PRIMARY CARE IN THE HEALTH CARE SYSTEM - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

PRIMARY CARE IN THE HEALTH CARE SYSTEM

Description:

PRIMARY CARE IN THE HEALTH CARE ... and technology made universally accessible to ... to overwork PRIMARY CARE REFORM All proposals feature ... – PowerPoint PPT presentation

Number of Views:790
Avg rating:3.0/5.0
Slides: 35
Provided by: Faculty169
Learn more at: http://www.med.uottawa.ca
Category:
Tags: care | health | primary | system | the | care | easy | health | made | reform

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: PRIMARY CARE IN THE HEALTH CARE SYSTEM


1
PRIMARY CARE IN THE HEALTH CARE SYSTEM
  • R.A. Spasoff, MD, Epidemiology Community
    Medicine
  • L. Muldoon, MD, Somerset West Community Health
    Centre
  • 2006 February 27

2
PBL Ms Sharon Smith
  • A thirty-five year old woman has a febrile
    illness with cough, malaise and pain in the chest
    that is aggravated with each breath. She has
    been drinking more heavily since her boyfriend
    was killed in a drug dispute. She visits an
    emergency department, having previously visited a
    walk-in clinic.

3
IMPORTANCE OFPRIMARY CARE
  • Strong primary care is the basis for a strong
    health care system
  • The best systems are the ones with strong primary
    care, e.g., UK, Netherlands
  • Romanow report devoted a whole chapter to primary
    care saw it as the basis of a transformed system

4
HEALTH FOR ALL 2000(WHO, 1981)
  • The main social target of governments and of WHO
    should be the attainment by all the people of the
    world by the year 2000 of a level of health which
    would permit them to lead a socially and
    economically productive life.
  • WHO determined that HFA2000 could best be
    achieved through primary health care

5
PRIMARY HEALTH CARE(WHO)
  • essential health care based on practical,
    scientifically sound and socially acceptable
    methods and technology made universally
    accessible to individuals and families in the
    community through their full participation and at
    a cost that the community and country can afford
    to maintain at each stage of their development,
    in the spirit of self-reliance and
    self-determination

6
Characteristics of General Practice/Family
Medicine (Draft Charter of GP/FM, WHO-EURO, 1998)
  • General (unselected health problems)
  • Continuous
  • Comprehensive
  • Coordinated
  • Collaborative
  • Family-oriented
  • Community-oriented

7
PRINCIPLES OF PRIMARY CARE (CFPC)
  • The doctor-patient relationship is central to
    what we do as family physicians
  • The practice of family medicine is
    community-based
  • The family physician is a resource to a defined
    population
  • The family physician must be a skilled, effective
    clinician

8
Other important attributes of primary care
  • First contact
  • Accessibility
  • Continuity
  • Case-management (responsibility for coordinating
    all the care that a person needs)

9
METHODS OF PAYING PHYSICIANS
  • Fee-for service
  • Capitation
  • Salary/sessional
  • Combinations (blended funding)

10
Fee-for-service
  • Unit of remuneration is the service
  • Rewards hard work, good patient relations,
    accessibility
  • Encourages high-volume practice, especially when
    fees are inadequate
  • Rewards talking services less well than doing
    services discourages prevention and a global
    approach to patients problems

11
Capitation
  • Unit of remuneration is the patient, not the
    number of services provided. Fixed payment per
    patient per month.
  • Implies a list or roster of patients, which may
    strengthen accountability
  • Encourages continuity of care
  • Provides incentive to keep patient healthy,
    therefore should encourage prevention
  • May encourage doctors to be unavailable

12
Salary/Session
  • Unit of remuneration is time (per hour, per
    month), not number of patients or services
  • Allows efficient use of time
  • May encourage low-volume practice, slacking off
  • Normally associated with practice in some sort of
    institutional setting, which provides
    accountability

13
SETTINGS FOR PRIMARY CARE IN CANADA
  • Private solo practice
  • Private group practice
  • FHN (HSO)
  • CHC / CLSC
  • Also (and not recommended)
  • Emergency department
  • Walk-in clinic
  • Specialist practice

14
Walk-in Clinics
  • Convenient for patients, flexible for physicians
  • Little continuity of care
  • Fee-for-service payment encourages high volume
    practice
  • Skim off the easy (remunerative) patients,
    leaving older and multi-problem patients to
    family physicians and thereby making family
    practice less financially viable

15
Emergency Departments
  • Accessible (with long waits) 24 hours/day
  • Ready access to technology
  • Staff not appropriately trained for primary care
    (emphasis on episodic care)
  • Very limited social support services
  • Poor continuity of care
  • Expensive (or are they?)

