Improving primary care in Europe and the US:
Towards patient-centered, proactive and coordinated
systems of care
The Rockefeller Foundation Bellagio Study and Conference Center, Italy
April 2 to 6, 2008
How incentives work
The Catalan single purchaser
integrated care experience:
evaluation results
Josep M. Argimon
Framework
Context:
 Chronic disease management
Goals:
 Promote cooperation among providers
 Facilitate the integration process of a fragmented
health system
Means:
 Provider payment mechanisms: Capitation
Purchasing 1.0: competition
System:
 Per health services lines since early 90’
INCENTIVES
Primary
Care
Adjusted
capitation
Activity
Specialized
adjusted by
Care
complexity
Costconsciousness
Poor incentives
for coordination
Purchaserprovider split
Sum-zero game
Clarity of rules
(contracts)
No risk sharing
Capitation pilot
Context:
 (2001) 5 pilots to test capitation as contract base for
integrated services
Goals:
 To improve healthcare equity, continuity and efficiency
through the promotion of territorial alliances among
providers
Method:
 Average per capita expenditure adjusted by “need”
proxies
Purchasing 2.0: coopetition
System:
 Integrated health services for a defined population
INCENTIVES
Strong incentives
for coordination
Primary
Care
Adjusted
per capita
expenditure
Specialized
Care
Risk sharing
Costconsciousness
Purchaserprovider split
Identity risks
Evaluation
Selected health indicators (2006)
Pilot
Control
Cat
CV risk assessment (%)
43.1
32.3
39.4
Geriatric assessment (%)
53.9
51.1
51.1
 BP (% control)
40.5
37.6
39.4
Diabetes (% control)
54.0
57.4
58.3
ACSC
6.9
7.1
6.8
Pre-alt
79.1
66.9
70.8
7.4
9.1
9.1
11.6
10.2
11.8
4.0
4.6
4.8
Generic drugs (%)
23.8
20.9
21.1
Global satisfaction
7.7 ± 1.7
7.6 ± 1.6
7.7 ± 1.7
Readmissions (%)
HF
COPD
Emergency room
Evaluation
Quantitative study:
 Chronic conditions selected: heart failure, COPD....
Qualitative study (2005):
 Semi-structured interviews to managers and health professionals
 Narrative analysis
Results:





Great variability of perceptions and facts
Good alternative to resource allocation
More dialogue and increased trust and transparency.
A service quality improvement tool.
Lack of knowledge in the base line
Conclusions
Qualitative study:
 Payment mechanisms need to be paired with
purchaser’s policy making capacity.
 Integrated networks perform better when cost,
benefits and risks are shared.
 Creating a culture of trust and cooperation needs time
 Managers and professionals need to be involved
Thank you