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Ministry of health 2003 investing in health

ministry of health 2003 investing in health

An update to the recommendations of Investing in Health A Framework for Activating Primary Health Care Nursing from the New Zealand. Investing in people's health also boosts economic growth by within the framework for action in the field of public health ( to ). The trend for increasing healthcare costs to individuals, the health sector and wider society is significant. Public health can be part of the. BGP HIJACKING BITCOINS

Friedman and Basu report similar findings, especially regarding the incidence of ACS admissions for children in three American states in There were substantial negative associations between the ACS rate and the availability of primary care services, and with the distance travelled to hospital and insurance coverage. These findings are similar to those of Haynes et al. This under-utilisation has probably contributed to the substantial rise and increased social differentiation in hospitalisation rates.

Jackson et al. New Zealand DHBs have, since , been charged with developing a local health service that integrates both primary and secondary care. Problems of access and associated hospital costs, then, are a challenge to these new institutions, and it is to a discussion of such issues that we now turn. Fee-for-service not only created barriers for patients, but provided little incentive for collaborative approaches by GPs or linkages with other parts of the health sector. However, during the s, in response to the proposals for health reform, general practice underwent a fundamental reorganisation with the development of primary care organisations of various kinds.

IPAs are professional collectives, owned and governed by their GP members, and while many have developed service and integrated care initiatives, the initial impetus for their formation was largely reactionary. They were concerned mainly with protecting the status of general practice and becoming a more effective negotiating body with regional purchasers, rather than with issues of access to care Barnett , Barnett et al.

An alternative to IPAs has been the development of the important, if numerically less significant, "third sector" provider network Crampton et al. These organisations rely on a community and multidisciplinary governance model and have goals related to improving access and serving disadvantaged groups. In promulgating PHOs, however, the government's policy discourse appeared to downplay IPAs, instead endorsing a community-orientated model along the lines of third sector organisations as the preferred vehicle to achieve its policy ends Minister of Health b.

Given the emphasis on equity of access it is not surprising that the PHOs are to be broad-based organisations composed of various primary care providers, such as iwi groups, midwives and non-government organisations, in addition to GPs. The new organisations are envisaged as being locally based, with population funding and having a particularly important role in the development of public health initiatives.

No single provider group must be seen to dominate Minister of Health a. A key prerequisite for PHO status is a register of the enrolled population in order to permit the application of the capitation funding formula Ministry of Health The new "low-cost access" formula encourages the formation of PHOs in areas of high health need. The additional funding will allow all enrolees to be charged low co-payments, or to access free care, making the CSC redundant.

For PHOs enrolling people from less deprived areas an "interim formula" will apply until sufficient funding is available for all PHOs to be on the low-cost formula Ministry of Health a. The interim formula will use the same variables as the low-cost access formula age, gender, ethnicity, deprivation and High User Health Card status , but with an additional weighting for CSC status. At the same time the threshold for the low-cost access formula will gradually be reduced to encompass a greater number of practices and PHOs.

In addition, funding pharmaceutical and laboratory tests through PHOs will be based on a needs-based formula. Of these 34 PHOs, 22 are funded under the low-cost access formula, thus reducing the financial barriers to access for all enrolees. Criticisms were based on the inevitability of temporary local inequities of access for PHO and non-PHO patients in local areas, the competitive edge that GPs in PHOs will have in attracting patients compared with non-PHO doctors, and concerns over the lack of effective targeting for specific high health needs.

IPAC referred to the funding model as "flawed and unfair" and strongly promoted an alternative based on more individualised needs-based funding IPAC The Minister initially rejected IPAC's overtures but subsequently agreed to test the proposals in selected areas, but without compromising her full support for the existing formula.

Although PHOs are not all geographically based, and there may be several PHOs covering similar areas, they nevertheless represent a much stronger orientation to locality-based primary health care. This represents a fundamental shift in both the organisation and funding of primary care in New Zealand, a strategy that is not entirely without problems. In the following discussion we briefly outline some of the potential benefits as well as the major challenges likely to arise from adopting a PHO-based targeted approach to addressing equity and access issues in primary health care.

