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PAPER 94-15
PRIMARY HEALTH CARE DELIVERY MODELS:
A REVIEW OF THE INTERNATIONAL LITERATURE
Julia Abelson
Brian Hutchison
"NOT FOR CITATION WITHOUT PERMISSION"
1
PRIMARY HEALTH CARE DELIVERY MODELS:
A Review of the International Literature
Julia Abelson, MSc1
Brian Hutchison, MD, MSc, CCFP2
1
Centre for Health Economics and Policy Analysis,
Department of Clinical Epidemiology and Biostatistics,
McMaster University
2
Department of Family Medicine,
Department of Clinical Epidemiology and Biostatistics,
Centre for Health Economics and Policy Analysis,
McMaster University
Cite as: Abelson, J and Hutchison, B, "Primary Health Care Delivery
Models: A Review
of the International Literature", McMaster University
Centre for Health
Economics and Policy Analysis Working Paper 94-15,
September, 1994.
2
McMaster University
Centre for Health Economics and Policy Analysis
Working Paper Series
Policy Abstract
Many Working Paper have both academic and policy relevance. Therefore, in addition
to the author (s)'s abstract (typically intended for an academic audience), this paper
has been summarized with input from a professional journalist to enhance its accessibility and readability. This summary is referred to as a Policy Abstract.
Primary Health Care Delivery Models
A Review of the International Literature
A review of primary health care delivery in Canada and other developed countries provides
little evidence of the superiority of one system over another. In spite of the “striking” lack of rigorous
evaluation of these different systems, there are wide-ranging and fast moving attempts to reform the
funding and management of primary care. The paper provides a comprehensive review of the
international literature dealing with primary health care delivery models.
In the paper, these models are classified according to the dominant service provider and
extensively described and evaluated in order to help policy makers in various parts of Canada
outside of Quebec who are attempting to reform what can be described as essentially “nonsystems” because primary care services are often provided without coordination and without
allocating resources in line with the need of the population.
Physicians-centred delivery models are by far the most prevalent form of primary care in the
developed world. “Almost all jurisdictions reviewed had a well-established system of office-based
general or family practice.” Less common are nurse-centred models or those which involve some
form of collaboration between health service providers.
Health Maintenance Organization (HMOs) were classified as physician-centred although
many employ a variety of health care providers. Although there were little data evaluating many
aspects of care provided by family physicians, research on HMOs is abundant. The review found
decreased hospital use among HMO-type delivery systems. In addition, the review indicated that
group practice appears to be associated with certain features of practice organization likely to
promote quality care.
3
The literature mentions few nurse-centred primary care delivery systems, although evaluations
of systems using nurse practitioners or other expanded role nurses were abundant. The limited
evaluation of such nurse-based care offers modest support for such an approach. However,
“growing interest among nursing associations and provincial governments across Canada in
expanding the role of nursing in primary health care delivery may be an indicator of what lies ahead
in this area.”
Collaborative delivery models, include health centres such as exist in some Scandinavian
countries and the community service centre (CLSC) approach in Quebec. Analysis showed a
successful health centre program to be based on small teams consisting of a general practitioner,
two nurses, and a social worker.
Overall, little evaluation research had been done to date on most models of primary care
delivery. What research there is “fails to point to any particular model as ‘ideal’ or ‘more suitable
than another’”. However, “there is evidence to suggest that certain directions for reforms are more
appropriate than others. These include multidisciplinary group practice, payment of providers on
other than an exclusive fee-for-service basis, and increased accountability for the provision of care
and services to defined populations through practice registration”.
4
ACKNOWLEDGEMENTS
The research upon which this report is based was funded by the Ontario Ministry of
Health’s Community Health Framework Project. We would like to acknowledge the
work of Michele Dupuis as research assistant to the project and members of the
Ministry’s Primary Health Care Delivery Models working group for comments on
and reactions to various sections of the report.
5
EXECUTIVE SUMMARY
A common element in many countries’ health system reform agenda is an
emphasis on changes to the organization, financing and delivery of primary health
care. Numerous objectives for primary health care reform have been cited in
jurisdictions around the world with different approaches being taken toward achieving stated objectives. This paper reviews the literature which has described and
evaluated experiences with different primary health care delivery models in Canadian and other jurisdictions. Models reviewed were categorized by dominant service
provider (e.g., nurse-centred, physician-centred, collaborative). In addition to reviewing the literature on delivery models, literature was also reviewed which
described or evaluated experiences with various characteristics of primary health
care delivery models including: responsiveness to community needs, collaboration
between health care providers, integration and coordination, provider payment, and
management and accountability structures.
Few delivery models exist in jurisdictions around the world. The physiciancentred model is the predominant mode of primary health care delivery in the
developed world. Health centres exist in many jurisdictions and are widely supported
as a desirable model of health care delivery. Nurse-managed models are the least
prevalent form of primary health care delivery in the developed world.
There is an abundance of descriptive literature and a paucity of evaluation
literature on primary health care delivery models. Most evaluation studies are
moderate to weak in their methodological rigour and results are often limited in their
generalizability to other settings. Although the research evidence does not point to
an “ideal” model, there is evidence to suggest that certain directions for reform are
more appropriate than others. These include mutidisciplinary group practice,
payment of providers on other than an exclusive fee-for-service basis, and increased
accountability for the provision of care and services to defined population through
practice registration.
The paucity of rigorous evaluation research in such a broad policy area as
primary health care delivery is striking. Whatever policies are contemplated for the
reform of primary health care systems’ around the world, their implementation
should be considered in the context of a strong policy-informing research agenda.
6
TABLE OF CONTENTS
I.
Introduction ..............................................................................................
8
II.
Definitions, Concepts and Boundaries ...............................................
10
III. Search Strategy and Description of the Literature .........................
12
IV. Description and Categorization of Models under Review ..............
13
V.
Evaluation of Primary Health Care Delivery Models What does the research tell us? .......................................................... 15
A.
B.
C.
Nurse-centred models ................................................................
Physician-centred models .........................................................
Collaborative models .................................................................
VI. Characteristics and Objectives of Delivery Models ........................
A.
B.
C.
D.
E.
15
19
23
33
Community orientation .............................................................
Collaboration and teamwork ....................................................
Integration and coordination ...................................................
Provider payment ................................................................... ..
Funding, management and accountability structures ......
34
39
42
45
52
VII. Conclusions ............................................................................................
63
References ..............................................................................................
66
Appendix 1 ...........................................................................................
77
7
I.
INTRODUCTION
Desire to improve health care system performance has spurred governments
throughout the world to ponder, propose and implement various reforms over the
past five years (Altman and Jackson, 1991; Ham, 1990; Hurst, 1991; Evans, 1992).
A common element in many countries’ reform agenda is an emphasis on changes to
the organization, financing and delivery of primary health care. The broader
context for these pragmatic country-specific reforms is a global strategy for primary
health care reform originating from the World Health Organization’s declaration of
“Health for All by the Year 2000” through primary health care development (Alma
Ata, 1978). Although many countries have embraced the Alma Ata declaration,
more recent and widespread health system reforms have provided the impetus for
implementing change within primary health care.
While the specific objectives cited for primary health care reform differ among
countries, most can be captured under a few common themes. These are:
*
to shift the emphasis from secondary, tertiary and other levels of care to
primary health care;
*
to increase accountability for the use of resources by primary health care
providers and managers;
*
to improve integration and coordination of service delivery within the primary
health care sector and between primary health care and other parts of the
health care system;
*
to increase the involvement of the public, consumers and communities in
identifying needs, planning and setting priorities for the delivery of services;
*
to increase the responsiveness of the primary health care system to the
population’s health needs;
*
to strengthen the role of disease prevention and health promotion in primary
health care.
8
Approaches taken to achieving these stated objectives also differ from one
jurisdiction to another. Some have proposed or introduced decentralized systems of
funding, management and service delivery with the aim of increasing the accountability and responsiveness of the health care system to local communities (Malcolm,
1993; Nova Scotia, 1994), while others have focused on developing a comprehensive
primary health care system which emphasizes the delivery of a carefully selected set
of services and the achievement of objectives for improving the population’s health
(NCEPH, 1992; Boerma, 1992). Still others have opted to do both simultaneously
(Boerma, 1992).
In Canada, primary health care has come under review by government commissions and task forces at different times over the past twenty years (Quebec, 1970-71;
Canada, 1973; Ontario Council of Health, 1973; Ontario Ministry of Health, 1982).
Despite the implementation of numerous recommendations from these reviews,
there is growing recognition that, perhaps with the exception of Quebec, primary
health care in most Canadian jurisdictions is a “non-system”. A myriad of services
are provided, yet service coordination is often lacking and resources are not being
allocated in line with the needs of populations.
Efforts to establish a “system” of primary health care delivery have been
initiated in numerous parts of the country. This paper is intended as an input to this
process by reviewing the experiences with primary care delivery models in Canadian
and other jurisdictions.
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II.
DEFINITIONS, CONCEPTS AND BOUNDARIES
Some of the terms and concepts that will be used in the paper will be clarified
before proceeding to the review and analysis of the literature. First, the definition of
primary health care that will be used throughout the report is that of the World
Health Organization, which has been adopted by the primary health care delivery
models working group:
“Primary Health Care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full
participation and at a cost that the community and country can afford. It forms an
integral part both of the country’s health care system of which it is the nucleus and of
the overall social and economic development of the community ... It is the first level of
contact of individuals, the family and community with the national health system
bringing health care as close as possible to where people live and work and constitutes
the first element of a continuing health care process ... Primary Health Care addresses
the main health problems in the community, providing promotive, preventive, curative, supportive and rehabilitative services accordingly.”
(World Health Organization, Alma Ata Declaration, 1978)
In evaluating the results of other jurisdictions’ experiences with different
models of primary health care delivery, “model” has been defined broadly as “an
arrangement for the delivery of primary health care services which incorporates
service providers, funding, payment and accountability structures which may be
configured in a variety of ways”. Using this definition, models may be prescribed
forms of health care delivery that are uniform throughout a jurisdiction or delivery
arrangements that are unique to a particular community or region and are voluntary developments. In addition to reviewing the literature describing and evaluating different organizational models for primary care delivery, we also examined the
literature dealing with certain “desired model characteristics” (Table 1) in order to
examine the relationship between characteristics of primary health care delivery
models and the achievement of policy objectives for primary health care.
10
Table 1
Characteristics of Primary Care Delivery Models
* Responsiveness of services to population needs
* Collaboration between health care providers within the model
* Service integration and coordination
* Methods used to reimburse providers within the model
* Funding, management and accountability structures established in the model
The WHO’s target of health for all by the year 2000 through the establishment
of primary health care systems has led to the establishment of numerous primary
health care initiatives in developing countries. Much has been written about these
initiatives; however, most of the literature is descriptive and we consider the few
available evaluations to be methodologically weak and of limited relevance for
developed countries. The majority of this literature, therefore, has been excluded
from the review.
