Five strategies for improving

Easy access to high-quality primary care is a prerequisite for good public . Five strategies can be used—alone or in combination—to improve the delivery of primary care. 69

Elisabeth Hansson Primary care is pivotal to any . agencies to ensure that their receive and Sorcha For most patients, primary care appropriate support at home. McKenna, PhD are the health system’s “face”—the providers they see most often and the ones with whom they To understand how well primary care is develop long-term relationships. currently being delivered in Western Europe, we analyzed data from six countries: , Most countries have found it hard to deliver Germany, the , , Sweden, and good primary care, though. Research we the . Some of these countries recently conducted in multiple European coun- rely principally on taxes to cover the cost of health tries uncovered similar problems in all of care; the other systems are insurance based. them. A growing number of patients, for example, Although the countries differ in their approach to are dissatisfied with their ability to get access primary care in several ways (Exhibit 1), some to primary care services. The productivity of general conclusions can be drawn. In insurance- many primary care physicians is declining, and based systems, most GPs are independent the quality of care delivered varies widely. practitioners who work in comparatively small and are reimbursed (in whole or in There is a better way. Health systems and part) on a fee-for-service basis. Because market payors can use five strategies—alone or forces tend to be stronger in these countries, in combination—to improve their primary care they often have more GPs per capita than services: they can increase competition countries with tax-based funding do. In contrast, among primary care physicians, tighten their the GPs in tax-based systems are usually public contracting and reimbursement mechanisms, employees who work in larger clinics; capitation strengthen their performance-management plays a more significant role in the mixed funding systems, improve their operating models, models used to pay these physicians. and increase the integration of primary care with secondary care and social care. However, all of the countries face significant challenges in delivering primary care. Challenges to primary care delivery These challenges can be grouped into six In virtually all health systems, primary care interrelated categories: physicians—typically, general practitioners (GPs)—are the clinicians most patients see first Access: In many countries, patients are dissat- when they have a health problem, as well as the isfied with their ability to see GPs in a timely clinicians they see most often. Our studies have fashion. As a result, some patients present to the shown, for example, that 70 percent of all emergency room for treatment instead, driving interactions UK patients have with the health up overall health system costs. Other patients system are with GPs. These physicians handle delay seeking help or go without needed care, their patients’ ordinary health problems them- which often results in more complications and selves, and they coordinate with the rest of the higher costs (this is particularly likely to occur health system when advanced care is needed. In when the patients have chronic conditions, such some health systems, GPs also coordinate as ). We have found that poor access to with social services and other community care care is a problem in most health systems, but it is 70 Health International 2009 Number 8

Health International 2009 Step change in primary care Exhibit 1 of 4 Glance: Tax-based and insurance-based health systems often take different approaches to primary care. Exhibit title: Different approaches

Exhibit 1 Different approaches General practitioners Role of GPs Structure (GPs), per Market rules Models of care Financing 1,000 population Tax-based and insurance- Tax Sweden 0.6 Varies by region 80% public Mix of budget, fee for based health systems often 51% of clinics have based more than 5 doctors service, and capitation take different approaches to primary care. United 0.7 Gatekeeper 80% quasi- 2 doctors Capitation with Kingdom independent per incentives Spain 0.7 Gatekeeper 90% public 4–6 doctors per Salary and capitation center per person Insurance Germany 1.0 No gatekeeper 100% 60% of clinics Fee for service based independent have 1 France 0.9 Gatekeeper 70% 40% of clinics Fee for service independent have 1 doctor Netherlands 1.8 Gatekeeper 100% 83% of clinics Capitation fee independent have 1–2 doctors and payment per procedure

Source: Organisation for Economic Co-operation and Development (OECD), Health Data 2008; Vektis; McKinsey analysis