There are likely to be improvements in population health, reductions in hospital use and greater empowerment for both co-operating providers and involved consumers. While the introduction of capitation, in itself, is no guarantee of improved access and population health, there is evidence that countries or areas with a strong primary health care orientation and fewer barriers to access have more positive health outcomes Shi , Shi , Vogel and Ackermann Starfield , , for instance, has shown that countries with a stronger primary health care infrastructure have better health outcomes than countries that do not, and that this is true particularly in countries where services are delivered by multidisciplinary teams.

Strong primary health care also has an added advantage of potentially reducing hospital admissions. This is an important objective in New Zealand given high levels of hospital spending as a percentage of total health care spending compared with other countries in the OECD Anderson and high levels of ASC admissions Jackson and Tobias There is, of course, no simple relationship between access to primary care and rates of hospital admission Ricketts et al.

However, evidence from the United States Roemer et al. Similarly, in New Zealand a number of studies have shown significant decline in hospitalisation following the removal of patient charges for GP consultations Moffat and Scott , Dovey If enrolment in PHOs leads to greater continuity of care, especially given frequent changes of doctor by very deprived patients Malcolm b, Barnett , then fewer hospitalisations are likely Weiss and Blustein However, while it is expected that PHO development will lower rates of admission, there will be a need for careful monitoring of trends in admission of patients from PHO and non-PHO practices.

Thirdly, the development of PHOs with a greater community emphasis has the potential to increase social empowerment among disadvantaged populations. This is significant because cultural as well as economic barriers influence the use of services.

While some IPAs have attempted to enlarge their community focus, the delivery of more community-oriented services has been more characteristic of "third sector" providers. In addition, given the aim of PHOs to foster broader links between a variety of organisations, the potential for a more holistic and social model of health is created. This may play a role in improving not only access to services but also other social conditions that lead to inequalities in health.

With respect to targeting, the funding formula for PHOs uses the characteristics of the areas in which people live, not the attributes of individuals themselves, as the basis for calculating funding levels. Such an approach presents three possible problems.

First, many individuals who are not deprived live in poorer neighbourhoods Barnett Area deprivation even when measured at the meshblock level , therefore, may not necessarily be an accurate measure of individual deprivation. Second, the degree to which deprivation is concentrated or dispersed is also an issue Fieldhouse and Tye Where deprivation is spatially concentrated, PHOs are more likely to qualify for the low-cost access formula and draw most of their patients from deprived areas.

However, even if this is the case, it is still likely that greater numbers of deprived people will live outside such areas than within them Eyles , Powell and Moon , Blakely and Pearce On the other hand, if deprived persons are spatially dispersed then PHOs may be financially disadvantaged because area deprivation scores will under-represent the individual level of deprivation.

Third, since some PHOs will comprise a diverse and geographically dispersed set of member organisations and clientele with special needs, in such cases it will be more difficult for PHOs to focus on local social and environmental contextual factors which also influence population health Macintyre et al. However, given that PHOs are not themselves specifically area-based they may have some difficulty in doing this.

The second challenge, the use of two need-based formulas to fund PHOs, is difficult and not usual in policy terms. Benefits to patients will vary depending on the composition of their PHO overall, with access formula PHOs being able to provide greater benefits than those with interim formula funding, thus providing additional, if temporary, funding differentials.

The robustness of the formulas in reflecting differential need becomes particularly important. Much the same criticism was levelled at the early application of the Jarman Index in the United Kingdom, resulting in regional modifications in its application Moore Third, while the government asserts that any inequities created by the use of two formulas may be temporary, this has the potential to distort utilisation and lead to inappropriate use of services.

While deprived patients will benefit if they are enrolled in PHOs, if their PHO is funded under the interim formula they will benefit less than equally or less deprived people in access-funded PHOs. In access-funded PHOs less deprived patients will also receive privileged access and so inappropriate use of services may result.

There is mixed evidence over the extent to which this might occur. Similar findings are evident in Northern Ireland where, following the introduction of geographically based targeting in the early s, GP workloads showed little relation to area deprivation Moore On the other hand, Dovey's work indicates that since the introduction of the Free Child Health Care Scheme in the increase in GP consultations was most profound among infants in the lowest socio-economic group Dovey et al.