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III. SEARCH STRATEGY AND DESCRIPTION OF LITERATURE
Searches were conducted of Medline and Health Administration databases
using the key words primary health care, community health centres, community
health services and evaluation, organization, delivery, financing, and costs. Federal
and provincial government departments were contacted to obtain unpublished
reports. Relevant bibliographies and literature reviews were reviewed to identify
additional articles. Finally, experts in various countries under study were contacted
to obtain other relevant materials. A detailed reference list for each topic area is
attached.
Literature reviewed fell into two broad categories of descriptive and evaluative
research. The descriptive literature (which accounted for the majority of publications) included articles describing approaches to and experiences with the delivery
of primary health care and its component characteristics (e.g., provider reimbursement, service integration and coordination, funding, management and accountability). The evaluative literature varied greatly in study design, methodological rigour,
and in what was being evaluated. Techniques used in evaluation studies included
meta-analysis, randomized controlled trials, historical and prospective cohort studies, case studies and program impact studies. The focus of evaluation studies varied
from entire programs or services, to provider performance and interaction, to the
effects of a specific intervention on service utilization and costs.
The literature on primary health care delivery models includes a number of
research overviews on specific subject areas (e.g., effectiveness of nurse practitioners
and health centre performance). These reviews and appraisals have been included
in our review and assessed for their comprehensiveness and methodological quality.
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IV. DESCRIPTION AND CATEGORIZATION OF MODELS
Before turning to our own categorization of primary health care delivery
models, the literature was searched to identify other descriptive analyses of primary
health care models. Boerma et al (1993) reviewed general practice and primary
medical care in European countries and Weiner (1987,1988) compared the primary
care systems in the United States, Finland, Sweden, Denmark and the United
Kingdom. While a variety of categorization schemes are available (e.g., governance
structures, practice organization, etc.) we found the dominant service provider to be
a logical basis upon which to classify the models under review. Models are listed
under each category represented in Table 2 with a brief description provided in the
section below.
Table 2
Categorization of Primary Health Care Delivery Models
Nurse-centred
Physician-centred
clinics or health centres
(solo or group)
general practice
(solo or group)
nursing programs within
larger organizations
health maintenance
organization
Collaborative
health centre
local community service
centre (CLSC)
comprehensive health
organization
multi-service system
Nurse-centred Models
Nurse-centred primary health care delivery may take a variety of forms
including nurse-run health centres or clinics, public health nursing programs, home
care (visiting nurses) or nursing stations located in remote areas.
13
Physician-centred Models
Physician-centred practices emphasize the delivery of primary health care by
physicians with the potential for other providers to work in a complementary role.
Physicians may work in either group or solo practices and may be paid in a variety
of ways. This is the dominant model of primary health care delivery in the developed
world.
The U.S. health maintenance organization (HMO) is a vertically-integrated
delivery model which provides a comprehensive range of services with an emphasis
on primary health care delivery. Although there are a variety of HMO models (e.g.
physician-sponsored, staff model) in existence, the majority are physician-centred.
Collaborative Models
The health centre is described throughout the literature as a model where
services are provided in a single location by a range of health care providers with a
community-sponsored governance structure. Variations on the model include the
mix of health care providers, the method of paying providers, and the services
provided. Existing models that are captured within this category include the United
States’ neighborhood health centres and community health centres that exist in
many European countries.
Quebec’s centre local de service communitaire (CLSC) is a collaborative model
which emphasizes the integration and coordination of a full range of health and
social services. Like health centres, CLSCs are governed by a community board.
The comprehensive health organization is a vertically-integrated model of
health care delivery which provides or purchases a comprehensive range of health
care services for enrollees with an emphasis on primary health care delivery. The
model is currently under development in Ontario and British Columbia.
Multi-service systems are horizontally-integrated delivery models which emphasize the coordination of service delivery either within or across organizations. A
Canadian example is Nova Scotia’s multi-service system which was established in
1985 to coordinate community health and social services delivery through joint
planning and programming (Marentette and Kurji, 1988).
14
V.
EXPERIENCE WITH PRIMARY CARE DELIVERY MODELS:
WHAT DOES THE RESEARCH TELL US?
In the sections below, research that has described and evaluated the experiences with various models of primary health care delivery in jurisdictions outside
Ontario and Canada is reviewed and appraised. Models included in the review are
those that have been identified in the classification scheme developed in Section IV
(Table 2). Conclusions are drawn at the end of each sub-section and a summary of the
literature including the sources, study designs employed, results, appraisal of both
the evidence and generalizability of results (to other scopes of practice and to other
primary health care settings and jurisdictions) are presented in tabular form at the
end of Section V. Criteria used to assess the strength of research evidence and
generalizability of results are summarized in Appendix 1.
A.
Nurse-Centred Primary Health Care
Despite long-standing involvement in the delivery of primary health care,
nurses have not traditionally functioned as sole providers of primary health care.
Exceptions occur mainly in remote areas where physicians have not been available
or where a decision has been made on financial grounds to employ nurses rather than
physicians because of the low volume of service required.
With primary health care reform underway in most Canadian provinces,
nursing associations have made efforts to highlight a potential expanded role for
nursing in the delivery of primary health care (AARN, 1993; MARN, 1993;Ontario
Ministry of Health, 1993).
Few discretely-defined nurse-centred models of primary health care delivery
are described in the literature. Nurse-managed health centres, clinics or departments are the models most commonly described. This literature is mainly descriptive
in nature and only two evaluations of the nurse-managed delivery models were
found. Nurse-managed clinics and health centres have been established in various
provinces throughout Canada but are more common in the United States. These
may take the form of either solo or group nurse practices.
Only one Canadian province has been involved in the implementation and
evaluation of a large-scale nurse-centred primary health care delivery model. As
15
part of the Danish-Newfoundland Primary Health Care Demonstration Project, the
Association of Registered Nurses of Newfoundland established a program of service
provision in remote areas of the province where existing public health nurses have
provided services within a primary health care framework. The purpose of this
demonstration project, which began providing services in June 1990, was to “effect a
measurable improvement in the health of selected communities in Denmark and
Newfoundland through the provision of PHC services managed and largely provided
by nurses” (Hall, 1989, p. 8). The evaluation of the Danish-Newfoundland demonstration project has taken the form of a process evaluation (involving a description
of the program) and an impact assessment (conducted to determine if the project is
meeting its goals). Evaluation results are due to be released in 1994.
A nurse-managed health centre demonstration project has recently been
funded in British Columbia. Scheduled to open in May, 1994, the Comox Health
Centre has a two-year demonstration project mandate, and its performance will be
the subject of an external evaluation (Whyte, 1994). In Winnipeg, Manitoba, two
nurse-managed departments (diabetes education and family health) have been in
operation for ten years at the Youville Clinic. Neither of these departments have
been evaluated (Sylvester, 1994).
Two evaluations (one of a nurse-managed health centre and the other of a
nurse-managed hypertension clinic) were found in our search. Woog et al (1981)
reported on an evaluation of a nurse-managed family-oriented health care centre in
the state of New York. The health centre served a low-income black community and
delivered a range of primary health care services including health education. Centre
staff included a manager, nurse practitioner, community health aide and part-time
physician consultant. Goals of the centre included assessing the health of the
community, screening for specific health problems, conducting clinics for case
finding, and managing medical problems through collaboration between all staff.
An external evaluation team was commissioned to conduct an evaluation of the
health centre to determine whether it was meeting its objectives. Lack of baseline
data for the health centre population and an inability to locate a suitable control
group made program impacts difficult to measure. Data were collected using a
structured questionnaire (The Nursing Center for Family Health Services Questionnaire) on patient use and satisfaction with health services and educational
16
activities provided at the centre, patient perceptions of their health status, and steps
to be taken when faced with illness. Results of the questionnaire demonstrated
favourable patient attitudes toward the health centre and health knowledge and
behaviours that were more positive than expected for the population under study
based on attitudinal survey results obtained from similar socio-economic groups.
Quality of care was found to range from average to excellent as compared to other
physician-centred community health centres (Woog et al, 1981). Overall, evaluation
results offer modest support for the nurse-managed health centre as a potential
delivery model for a specified population. These results must be qualified, however,
due to the absence of a suitable control group.
Results of an evaluation of a nurse-managed hypertension clinic demonstrated
equivalent outcomes for nurses and general practitioners in controlling hypertension (Jewell and Hope, 1988). Thirty-four newly diagnosed or poorly controlled
hypertensive patients were randomly allocated to be managed in a hypertension
clinic run by a nurse or by their own general practitioner. Blood pressure fell in both
groups and at the end of a one-year study, 67% of patients assigned to the nurse group
and 63% of patients assigned to the physician group had normal blood pressure
levels. These results reinforce findings described below concerning the effectiveness
of nurse practitioners in managing hypertension in primary care delivery settings.
Studies evaluating the impact of using an expanded role nurse, nurse practitioner or family practice nurse in primary care delivery settings are both abundant
and of high methodological quality. A comprehensive review and critical appraisal
of this literature has recently been submitted to the Ontario Ministry of Health
(Mitchell et al, 1993). In their report on the Utilization of Nurse Practitioners in
Ontario, Mitchell and colleagues reviewed 29 studies of nurse practitioner (NP)
effectiveness in primary health care settings which revealed equivalent outcomes for
NPs and physicians in the management of headaches, hypertension, well child care
and perinatal care, and superior patient outcomes for NPs over physicians in areas
such as blood pressure and weight control.
A meta-analysis of studies of the effectiveness of nurse practitioners was
recently completed by the American Nurses’ Association. A meta-analysis involves
the statistical pooling of results from individual studies addressing a single question
in order to obtain an overall estimate of effect. Thirty-eight NP studies were included
17
in the analysis, 12 of which were randomized controlled trials, the most rigorous
study design and, therefore, the one most likely to produce valid results. The authors
concluded that:
For clinical outcomes, NPs achieved equivalent outcomes to or
scored more favourably than physicians on most variables. Compared
to physician patients, NP patients demonstrated equivalent or greater
satisfaction with their health care provider, compliance with health
promotion/treatment recommendations, and knowledge of their health
status and treatment plans ... NPs spent more time per visit with their
patients than physicians, although the average number of visits per
patient was equivalent ... NPs ordered more laboratory tests than
physicians, although the average laboratory cost per NP patient was
less than for the physician patient.
(ANA, 1993, p. xii-xiii)
Conclusions from the Research and Lessons for Policy Development and
Research
With the exception of the nurse practitioner literature, there is a paucity of
research that has rigorously evaluated nurse-centred delivery models. The relative
scarcity of these models in jurisdictions around the world may be one important
explanation for this finding. Other explanations offered include the absence of a
strong nursing research base partly due to limited graduate education and research
funding opportunities, and the methodological challenges of conducting research on
primary care nursing (Hayward et al, 1993). Growing interest among nursing
associations and provincial governments across Canada in expanding the role of
nursing in primary health care delivery may be an indicator of what lies ahead in this
area. Recent funding of a two-year nurse-managed health centre demonstration
project in British Columbia with an external evaluation team is a laudable example
of combining the introduction of a new delivery model with evaluation research
(Whyte, 1994).