16
Specialists(paediatrics, gynaecology, etc)
  • Some specialists provide a certain amount of
    primary care
  • They tend to work in solo practice or
    partnerships, without a broad range of support
    services
  • Their training is not appropriate for primary
    care (expertise in depth rather than breadth, no
    emphasis on family or continuity)

17
Solo Practice/Partnerships
  • Historically the most common pattern
  • For doctors maximum professional autonomy and
    individual responsibility, but minimum
    professional support
  • For patients doctor-patient relationship,
    continuity (in office hours), limited services
  • Fee-for-service payment encourages high volume
    practice, discourages prevention

18
Group Practice
  • For doctors colleague support, sharing of
    expenses and call duty, reduced capital costs
  • For patients one-stop provision of medical care
    (wider range of services)
  • Usually fee-for-service payment
  • Similar to solo practice in terms of hospital
    utilization, costs and quality of care

19
Health Maintenance Organizations (HMOs)
  • USA only do not exist in Canada
  • Prepayment plan (equivalent of capitation)
    combined with a large group practice, sometimes
    with own hospital
  • Community-sponsored ones reduced hospitalizations
    and total costs of care
  • Commercial sponsorship (managed care) has given
    a good approach a bad name

20
Health Services Organizations (HSOs)
  • Ontario group practices funded by capitation
  • Defined patient registers
  • No provision for community input
  • No provision for other professionals
  • There were about 50 have been replaced by Family
    Health Networks (see below)

21
Community Health Centres (CHCs)
  • Community-sponsored clinics with boards
  • About 50 in Ontario, 6 in Ottawa-Carleton
  • Wide range of health and social services
  • Care mainly for disadvantaged populations
  • Funded by Ministry of Health via global budget,
    with salaried staff
  • Funding provides flexibility, e.g., use of nurse
    practitioners

22
Centres locaux de services communataires (CLSCs)
  • Cover the entire province of Quebec
  • Provide a range of medical, public health and
    social services (similar to the WHO concept of
    primary health care)
  • Global budget with salaried staff
  • Primary medical care role has not developed to
    the extent originally envisaged

23
STRENGTHS OF PRIMARY CARE IN CANADA
  • Well-trained family physicians, although not
    enough of them
  • Family physicians can usually obtain hospital
    privileges (although they can no longer afford to
    do hospital practice)
  • Few direct financial barriers to prevent patients
    from seeking care

24
WEAKNESSES OF PRIMARY CARE IN CANADA
  • Patients are free to shop around
  • Physicians can practise where they want, rather
    than where they are needed
  • Family physicians are isolated from each other,
    other health and social workers, public health
  • Fee-for-service system does not permit use of
    other health workers, e.g, nurse practitioners
  • Combination of inadequate fees and inadequate
    numbers leads to overwork

25
PRIMARY CARE REFORM
  • Need for reform widely recognized family doctors
    leaving practice, few new graduates entering
  • Many proposals have been considered

26
Choices for Change Restructuring Primary Health
Care in Canada
  • Prepared for Canadian Health Services Research
    Foundation, 3 provinces, Health Canada. Nov 2003
  • Evaluated 4 models of care on Effectiveness,
    Productivity, Accessibility/Equity, Continuity,
    Quality and Responsiveness, using evidence and
    (mostly) expert judgment

27
Findings of Report
  • CHC-like model best on effectiveness,
    productivity, continuity and quality, if
    integrated with rest of health care system
  • HSO-like model best on accessibility,
    responsiveness

28
Recommendations of Report
  • CHC-like model preferred HSO-like model
    acceptable as transitional form
  • Organizations to be paid by capitation, personnel
    (including MDs) to be paid by session
  • Should be multidisciplinary
  • Information systems crucial

29
Three Newer Ontario Models
  • Family Health Networks
  • Family Health Groups
  • Family Health Teams

30
Family Health Networks(FHNs), 2001-
  • Have replaced HSOs
  • Networks of family doctors working from common
    or own offices (virtual clinics)
  • Defined patient registers, for which doctors
    accept responsibility for 24-7 availability
  • Capitation, plus incentives for prevention.
    Access bonus if patients don't go elsewhere.

31
FHNs (continued)
  • Very limited provision for other professionals
  • Extensive use of IT
  • Was supposed to cover 80 of family doctors by
    2004, but didnt come close
  • In early 2005, accounted for gt1800 family
    physicians, caring for gt2.5 million Ontarians

32
Family Health Groups (FHGs), 2004- (Conservatives)
  • Introduced when FHNs slow to develop
  • As for FHNs, patients have to enrol, and group is
    on-call 24/7
  • Payment is not by capitation. Some enhanced FFS
    billing, a few premiums andbonuses
  • Attractive to many FFS doctors, partly due to
    increased income

33
Family Health Teams (FHTs), 2004- (Liberals)
  • Much more multidisciplinary than FHNs
  • Two models
  • Professional e.g., Family Medicine Centre
  • Community similar to CHCs
  • Payment blended capitation with bonuses,
    premiums and ability to bill up to 40,000 per
    year for non-enrolled patients.

34
Summing Up
  • New models should encourage continuity,
    multidisciplinarity, and prevention should
    discourage duplicated services
  • Will they attract more graduates into family
    practice?
  • See http//www.health.gov.on.ca for a very
    little more info
About PowerShow.com