particularly in tax-based systems because of the baby boom generation moves into retirement. their lower number of GPs per capita. In Sweden, In Germany, for example, the average age for example, many patients report that they of physicians has risen substantially in the past cannot get timely access to their GP, especially by 15 years (Exhibit 2). As the older GPs retire, 1 1Väntetider i vården, telephone. Achieving the right level of access there is likely to be an insufficient number of vantetider.se. is a significant challenge for all health systems, replacements available. 2For insight into how easy access to care has driven up because costs can rise dramatically if patients find Japan’s health care costs, 2 see “Reforming Japan’s health it too easy to access care. Furthermore, easier Productivity: GP productivity (as measured by system,” p. 36. access to GPs does not necessarily result in a the number of patients seen by a 3D. S. Furmedge, “General practice stigma at medical lower number of specialist consultations, as some per week or the number of patients in a given GP’s school and beyond—do we need to take action?” British Journal Swedish payors have discovered. Nevertheless, practice) often varies markedly—not only of General Practice, 2008, long wait times for treatment frustrate patients between countries but also between regions Volume 58, Number 553, p. 581; B. Ali, M. Jones, “Do and make an otherwise good health system look in the same country, between different medical students want to as if it is performing poorly in the public’s eyes. GP offices, and even between individual doctors become GPs?” British Journal of General Practice, 2003, in the same office. In Spain, for example, Volume 53, Number 488, p. 241; E. D. Avgerinos et al., Workforce supply: Even countries with GP productivity is twice as high in Baleares as it is “Greek medical students’ insurance-based funding often have a shortage of in Castilla y León (Exhibit 3). The differences career choices indicate strong tendency towards GPs for a simple reason: many physicians in in productivity remain even after the analyses specialization and training abroad,” , 2006, training do not view primary care as intellectually are adjusted for demographics Volume 79, pp. 101–6; and challenging or economically attractive. Surveys and other relevant factors, which suggests that B. Wright, “Career choice of new medical students at three in several countries have shown that fewer than significant opportunities to improve GP Canadian universities: family versus specialty 20 percent of medical students are interested productivity exist. Taking advantage of those medicine,” Canadian Medical in becoming GPs.3 Furthermore, the shortage of opportunities is becoming increasingly important, Association Journal, 2004, Volume 170, pp. 1920–24. GPs is likely to get worse in coming years as because GP productivity is declining in some Five strategies for improving primary care 71

Health International 2009 Step change in primary care Exhibit 2 of 4 Glance: The number of physicians in Germany are aged 60 and older is increasing. Exhibit title: Aging physicians

Exhibit 2 Aging physicians Comparison 1993 vs 2007 Average age The number of physicians 1993 = 47.5 2007 = 51.5 in Germany aged 60 and older 6,000 is increasing. Share of physicians 5,000 aged 60 and older: 1993: 8.8% 2007: 17.5% 4,000

2007 3,000

2,000 Number or physicians

1993 1,000

25 30 35 40 45 50 55 60 65 70 75 80 Age

Source: German National Association of Statutory Physicians; McKinsey analysis

countries. The productivity of British GPs, for best quality metrics for primary care should example, has dropped sharply in the past be (for instance, which evidence-based practices 15 years despite the fact that the government has should be considered the standard of care). markedly increased what it pays them.4 (The And given that GPs are often widely dispersed United Kingdom is the exception to the general throughout their communities, it is often rule that primary care is financially unattrac- quite difficult for health systems and payors tive.) Whether GP productivity is higher in to determine what care has actually been insurance-based systems than in tax-based ones delivered. The United Kingdom has attempted is currently unclear, because insurance-based to improve the quality of its primary care systems do not typically measure GP productivity. services through a new program, the Quality and Outcomes Framework (QOF), which gives Quality: A challenge that all countries face GPs additional payments if they meet specified is how to ensure that the quality of care outcome metrics (for instance, the percentage delivered by GPs is high; indeed, most health of hypertensive patients whose blood pressure is systems—and the payors within those systems— lowered to the normal range). The program acknowledge that this challenge is one of their has been successful in focusing attention and core concerns. Unfortunately, very little reliable improving scores on those metrics, but it 4NHS Information Centre, 2006–07 GP workload survey; information is available to enable them to gauge has become clear that a GP’s performance on NHS Information Centre, the relative quality of primary care services. those metrics does not always reflect the overall GP earnings and expenses enquiry 2006–07. There is currently little consensus about what the quality of his or her practice. 72 Health International 2009 Number 8

Health International 2009 Step change in primary care Exhibit 3 of 4 Glance: There are vast differences in productivity among general practitioners in Spain. Exhibit title: Regional variations in Spain

Exhibit 3 Variable productivity Number of health care cards by (GP) in the region, 2007 in Spain Baleares 1,867 País Vasco 1,724 There are vast differences Murcia 1,610 in productivity among general practitioners in Spain. Valencia 1,594 Madrid 1,571 Canarias 1,568 Ceuta and Melilla 1,539 Asturias 1,487 Cataluña 1,433 Andalucía 1,415 Navarra 1,382 Cantabria 1,370 La Rioja 1,370 Galicia 1,358 Castilla la Mancha 1,328 Aragón 1,219 Extremadura 1,218 Castilla y León 978 Average for Spain 1,416