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B.
Physician-Centred Delivery Models
1.
General/Family practice
Almost all jurisdictions reviewed had a well-established system of office-based
general or family practice. Eastern European countries were the exception to this
phenomenon where, until recently, all primary health care services were delivered
in state-run health centres. Countries differed from one another in the relative
emphasis given to general practitioners vs. specialists in determining patient access
to services. Countries like the U.K., Denmark, Canada and the Netherlands have
given prominence to general practitioners by assigning them the gate-keeping
function and limiting direct access to specialty care. The notion of patients having
a “personal doctor” is another characteristic common to many countries and an
objective that others are pursuing (Boerma, 1993).
The literature that has evaluated general practice is abundant and covers
numerous areas including:
*
*
*
the effect of different provider payment methods on utilization of services;
comparisons of service delivery costs and quality of care between different
practice types;
the effects of implementing various interventions designed to change provider
behaviour.
Issues of provider payment will be discussed in another section. Since the literature
is so vast for the other two areas, our review will be restricted to the literature
evaluating overall practice organization and its influence on the cost and quality of
service delivery.
A growing body of literature traces the development of different forms of
practice organization (Eisenberg, 1988; Williams et al, 1990). The majority of this
literature is descriptive and focuses on the proliferation of different practice arrangements in the United States. In Canada, there has been much less experimentation
with different models of practice organization. This is due, in part, to the limited
incentives that exist for competition and innovation under a government-sponsored
health insurance scheme. In an attempt to develop a typology of practice organization in Canada, Williams et al (1990) conducted a survey of 2,398 Canadian
19
physicians which was used to identify and describe different types of practice
organization and to provide an assessment of the costs and benefits of each for
physicians, patients and the overall health care system. In addition to identifying
solo and group practice, they also identified partnership arrangements (described as
economic associations that do not involve any sharing of patient records or service
delivery). An institutional domain of practice was also identified which included
hospital practice as well as the community health centre, health service organization
and local community service centre models which will be discussed in subsequent
sections.
Because the survey was conducted in 1986-87, the results do not reflect current
trends in practice organization. However, they do demonstrate a relationship
between practice type and certain aspects of practice organization. For example, the
proportion of physicians who reported the use of: (i) formal standards of care; (ii) recall
systems; and (iii) computers for diagnosis, maintenance of patient records or billings
was higher among group practices and “alternative payment and delivery models”
such as community health centres, health service organizations and CLSCs compared to loose partnerships or solo practices. Survey results are summarized below:
Practice Type
Characteristics of Practice
Formal Standards
Recall Systems
(%)
(%)
Use Computers
(%)
Private
Solo
Group
Partnership
0
38.5
21.1
42.4
46.7
41.5
15.1
49.7
31.0
CHC/HSO/CLSC
52.9
54.9
41.2
(Williams, et al, 1990)
The recall system results were supported by the results of a subsequent study
that compared physicians working under different practice arrangements in Ontario. Community health centres (59%) and health service organizations (50%) were
20
more likely to have patient recall systems than fee-for-service practices (39.3%)
(Abelson and Lomas, 1990).
2.
Health maintenance organizations
Although health maintenance organizations are responsible for the provision
of a full range of health services to their patient enrollees, primary health care is the
principal route through which patients gain access to the model. Although they have
been classified as physician-centred, many of them do employ a variety of health care
providers and some might be more appropriately described as collaborative. The
considerable variation that exists among HMOs should be taken into account when
interpreting studies of HMO performance. Unlike a community health centre model
which has a unique community-sponsored governance structure, HMOs vary on a
variety of dimensions including sponsorship, profit status, university affiliation and
ownership of institutions.
The literature on HMO performance has been reviewed and appraised by others
(Birch, Lomas, Rachlis and Abelson, 1990). In their review of the clinical and
economic performance of Ontario’s Health Service Organizations, Birch and colleagues summarized HMO study findings along six dimensions including their effect
on hospital utilization and ambulatory care, human resource utilization, use of nonphysician personnel, quality of care, preventive service delivery and patient and
provider satisfaction. A comprehensive review and appraisal of the literature was
conducted and important limitations of the studies reviewed were identified. In
addition, criteria were used to appraise the strength of the evidence presented.
They found strong evidence that HMO patients have lower hospital utilization
than patients of fee-for-service (FFS) physicians and that HMO and FFS patients use
about the same amount of ambulatory care. The evidence was not as strong but
indicated no differences in the quality of care delivered by HMOs and FFS practices.
There was some evidence that HMO patients were less satisfied than FFS patients
and weak evidence that HMOs delivered more preventive services and that provider
satisfaction was equal in HMOs and FFS practice.
21
Conclusions from the Research and Lessons for Policy Development and
Research
The majority of evaluations of general/family practice have compared the
influence of different provider reimbursement methods on service utilization and
costs (this literature will be reviewed in Section VI.D.). There is little evaluative
research on other aspects of general/family practice such as the influence of different
practice models on cost and quality of service delivery. In contrast, research on
HMOs is abundant and often involves comparisons of performance between HMOs
and the dominant FFS model. A possible explanation for this finding may be that
while general/family practice has been the predominant service delivery model in the
developed world for centuries, an innovation like the HMO is new, “unproven”, and
therefore subjected to intense scrutiny.
Our review of the literature evaluating physician-centred models of primary
health care delivery has revealed findings of decreased hospital utilization among
vertically-integrated health care organizations that have a strong primary care
base. In addition, group (as compared with solo or partnership) practice was found to
be associated with features of practice organization that are likely to promote the
delivery of quality and appropriate care.
22
C. Collaborative Delivery Models
1.
Health Centres
Health centres provide primary health care in a number of countries. With the
exception of eastern European countries and a few Scandinavian countries (e.g.,
Finland and Sweden), they rarely operate as the predominant model of delivery, and
more frequently co-exist with general/family practice (Boerma et al. 1993; ARA
Consulting Group, 1992; Boerma, 1989; Weiner, 1987). Literature examining other
jurisdictions’ experiences with health centres has been reviewed elsewhere (Abelson
and Birch, 1993; ARA Consulting Group, 1992; Birch et al, 1990). These reviews are
summarized below. Studies reviewing health centre performance fall into the
following categories:
(i)
descriptive studies that highlight the development of health centre movement
or the the establishment of health centres in a community;
(ii)
evaluation studies that compare health care cost and utilization in health
centres and other delivery models (e.g., health centres vs. fee-for-service
practice).
Descriptive studies
Descriptive studies have documented the history of the health centre movement in the United States and Canada. Neighborhood health centres were established in the 1960s as an instrument of social change and community empowerment
(Sardell, 1983; Ginzberg and Ostow, 1985; Boufford, 1990; Sherraden and Wallace,
1992). In Canada, Lomas (1985) traced the development of Ontario’s oldest health
centre, Sault Ste. Marie’s Group Health Centre, which was established to provide
health care to the steelworkers’ union.
Evaluation Studies
A major health policy objective for health centres in many jurisdictions is to
reduce service utilization in other parts of the health care system. This is assumed
to result from the health centre’s coordinated approach to comprehensive primary
health care delivery and from the alternative payment methods used to reimburse
23
physician providers. Numerous studies have attempted to evaluate attainment of
this objective with inconsistent results.
Results from a study comparing the health care costs of two community health
clinics in Saskatchewan, Canada with costs of fee-for-service practices in the same
communities revealed lower overall costs for each of the health centres (13% and 17%)
than for their comparison fee-for-service groups (Saskatchewan Health, 1983).
Methodological problems related to data sources, the denominator used to define
comparison populations, and sample selection reduce confidence in the validity of
these study findings (Abelson and Birch, 1993). In the Netherlands, cross-sectional
data were used to compare trends in hospital utilization for a population served by
a network of newly-established health centres against hospital utilization for the
population served by traditional Dutch general practice. For the period between
1984 and 1991, hospital admissions per 1000 inhabitants decreased for the health
centre population as well as for the general population, although reduced admissions
were greater for the health centre population. The 1990 admission rate for the health
centre population was 80% of the 1984 rate while the rate for the general population
was 89% of the 1984 rate. Analysis of the number of occupied beds over this period
of time revealed the same general trends (Sixma et al, 1993). As with the previous
study, methodological problems raise doubt about the validity of these findings. In
particular, the health centre community under study was a newly-established and
had no hospital for the duration of the study. A hospital did open in 1991 when there
was a 4% increase in the number of hospital admissions.
Other research conducted in the Netherlands has attempted to explain why
referral rates are lower among general practitioners working in health centres than
among other general practitioners. Analyses were conducted to determine whether
the lower referral rates were due to: (i) healthier patients in health centres; (ii) more
highly motivated health centre GPs; or (iii) greater cooperation among health centre
providers. Results indicated that neither patient mix nor a GP’s motivation for
practising in a health centre could explain the lower referral rates among health
centre physicians. In examining the level of cooperation as a potential influence on
referral rates, results showed the amount of time spent in team meetings to be
unrelated to mean referral rates. However, a weak relationship was found between
a higher number of consultations with colleagues (a form of peer review) and lower
referral rates for GPs practising in groups (Wijkel, 1986). Future research on the
24
measurement of cooperation between and within teams was recommended.
The organization of Finland’s primary health care system is based on a model
in which most general practitioners are employees of the state and work out of
publicly-operated health centres that serve a defined population. Finland’s health
centre delivery model was characterized as an “assembly line” approach emphasizing episodic, as opposed to continuous, care. Interest in reorganizing the delivery of
primary health care to improve continuity, quality of care and patient and physician
satisfaction led to the establishment of a demonstration project in Finland’s four
largest cities between 1983 and 1987. An evaluation of the demonstration project
was conducted to assess the impact of different organizational models on the content,
delivery and effectiveness of primary medical services (Vohlonen, 1989).
Population panels were selected in each city and were assigned to selected
physicians. Panels were balanced with respect to age distribution, sex, social
characteristics, and travel distance to health centres. Three organizational models
were compared, each with different organizational and physician payment characteristics, on the basis of feasibility (ability to successfully implement organizational
changes), adequacy (improvement in content process of service delivery) and effectiveness (access to care and improvements in population health).
One of the most important findings from the perspective of our analysis of
delivery models is that the program was most successful in health centres where
service delivery was based on small teams consisting of a general practitioner, two
nurses, and an assigned social worker. Overall, the change to a system in which
patients have their own personal physician resulted in higher reported quality of
care, physician job satisfaction and continuity of care (Vohlonen, 1989). A limitation
of the study is that due to simultaneous changes to organization and payment, it is
difficult to assess their independent effects.
