Greece: Primary Care in a time of crisis. 2nd VdGM Forum, Dublin 2015
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2nd Vasco Da Gama Movement Forum, Dublin 2015 The Effect of the Economic Crisis on the Health Systems of the peripheral countries: Greece, Ireland, Spain, Portugal and Italy.
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Semelhante a Greece: Primary Care in a time of crisis. 2nd VdGM Forum, Dublin 2015
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Greece: Primary Care in a time of crisis. 2nd VdGM Forum, Dublin 2015
- 1. Primary Health Care in a time of crisis Evangelos A. Fragkoulis, MD, GP Secretary General of the Greek Union of GPs MSc in Health Care Management National Delegate VdGM
- 2. Financial sustainability of health systems in Europe • ageing populations/ cost-increasing developments in technology/ changing public expectations how to pay for health care in thirty years’ time • economic crisis how to pay for it in the next three months
- 3. Countries most affected by the crisis- Greece the most affected one: substantial and sustained fall in GDP
- 4. Sustained declines in GDP in Greece: 5 years of negative growth
- 5. UNemployment rates rocketed in Greece 2014Q1 GRE 27.3% OECD 7.6% 2014Q2 GRE 56.6% OECD 15.4% 2013Q4 GRE 70.6% OECD 35.9% 7.8% in 2007
- 6. Health insurance coverage NOT universal • long-term unemployed • many self-employed workers not able to pay their contributions • 2.500.000 NOT covered
- 7. Social spending declined in Greece in parallel with GDP
- 8. 12% of total government spending goes to health Cuts in: - ministry of health budget - government budget transfers to health insurance schemes (EOPYY)
- 9. Health expenditure in Greece- 2012
- 10. Fall in health spending in GRE Greece OECD
- 11. Growth in health expenditure reversed in 2009-2012
- 13. Dramatic decline of outpatient care budget 2009-2014 2009 2014 Change % Total health expenditure 23,3 billions € 15,3 billions € -34% Per capita total health expenditure 2,148 € 1,417 € -34% Health expenditure for outpatient care 6,6 billions 2,9 billions -56% Per capita expenditure for outpatient care 611 269 -56% Source: National School of Public Health www.esdy.gr
- 14. Out of pocket medical spending Depends on the ability to pay- fell about 15% during 2007-2012
- 15. Evolution of health expenditure -70.00% -60.00% -50.00% -40.00% -30.00% -20.00% -10.00% 0.00% 10.00% 20.00% 30.00% total health expenditure pharmaceutical expenditure expenditure for outpatient care expenditure for inpatient care Evolution in health expenditure Expenditurebyfunction Total Public Private Source: National School of Public Health www.esdy.gr
- 16. Unmet need couldn’t afford it>> waiting time, too far to travel
- 17. 28th in Euro Health Consumer Index 2014 (down from22th in 2012)
- 18. Countries may be able to cope with budget reductions • the health system is adequately publicly funded – the health share of public spending is high • out-of-pocket payments are low as a share of total spending on health • there is political will to address waste in the health system and the gap between revenue and expenditure is small enough to be bridged through efficiency gains • social policies to support those experiencing or at risk of poverty, unemployment and social exclusion
- 20. Ten leading causes of inefficiency in health systems
- 21. #1 in overweight children
- 22. #1 in daily smoking adults
- 23. Poor performance in cancer screening
- 24. #1 in practising doctors per population
- 26. • Last in practising nurses per population 3,6/1000 • Nurses/ doctors: 0,6
- 27. #2 in MRI units/ #1 in CT scanners
- 28. #2 in MRI exams/ #1 in CT exams- 2011
- 29. # 1 in antibiotic consumption
- 30. #1 in pharmaceutical spending in 2008
- 31. #1 in under the table payments to docs
- 33. Primary Care in Greece- LOW strength
- 35. Governance • Unclear distribution of responsibilities between central government and local authorities, health insurance funds and NHS, public and private sector. • No broadly supported vision of Primary Care, priority setting, financing, supply planning and management, service provision or quality monitoring. Technical Assessment Report: Primary Health Care, Groenewegen P, Jurgutis A- TFGR of the EC Source: Theodorakis P
- 36. Economic conditions for PC • Low payment for GPs (compared to other specialists / other countries), mainly in salaried service, but also self-employed on fee-for- service basis (potential problem of incentives). • Large share of private spending and under the table payments Technical Assessment Report: Primary Health Care
- 37. Workforce development • Unbalanced, lack of GPs and nurses in PC • No clear job/task description for GPs and other PC providers. • No policy in health education to redress the balance between generalists and specialists. • Lack of proper attitudes and public health management competences for the managers of PHC institutions. Technical Assessment Report: Primary Health Care
- 38. Access • Patient satisfaction with the ease to access GPs was relatively low. • Access depends on the cost of money (Cost sharing for consultations) or time • Regional differences in access due to low number of GPs, vacancies Technical Assessment Report: Primary Health Care
