The paradox between the evidence supporting primary care and how international health systems are run

1. The paradox between current models of
Primary Care and evolving Evidence Based
Medicine concepts – International
comparisons
William Behan
November 2014
National Primary Care Conference
Lyrath Estate, Kilkenny, Ireland
twitter@DrWilliamBehan

2. Health vs Healthcare Activity
WHO definition of Health
Health is a state of complete physical, mental and social
well-being and not merely the absence of disease or
infirmity (1948)
Determinants of health
Income and social status, Education, Gender,
Physical environment, Social support, Genetics, Personal
behaviour and coping, Health services - access and use of
services that prevent and treat disease influences health

3. Health vs Healthcare Activity
Health industry related activities
Clinical: Acute and Chronic including long term care,
Education, Research, Administrative, Pharma, Infrastructure
Development, Insurance, Promotion/Public Relations, Legal
(Defensive Medicine)
What does the payment model reward?
Marginal cost vs Marginal Benefit
Opportunity Cost: benefit, profit, or value of something that
must be given up to acquire or achieve something else
Price vs Cost vs Value eg. Pandemic Influenza
Finite Budget – Good or Bad?

4. U.S. Hospital Administration Costs Exceed All Others by Far
• 25 percent of total U.S. hospital spending = Administrative costs
• Reducing U.S. spending for hospital administration to Scottish or
Canadian levels would have saved more than $150 billion in 2011
Monopolizing medicine: Why hospital consolidation may
increase healthcare costs
• Financial incentives in the current payment system: Same Doctor Visit,
Double the Cost: “Facility Fees”
• Survey by American Medical Association: 58% of family physicians and
50% of internists are employees.
Eg.: In 2011 Medicare spent €1.5 billion more on only two services alone:
evaluation and management visits and ECHO fees due to changes alone

5. Professor Kaplan: Time-Driven Activity-Based Costing in Healthcare

8. Marc Jamoulle: Quaternary Prevention 1986
Combine Narrative and Evidence Based Medicine

9. Marc Jamoulle: Quaternary Prevention 1986
Combine Narrative and Evidence Based Medicine
Too Much Medicine Campaign, BMJ 2002 & 2013
Highlight the threat to human health posed by over-diagnosis and the
waste of resources on unnecessary care
Measuring Low-Value Care in Medicare JAMA 2014
Australian Study:150 Potentially Low-Value Health Care Practices:
Cervical & Prostate cancer screening in elderly. Back imaging for patients
with low back pain
The low-value services accounted for 0.6% to 2.7% of overall spending but
these findings may be just the ‘tip of the ice berg’
General health checks don’t work Editorial: BMJ 2014;348:g3680
Screenings and Executive Physicals: Hazardous to Your Health JACC 2014

10. THE INVERSE CARE LAW
Julian Tudor Hart 1971 Lancet
• The availability of good medical care tends to vary inversely
with the need for it in the population served
• Operates more completely where medical care is most
exposed to market forces, and less so where such exposure is
reduced
• BMJ Editorial 2012: Doctor-patient relationship more
adversely affected in deprived areas by the lack of time

11. Recent International Evidence Supporting Primary Care
2009 Annals of Family Medicine editorial; ‘The Paradox of Primary Care’
• “Different levels of analysis yield different views”
• The Paradox of primary care is that primary care provides poorer quality
disease specific care but better overall patient outcomes and at lower costs
compared to specialty care
2012 Barbara Starfields SESPAS Report
Adding one more one primary care physician per 10,000 population reduces
• death rates from 2% to 6%, particularly reducing health inequality
• inpatient admissions by 6%, outpatient visits by 5%, emergency room visits
by 10%, and surgeries by over 7%

12. Recent International Evidence Supporting Primary Care
2014 Annals Family Medicine editorial:
‘Health Is Primary: Family Medicine for America’s Health
• 2007-11 Rhode Island increased primary care spending from
5.4% to 8.0%: 23% increase in primary care spending = 18%
reduction in total spending:
• 15-fold return on investment. (Commonwealth Fund 6-fold)
BMJ 2014 Review 48 studies:
• Seeing the same GP each time can reduce emergency
department attendance BMJ 2014;349:g4847

13. Small US Primary Care Physician Practices Have Low Rates
of Preventable Hospital Admissions
Survey of 1,045 primary care practices found that:
• Practices with three to nine physicians had 27 percent lower unnecessary
admission rates compared to larger practices
• One or two doctor owned practices had 33% lower preventable hospital
admission rates than practices with 10 to 19 physicians
• The largest practices had in place significantly more patient-centered
medical home processes which were not associated with lower rates of
preventable hospital admissions
• Small practices have unmeasured characteristics that may contribute to
their lower rates of preventable hospital admissions (Patient-staff relatnshp)
• Practices owned by physicians had significantly lower ambulatory care–
sensitive admission rates than those owned by hospitals.