A study comparing the quality of care provided by private and publiclymanaged health centres in Stockholm, Sweden found similar results on a variety of
quality dimensions. Patient questionnaires, analysis of prescriptions over a threemonth period, telephone calls, cost and utilization data were used to assess four
dimensions of quality: first level of responsibility, accessibility, holistic view of the
patient and continuity of care and safety. Study limitations include a very small
25
sample size (1 private and 3 public health centres). Few details were provided about
the population served by the centres or about the organization of service delivery
between public and private centres. Variations in all dimensions of quality measured
were reported across all health centres. Results should, therefore, be interpreted with
caution (Hansagi et al, 1993).
2.
Local Community Services Centres (CLSCs)
Quebec’s local community service centres (CLSCs) have their roots in the U.S.
neighborhood health centre movement (Crichton et al, 1991). They have most of the
features of health centres but, in contrast to health centres, CLSCs have responsibility for the delivery of social services as well as health services, to their population.
The CLSC literature is sparse. A number of studies have evaluated specific
aspects of care delivered in CLSCs while others have looked at the overall organization of CLSCs. Still others have assessed the CLSC experience with community
development and community-based governance structures.
Descriptive Studies
Crichton et al (1991) describe the historical development of the CLSC movement in detail; and an extensive review of the organizational characteristics of
CLSCs was undertaken by Bozzini (1988). Bozzini’s analysis presented program
data collected for CLSCs throughout the province which highlighted various program features such as the level of awareness of CLSCs across the province (84%
aware, 27% users), range and mix of health care providers and services offered.
Studies comparing CLSC physician characteristics with those of fee-for-service
physicians have found more CLSC physicians to be young, female, graduates of
innovative primary care training programs and interested in giving patients a
greater role in their care. These results suggest that alternative practice settings
may attract a group of physicians with special characteristics (Pineault et al, 1991).
Evaluation Studies
Three studies have compared the care provided by physicians working in
CLSCs to the care provided in fee-for-service practices (Renaud et al, 1980; Battista
and Spitzer, 1983; Battista et al, 1986). In one study, treatment provided by
physicians in CLSCs and private practices was compared using patients simulating
tension headaches. Study results revealed that CLSC physicians: (i) prescribed less
26
for the presenting problem; (ii) were more likely to provide a warning to the patient
about the use of medication; and (iii) were more likely to provide alternative therapy.
Physicians in CLSCs also spent more time with patients than did fee-for-service
physicians (Renaud et al, 1980).
Battista et al (1986) surveyed 430 general practitioners working in urban and
rural fee-for-service practices, CLSCs and family medicine teaching centres about
their attitudes and behaviours regarding cancer prevention. Physicians working in
the CLSCs under study (and paid on a salaried basis) reported more appropriate
clinical prevention activities for four types of cancer than fee-for-service physicians.
More appropriate cancer screening among CLSC physicians was also found in an
earlier study of physician self-reported preventive practices (Battista and Spitzer,
1983).
3.
Comprehensive Health Organization
The comprehensive health organization (CHO) is a nonprofit corporation that
purchases or provides a broad range of health and related services (including
physicians’ services and hospital care) for residents of a community who choose to
become members. As a vertically-integrated structure, the CHO has the potential to
integrate primary health care services with other levels of care. Its emphasis on the
delivery of primary health care by a multidisciplinary health care team positions the
CHO as a potential model of primary health care delivery. CHOs have yet to become
operational in Ontario, prohibiting any judgments about performance.
Conclusions from the Research and Lessons for Policy Development and
Research
The descriptive literature on collaborative models of primary health care
delivery offers some interesting insights into the development of health centres and
the characteristics of providers working in CLSCs. The evaluation literature fails
to establish the superiority of these or any other models in terms of either quality of
care or efficient use of resources. Weak evidence exists to suggest that health centres
reduce hospital admission rates and overall costs of service provision when compared
to fee-for-service practice. Stronger evidence exists to support the claim that CLSCs
provide superior quality of care than fee-for-service physicians for the treatment of
headaches and in their self-reported preventive practices. Generalizability is
limited, however, due to the narrow clinical focus taken in these studies.
27
Experience with Primary Health Care Delivery Models
in Other Jurisdictions:
What have we Learned so Far?
Table 3 presents a summary of the evaluation literature on primary health care
delivery models. While the strongest available evidence is found in the nurse
practitioner and health maintenance organization literature, the results of these
studies must be considered in light of their limited generalizability in terms of scope
of practice (in the case of nurse practitioner studies) and setting (in the case of HMO
studies). Neither of these models currently exists in Canada. While the nurse
practitioner literature supports a recent government announcement to increase the
number of nurse practitioners in Ontario the literature provides only weak evidence
to support the introduction of nurse-managed health centres. Demonstration project
evaluations near completion in Newfoundland and beginning in British Columbia
will provide much-needed evidence to inform future policy decisions in this area.
Despite the prevalence of health centres in countries such as Finland and
Sweden, and their existence in others such as Canada, Australia and the Netherlands, the evaluation research in this area is sparse and methodologically weak.
Studies reviewed offer only weak support for claims of health centre cost savings and
superior quality of care. Community health centre evaluation initiatives currently
under discussion in Ontario hold some promise for policy-informing research in this
area.
The literature evaluating general or family practice as a model of care is even
less informative. Group practice appears, however, to be associated with certain
features of practice organization likely to promote quality and appropriateness of
care. In conclusion, the research fails to point to any particular model as “ideal” or
“more suitable than another”.
28
Table 3
Summary of Evaluation Literature on Promary Health Care Delivery Models
MODEL
SOURCE
STUDY DESIGN
RESULTS
Nursecentred
American Nurses’
Association
(ANA) (1993)
meta-analysis (38
studies)
NPs equivalent to or better
than physicians on most
outcome variables
equivalent patient
outcomes for NPs and
MDs in some areas;
superior patient outcomes
for NPs vs. MDs in other
areas
improved health
knowledge and behaviours
+++
Nursecentred
Nursecentred
Nursecentred
Physiciancentred
General/Fam
ily
Practice
Mitchell et al
(1993)
Woog et al (1981)
Jewell and Hope
(1988)
Williams et al
(1990)
critical appraisal
of literature (29
studies)
evaluation of
program impacts
using population
survey
Randomized
controlled trial
descriptive
EVIDENCE
GENERALIZABILITY
Scope of
Other
practice
settings
**
***
+++
*
**
+
**
*
equivalent hypertension
treatment provided by NPs
and MDs
++
*
**
higher proportion of recall
system, standards of care
and computers in group vs.
solo practice
++
**
**
29
Table 3 (cont'd)
MODEL
Physiciancentred
(con’t)
Health
maintenance
organization
SOURCE
STUDY DESIGN
RESULTS
Birch et al (1990)
critical appraisal
of literature
Lower hospital utilization
among HMO vs FFS pts.
EVIDENCE
GENERALIZABILITY
Scope of
Other
practice
settings
+++
**
**
+++
**
**
HMO pts. Less satisfied
than FFS patients
++
***
*
HMOs do more prevention
than FFS practices
+
*
**
+
*
**
Equivalent use of
ambulatory care for FFS
and HMO patients
HMOs do more prevention
than FFS practices
30
Table 3 (cont'd)
MODEL
Collaborative
SOURCE
STUDY DESIGN
RESULTS
Saskatchewan
Health (1983)
Comparison of
service utilization
and costs
Lower overall costs of
service provision for
community clinics than for
FFS practice
Cross-sectional
analysis of
hospital use for
health centre
population vs.
general population
Explanatory
analysis of lower
referral rates for
health centre vs.
general/family
practice MDs
Lower hospital admission
rates for health centre vs.
general population
Health
Centres
Collaborative
Sixma (1993)
Health
Centres
Collaborative
Wijkel (1986)
Health
Centres
Collaborative
Vohlonen (1989)
Health
Centres
Collaborative
Health
Centres
Hansagi (1993)
Before-after
design of three
experimental
delivery and
payment models
Comparison study
of private and
public health
centre models
No relationship found
between lower referral
rates and patient mix,
physician characteristics,
time spent in team
meetings; weak
relationship found between
low referral rates and
higher number of
consultations with
colleagues (i.e., peer
review)
Assignment of personal
physician resulted in
higher reported quality of
care, physician satisfaction
and partient continuity of
care;
Equivalent quality of care
found on four dismensions
of quality (e.g.,
accessibility, first level of
responsibility, holistic
view of patient and
continuity of care)
31
EVIDENCE
GENERALIZABILITY
Scope of
Other
practice
settings
+
***
*
+
***
*
+
***
**
+
***
*
+
**
*
Table 3 (cont'd)
MODEL
SOURCE
CLSCs
Pineault et al
(1991)
CLSCs
CLSCs
Renaud et al
(1980)
Battista and
Spitzer (1983)
STUDY DESIGN
RESULTS
Comparison of
physician
characteristics in
CLSCs and FFS
Comparison of
treatment practices
between CLSC
and FFS settings
CLSC physicians tend to
be younger, female, and
receive innovative primary
care training
CLSC physicians
prescribed less for tension
headaches; warned patient
more about use of
medication; provided
alternative therapy more
often
Self-reported adherence to
official preventive servies
recommendations is
greater among CLSC vs.
FFS physicians
Survey of
physician selfreported patterns
of preventive
practice in CLSCs,
FFS and family
practice teaching
centres (n = 480)
32
EVIDENCE
GENERALIZABILITY
Scope of
Other
practice
settings
+++
**
**
++
*
**
++
*
*
VI. OBJECTIVES OF PRIMARY HEALTH CARE DELIVERY MODELS:
HAVE THEY BEEN ACHIEVED?
Primary health care delivery models are often established with the aim of
achieving a set of pre-determined objectives. As discussed in the paper’s introductory
section, these objectives may be related to improving the funding and managerial
accountability structures, reducing the fragmentation in service delivery or increasing the responsiveness of service delivery to the community’s needs and preferences.
Different features or characteristics may be incorporated into a given delivery model
to achieve these objectives. These are presented in Table 1.
Despite attempts to restrict our review to model features and their influence on
achieving objectives, the distinction between the two is sometimes blurred. In the
sections below, literature is reviewed which describes and evaluates the relationship
between characteristics of primary health care delivery models and the achievement
of policy objectives for primary health care. A summary of the literature reviewed
and an assessment of the strength of the evidence and its generalizability is been
presented at the end of this section (i.e., Section VI). Assessment criteria are listed in
Appendix 1.
33
A. Service Responsiveness: Responding to the Community’s Health
Needs through Community-Oriented Primary Care
Community-Oriented Primary Care (COPC), for the purposes of this review,
will be considered as both an objective and defining characteristic of delivery models.