- 39. Comprehensiveness • Often very small role of GPs, limited to prescribing and referring • Often lacking a community orientation (especially in urban regions). • Private practices (mostly solo) mainly focus on the patients visiting practice • Sometimes lack of crucial equipment. Technical Assessment Report: Primary Health Care
- 40. Continuity • Personal continuity is a problem due to the fragmented health care system. Too many first contact points. Everyone can decide to visit whoever. • Referral letters are not common. • No communication between specialists and GPs after the completion of an episode of treatment. Technical Assessment Report: Primary Health Care
- 41. Coordination • No referral system. • No information about actual coordination. Technical Assessment Report: Primary Health Care
- 42. Quality • No information • Some private practices and diagnostic centres have more advanced quality assurance systems. Technical Assessment Report: Primary Health Care
- 43. Efficiency • Not enough information to assess • Monitoring of quantity of services (visits, lab tests etc), but not of the value of care (the outcomes to health) Technical Assessment Report: Primary Health Care
- 44. Equity • Clear and increasing inequities in health care in Greece. • Relate to health status, socio-economic status and place of living. Technical Assessment Report: Primary Health Care
- 46. EOPYY • a new purchasing agency through the merger of health insurance funds, unified benefit package, e-prescribing, monitoring, auditing, claw back, rebates, global budgets
- 47. 3 dimensions of health coverage people should be able to access the care they need without facing financial hardship
- 48. Extended entitlement of coverage Policies to extend entitlement to vulnerable groups- action to protect these people was initially limited, slow and ineffective OAED: covers long term unemployed for maximum 2 years: 500.000 people enrolled (7/2014) for more than a year Coverage of poor: covers poor, uninsured people under strict conditions- low demand for this coverage: 100.000 people in 2012 Health vouchers (9/2013): covers outpatient visits and diagnostic tests for a restricted period (4 months). Low demand, only 21.000 issued till 31/1/2014 out of the 230.000 announced for 2013-2014. PEDY (2/2014): open access to all in PEDY public health centers, but only for visits- medications, tests not covered Ministerial decision (6/2014): covers all uninsured, outpatient prescriptions and inpatient care, as long as they have a referral from the PEDY Public Health Centers and they pay their copayments (as if they were insured)
- 49. Lowered depth of coverage by instituting or increasing patient user charges • outpatient prescription drugs: copayment from 12.85% (2012) to 29.30%(2014) • diagnostic tests: 15% flat co-payments when private sector is chosen • inpatient care: 30-50% charge when contracted with EOPYY private hospital is chosen • outpatient specialist care: 5€ per visit in outpatient departments of public hospitals/ 45-90 € per private- afternoon visit to a public hospital specialist • primary care: 5€ per visit in Primary Health Centers, Full payment of GP consultations under ΕΟPΥΥ once cap on consultations is reached (200/month)
- 50. Evolution of the user charge in outpatient prescription drugs
- 51. Patient user charges undermine health system performance: • little selective effect, reducing appropriate and inappropriate use • deter people from appropriate and cost-effective care (especially preventive and patient-initiated services) • negatively affect health, particularly among poorer people • result in cost-increasing substitution (resource-intensive emergency services instead of cost-effective primary care)
- 52. Pharmaceutical expenditure • National Pharmaceutical Policy (NPP), Pricing, Reimbursement, Generics, Pharmacists profit, Cost sharing, Clinical Practice Guidelines, HTA, Positive list, e- prescription, budget per doctor, monitoring, risk sharing agreement, claw back, rebate, uninsured…
- 55. Strengthening Primary Care • Increase funding for primary care • Reform primary care payment methods • Shift care out of hospitals • Improve access to primary care • Change the skill mix Economic crisis, health systems and health in Europe: impact and implications for policy WHO Europe/ European Observatory on Health Systems and Policies, 2014
- 56. Strong Primary Care • clear vision on strengthening primary care with GPs as core profession. • Access to PC with the lowest possible cost-sharing. • System of stepped access through mandatory referrals to specialist/ hospital care/ diagnostic services. • Redefined links between PHC and specialist and hospital care • Patients should be on the list of specific physicians (personal list system). • freedom of choice for patients of their preferred primary health care provider • Community orientation of PHC through relations with preventive services, community care and primary level mental health care Technical Assessment Report: Primary Health Care
