THE ROLE OF PAY-FOR-PERFORMANCE IN IMPROVING THE STRENGTH OF PRIMARY HEALTHCARE IN CANADA TAMARA BROWN THE CONFERENCE BOARD OF CANADA NHCL CONFERENCE, WHISTLER 2011 June 6, 2011
The Conference Board of Canada Mission The Conference Board builds leadership capacity for a better Canada by creating and sharing insights on economic trends, public policy, and organizational performance.
The Conference Board s How Canada Performsreport gives Canada a B grade for overall health performance. But where do we rank in terms of primary healthcarein relation to our peers?
Report Card on Primary Care Ranking Country Grade 1. Japan A 2. Italy A 3. Netherlands A 3. Australia A 4. Switzerland B 5. France B 6. United Kingdom B 7. Sweden B Canada ranks 11 th out of 13 peer countries, and receives an overall C grade for primary healthcare. 8. Norway B 9. Germany B 10. New Zealand B 11. Canada C 12. United States D Source: The Conference Board of Canada
Individual Grades on Subthemes within Primary Care Score Theme Access to care Immunization Rates Quality of care Potential Years of Life Lost - Diabetes Causes of Mortality - Diabetes Non-medical determinants of health Life Expectancy Australia Canada France Germany Italy Japan Netherlands New Zealand Norway Sweden Switzerland United Kingdom B D A B A - A A B C - A B B B C B C D A D B A D C D B D D C B - B A D C - A D A B A A A A A C A A A A D B D B C C A C D B B B A D C B D D C A C B B A C D C A B B C A A B B B B A C D Source: The Conference Board of Canada United States
The Role of Pay-For-Performance in High Quality Primary Healthcare The UK s Quality and Outcomes Framework 134 indicators awarding incentives based on four domains: Clinical (e.g., coronary heart disease, hypertension, diabetes, asthma) Organizational (e.g., practice management, education and training) Patient Care Experience Additional Services (e.g., child health, maternity services, screening)
Pay-for-performance is improving quality of care in the UK, and allowing for better management of chronic conditions preventing unnecessary deaths as a result.
Median Clinical Achievement in General Practice in Years 1-3 of QOF Source: Doran T, Fullwood C, Kontopantelis E, Reeves D. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet. 2008 Aug 11.
Clinical Achievement of Diabetes Care Since Inception of QOF Source: National Primary Care Research And Development Centre. Spotlight - What should happen to the Quality and Outcomes Framework. November 2007. http://www.npcrdc.ac.uk/publications/qof_spotlight.pdf
Pay-for-Performance in Canada Drivers Increased prevalence of chronic diseases Changing demographics Higher emphasis on quality-of-care Shifting focus to value-for-money
Advantages and Disadvantages of Payment Models
Fee-for-Service Advantages Motivates long hours Encourages efficient time management Motivates performing difficult procedures Motivates caring for the chronically ill Detailed record-keeping Disadvantages Can result in over-provision of care No incentive for unremunerated tasks Motivates fraudulent upcoding of visits and procedures Leads to fragmentation and failures of coordination in healthcare High acceptance and comfort
Capitation Advantages Encourages good communication with patients and fosters long-term relationships Encourages personalized care Motivates early treatment and prevention Encourages cooperation between providers Disadvantages May encourage selective admission of patients Patients with chronic illness may lose, as their care is more costly Promotes excessive referrals, increasing healthcare costs Supports behavioural shift towards a population-based approach
Salary Advantages Encourages longer more comprehensive visits Offers predictability and better hours Less administrative work Disadvantages May encourage low productivity May lead to a preference to treat easier patients that consume less time and resources Benefits, ex. vacation time Access to expensive medical technology if in place at the organization
Blended Models Advantages Promotes working in a team-based environment Disadvantages Methods need to be blended effectively for care to improve Provides incentives for preventative care, which also encourages desirable target activities Minimizes the undesirable effects of FFS and capitation, while promoting the benefits of both
Total number of physicians Percent of physicians paid through alternative modes Percent of physicians who receive at least 50% of all clinical income through alternative modes NL 1049 37.8% 2.0% PEI 233 54.9% 36.9% NS 2220 76.1% 23.6% NB 1444 58.4% 34.3% QC 14605 61.1% N/A ON 22555 28.8% 13.7% MA N 2317 74.8% 18.0% SASK 1708 23.7% N/A ALTA 5912 10.3% N/A BC 8998 29.3% 11.3% YT 64 12.5% 12.5% NW 78 96.1% 96.1% TOTAL 61183 39.1% N/A Source: CIHI
Source: The Conference Board of Canada, 2008. Funding Discussion Paper.
Physician Interviews Methodology 13 one-hour interviews conducted with primary care physicians across Canada, from both FFS and alternative compensation models Standardized questions related to physician compensation and the status of primary care reform in Canada
Summary of Findings -Compensation Comments largely echoed advantages/disadvantages found in the literature. All physicians were happy with their current model. Primary advantage noted in FFS: Getting paid for the work being done Primary advantages of alternative models: Work-life balance (vacation time, steady hours) Ability to work effectively in a multidisciplinary team being able to delegate tasks to other HCPs, while reserving physician time for difficult cases Improved management of chronically ill patients Ability to take time off to participate in training, career development, and primary care reform initiatives.
Compensation alone may not be enough to advance primary care reform physician engagement is also critical.
Summary of Key Messages Canada does poorly when it comes to primary healthcare, and a stronger focus on quality is needed to improve health outcomes. Pay-for-performance has been shown to be effective in boosting the implementation of a quality agenda in primary healthcare Ontario is setting a good example with the new legislation - The Excellent Care for All Act. A larger proportion of physicians are embracing blended compensation models. This indicates that the wind is favorable to effect the change in primary care that Canada needs.
Stay tuned for the primary healthcare report to be released this summer... www.conferenceboard.ca Thank you!