While the development of PHOs will undoubtedly increase government spending on primary care, the extent to which this occurs will, in part, depend upon two things: the extent to which capitation provides an incentive to PHOs to control unnecessary utilisation on the part of their more affluent enrolees, and the degree to which individual fee-for-service providers within PHOs respond to such pressures Raymont and Cumming Finally, while the Primary Health Care Strategy has given political prominence to PHO development, it needs to build on the significant advances made by IPAs since the mids in promoting population health and in managing the use of pharmaceuticals and laboratory tests Malcolm et al.

IPAs, however, were less successful in dealing with equity issues Ministry of Health d , and although governments and funders since the mids have tried to address this, the continued concentration of doctors, and subsequent over-servicing Malcolm a in more affluent areas has led to significant increases in costs Barnett At the same time "shortages" in poorer areas limit the achievement of equity objectives Ministry of Health d.

The implication is that limiting or removing co-payments for care through PHOs is, in itself, unlikely to produce greater equity if significant geographic barriers to the use of services remain Haynes et al. Furthermore, the current presence of two systems of financing and care PHOs and IPAs , even in the short term, is likely to create local differences in access for persons of similar need and maybe create inequities for practitioners, which may influence supply and distribution in unknown ways.

The way in which medical practice is incorporated into PHOs, avoiding polarisation and factionalism, will be an important prerequisite for attaining equity objectives Greater Wellington Health Trust It represents a fundamental shift in national primary health care policy away from an individual to a population focus although this has been emerging among primary care organisations for some time , and from fee-for-service to a funding approach stressing capitation with reduced co-payments, with inter-regional distribution of funds based on population need.

The potential is for a fairer system of primary health care where services will be more freely available to those in need. However, improved equity of access may be difficult to achieve, given the problems and risks in developing PHOs. In New Zealand these include fragmentation of providers, inadequate attention to the regional sensitivity of allocation formulas, concern over the extent to which funding should be based on individuals or areas, and the extent to which full participation of both providers and the public is secured.

Given the significant additional investment by the government, PHOs will need to demonstrate not only fairer access to primary care reductions in health inequalities, but also improvements in population health overall. References Acheson, D. Anderson, G. Poullier "Health spending, access, and outcomes: trends in industrialised countries" Health Affairs, Barnett, J. Barnett and R. Kearns "Declining professional dominance?

Coyle and R. Kearns "Holes in the safety net? Kearns "Shopping around? Lauer "Urban deprivation and public hospital admissions in Christchurch, New Zealand, " Health and Social Care in the Community, 11 4 Newton "Intra-urban disparities in the provision of primary care: an examination of three urban areas" Australia and New Zealand Journal of Sociology, Barnett, P.

Grumbach, D. Osmond, M. Komaromy and K. Vranzian "Preventable hospitalisations and access to health care" Journal of the American Medical Associati on, Blakely, T. Brown, M. Crampton "New Zealand policy strategies concerning the funding of general practitioner care" Health Policy, Coburn, D. Crampton, P. Dowell and A. Woodward "Third sector primary care for vulnerable populations" Social Science and Medicine, Dowell, A. Woodward and C. Salmond "Utilisation rates in capitated primary care centres serving low income populations" New Zealand Medical Journal, Davis, P.

Gribben, R. Lay-Yee and B. Gribben, A. Scott and R. Lay-Yee "The supply hypothesis and medical practice variation in primary care: Testing economic and clinical models of inter-practitioner variation" Social Science and Medicine, Lay-Yee, S. Maingay and B.

Gribben a "Patterns of general practitioner usage among Pacific people: indicative results from the Waikato medical care survey " New Zealand Medical Journal, Lay-Yee, O. Sinclair and B. Donelan, K. Blendon, C. Schoen, K. Davis and K.

Binns "The cost of health system change: Public discontent in five nations" Health Affairs, Dovey, S. Morton and M. Tilyard "What is happening to primary health care access for young children? Eyles, J. Herbert and D. Smith eds. Horwood and F.

Shannon "Patient perceptions of general practitioner fees" New Zealand Medical Journal, Fieldhouse, E. Tye "Deprived people or deprived places? The Primary Care Network model allows for wide local variation in the organization and delivery of services. As of January , there were thirty-nine Primary Care Networks, with 3 to physicians, averaging 58 physicians per network as well as other health professionals, which may include nurses, dietitians, social workers, mental health workers, and pharmacists.