- 57. Strong Primary Care • Funding of PC geared to population needs through an adequate resource allocation formula • Payment of GPs: a mix of capitation, fee-for-services and/or bonuses for specific targets (incentives) • The level of payment of GPs should be in line with their increased responsibilities. • Development of PC clinical guidelines Technical Assessment Report: Primary Health Care
- 58. Strong Primary Care • Development of a system of quality indicators- part of quality improvement cycles at different levels. • Continuity of care facilitated by well-developed medical records. • independent monitoring and evaluation • investment in collecting and analyzing information. Technical Assessment Report: Primary Health Care
- 59. Strong Primary Care • PC professionals should have clear job descriptions that guide: - educational requirements - contracts - inform patients on what they can expect from primary care providers. • Assessment of training needs for PHC doctors and nurses • Short training courses to obtain core competences, required by job description. • Policies for education and training of health professionals should address the misbalance between generalists- specialists Technical Assessment Report: Primary Health Care
- 61. Development of a unified Primary Health Care Network- Implementation of the Family Physician
- 62. impact of economic crisis on population health • full scale of the effects may not be apparent for years – especially those due to inadequate and delayed access to health services and breakdowns in the management of chronic disease. • Mental health has been most sensitive to economic changes. Unemployment and financial insecurity increase the risk of mental health problems. • There has been a notable increase in suicides. • Limited evidence of a decrease in general health status and increases in communicable diseases, such as HIV and malaria.
- 63. Suicides in Greece- lowest in Europe
- 64. Will the new government endanger the PHC reform?
- 65. We hope and believe NOT this time!
Notas do Editor
- It ‘s a great honor for me to be here to present you the unique case of Primary Care in Greece during this time of austerity
- The old debate about the financial sustainability of health systems has been reset from how to pay for healthcare in 30 years time to how to pay for it in the next 3 months
- Greece was the most affected by the crisis country with a substantial and sustained fall in GDP
- There were 5 sequential years of negative growth
- Unemployment rocketed from 8 to 27% in 7 years, being even worst in youth
- Unemployment and inability to pay contributions left almost 2,5 millions without health coverage
- social spending dropped in parallel with GDP. Goverment, instead of protecting vulnerable groups, took money from the health sector to finance other areas
- only 12% of the spending goes to health
- Health spending from 10% of GDP in 2009 dropped to 9.3% in 2012 (the OECD average). The public share was 67%, below the average of 72%
- The overall drop from its peak in 2008 was 25%
- a unique number in Europe
- The allocation of resources reveals a health system focused in hospital care, in illness and not in health
- Outpatient care moreover suffered the bigger cut in the budget during the crisis
- The share of the private spending remained still high, although substantially lower than the past, as it depends on the ability to pay
- Out of pocket money, go to inpatient care and pharma spending, while it is severely cut in outpatient care
- Unmet medical needs rise high, posing an issue of equity. They represent undetected illness and bad health for tomorrow
- The evaluation of the Greek Health system in Euro Health Consumer, year by year worsens!
- Health systems may cope with budget cuts for a limited period, if they are adequately publicly funded and the out-of-pocket payments are low (not the case in Greece). Policies must be implemented to gain efficiency and to support the vulnerable.
- Efficiency gain means doing the same or more with less resources
- Greek health system is characterized by almost all the leading causes of inefficiency. If we have a positive approach there is a lot of waste that can be addresed
- Health promotion is poor, with high prevalence of unhealthy lifestyle factors. 1st in overweight children
- 1st in daily smokers
- Poor performance in prevention, like cancer screening
- The most inappropriate staff mix. The highest number of doctors per population
- With the lowest ratio of generalists to specialists
- And the lowest ratio of nurses to doctors.
- Oversupply of high teq equipment,
- inducing demand of investigations like CT and MRIs
- Overuse and inappropriate use of medications, like antibiotics
- Inflating the pharmaceutical spending- #1 in 2008
- System characterized by corruption- #1 in under the table payments to doctors
- In the study of Kringos, about the strength of PC in Europe
- The greek was evaluated as the worst
- As it scored badly in almost all the dimensions of the structure and the process of Primary care
- These dimensions were also assessed in a technical report conducted by the Task Force for GR. There was an unclear distribution of responsibilities between the various players of the system And not a broadly supported vision of Primary Care.