14. Irish Health Policy Development Time Line
2001 Department of Health: Health strategy document ‘Primary Care; A New
Direction’ - 1978 Declaration of Alma Ata
2003 Brennan Report: health service administration & financial accountability
2003 the World Health Report “health systems with strong, integrated primary
care are associated with better outcomes probably because they provide for
more comprehensive, longitudinal and coordinated care”
2004 Irish College of General Practice attributes of primary care: personal, first
contact, continuous, comprehensive, co-ordinated, cost effective, high quality,
equitably distributed, community orientated & accountable (WONCA)
2014 – HSE/DoH ignores all recent evidence on what makes public health care
more equitable, cheaper and effective but refers to 1978 Alma Ata

15. Quality of Healthcare in Ireland
Comparing the USA, UK and 17 Western countries' efficiency and
effectiveness in reducing mortality 1979-2005: JRSM 2011
First Ireland
2nd UK
17th USA
Perceived and reported access to the general practitioner: An
international comparison of universal access and mixed
private/public systems
K Galway, A Murphy, A Kelly, A Gilliland, AW Murphy, D O'Reilly, T O’Dowd, C O'Neill, E Shryane, K Steel, G Bury
Ir Med J. 2007 Jun;100(6):494-7
How quickly do you get to see
a PARTICULAR doctor? n (%)
Country NI ROI
Same day 12.7% 40.1%
Next day 18.4% 32.5%
2 working days 19.0% 13.6%
3+ working days 45.0% 8.1%

16. Universal Health Insurance Ireland
Costs?
Cover current private budget = €5.5 billion
+ Excess administrative costs due to Kaplan style
multipayer fee-per-item system: 10% €18.3 billion = €1.8 billion
Total = €7.3 billion
Who Pays?
Ireland population: 4.6 million
Non-payers, current medical card patients: 1.92 million
Next 30% “nominal payment”: 1.38 million
Balance population to pay approx. €6 billion: 1.3 million
= €4,600 per man, woman or child or €18,400 per family

17. Leadership skills
• Integrity/Fairness/Honesty
• Technical Competence/Understand program,
• True engagement with team (Arnstein’s Ladder)
• Vision/Creativity/Initiative => Proactive>Reactive
• Ability to Delegate
• Communicate: both transmitting and receiving information
• Commitment/Enthusiastic
• Open to Change
• Motivate/Team Builder/Enable members of group to grow

18. 3.1 3.4
2.5
4
3.5
3
2.5
2
1.5
1
0.5
0
K Lynch
predicted
figure
Gov. Survey
GMS 2 week
recollection
Gov. Survey
Private 2
week
recollection
UK
QRESEARCH
Audit
IMJ GMS
Audit
IMJ Private
Audit
Lifeways
2006 GMS
Under 5s
Audit
Lifeways
2006 Private
Under 5s
Audit
Under 6s attendance rate:
Minister Kathleen Lynch Figures

19. 3.1 3.4
2.5
6.5
7
6
5
4
3
2
1
0
K Lynch
predicted
figure
Gov. Survey
GMS 2 week
recollection
Gov. Survey
Private 2
week
recollection
UK
QRESEARCH
Audit Under
6s
IMJ GMS
Audit Under
6s
IMJ Private
Audit Under
6s
Lifeways
2006 GMS
Under 5s
Audit
Lifeways
2006 Private
Under 5s
Audit
Under 6s attendance rate: UK figures

20. 3.1 3.4
2.5
6.5 6.6
5.1
7
6
5
4
3
2
1
0
K Lynch
predicted
figure
Gov. Survey
GMS 2 week
recollection
Gov. Survey
Private 2
week
recollection
UK
QRESEARCH
Audit Under
6s
IMJ GMS
Audit Under
6s
IMJ Private
Audit Under
6s
Lifeways
2006 GMS
Under 5s
Audit
Lifeways
2006 Private
Under 5s
Audit
Under 6s attendance rate: NUIG figures

21. 3.1 3.4
2.5
6.5
5.8
2.7
6.6
5.1
7
6
5
4
3
2
1
0
K Lynch
predicted
figure
Gov. Survey
GMS 2 week
recollection
Gov. Survey
Private 2
week
recollection
UK
QRESEARCH
Audit Under
6s
IMJ GMS
Audit Under
6s
IMJ Private
Audit Under
6s
Lifeways
2006 GMS
Under 5s
Audit
Lifeways
2006 Private
Under 5s
Audit
Under 6s attendance rate: 2014 IMJ
What figures do you believe?