Nutting (1985) defines COPC as:
“the provision of primary care services to a defined community, coupled
with systematic efforts to identify and address the major health problems of that community through effective modifications in both the
primary care services and other appropriate community health programs”
A substantial body of literature exists on COPC which falls into the broad
categories of:
i)
ii)
descriptive studies that discuss COPC’s origins, definitions, and applications;
and
evaluation studies that assess COPC’s effectiveness.
Descriptive Studies
Tollman (1991) traces the origin of the COPC concept to South Africa where, in
the 1940s, the ruling government envisioned the establishment of a network of
community-based primary health care centres which would provide services based
on the needs of the population. Service delivery was to be combined with the training
of health care providers in community health practices such as epidemiology, data
collection, and health education. When the government changed in 1948, the health
centre movement, which amounted to 40 health centres throughout the country, was
no longer supported and its proponents moved to Israel where COPC has undergone
continued development since.
Based on their experiences with COPC development in South Africa, Kark and
Abramson identify “essential” and “highly desirable” features of COPC:
34
Table 4
Essential and Desirable Features of COPC
Essential features:
*
*
*
*
*
Complementary use of epidemiologic and clinical skills
A defined population for which the service is available
Defined programs to address community health needs
Community involvement in promoting health
Accessibility to health services
Highly desirable features:
* Integration, or at least coordination, of curative, rehabilitative, preventive
and promotive care
* A comprehensive approach extending to behavioral, social and environmental determinants
* A multidisciplinary team
* Mobility, including ‘outreach’ capability, of the health team
* Extension of community health programs into broader programs of community development
(Kark and Abramson, 1981 in Tollman, 1991)
The “essential features” of COPC resonate strongly with previously-stated
objectives for many primary health care reform initiatives. In particular, the
objectives of increasing community involvement in identifying needs, planning and
setting priorities for service delivery and increasing the responsiveness of the
primary health care system to the population’s health needs are directly addressed
by COPC.
35
Evaluation Studies
To date, the operationalization of COPC has been limited to local communities
or demonstration projects with no widespread application across a region or country.
Health problems that have been addressed through local COPC programs include:
immunization coverage, communicable and non-communicable diseases, infant
mortality, child growth and development, prevalence of risk factors for cardiovascular diseases, and changes in health-relevant behaviours. Studies of the effectiveness
of the COPC approach to primary health delivery have been conducted in Israel,
South Africa, the United States, Wales and Canada.
Abramson (1988) presents data on the effectiveness of COPC practices throughout the world. All the evidence presented demonstrated improvements in health
outcomes including infant mortality rates and population immunization rates for
children and the elderly. COPC practices appear to be applied most frequently and
successfully in communities of low-income, disadvantaged populations where priority needs are identified and services are targeted to these needs. Abramson’s review
reported only on the positive outcomes of COPC practice and failed to identify any
study limitations. His “activism” in the COPC movement warrants cautious interpretation of his review of COPC effectiveness.
Our review of the literature on COPC effectiveness included a review of Israel’s
experience with COPC. This has been evaluated through a community-focused
intervention called the CHAD program designed to control cardiovascular disease
risk factors such as hypertension, overweight, hypercholesterolemia and smoking
(Abramson et al, 1981; Hopp, 1983; Gofin et al, 1986).
Upon examination of patient records in a Jerusalem neighbourhood family
practice in the 1960s, cardiovascular diseases and diabetes were found to be major
causes of death. A community health survey was conducted to identify the prevalence of cardiovascular disease and known risk factors such as hypertension and
smoking around which an intervention was designed to modify behaviour and treat
risk factors within the family practice population. The effectiveness of the program
was first evaluated by comparing changes in risk factors through surveys conducted
in 1970 (before the CHAD program was introduced) and in 1975 with those observed
in a nearby control neighbourhood. Both populations received free access to primary
health care. Compared to reductions observed in the control population, the program
36
was found to result in significantly greater reductions of prevalence for hypertension
(20%), cigarette smoking among men (11%) and overweight (13%) (Abramson et al,
1981).
A follow-up study of program effectiveness (1975-76 to 1981) was conducted for
the CHAD program population only. The analysis was based on a matched comparison of data for 1976 and 1981 for a cohort of 441 people who were exposed to the
program for the full period. Results demonstrate that the prevalence of hypertension
continued to decrease during this period (from 12.5 to 9.1%). Prevalence of cigarette
smoking for the population over 30 years of age also decreased during this period,
while national survey data showed no evidence of decreased smoking (Gofin et al,
1986).
Conclusions from the Research and Lessons for Policy Development and
Research
Despite small-scale successes, COPC features have not been adopted widely
(O’Connor, 1989; Abramson, 1988). Unwillingness to generalize study findings in
disadvantaged populations to mainstream primary heath care delivery may be one
impediment to its widespread application, but even if COPC results were generalizable
to other settings and jurisdictions, there are other barriers that are likely to pose
greater challenges to its development. These barriers are highly relevant to the
current primary health care environment in Ontario.
Several authors have suggested reasons why successful COPC demonstration
programmes have rarely expanded to provide care for a larger population or region.
One argument put forward is that COPC has remained a philosophical approach to
primary health care delivery to which only a few practitioners are committed. Others
attribute the lack of appropriate combined training in clinical medicine and epidemiology required to implement COPC and the absence of an obvious career path for
individuals investing in this type of training (Tollman, 1991; O’Connor, 1989;
Wright, 1993). A third argument put forward, is the absence of a policy environment
which supports its more widespread application of COPC principles (Waitzkin and
Hubbell, 1992). A policy environment which was supportive of COPC might include
the following:
37
*
clearly-defined community and a fixed patient list which would allow for the
identification of a population’s needs;
*
resource investments to establish and operate information systems and to
design and evaluate programs;
*
flexible provider payment system which would does not penalize providers for
time spent in non-service delivery activities.
38
B.
Collaboration between Health Care Providers: Teamwork in Primary
Health Care
The WHO’s Primary Health Care strategy emphasizes the importance of
collaboration between different sectors working in the health care system (Boerma,
1987). In support of this objective, the WHO’s Health Manpower requirements for the
achievement of Health for All by the Year 2000 through PHC define the primary
health care team as:
“A group of persons who share a common health goal and common
objectives determined by community needs, to which the achievement
of each member of the team contributes, in a coordinated manner, in
accordance with his/her competence and skills and respecting the
functions of others”
(WHO Technical Report Series No. 717, 1985)
The WHO’s emphasis on collaboration is consistent with the efforts that many
jurisdictions are making to encourage a multidisciplinary and collaborative approach to primary health care delivery. The limitations of solo general practice in
responding to a wide range of patient needs combined with a fragmented system of
primary health care delivery in which numerous providers interact with the same
patient led the Dutch government to promote group general practice, the widespread
establishment of multidisciplinary health centres and teamwork (Boerma, 1989;
Boerma et al, 1993). In 1987, the government of the United Kingdom emphasized the
importance of teamwork in primary health care proposals. The potential benefits of
teamwork to patients included increased efficiency and the provision of higher
quality of care and greater patient choice (Promoting Better Health in Gregson,
Cartlidge and Bond, 1991). Norway has also developed a policy to stimulate health
centres and multidisciplinary teamwork among groups of general practitioners,
nurses, physiotherapists and others (Boerma et al, 1993).
While some evidence exists to support the promotion of group over solo practice,
there is limited evidence to support the widespread belief in multidisciplinary
teamwork as a characteristic to be used to achieve primary health care objectives
such as improved service coordination, more efficient use of resources or increased
responsiveness to consumer needs and preferences.
In their review, Gregson, Cartlidge and Bond (1991) found few empirical studies
39
of collaborative working arrangements in primary health care settings. Studies
reviewed fell into two broad categories:
*
Examinations of the work environment (e.g., structure and process) of different health care providers and its influence on collaboration;
*
Surveys of attitudes and opinions about collaboration held by different
provider groups.
In their own study of interprofessional collaboration, the authors measured the
existence and extent of interprofessional collaboration among district nurses, general practitioners and health visitors in England and identified factors associated
with higher levels of collaboration. Low levels of collaboration were found in each of
the study districts. Factors associated with higher levels of collaboration included
the location of the district nurse (employed directly by the National Health Service)
in close proximity to or in the general practitioner’s office, arranged meetings,
frequent consultations, and sharing of the patient record (Gregson, Cartlidge and
Bond, 1991). Study findings do not provide any insights into the relationship
between the multidisciplinary team and quality of care delivered. Also, the focus of
the study was on collaboration between providers who work in the same geographic
area but not necessarily within the same practice. Therefore, generalizability to
other practice settings is limited.
In our earlier review of the Finnish demonstration project which evaluated the
Personal Doctor Program, study results provided modest support for the notion that
a team-based model of primary care delivery may be associated with superior quality
of patient care and a greater capacity to implement organizational change (Vohlonen
et al, 1989).
In a review of studies comparing the effects of interdisciplinary teams versus
traditional care on patient outcomes, Patterson et al (1994) identified a number of
methodological deficiencies. The authors’ review of 17 studies of team care provided
some evidence that interdisciplinary teams can be more effective than traditional
care. There was, however, considerable variability in study findings and methodological weaknesses, most notably the lack of reliable and valid instruments to
measure components of team functioning, posed threats to the internal validity of
study results.
40
Conclusions from the Research and Lessons for Policy Development and
Research
The literature is sparse and inconclusive in this area. Despite widespread
support for multidisciplinary and collaborative approaches to primary health care
delivery across numerous jurisdictions, only weak evidence exists to indicate that
this approach leads to the delivery of more effective or efficient care.
Despite the lack of evidence to support this approach to service delivery, the
concept of teamwork and collaboration has intuitive appeal. Policies developed to
support collaborative approaches to primary health care delivery, however, should
be accompanied by a commitment to promote research into appropriate models and
methods for achieving effective collaboration. The community health centre model,
with an established emphasis on teamwork would provide an excellent environment
for conducting research in this area to inform future policy decisions.
41
C.
Integration and Coordination within the Primary Health Care Sector
Integration and coordination have been described as “different approaches to
achieving similar results”. Through integration, organizations and/or services are
combined to create a unified structure or organization. In contrast, coordination
involves the establishment of links between separate services or organizations to
encourage common action or communication between them (Deber and Rondeau,
1989).
Although frequently cited as goals for countries’ reform initiatives, integration
and coordination have also been incorporated as features of delivery models. We will
consider integration and coordination as both features of and objectives for delivery
models in our review. The literature on service coordination is sparse but literature
on integration is more abundant and crosses a variety of service sectors within
primary care. Examples include studies of the integration of community psychiatry
and primary care, public health and community health centres and more broadly,
health and social services. The literature is mostly descriptive, presenting models for
or case studies of improved integration.