Given the networks' large size and organizational diversity, the extent to which care is delivered by teams at the practice level is highly variable. The Ministry of Health and Social Services hopes to accredit groups, which are expected to cover 75 percent of Quebec's population.

Family Medicine Groups consist of six to ten physicians working with nurses and sometimes other providers to offer primary care services to registered patients on the basis of contractual agreements with the provincial government. A second private clinic model, the Network Clinic, was established in many regions through contractual agreements with regional health authorities.

Network Clinics have an enhanced interdisciplinary team and complement Family Medicine Groups by providing extended hours of service and on-site access to diagnostic services Pineault et al. Introduced in , CLSCs were intended to be the dominant or exclusive model of primary health care in Quebec. Early evidence suggests that the performance of Quebec's Family Medicine Groups is superior to that of other primary health care models Beaulieu et al.

For example, Beaulieu and colleagues found that the integration of nurses and a linked clinical care protocol in Family Medicine Groups had a positive impact on the accessibility, coordination, and comprehensiveness of care and patient knowledge.

And in a study of the provision of clinical preventive services, Provost and colleagues found that rates of preventive care delivery were higher in Family Medicine Groups and CLSCs than in traditional fee-for-service practices. Together they now account for 21 percent of family physicians practicing in the province.

The number of family physicians working in interprofessional teams increased from in to more than 2, in early The first Community Health Centres were established in Forty-eight new centers and satellites are now in operation, bringing the number of Community Health Centres not including satellites to seventy-three. Community Health Centres employ more than physicians; nurse practitioners; more than 1, other clinical, health promotion, and community development professionals; and more than administrative and management personnel.

Established in , Family Health Teams are the provincial government's flagship initiative in primary health care renewal and are the first explicitly interprofessional primary health care model introduced to Ontario in three decades. Currently, teams are operational, and 30 are under development. They include more than 2, family physicians and approximately 1, other primary health care professionals, most commonly nurses, nurse practitioners, dietitians, mental health workers, social workers, pharmacists, and health educators.

Nurse Practitioner—Led Clinics are similar in concept to Family Health Teams except that the ratio of family physicians to nurse practitioners is much lower and physicians function mainly as consultants. Four Nurse Practitioner—Led Clinics have been established, and twenty-two are in various stages of development. No studies of Family Health Teams' performance have been published to date, but a multiyear evaluation of the Family Health Team initiative, commissioned by the Ontario Ministry of Health and Long-Term Care, is in its third year.

Smaller-scale initiatives to create interprofessional primary health care teams, some led by physicians and others by the community, are under way in the remaining provinces and territories. Most teams are based in rural or northern regions. Group Practices and Networks The encouragement of group practice and the support of primary health care networks have been a key part of the reform strategies in Quebec, Alberta, and Ontario.

Ontario has created an alphabet soup of primary health care organizational models referred to as Patient Enrolment Models , most of which require participating physicians to be part of a group practice or practice network.

Such models now encompass two-thirds of Ontario's family physicians. Practice networks in Ontario, as elsewhere, include both solo and group practices. Patient Enrollment with a Primary Care Provider Patients' formal enrollment with a primary care physician or group is an integral feature of primary care reform only in Quebec and Ontario.

In both cases, enrollment is voluntary. More than half of the Quebec population is currently registered with a family physician; enrollments with a primary care physician in Ontario grew from , in to 9. Financial Incentives and Blended-Payment Schemes During the past decade, primary health care reform initiatives throughout Canada have included a shift from unitary physician payment methods mainly fee-for-service but also capitation or salary to payment arrangements that include blends of fee-for-service, capitation, salary, or payments per session e.

Nationally, the proportion of family physicians who receive 90 percent or more of their professional income from fee-for-service payments declined from The shift has been most far-reaching in Alberta, Quebec, and Ontario in association with the development of Primary Care Networks, Family Medicine Groups, and patient enrollment models, respectively, and in British Columbia through a program of targeted incentive payments known as the Full Service Family Practice Incentive Program.

