断完善;（3）基本公共卫生服务在医改政策推动下进展明显,后续要加大力度推进;（4）新型农村合作医疗制度不断完善;（5）基本药物制度实施使基层医疗卫生机构面临发展困境。     

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.