The literature on integration and coordination within the primary health care
sector includes both descriptive and evaluation studies. No studies were found that
documented specific problems with integration or coordination in a given jurisdiction. However, since the majority of the literature focused on attempts or proposals
to increase integration and/or coordination of service delivery, it appears to be a
problem common to many jurisdictions’ primary health care systems. Specifically,
jurisdictions like the United Kingdom and the Netherlands are characterized by
administrative boundaries that isolate provider groups from each other on the basis
of employment arrangements leading to duplication of services and poor communication. For example, community nurses in the United Kingdom can be employed as
practice nurses or by the District Health Authority as community unit nurses, often
performing the same functions for the same population in isolation of one another
(Southworth, 1992).
A case study of the integration of a community health centre and a local health
department provides insights into the causes and catalysts for, as well as the barriers
to, integration between these two facilities (Lambrew, Ricketts and Morrissey, 1993).
42
Background research reported in the study cites evidence for the potential development of alliances between these types of organizations on a large scale. Surveys of
providers in each group demonstrated high levels awareness of and collaboration
with the other organization. Common collaborative activities included referral
arrangements, prenatal care, family planning, and AIDS programs (National Association of County Health Officials, 1990 reported in Lambrew, Ricketts and Morrissey,
1993).
Attempts to integrate health and social services within a neighbourhood health
centre in Israel were analyzed to identify reasons for failure and lessons for the
future. Problems with administration, lack of leadership and inadequate attention
given to overcoming barriers to organizational change were identified (Lazin, 1983).
Our review of an unpublished report on nursing case management revealed the
relevance of case management to the achievement of a coordinated approach to
service delivery. In their review of nursing case management, Frisch et al (1991)
trace the history of case management as a concept dating back to the 1970s with its
roots in the social welfare literature. Literature is reviewed on case management
approaches among the community dwelling elderly and the results of their review are
used to assess case management’s feasibility as a feature of primary health care
delivery models. The literature review is narrow in scope being confined to case
management approaches among the elderly provided by nurses. As such,
generalizability is limited.
As reported in their review, the majority of studies of case management
effectiveness have been conducted in the United States. Outcome measures used in
various studies included program costs, the ability to maintain clients in the
community, utilization of hospital, nursing home and various community services,
health and functional status, and the effect on the amount of informal caregiving
provided. Although positive effects were found for some community-based case
management programs, these effects were often outweighed by the costs of the
programs. The effects on nursing home and acute care utilization were small.
Studies did demonstrate positive effects on caregiver satisfaction and quality of life.
Challenges faced in conducting evaluations of case management programs for the
elderly were identified. These included issues of internal validity and generalizability,
the selection of clients and services to be offered, selection of appropriate outcome
43
measures, and evaluation designs (Frisch et al, 1991).
The findings from this literature review fail to provide any strong evidence to
support community-based case management, limited to the elderly or extended to
the general population, as a “desirable feature” of primary health care delivery
models.
Conclusions from the Research and Lessons for Policy Development and
Research
Despite widespread perception of a need for improved service integration and
coordination, little evidence exists to support the adoption of one approach over
another. Other jurisdictions’ problems with service duplication and system fragmentation resonate with those in Canada.
The case study of the integration between a public health department and
community health centre offers some useful insights for provincial settings particularly in Ontario where public health agencies and community health centres engage
in some of the same collaborative activities around referral arrangements, prenatal
care, family planning, and AIDS programs. In contrast, the challenges faced in
attempting to integrate health and social services as the CLSC has done in Quebec
are significant given the institutional structures in place at the provincial government level in other provinces (e.g. separate ministries).
44
D.
Paying Providers: A Policy Instrument for Achieving Primary Health
Care Objectives
The literature reviewed in this area deals almost exclusively with physician
payment as a mechanism for achieving primary health care objectives. The smaller
relative proportion of expenditures on paying other primary health care providers as
well as the predominance of salaried payment explains the lack of attention paid to
payment issues for other providers. However, as newly-regulated health care
providers, such as midwives and nurse practitioners, move into Ontario’s health care
system, this literature will become increasingly relevant in establishing payment
policies for these and other providers.
Changes to physician payment have been used in many jurisdictions to achieve
policy objectives in primary care as well as other health care sectors. As discussed in
our review of the general/family practice literature, physician payment and practice
organization are often closely linked to one another, making it difficult to determine
which characteristic is being used as the mechanism for achieving a given policy
objective.
In the sections below, different provider payment methods are outlined with a
discussion of their underlying objectives. This is followed by an analysis of the
research evidence evaluating their effects. However, before reviewing this literature, we want to draw a distinction between the concepts of paying providers in
different ways and employing different methods to allocate funds to a delivery model.
A variety of methods may be used to determine the amount of funds to be allocated
to a particular delivery model or health plan. These include capitated prepayment
methods which involve the delivery of services based on an established fee per capita
arrangement or a global budget which involves a lump sum payment for the delivery
of services. Within a delivery model, there may also be a number of different ways of
reimbursing providers for the services delivered. The three principal methods are:
fee-for-service, capitation, and salary. Within each of these payment methods there
may be different units of payment. For example, a physician or other provider may
be paid for each: (i) procedure performed (traditional fee-for-service); (ii) case presented (for surgical or obstetrical care); (iii) patient (capitation); or (iv) time spent
(salary) (Lee et al, 1990). For many countries reviewed, a mix of different payment
methods are used. A summary of primary health care provider reimbursement
45
methods used in selected countries is presented in Table 5.
Table 5
General Practitioner Reimbursement Methods for Selected European
Countries
Country
Austria
Belgium
Denmark
Salary
Finland
X (for 95%of MDs)
Capitation
X (for some MDs)
Combination
-2/5 capitation
-2/5 FFS (per visit)
-1/5 practice allowance
X (for private practice
and on-call work)
X
France
Iceland
-salary and FFS (health
centre MDs)
-capitation and FFS (nonhealth centre MDs)
Italy
Netherlands
Norway
Sweden
United Kingdom
Fee-for-service
X (for some MDs)
X
X
X (yearly flat fee per pt.
includes net incomes,
pensions and practice
costs)
X (for public MDs)
X
X (for private MDs)
X (for small minority)
-capitation (for money)
-FFS (for minor surgery)
-target fees (for prevention)
-practice allowance
Capitation
Capitation has been used as a physician payment method by governments and
insurance organizations in a number of countries (Boerma, 1993). Some of the
objectives of capitation payment systems include the ability to achieve predictability
in physician expenditures for a defined population and reduction in hospital utilization through substitution of ambulatory for hospital care and improved preventive
services. Jurisdictions’ attempts to achieve these objectives have led to differing
results.
46
Studies of the effects of capitation payment on service utilization have been
conducted in the United States, Denmark, Finland and Canada. In their review of
these studies, Hutchison et al. (1994) found capitation payments to lead to reductions
in hospitalization rates for some populations and increased referral costs for others.
In a study of general practitioners who switched from a total capitation-based
payment system to a mixed fee-for-service and capitation system, Krasnik et al (1990)
found that physicians who were previously paid on a capitation system reduced their
referrals to secondary care and hospitals while referrals among the control group
physicians were unchanged.
Finland has introduced a series of physician payment changes designed to
achieve health care objectives such as:
*
increased continuity and quality of care;
*
increased accessibility and coverage of physician services.
The influence of these changes on achieving desired objectives has been evaluated
in several studies.
Vohlonen et al (1989) examined the effects of a change in both payment method
and practice organization for primary medical care. The implementation of both
changes at the same time prevented any assessment of the independent effect of
changes in reimbursement method.
When physician payment was changed from salary with some fee-for-service to
capitation with more fee-for-service and a contract designed to improve accessibility,
increases were found in the number of visits with corresponding decreases in waiting
times. Patients experienced improved quality of care and satisfaction (Aro and
Liukko, 1993).
Fee-for-Service
Fee-for-service payment is often considered less desirable than other methods
(from the perspective of governments and planning agencies) because expenditures
are unpredictable and providers are paid for the quantity of services provided
regardless of their benefits to patients. Under conditions of excess physician supply,
it also provides an incentive for physicians to induce demand for their services.
Evidence of this phenomenon has not been conclusive but the subject has received
47
much attention from North American researchers (Rice, 1983).
On the benefits side, incentives to maximize the quantity of services provided
under a fee-for-service remuneration system can be used to achieve the objective of
increasing the provision of a particular service (e.g. immunizations, screening tests).
Kristiansen and Mooney (1993) reviewed the remuneration of general practitioner (GP) services in five countries (Australia, Canada, Denmark, Norway and the
U.K.) to determine the extent to which remuneration was being used to achieve
specific objectives for GP activities. Australia and Norway were reported to have
overall goals and to have identified desirable features for general practice and the
primary health care system. Canada and Denmark had no explicit objectives about
family or general practice written into their health legislation. Only the U.K. had
explicit objectives for general practitioner services which were written into a new GP
contract in 1990. Remuneration systems for the countries under study (with the
exception of the U.K.) were directed more towards determining income levels and
controlling physician expenditures than towards achieving pre-determined health
care objectives.
Hughes (1993) reviewed the changes to the GP contract in the United Kingdom,
which were driven by the government’s interest in emphasizing preventive activities, controlling spending on primary health care, particularly in the area of drug
prescribing, and increasing the accountability of general practitioners (GPs) for the
use of resources (Day and Klein, 1991).
Prior to 1990, remuneration to GPs came in the form of:
*
Capitation payments
*
Practice and other allowances (which included a basic allowance for practices
with more than 1000 patients, a group practice allowance for practices with
three or more partners, and a supplementary allowance for after-hours care)
*
Fee-for-service (for maternity care, contraceptive services, vaccination and
immunization, and cervical cytologies)
The introduction of the new GP contract in 1990 abolished all allowances and
48
replaced fee-for-service payment for cervical cytologies and childhood immunizations with target payments for achieving a percentage coverage of the eligible patient
population. Other financial rewards offered to encourage physicians to emphasize
prevention activities in their practice include:
(i)
(ii)
subsidies to GPs who employ practice staff (limit of 2 per practitioner)
opportunities for increased income through fee-for-service payment for minor
surgery and health promotion clinics.
Targets and Sessional Fees
Target payments are used to encourage providers to meet health care objectives
but they have the disadvantage of providing an incentive to provide no service at all
if the provider does not think they can achieve the target or fails to do so over one time
period (Hughes, 1993). The target payments implemented through the GP contract
will reward those practices that already have high rates of coverage and that serve
a relatively “easy to reach” population. Unless adjusted in some way to account for
highly mobile inner city neighbourhoods, they run the risk of leading to service
decline.
Preliminary analyses estimating the impact of target payments on cervical
cytologies performed found that for the first year of target payments, there was a 50%
increase in the number of cervical cytologies performed relative to the level that
would have been performed if fee-for-service payments were retained (Hughes and
Yule, 1993). Results should be interpreted cautiously, however, as this may merely
represent an adjustment period during which physicians are determining which
target levels are easily reached.