Source: Spanish Ministry of Health; McKinsey analysis

Integration: Another major challenge that The two groups have put considerable effort into all of the countries face is how to better integrate designing care-planning processes to better primary care with the rest of the health coordinate the services delivered by primary care, system. Regardless of whether or not GPs serve care, and geriatric care providers. as a health system’s gatekeepers, they Nevertheless, coordination remains suboptimal, are typically responsible for coordinating with which most regional health authorities view all of the other providers that deliver care as one of the health system’s key deficiencies. to a given patient. However, few health systems have established the communication chan- Regional variations: It is not only GP produc- nels that would enable GPs to do this effectively. tivity that varies widely within countries— This is true even in tax-based systems with so do many other factors that affect the delivery comparatively few stakeholders. In Sweden, of primary care. For example, many countries for example, the regional health authorities are have long found it difficult to recruit GPs to rural responsible for providing both primary areas and low-income neighborhoods. However, care and hospital care; the municipalities are lifestyle concerns, such as a desire for good responsible for providing geriatric care. weather, also contribute to regional variations in Five strategies for improving primary care 73

care availability. The south of France, for levers; however, health systems can greatly example, has markedly more GPs per capita than increase the effectiveness of the levers do the northwestern parts of that country (particularly increased competition and inte- (Exhibit 4). Similar variations in the quality of gration) through supporting policies. It primary care services have also been documented is not necessary that all five levers be pulled; in many countries. The result of these regional the ones selected should depend on the variations is unacceptable differences in service particular challenges the payor and health system levels for inhabitants of the same country. face and the issues they want to prioritize. Here, we describe the five levers; in the next Strategies for improving primary section, we provide examples of how diff- care delivery erent combinations of approaches have been Our experience working in countries around used to improve primary care. the world reveals that there are five levers Health International 2009 health systems and payors can use to improve Increased private provision/competition: Step change in primary care primary care. In general, it is usually payors In both tax-based and insurance-based Exhibit 4 of 4 who have the greatest control over most of these systems, competition is a way to increase GP Glance: Throughout France, the number of general practitioners by region varies widely. Exhibit title: Regional variations in France

Exhibit 4 General-practitioner There are large regional differences in . . . and those differences are even larger at department level. general-practitioner (GP) density . . . availability in France GPs per 1,000 inhabitants by region, 2007 GPs per 1,000 inhabitants by department, 2007 1.3–1.39 1.4–1.49 1.5–1.59 Lot-et-Garonne 3.1 Throughout France, the 1.6–1.79 1.8–2.0 number of general practitioners Paris 3.1 varies widely by region. Hautes-Alpes 2.4 Bouches-du-Rhone 2.1 Hautes-Pyrenees 2.0

Seine-et-Marne 1.2 Ain 1.2 Cher 1.2 Mayenne 1.2 Eure 1.2 Average 1.6

t ~2.6 million people live in a poorly ‘medicalized’ area (low density of GPs, high turnover per GPs), which affects the general health of a population t This gap will increase in the future, because 63% of medical students refuse to practice in the countryside or in economically deprived suburbs

Source: DREES; report of Mr. Ritter to the Ministry of Health on the creation of Regional Health Agencies, January 2008; McKinsey analysis 74 Health International 2009 Number 8

