The Paradox between current models of Primary Care and evolving evidence based medicine concepts - International comparisons

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
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

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

8. 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 overdiagnosis 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

9. 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

10. 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% percent to 6%, particularly reducing health inequality
• inpatient admissions by 6%, outpatient visits by 5%, emergency room visits
by 10%, and surgeries by over 7%

11. 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

12. 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

13. 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%

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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