A study of universal access and
separatist primary care systems
on the island of Ireland
1
Project Team
Queen’s University Belfast
NUI Galway
Dr. Dermot O’Reilly
• Dr. Keith Steele
• Dr. Drew Gilliland
• Ms. Karen Thompson
• Professor Andrew W Murphy
• Mrs. Ethna Shryane
•
University Of Ulster
• Professor Ciaran O’Neill
Trinity College Dublin
• Professor Tom O’Dowd
• Dr Alan Kelly
University College Dublin
• Professor Gerry Bury
2
Original research questions (N vs S)
Question 1.
Does health status differ between patients ?
Yes; south are healthier
Question 2.
How do patients view the issue of cost?
In south: good idea; in north, not so
Question 3.
Does a co-payment effect health seeking behaviour?
Yes; very much so in the south
Question 4.
Does patient satisfaction differ ?
Yes; south are more satisfied
3
Post hoc question (south only)
Question 5.
Are primary care services different for those who pay?
i.e. GMS (capitation) vs private patients (FFS)
4
The effects of capitation
and fee for service on the
consultation process: a
cross sectional study and
associated dissemination
issues
5
Background literature
Payment systems
– Prospective: Salary and capitation
– Retrospective: Fee for service (FFS)
– Mixed
Market theories
– Supplier Induced Demand (SID)
– Consumerism
Cochrane review (2000)
– 4 studies of 6, 400 patients; 2 children only
– Concerns regarding generalisability and confounding esp. health
status and patient satisfaction
– Need for further standardised and prospective studies
6
Study hypotheses
1. That GP initiated visits will be higher in FFS in
comparison to capitation patients
2. That prescription, investigation and referral
rates will all be higher in FFS in comparison to
capitation patients
3. That satisfaction with communication will be
higher in FFS in comparison to capitation
patients
7
The Island of Ireland
Ireland:
30% free (low income & 70+yrs):
Capitation
70% pay (€35-55): Fee for
service ‘FFS’
8
Methodology
1st Phase - Baseline survey

20 practices in Ireland, 20 in N.Ireland (matched)

625 patients randomly selected from lists

Postal survey (Autumn 2003; 2 reminders): RR 52%
2nd Phase – Audit of consultations (Ireland only)



Random selection of up to 200 survey respondents per practice
Random selection of 1 consultation per patient
Up to 4 outcomes categorised per consultation & summarised;
- Prescription (Yes/No)
- Investigation (Yes/No)
- Referral (Yes/No)
9
Study instruments
Health status
– Limiting long term illness (LLTI)
– Perceived general health
– Case finding for depression
Classification of ‘GP initiated’ or not
Process outcome
– Prescription; investigation; referral
10
Study Instruments:
GP Assessment Questionnaire
Dimensions of patient satisfaction:




Continuity of Care
Patient / Doctor Communication
Access to services
Overall Satisfaction