productivity and the quality of care, because it that they have established safeguards to prevent signals to physicians that they will have to perform providers from overdelivering health services. better if they want to retain their contracts and When reimbursement is based solely on patients. Competition can be introduced in activity levels, some physicians may be tempted several ways. For example, payors can use their to provide more services than are medically tendering process to promote competition among necessary. To minimize this risk, payors should the GPs they currently contract with. They can put controls in place so that they can compare also encourage new GPs to enter the market what services are delivered and what services in areas with local monopolies. For competition are necessary. This will require them to define the to be effective in improving primary care, types of care that should be given to patients however, patients must be able to choose freely with the conditions most commonly treated in among providers. Real requires primary care (for example, diabetes, hyper- that there be easily available information tension, ) and to build the types of IT about GP performance, few bureaucratic barriers systems that would enable them to compare care to switching providers, and a geographic spread delivered against care needed. of GPs (to ensure that changing physicians does not entail unreasonable additional travel Strengthened performance management: time for patients). Strong performance management is crucial for driving sustainable improvement in primary Tightened contracting and reimbursement: care. It includes three key elements: first, payors Many payors, particularly those in tax-based must define the standards by which they will systems, use block contracts or calculate measure primary care performance and develop their reimbursement to GPs based partially or a balanced scorecard that will enable them to wholly on historical patterns (for instance, segment GPs and establish a clear segmentation the number of patients seen in the previous (or rating) based on their performance. To year). However, these approaches do not reflect ensure simplicity and focus, the scorecard should current activity levels or quality of care. By include only a manageable number of appro- tightening their contracting and altering their priate metrics, but the metrics must be diverse to reimbursement formulas, payors can ensure make certain that they encourage the right that the money they are spending rewards behaviors—thus, the scorecard should include higher levels of activity and increases patients’ metrics that assess population-wide preventive access to care. For example, payors can agree measures (for example, coverage), to reimburse for some forms of treatment patient outcomes (such as mortality or on a fee-for-service basis. They can also use admissions rates), and -management pay-for-performance or other financial incentives efforts (for instance, blood-pressure and to encourage improved quality. cholesterol levels). The selected metrics should also be explicitly linked to any performance There is, however, a danger that payors should goals included in contracts or incentive schemes. be aware of if they opt to pull this lever. As Second, a management process that includes they move away from block contracts and histor- regular performance dialogues must be put ically based funding, payors must make sure in place; the frequency of monitoring should be Five strategies for improving primary care 75

proportionate to each GP’s rating. Third, a set Coordination is hampered, however, by the fact of interventions to address underperformance that few health systems have effective methods must be established. The performance- for ensuring that information is transmitted to management system—and its implications— the appropriate places. Ensuring that such should be communicated clearly to all GPs. communication takes place does not require that all providers be part of a single organization. Improving the operating model: This lever However, it does require that all providers is conceptually simple but often difficult to imple- commit to sharing information and coordinating ment. For example, it often makes a great care and that a strong IT system operating on a deal of sense to move physicians away from small joint platform is available to facilitate data (often solo) practices and into larger primary exchange. Payors can encourage this type of care practices or polyclinics (which include a wider alignment through their contracting (for instance, variety of services, including diagnostics and by requiring the providers to report the same set outpatient clinics). Larger practices and polyclin- of metrics). ics allow physicians to achieve economies of scale in some areas, such as administration. How these levers have been used Furthermore, having a mix of physicians The levers we just described can be used in working together can improve quality and provide various combinations to enhance the delivery of a more attractive working environment for primary care services. In Sweden, for example, new physicians (which might then help increase several regional health authorities have used the workforce supply). competition, contracting, and reimbursement. In , a primary care trust (PCT) has focused If a health system does decide to change its on competition and performance management. In primary care operating model, it should Germany, a private payor changed its operating consider a question even more radical than model and its approach to contracting. where physicians should work—it should ask whether certain primary care services need Swedish primary care reform—Vårdval to be delivered by physicians at all. In the In response to concerns from politicians about , for example, certain nurses with poor access to primary care, 3 of the 21 regional advanced training (nurse practitioners) are health authorities in Sweden have launched legally able to perform physical examinations, primary care reform programs called Vårdval, take patient histories, prescribe drugs, and and several additional authorities are planning to administer many other basic treatments. Nurse launch similar programs. The reforms have practitioners can usually provide these serv- focused primarily on three areas: improving each ices at a much lower rate than physicians typically patient’s opportunity to choose among GPs, can, but with comparable quality. increasing the number of private providers, and having reimbursement follow each patient’s Increased integration: As we discussed earlier, choice of provider. Because there are a number of GPs are typically responsible for coordinating design choices in each of these areas, the regional with all the other health professionals and health authorities have implemented their organizations that provide care for a patient. reforms in slightly different ways. 76 Health International 2009 Number 8