Alberta's Primary Care Network physicians receive a base remuneration usually fee-for-service plus targeted payments for after-hours coverage and other priority activities. Quebec's Family Medicine Groups receive a small annual fee for each registered patient, supplemental fees for registered patients from vulnerable populations, and payment for time spent attending meetings and completing paperwork.

Funding also is available to support staffing, premises, and information technology. The bulk of the remuneration for physicians in Family Medicine Groups and Network Clinics continues to come from fee-for-service payments Pineault et al. The two-thirds of Ontario's family physicians who practice in a Patient Enrolment Model are paid through various blends of capitation, fee-for-service, and targeted payments.

Capitation is the principal component for 50 percent of Patient Enrolment Model physicians, and fee-for-service is the main element for another 45 percent. The rest receive salary-based blended payments. All payment models include special fees or premiums which vary across models for providing priority services such as care of seniors, enrollment of new patients, and after-hours care. Most payment models include fees for preventive care outreach, pay-for-performance payments for preventive screening and immunizations, and bonus payments for the provision of certain services obstetrical deliveries, hospital services, palliative care, prenatal care, and care of patients with serious mental illness above threshold levels.

A growing, but still limited, body of evidence suggests that the payment models and incentives introduced in Ontario are improving preventive care delivery, chronic disease management, physician productivity, and access to care. A study during the mids of the provision of preventive care to unannounced standardized patients by primary care physicians in south central Ontario found that being paid by salary or capitation versus fee-for-service payment was positively associated with the provision of evidence-based preventive care Hutchison et al.

An econometric study by investigators from the McMaster University Centre for Health Economics and Policy Analysis assessed physicians' responses to financial incentives, including preventive care pay-for-performance bonuses and special payments for priority services e. Using a controlled before-after design, the study found that the pay-for-performance incentives led to an increase over baseline levels in the provision of four of five preventive services: 5.

There was no detectable response to the special payments for priority services above threshold levels. After controlling for patients' sociodemographic factors and co-morbid conditions, treatment and control rates were found to be higher in the Primary Care Network capitation model practices, which were more likely than the fee-for-service practices to employ nurses and nurse practitioners.

Kantarevic, Kralj, and Weinkauf found that Family Health Group fee-for-service-based, blended-payment model physicians provided more services and visits, saw more patients, made fewer referrals, and treated more complex patients than did traditional fee-for-service physicians, suggesting that the incentives included in this model increase physicians' productivity.

Effects on quality of care were not assessed. In a study of after-hours care in a single northern Ontario community, Howard and colleagues observed a lower six-month prevalence of emergency department use by patients of Family Health Network physicians capitation-based, blended-payment model , compared with patients of physicians in Family Health Groups fee-for-service-based, blended-payment model and traditional fee-for-service practices.

Manitoba initiated a demonstration project that supports fee-for-service family physician groups to establish interprofessional collaborative teams and integrate electronic medical records into day-to-day patient management. The initiative includes a pay-for-performance scheme based on twenty-seven clinical process indicators.

Beginning in , the Northwest Territories government negotiated and implemented a wholesale transition from fee-for-service to salary remuneration of family physicians. By , 95 percent of family physicians were on a salary-based contract that includes sick leave, maternity leave, and recruitment and retention bonuses. Primary Health Care Governance The predominance of independent, physician-owned and -managed solo and small-group family practices has inhibited the development of regional or local governance mechanisms for primary health care.

Primary health care providers and stakeholders in most communities and health regions have no collective voice and no means for assuming collective responsibility and being held accountable for addressing their patients' and the local population's needs. The current wave of reform does, however, offer examples of primary health care governance initiatives, sometimes aligned with other reform elements such as funding mechanisms and organizational arrangements.

In Quebec, Family Medicine Groups have been associated from the outset with a set of contractual agreements between accredited clinics and other health institutions at the local, regional, and provincial levels. These contractual agreements formalize the collaboration and sharing of resources among and within primary care clinics. These departments, composed of elected representatives from each local area's pool of general practitioners, have a mandate to coordinate the supply and planning of primary care services and to work in close collaboration with regional health authorities and local health centers.