49
Conclusions from the Research and Lessons for Policy Development and
Research
The literature reviewed in this section raises a number of critical issues for
Ontario as it considers ways to fund primary health care delivery models and
reimburse providers working within these models. The issues are summarized below:
1.
Fee-for-service is the predominant payment method used in some countries
(Belgium, Canada, France, Germany, Switzerland and the United States). It
is also the favoured reimbursement method for the private practice sector of
publicly-financed health care systems.
2.
Many countries use a combination of methods for reimbursing primary care
providers. Typically included is a base salary or capitation payment for
patients registered to a physician’s list with additional practice allow
ances and/or fee-for-service payments designed to provide incentives to perform specified activities (e.g, preventive services, after-hours coverage, etc.).
All Scandinavian countries (including Denmark and Iceland), the Netherlands, the United Kingdom and Austria use a mixed method approach. The
blended funding system proposed by the College of Family Physicians of
Canada is an example of a mixed model approach which incorporates some of
the elements of the payment systems reviewed in this section.
3.
A requirement for the introduction of a capitation payment system is the
identification of a discretely-defined practice population. With the exception
of Ontario, jurisdictions employing any form of capitation payment have also
implemented a patient registration system. Under such a system, patients
register with a physician or health centre and may only receive services from
the physician with whom they are registered. The issue of patient registration
must be addressed if Ontario considers moving towards any system of capitation payment.
4.
Few countries have used provider remuneration as a means of pursuing
explicit health care objectives. Recent experimentation with performance
50
targets in the United Kingdom offers some innovative ways to link payment
to the achievement of specific preventive health objectives. The patient
registration system described above would facilitate this type of payment
policy.
5.
Numerous countries have experimented with modifications to their remuneration systems with inconclusive results. Only limited generalizability
from study results is warranted due to the unique characteristics of the
primary health care settings and health care systems under study.
51
E.
Funding, Management and Accountability Structures
In many jurisdictions throughout the world primary health care reform has
involved changes to funding, management and accountability structures. These
changes are often so closely connected to each other that it is extremely difficult to
isolate their independent characteristics and effects. For this reason, they will be
reviewed together in the paragraphs below.
In this section, we review the literature that has examined structural changes
to funding, management and accountability mechanisms for primary health care.
Changes of this nature may involve fundamental reform of a country’s health care
system and, as such, their achievements can only be measured (if at all) over long
periods of time. For this reason, only preliminary evaluation results are available for
some studies.
In order to provide a context for our review of this literature, the basic funding,
management and governance structures of selected primary health care systems will
be outlined followed by a discussion of the reforms and their intended outcomes. This
summary is not intended to be comprehensive but to highlight common features of
different systems.
Funding, management and accountability structures for primary health care
in Sweden, Finland and Denmark are highly decentralized. While the central
government is responsible for macro-allocation decisions (how much funding goes to
the regional level), it is at the county or community level where most allocation and
management decisions are made. In Denmark and most of Sweden, regional county
councils are responsible for primary health care. These are locally-elected special
purpose bodies with exclusive responsibility for health care and some social services.
In Finland, boards of health nominated by elected municipal councils oversee health
care (and sometimes social services). County council regions may range in population size from 100,000 to 1.5 million. For the purposes of primary care planning and
management, therefore, these regions are sub-divided into community-sized districts. Primary health care systems in Finland and Sweden are also characterized by
a coordinated approach to delivery through government-sponsored health centres
staffed by physicians, nurses and other health care providers responsible for providing services to a population residing in a specified geographic region. This is in
52
contrast to Denmark where services are provided by self-employed physicians who
contract with the government to provide primary health care to patients registered
with their practice (Weiner, 1988; Boerma et al, 1993).
The separation of funding from the provision of services is becoming a more
common feature of numerous countries’ health care systems. The rationale for
“splitting” the roles of providers and funders is to create a competitive market for the
provision and purchasing of services. Funders (or purchasers as they are often
called) have the incentive to purchase services from efficient providers while
providers in turn are interested in producing efficiently in order to “sell” their
services. The purchaser/provider split was a principal feature of the U.K.’s 1991
health reforms and is also a feature of the U.S. health maintenance organization
model. The U.K. has gone even further in introducing competition into its health
care system through the general practice fundholding scheme which will be reviewed in the following section.
An additional benefit to be reaped from the separation of purchaser and
provider is increased provider accountability. Specifically, accountability can be
achieved through the use of contracts that specify measures of quality, audit
practices and the achievement of certain health care objectives.
United Kingdom
The most significant reform to the United Kingdom’s primary health care
system has been the introduction, in 1991, of a new method for funding primary and
secondary care through general practitioner (GP) fundholding practices. Under this
new scheme, the budget for a specified set of services is transferred from the District
Health Authority (which is responsible for purchasing all health care services for a
designated geographic area) to the fundholding practice along with the authority for
purchasing on behalf of patients registered with the practice. The purchasing
responsibility rests, in theory, closer to the patient, and the balance of power shifts
away from hospitals towards GPs and primary health care. Fundholding practices
contract independently with hospitals and other service organizations and, in effect,
become “customers” seeking appropriate, efficiently delivered services on behalf of
their patients (Glennerster, 1992). The areas covered under the budget include:
*
hospital in-patient care for ophthalmology, ear nose and throat, thoracic
surgery, cardiovascular operations, general surgery, gynaecology, and ortho53
*
*
*
*
paedics
all outpatient treatment
diagnostic tests done on an outpatient basis (including blood and urine tests
and X-rays)
pharmaceuticals prescribed by the practice
practice staff
As of April, 1993 the following services were added to the budget:
*
community health services, district nursing, health visiting, chiropody, dietetics, community and outpatient mental health counselling, and health services
for the learning disabled.
Improved coordination between general practice and community services (areas which had traditionally been isolated from one another) were sought through the
addition of these budget items.
In contrast to the methods used to allocate funds to the district health authorities (i.e., population-based health planning principles), fundholding budgets were
negotiated, at the outset, on the basis of historical utilization with the objective of
moving towards a needs-based allocation formula over time. Eligible practices must
have a minimum of 7000 patients (although the required numbers continue to
decline as more practices seek to enter the new scheme) to achieve a large enough risk
pool. To prevent bankruptcy caused by catastrophic illness, an expenditure ceiling
of $10,000 has been set for each patient, above which the district health authority will
cover any treatment costs.
An evaluation of the GP fundholding scheme has been initiated with the
objective of studying the administrative process of entering into fundholding practices by:
*
*
describing the initial phases and subsequent development of the scheme over
the first three years of implementation;
describing the impact of fundholding on the budget process, practice management and service outcomes;
54
*
comparing the experience of newly-established fundholding practices (third
wave) with those who established practices at the outset (first wave).
Preliminary studies of a sample of the original fundholding practices have revealed
the following benefits:
*
*
*
*
improved efficiency of laboratory testing arrangements (i.e., turn-around
times);
negotiation of contracts with hospitals that led to reduced waiting times and
increased patient satisfaction;
major savings in drug spending by switching to more generic prescribing and
reviewing prescribing patterns;
flexible use of the GP budget between outpatient and GP practices and
community services and GP practices has the potential to encourage more
efficient organization of service delivery.
Costs to the British National Health Service of establishing GP fundholding
practices have been considerable. Administrative costs are higher under GP
fundholding than under a single district purchasing scheme. This is due to the
increased administrative staff required in each fundholding practice to process
patient data and the multiple contracting that takes place between hospitals and
fundholders.
Concerns have been raised about the implications of GP fundholding for the
achievement of equity both between fundholding and non-fundholding practices and
within the pool of fundholding practices. For example, concerns about inequalities
in access to services have been raised due to preferential treatment given to
fundholding versus non-fundholding practices. Also, fundholding practices have
tended to serve more affluent populations leading to concerns that practices that are
already doing well will only get better under the fundholding scheme. Insufficient
evidence exists to assess the validity of these concerns.
One third of the population of the United Kingdom is now covered by fundholding
and it is expected that this will increase to one-half of the population in the next two
to three years (Glennerster, 1994).
55
An accountability mechanism built into the U.K. reforms which will apply to all
general practitioners is the establishment of Family Health Service Authorities
(FHSAs) which will have the managerial responsibility for overseeing primary
health care delivery and monitoring activities such as GP referrals and prescription
patterns (Klein and Day, 1991). This is seen as an attempt to improve the accountability of general practitioners for their performance. However, the success of this
initiative will largely depend on the FHSAs’ ability to establish appropriate monitoring systems.
New Zealand
New Zealand’s health care system has been in transition since 1989. Following
the establishment of a comprehensive system of area health boards throughout the
country, the newly-elected government has introduced yet another reform plan
based on a model of regional health authorities which would purchase services from
competing providers. A feature of this reform process is an increasing emphasis on
general practitioners as the purchasers of services, similar to the U.K. fundholding
practices.
The establishment of the regional health authorities and service contracting
has stimulated numerous innovations within the primary health care system.
Budget holding has developed for a number of provider groups including a group
which has contracted with a regional health authority for the provision of care to an
aboriginal population group. Greater accountability of general practitioners for
resource allocation within a fixed budget is a significant objective of these reforms.
The New Zealand reforms are still in their infancy, and as such, their ability to
achieve their stated objectives of increased accountability and improved health
status for the population remains unknown.
Sweden
Fundamental health system reform has been underway in Sweden since 1989.
Moving away from their traditional planned, needs-based approach to service
delivery, each of the country’s 26 independently-operated county councils and three
municipal health providers have introduced new organizational models for health
services delivery. Most of these models incorporate elements of either a “public
competition” or “mixed market” approach to service delivery.
56
In his review of Swedish health system reforms, Saltman (1991) describes each
of the prevailing models. The public competition model involves the organization of
providers into “public firms” that compete with each other on the basis of quality to
provide services to patients who may choose their treatment site and provider.
Budgets for service provision are determined by the patient’s choice of service
provider and are calculated either on a capitation basis (for primary care) or an
episode basis (for hospitals).
The mixed market model is similar to the reforms introduced in the U.K. where
both private and public providers will compete for contracts to provide hospital and
specialist services. Under this model, all hospital and primary care funds are
transferred to local district boards, composed of elected politicians. District boards
run the primary health centre in their district and negotiate contracts for hospital
services. Individuals can attend the health centre of their choice but are restricted
to the hospital care that is negotiated for them by the district board. The principal
element of the model is the contractual relationship that is introduced which provides
incentives for hospitals to increase efficiency in order to attract and retain primary
health centre referrals.
According to Saltman, differences between the two models lie in the level at
which the decision-making power rests. Public competition shifts the balance of
power to the patients who bring institutional budgets and personnel salaries with
them, whereas the mixed market model gives administrators and politicians more
power in negotiating hospital contracts. Both models, however, are characterized by
their market-style incentives, a significant departure from the tightly-controlled and
somewhat unresponsive system of the past.