London PCT This PCT, which covers one of the most deprived areas of London, had the worst record for primary care access in England. It was also concerned that at least some of the primary care services it was paying for were suboptimal. It therefore decided to employ two levers—competition and performance management—to improve care Although the reforms are still in their early days, access and quality. initial results suggest that the regional health authorities are increasing access to care. In the In England, GPs are private practitioners who Stockholm area, for example, results from the contract with the PCTs to provide patient first six months show that patient visits to GPs care. Thus, they theoretically compete with each rose by 12 percent, and most of the increase other, but in reality, this does not often occur. occurred in previously underserved areas. To introduce competition, this PCT contracted Furthermore, the number of GP offices grew by with a private company to staff a large polyclinic. 10 percent; the percentage of patients listed with It also removed several of the worst-performing specific GPs rose to 91 percent, from 87 percent; GPs from its rolls. In addition, the PCT took and patients’ satisfaction with access times a number of steps to improve the performance of increased to 82 percent, from 76 percent.5 its weaker GPs; for example, it analyzed the problems their practices were encountering, gave All of the regional health authorities will be them specific recommendations for change, continuously evaluating the results of and then developed a suite of tools they could use their reforms, and they plan to adjust their to strengthen their operations. In addition, the efforts as needed to counteract any negative PCT implemented new procedures that strength- effects they detect (for example, decreased ened its ability to assess the GPs’ performance. attractiveness of practicing medicine in The PCT then announced that it would monitor socioeconomically deprived areas, lower the GPs’ performance and require them to report prioritization of patients in certain age groups). certain metrics. In addition, the regional health authorities are reviewing their reimbursement models to The effect of these changes was dramatic. ensure that, to as large an extent as is possible, Many of the local GPs realized that they would the models reimburse for actual care delivered. have to provide better access and better care quality if they wanted to retain their patients, and Primary care reform is likely to become more their productivity rose markedly. Access to widespread in Sweden, because the government is primary care also improved significantly; on one planning to enact a law requiring all regional national survey, this PCT showed greater health authorities to introduce Vårdval reforms. improvement than any other PCT did. As a result, 5“ Vårdval Stockholm 2008 – Första Kartläggningen,” The law focuses on the free establishment of GP the number of patients who sought treatment Hälso- och offices and reimbursement that follows patients’ in the PCT’s emergency rooms has dropped and sjukvårdnämndens förvaltning. free choice of providers. patient satisfaction has risen substantially. Five strategies for improving primary care 77

By increasing competition and strengthening on their access to specialists, the insurer waives performance management, the PCT was the quarterly copayment fees for physician visits. able to increase its primary care capacity by a third. Furthermore, it has been able to The new contracts were introduced only sustain the improvements through ongoing in May 2008, and thus it is too early to tell what performance management, including their long-term impact on health care costs regular assessment of key access metrics. will be. However, the insurer has already reported that it is signing up thousands of patients German private payor each week and is on track to meet its enroll- A large health insurer in Germany wanted to get ment targets. better control over its health care costs and, simultaneously, improve the quality of the care it was paying for. It therefore took advantage of changes to German law that would allow it to Any payor or health system that wants to use one contract for services directly with physicians or more of these levers to improve primary (previously, the country’s medical associations care services must first define the problem it is had served as intermediaries). trying to correct; it must also consider the feasibility of implementation. In addition, the Under the new contract, a GP signs up patients, payor or health system must remember that it who agree to use that GP as their primary should not try to do too much at once; focus is point of contact for health care. The insurer crucial when the reforms will affect a large pays the GP an annual flat amount for each number of diverse providers. It is also crucial that beneficiary he or she signs up and a quarterly the GPs be engaged in the reforms throughout flat amount for each patient actually seen; the process; they must be given a clear under- the GP is also given additional amounts for standing of how the changes will benefit them— treating chronically ill patients and performing and the patients they serve. certain preventive services (for example, screenings). The new contract is attractive to GPs because it increases their earning potential significantly (previously, they were at a severe Elisabeth Hansson, an associate principal economic disadvantage to specialists), but in McKinsey’s Stockholm office, works extensively on strategies for health care payors, including primary it also increases their overall responsibility for care reform in the Scandinavian countries. Sorcha health care costs. For example, the GPs must McKenna, PhD, an associate principal in the consent to meet certain performance targets, such Dublin office, has served numerous clients on primary as restrictions on their prescription-writing care commissioning and improvement. The authors behavior. They must also agree to work more colead McKinsey’s primary care interest group. closely with the insurer and to meet periodically with company representatives to discuss how they can improve the quality and efficiency of the care they deliver. To encourage patients to use their GPs as gatekeepers and accept restrictions