For example, these departments control the entry of new general practitioners into the area and determine where these newcomers will perform their mandatory emergency room or long-term care service requirements. As such, they represent one of the first attempts at integrating general practitioners into the governance of Quebec's health system. British Columbia has supported the development of Divisions of Family Practice in eighteen communities and plans, by , to extend this support to any community or region in the province where family physicians wish to establish a division.

These divisions are local organizations of family physicians who are prepared to work together at the community level to improve clinical practice, offer comprehensive services to patients, and participate in health-service decision making in partnership with their regional health authority and the Ministry of Health Services.

Five regional health authorities govern, plan, and coordinate health care services in conformity with the goals, standards, and performance agreements established by the Ministry of Health. The divisions are expected to work with their health authority and local community agencies to identify and address gaps in the delivery of health services at the community level. Although membership in the divisions is voluntary, a division must include the majority of family physicians in the community.

Expansion of the Primary Health Care Provider Pool In response to public concerns about access to primary health care and pressure from professional associations and advocacy groups, provincial and territorial governments moved during the last decade to increase the numbers and types of primary health care providers. The greater number of medical school spaces and family medicine residency positions has resulted in a 9 percent rise in the number of family physicians per , Canadians, from 94 in to in Canadian Institute for Health Information c.

Midwifery is now a legal and regulated profession in eight provinces and one territory: Ontario , British Columbia , Alberta , Quebec , Manitoba , Northwest Territories , Saskatchewan , Nova Scotia , and New Brunswick In Ontario, the first province to recognize midwifery and fund midwifery services, the number of midwives has grown by percent since to more than five hundred, and midwives now attend 10 percent of births in Ontario.

Nurse practitioners are licensed in every Canadian province and territory. The number of licensed nurse practitioners in Canada, most of whom are primary health care nurse practitioners Donald et al. In , more than 50 percent of Canadian nurse practitioners were based in Ontario Canadian Institute for Health Information a , and between and , the number of primary health care nurse practitioners licensed in Ontario increased tenfold from to 1, College of Nurses of Ontario , In comparison, the province of Quebec still has fewer than nurse practitioners.

In a study of chronic disease management by Ontario's primary health care practices Russell et al. Perhaps not surprisingly given the population growth, the interprovincial variability in the introduction of nonphysician primary health care providers, and the recency of many of these initiatives, this expansion of the provider pool has yet to be reflected in greater national-level access to care.

For example, the percentage of adult Canadians with no regular place of care rose from 9 to 14 percent between the and Commonwealth Fund International Health Policy Surveys Commonwealth Fund ; Schoen et al. While the percentage that were seen on the same day the last time they were sick increased from 22 to 28 percent, the percentage waiting six or more days to be seen also increased, from 30 to 32 percent.

The percentage that found it somewhat or very difficult to get care on nights and weekends without going to the emergency room declined only marginally, from 65 to 63 percent. Implementation of Electronic Medical Records Family physicians' use of electronic medical records varies widely among the provinces from Across the provinces, the use of paper-only charts ranged from 37 percent Alberta to 83 percent Prince Edward Island , and the exclusive use of electronic records ranged from 0 percent Prince Edward Island to In large measure, this variation reflects the extent to which provinces have subsidized the acquisition, implementation, and ongoing use of electronic records.

Since , government support for the implementation of electronic medical records has accelerated in some provinces. For example, the Ontario government is extending to all primary care physicians its subsidies for the adoption and continued use of electronic medical records, which previously were available only to physicians working in specific primary care reform models. In the Commonwealth Fund's International Health Policy Surveys of primary care physicians, the use of electronic medical records reported by Canadian respondents increased from 23 to 37 percent between and Schoen et al.

Quality Improvement Training and Support Over the last several years, sometimes in partnership with the provincial medical association, governments and health ministries in British Columbia, Alberta, Saskatchewan, and Ontario have attempted to address the quality gap between current and achievable primary health care performance by mounting quality improvement learning collaboratives based on the Institute for Healthcare Improvement's Breakthrough Series model Institute for Healthcare Improvement Primary health care quality improvement in British Columbia is funded and organized through the Practice Support Program, a joint initiative of the British Columbia Medical Association Section of General Practice, the Ministry of Health Services, and the regional health authorities.

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