No studies were found that evaluated the Swedish reforms. However, the
influence of Sweden’s planned market approach is evident in the introduction of a
similar experiment in Finland.
Nova Scotia
The Province of Nova Scotia recently released the report of its Task Force on
Primary Health Care (Nova Scotia, 1994). The Task Force proposes a system model
for primary health care which includes fundamental restructuring of the health care
57
system through the establishment of regional health authorities and local health
councils which will have the responsibility for overseeing local primary health care
planning. Council members will be elected from the local community, one-half
representing local residents not employed by the health system and one-half representing local primary health care professionals. The regional health authority will
control the allocation of funds for primary and secondary care. Both local health
councils and regional health authorities will be accountable to the community for the
achievement of specified goals, whether they be planning or health outcomes.
Conclusions from the Research and Lessons for Policy Development and
Research
Characteristic of the reform proposals described above is the emphasis on
increasing management efficiency, strengthening accountability structures (to either local communities through devolution or individual patients) and establishing
flexible funding models that are responsive to community needs.
Although the results of different countries’ reform experiments (if they were
available) are worthy of scrutiny, it is equally important to analyze the environments
within which these reforms are taking place to assess their relevance to the Ontario
setting. In the U.K., for example, the underlying objective of their reforms was to
increase the technical efficiency of the system (e.g., reduce waiting lists). This
objective was achieved, in part, by injecting new funds (over a short period of time)
into the system. The political environment in the U.K. is also worthy of comment. The
Conservative government, under Margaret Thatcher, was determined to implement
the reforms and was not prepared to compromise in achieving its objectives. Despite
overwhelming resistance to the GP fundholding scheme from the British Medical
Association, the GP fundholding scheme proceeded. An enabling factor for the
introduction of this scheme was the existence of a capitation payment system and a
patient registration system. These are structural elements of the U.K. system that
do not exist currently in Ontario. What is perhaps most relevant to the Ontario
setting is the power that carefully-chosen financial incentives or disincentives wield
in changing provider behaviour.
In the case of the Swedish reforms, the country was moving away from a tightlycontrolled, centrally-planned delivery system characterized as “inefficient, rigid and
58
insular” (Saltman, 1991) to one that retained existing planning mechanisms in
combination with market-style incentives. Relating these reforms to the Ontario
setting, the elements of Sweden’s “old” system do not currently exist in Ontario.
The common theme running through these reform examples is that of increasing accountability for the use of resources by shifting control over the funding and
management of the system to the local or community level and increasing accountability for provider performance using service contracts between providers and
funders.
Conclusions about Characteristics and Objectives of Delivery Models
Table 6 presents a summary of the literature on characteristics of primary
health care models and their influence on the achievement of objectives for primary
health care delivery.
59
Table 6
Summart of Literature Evaluating Characteristics of Primary Health Care Delivery Models
Characteristic
SOURCE
STUDY DESIGN
RESULTS
EVIDENCE
GENERALIZABILITY
Scope of
practice
CommunityOriented
Primary Care
Abramson et al
(1981)
Before-after with
non-equivalent
comparison group
CommunityOriented
Primary Care
CommunityOriented
Primary Care
Collaboration/
Teamwork
Gofin et al
(1986)
Cohort follow-up
(1976-1981)
Abramcon
(1988)
Descriptive
Gregson et al
(1991)
Collaboration/
Teamwork
Patterson et al
(1994)
Analyzed degree
of collaboration
between different
health care
providers
Critical appraisal
of literature and
analysis
20% net reduction in
hypertension; 11% reduction in
smoking for men; 13% reduction
for overweight
Decrease in hypertension (12.5%
to 9.1%); decrease in smoking
prevalence
Documents evidence of COPC
effectiveness in various settings
Low levels of collaboration;
tendency towards collaboration
between providers located in
close geographic proximity to
each other
Studies of teamwork are
methodologically weak; need to
develop appropriate tools to
measure interdisciplinary
teamwork
60
Other
settings
++
*
*
++
*
*
+
**
**
+
*
*
++
**
**
Table 6
(cont'd)
Characteristic
Integration and
Coordination
SOURCE
STUDY DESIGN
Lambrew et al
(1993)
Case study
Lazin (1983)
Case study
Frisch (1991)
Critical appraisal
of case
management
effectiveness
RESULTS
High level of awareness of and
collaboration between health
centre and public health
department; frequent
collaboration on referral
arrangements prenatal care,
family planning, AIDS programs
Failed attempt to integrate health
and social services within a
neighborhood health centre; lack
of leadership, poor
Positive effects found for case
management programs are often
outweighed by cost; small
effects on reducing nursing
home and acute care utilization;
positive effects demonstrated on
caregiver satisfaction and quality
of life; methodological problems
identified
61
EVIDENCE
GENERALIZABILITY
Scope of
practice
Other
settings
+
*
*
+
**
*
+
**
**
Table 6
(cont'd)
Characteristic
SOURCE
STUDY DESIGN
RESULTS
EVIDENCE
GENERALIZABILITY
Scope of
practice
Provider
Payment
Hutchison et al
(1994)
Historical cohort
Krasnik et al
(1990)
Follow-up study
of experimental
and control group
Before-after
design of three
experimental
delivery and
payment models
Descriptive
analysis (5 country
comparison)
Descriptive
analysis
Vohlonen et al
(1989)
Kristiansen and
Mooney (1993)
Hughes (1993)
Funding/
Accountability
Glennerster
(1992; 1993)
Prospective
analysis of reform
introduction
No difference between
captivated and FFS practice
hospital utilization rates for three
time periods
Changes from capitation to FFS
led to reduction in referrals to
secondary care
Unable to assess independent
effect of change in payment
method
No explicit objectives for MD
remuneration except in U.K.
Examines changes to physician
remuneration under U.K.’s GP
contract
Increased efficiencies in
laboratory testing arrangements;
major savings in drug spending;
reduced waiting times; increased
patient satisfaction
62
Other
settings
++
**
*
++
**
*
+
**
*
++
n/a
**
n/a
n/a
*
++
*
*
VII. CONCLUSIONS
Several key conclusions arise from our review of the literature on primary
health care delivery models and their individual characteristics:
Delivery Models
1.
Few discrete delivery models exist in jurisdictions around the world. The
physician-centred model, and family/general practice in particular, is the
predominant mode of primary care delivery in the developed world. Collaborative models are rarely the predominant mode of delivery in a jurisdiction,
although health centres exist in many countries and are widely supported as
a desirable model of health care delivery. Delivery models which integrate
and/or coordinate services are uncommon. Nurse-managed health centres are
the least prevalent form of primary care delivery.
2.
There is an abundance of descriptive literature and a paucity of evaluation
literature on primary health care delivery models. Most evaluation studies
are moderate to weak in their methodological rigour and results are often
limited in their generalizability to other settings. A major challenge in conducting evaluation studies of delivery models is to separate and identify the
independent effects of organizational and payment arrangements.
3.
The literature fails to point to an “ideal” or “most suitable” primary health care
delivery model.
4.
The paucity of rigorous evaluation research in such a broad policy area as
primary health care delivery is striking. Whatever policies are contemplated
for the reform of Ontario’s primary health care system, their implementation
should be considered in the context of a strong policy-informing research
agenda.
63
Responsiveness to Community Needs
5.
Despite small-scale successes, Community-Oriented Primary Care practice
has not been implemented on a widespread basis. Features of an environment
supportive to COPC include a clearly-defined community and a fixed patient
list which would allow for the identification of a population’s needs, resource
investments to establish and operate information systems and design and
evaluate programs, a flexible provider payment system which does not
penalize providers for time spent in non- service delivery activities.
Collaboration between Health Care Providers
6.
Although collaboration and teamwork are widely supported as a means for
achieving effective and efficient service delivery, there is almost no empirical
research to support such an approach to service delivery. Significant methodological challenges such as the absence of appropriate measurement tools have
been cited as reasons for the absence of research evidence in this area.
Integration and Coordination
7.
Recognition of problems with integration of and coordination between primary
health care services is widespread. One case study points to the potential for
successful integration of and improved coordination between public health
agencies and community health centres. Pilot studies of service integration
would inform continued policy development in this area.
Provider Payment
8.
Much of the evaluation literature focused on comparing the effects of different
payment methods on the cost and utilization of ambulatory, hospital and
specialists’ services.
9.
Blended methods for reimbursing primary care providers are common to many
jurisdictions.
64
10. A requirement for most jurisdictions using a capitation payment system is a
discrete practice population of registered patients. Under such a system,
patients register with a physician or health centre and may only receive
services from the physician with whom they are registered. The issue of
patient registration must be addressed as provinces consider moving towards
any system of capitation payment.
11. Experimentation with performance targets in the United Kingdom offers an
innovative approach to linking payment to the achievement of specific health
and health care performance objectives. A patient registration system would
facilitate this type of payment policy.
Funding, Management and Accountability Structures
12. The separation of funding from the provision of services is becoming a more
common feature of numerous countries’ health care systems. Separating the
roles of providers and funders creates a competitive market designed to lead
to efficiency in the purchasing and provision of services. A potential benefit
of separating the purchaser and provider is increased provider accountability
through the use of service contracts that specify the achievement of certain
health care objectives. Increased decentralization for planning and purchasing (for primary and secondary services) is also characteristic of some countries’ reform initiatives. With the exception of the U.K., where the general
practice fundholding experiment has demonstrated measurable improvements in a number of areas, there is little evidence to support the adoption of
one reform initiative over another. What is evident, however, is the extent to
which countries are reforming their systems of funding and management
throughout the world and the pace at which reform is taking place.
65
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76
Appendix 1
CRITERIA USED TO ASSESS STRENGTH OF EVIDENCE AND
GENERALIZABILITY
EVIDENCE (taken from Luft, 1981 in Birch et al, 1990)
+
Some justification for making the statement but the confidence level is low and
further investigation could alter conclusion.
++
More justification for the statement but the results should still be considered
tentative for important policy decisions without further investigation.
+++ Based on convincing empirical investigations from a substantial number of
studies. A large number of studies showing different results would be
necessary to reverse this conclusion.
GENERALIZABILITY
Scope of practice
*
Only a small number of clinical activities or health problems were examined.
Results cannot be generalized beyond these.
**
A limited range of clinical activities and health problems were examined.
Cautious generalization to other activities and problems may be justified.
*** A broad range of clinical activities and health problems were examined
covering the full scope of primary health care.
Other settings
*
Characteristics of the primary health care setting or of the jurisdiction’s health
care system prohibit generalization to other jurisdictions and primary health
care settings.
**
Characteristics of the primary health care setting and/or health care system
allow for some generalization to other settings/jurisdictions.
*** Similar results were obtained in a variety of numerous settings/jurisdictions
under different payment/organizational arrangements.
77