- GPs were badly paid and by oldfashioned methods- salaried or on fee-for-service the share of private spending was large and often under the table
- Lack of GPs and nurses in PC and No clear job description for them No policies to address the imbalance
- Low patient satisfaction with the ease of access. It depends on money and waiting time.
- The role of GP is often limited to prescribing and referring There is weak community orientation, focusing on the patients visiting the practice
- Fragmented PC system makes personal continuity a problem, There are no referrals and usually no communication between GPs and specialists
- Quality
- And efficiency can not be assessed, as there is monitoring only of quantity of services and not of the value of delivered care
- Inequity is a clear and worsening problem
- Gain efficiency with elimination of inappropriate and ineffective services, and reallocation of the resources towards the more cost effective primary care and public health are the answers to the restricted health budgets.
- EOPYY, the new national insurance scheme was established by the merger of the numerous funds. EOPYY formed a unified benefit package and by targeting to efficiency abandoned some services, covered by the noble funds in the past.
- The unified benefit package restricted the range of the covered services. What happened to the share of the population entitled to coverage and to the level of the user charges for the services? Reductions in coverage shift responsibility for paying for health services on to individuals and will usually increase the role of out-of-pocket payments in the health system (direct payments for non-covered services and user charges for covered services). Cost shifting is likely to delay care seeking, increase financial hardship and unmet need, exacerbate inequalities in access to care, lower equity in financing and make the health system less transparent. It can also promote inefficiencies – for example, by skewing resources away from need or encouraging people to use resource-intensive emergency services instead of cost-effective primary care. As a result, coverage restrictions may provide a degree of short-term fiscal relief but could add to health system costs in the longer term.
- Policies to extent entitlement to vulnerable groups were necessary. These actions were initially limited, slow and ineffective. Only since June 2014, uninsured people are covered for prescribed pharmaceuticals and for non-emergency hospital care
- User charges increased in almost any function of care: drugs, tests, consultations, inpatient care
- Copayment for prescription drugs raised from 12% to 29% in 2 years
- The increased user charges undermine performance, as they have little selective effect, and deter people from appropriate care and especially preventive care. It also leads to cost increasing substitution
- Pharmaceutical spending was confronted with a new pricing policy, e-prescribing, positive list, guidelines, budget for doctor, etc. As a result Greece is not any more an eager and early adopter of novel pharmaceuticals,
- And the spending for drugs dropped From the high of 5,4 billions euros in 2009 to 2,1 billions in 2014
- If we want to absorb further savings without damaging front line services, the only way is to perform Structural reforms with a focus in primary Care. Crisis poses a unique opportunity to implement the reform, that we are planning again and again since 1980, but never managed to succeed, as there was never enough political will to confront the reactions of many interest groups. It’s primary care now more than ever!
- If we want to strengthen PC, we have to increase its funding, reform the payment methods, shift the care out of hospitals, improve the access and change the skill mix
- Individualizing these recommendations for Greece, there must be a clear vision of PC with GPs as core profession, the access must be with the lowest cost, stepped access with mandatory referrals, personal list of patients for each GP, freedom of choice in the selection of the GP, community orientation
- Funding matched to the needs of the population, payment of GP by a mix of capitation, fee for service and pay4p, Reimbursement of GPs in line with their role, development of guidelines
- Development Of quality indicators, as a part of quality improvement cycles, Well developed medical records facilitating continuity of care, monitoring and evaluation
- Clear job description of GPs that defines their educational and training needs. Short training to obtain the core competencies
- One year ago, greece launhed a new phc law
- That establish the development of a unified Primary Health Care Network and the Implementation of the Family Physician. Since then the MoH works on the necessary ministerial decisionsaccording to the reccomendations to activate the law
- The full scale of the effects of the crisis in health may not be apparent for years, especially those due to suboptimal management of chronic diseases. Unemployment and financial insecurity are associated with Mental health problems. There has been an increase in deaths from suicides and limited evidence of a decrease in general health status and increases in HIV and malaria
- Deaths from suicides in Greece increased from 328 in 2007 to 508 in 2012, a 50% increase. We have to monitor the numbers, to see if this is an established trend out of the yearly variability. Nonetheless, the suicide rate in Greece still remains the lowest in europe .
- You all know that we have a new government in greece. Will this endanger the PHC reform?