22. Individual Performance and Burnout
• Satisfying work provides autonomy, complexity, and a
connection between effort and reward - Malcolm Gladwell
• Should there be a relationship between the added value an
individual brings to an enterprise and remuneration?
Burnout
• Cognitive, emotional and physical intensity of job (Good features also)
• Patients poor access to resources/being deprived of their entitlements
• Lack of association between national policy and best evidence based
practice
• Politics/public service unions driving health care policy
• Clinical leaders having to cede all authority to administrators
• Lack of association between health care inputs and outputs

23. Burnout
• Regulatory bodies confusing bureaucratic achievements/ adherence
with hospital based protocols with good primary care
• Good work is penalised (particularly in US)
• Unnecessary administration/bureaucratic barriers to fair payment
• Hostile media
• General Practice exposed to much greater financial cuts than public
service
• Media/corporate healthcare influences on patients causing
inappropriate scaremongering.
• Patients unrealistic perceptions
• Constant weight of personal responsibility and public accountability
• Dealing with uncertainty

24. Affect of Stress or Burnout on Performance: Science; 2013
Being preoccupied with money problems affects attention
= 13 IQ points loss on formal cognitive assessment
= losing a night's sleep
= difference in IQ between a person who is a normal adult versus a
chronic alcoholic
Annals of Family Medicine; 2014
Care of the Patient Requires Care of the Provider:
The Triple Aim—enhancing patient experience, improving
population health, and reducing costs
Burnout is associated with lower patient satisfaction, reduced
health outcomes, and it may increase costs
Burnout thus imperils the Triple Aim

25. The paradox between current models of Primary Care and
evolving Evidence Based Medicine concepts
US Model
• Healthcare run by corporations
• Total health spend: 16.2% GDP
• 4% total health spend on general practice
• Fee-per-item with heavy emphasis on administration not true outcomes
• Focus on commoditising and fragmenting care
• Activity generation is promoted by hospitals buying up primary care
• Medicare / Health Maintenance Organisations policies promotes this by
paying more to GPs attached to hospitals
• Outcomes: Profit
• Most inefficient in the OECD

26. The paradox between current models of Primary Care and
evolving Evidence Based Medicine concepts
UK Model
• Universal Entitlement
• Total health spend: 8.9% GDP
• 8% public spend or 7% total health spend on general practice
• Very big GP practices – less continuity of care
• Capitation payments > Fee-per-item
• Focus political agenda primary care on consumer wants > needs
• Massive burden of clinical & social care as well as administrative
activity
• Rewarding easily measured outputs rather then true outcomes
• High death rates

27. The paradox between current models of Primary Care and
evolving Evidence Based Medicine concepts
Irish Model
• Oldest, Poorest & Sickest have Full Entitlement – Most Equitable
• Total health spend: 8.5% GDP
• 3.2% HSE spend or 2.5% total health spend is on GP
• Possible total spend including private income 3.8% (Gov. data)
• Smaller GP owned practices: more accessible, flexible,
innovative, personalised service & more continuity of care
• GMS Capitation payments > Fee-per-item/Private Fee-per-item
• General Practice is focused on consumer needs > wants
• Massive drive to corporatise, increase bureaucracy, commoditise
and fragment care, removing clinicians from policy decisions

28. The paradox between current models of Primary
Care and evolving Evidence Based Medicine
concepts – International comparisons
What Works Well
Small, motivated, well resourced GP led surgeries with good
administrative, nursing & I.T. focusing on personalised patient care >
disease care being paid on a predominantly capitation basis
What Does Not Work
Large, over-resourced, highly bureaucratic, corporate primary care
centres with good administrative and I.T. support where individual
clinicians focus on administering fragments of care rather than
whole patient outcomes being paid on a commoditised, fee-per-item
basis
William Behan
twitter@DrWilliamBehan