Receptionists
Nursing
* © The National Primary Care Research and Development Centre,
University of Manchester and Safran/NEMCH
11
Questions that form the communication scale of the General Practice
Assessment Questionnaire
Thinking about consulting with your doctor, how would you
rate the following:
1. How thoroughly your doctor asks about your symptoms?
2. How well your doctor listens to what you say?
3. How well the doctor puts you at ease during your physical
examination?
4. How much the doctor involves you in decisions about your
care?
5. How well your doctor explains your problems or treatments
you need?
6. The amount of time your doctor spends with you?
7. Doctor’s patience with your questions or worries?
8. Doctor’s caring and concern for you?
12
Methods
Analysis
– Logistic regression with robust confidence
intervals to account for clustering within
practices
Ethical approval from ICGP
13
Results
1, 668 patients from 20 practices
–
–
–
–
Mean age 34.7 (SD 19.5)
62.6% female
28.4% capitation and 70.4% FFS
Education
1O: 24.3%; 2O: 43.2%;3O 29.8%
– Car ownership
None: 14.7%; One: 39.0%; 2+cars: 45.7%
– 77.4% owner occupier
– LLTI: Yes 24.5%
– Depression: Yes 38.4%
14
Structure of Data in South
Survey respondents
(5,291; RR 52%)
Random Selection
(3, 351)
Patients aged 20-69 yrs who
consulted during 12 mth period
(2, 584; 77.1%)
Prescription
(993; 59.5%)
Investigation
(239; 14.3%)
Referral
(237; 14.2%)
15
Study hypotheses
1. That GP initiated visits will be higher in
the FFS group in comparison to the
capitation group
Total mean consultation rate
– Capitation 6.0 (n = 693); FFS 3.6 (n = 548)
– Mean difference 2.38 (95% CI 1.90-2.87)
Initiation: GP 11.1% and Patient 85.8%
– FFS 9.6%
– Capitation 14.6%
16
Logistic regression determinant
of having a GP initiated visit
Adjusting for sex, age, general health,
LLTI, Depression, GMS eligibility,
household income and geography
Only GMS eligibility significant:
– Capitation
– FFS
1.00
0.56 (95% CI 0.37-84)
17
Study hypotheses
1. That GP initiated visits will be higher in
the FFS group in comparison to the
capitation group
2. That prescription, investigation and
referral rates will all be higher in FFS
patients in comparison to capitation
patients
18
Prescription, investigation and
referral rates by age
70
60
%
50
0-19
40
20-44
45-69
30
20
10
0
Prescriptions (p=ns)
Investigations
(p<0.001)
Referrals (p<0.001)
19
Prescription, investigation and
referral rates self-reported
general health
70
Excellent
Very Good
Good
Fair/Poor
60
50
%
40
30
20
10
0
Prescriptions
(p=0.002)
Investigations
(p=0.044)
Referral (p=0.036)
20
Prescription, investigation and
referral rates by payment status
70
Captiation (GMS)
Fee for service (Non-GMS)
60
50
%
40
30
20
10
0
Prescription
(p<0.001)
Investgation
(p<0.001)
Referral (p=ns)
21
Logistic regression determinants
of being issued a Rx
CI’s
P value
1.60
1.27-2.02
< 0.001
Good
1.59
1.22-2.10
0.001
Fair/Poor
1.31
0.94-1.82
0.109
General
health
Excellent
Adj OR
Very good
1.00
22
Logistic regression determinants
of being issued a Rx
GMS
status
Capitation
Adj OR
FFS
0.75
CI’s
P value
0.66-0.85
< 0.001
1.00
23
Logistic regression determinants
of being investigated
GMS
status
Capitation
Adj OR
FFS
2.26
CI’s
P value
1.50-3.40
0.001
1.00
24
Logistic regression determinants
of being referred
Adj OR
CI’s
P value
25
Study hypotheses
1. That GP initiated visits will be higher in the
FFS group in comparison to the capitation
group
2. That prescription, investigation and referral
rates will all be higher in FFS patients in
comparison to capitation patients
3. That satisfaction with communication will be
higher in FFS patients in comparison to
capitation patients
26
Logistic regression determinants
of a high communication score
CI’s
P value
0.70
0.53-0.93
0.014
40-49
0.57
0.42-0.78
< 0.001
50-59
0.64
0.44-0.93
0.020
60-69
0.86
0.59-1.25
0.433
Age
Adj OR
20-29
1.00
30-39
27
Logistic regression determinants
of a high communication score
CI’s
P value
0.76
0.56-1.03
0.740
Good
0.48
0.34-0.68
< 0.001
Fair/Poor
0.52
0.35-0.77
0.001
General
health
Excellent
Adj OR
Very good
1.00
28
Logistic regression determinants
of a high communication score
GMS
status
Capitation
Adj OR
FFS
0.79
CI’s
P value
0.66-0.95
0.014
1.00
29
Logistic regression determinants
of a high communication score
Process
Adj OR
Not Ix’ed
1.00
Ix’ed
1.29
CI’s
P value
1.01-1.65
0.038
30
Discussion
Limitations
–
–
–
–
Cross sectional study: ‘Association, not causation’
Retrospective determination of consultation initiation
Long term, not acute, health status
All GP’s receive mixed payments
Strengths
– Mixed is reflective of international practice
– Clustering accounted for during analysis
– Relatively large (n=1, 668) study in nationally
representative sample
– Disaggregated consultation data with potential
confounders included
31
Study hypotheses
1.
That GP initiated visits will be higher in FFS in
comparison to capitation patients
 FFS OR 0.75
95%CI 0.66-0.85
2.
That prescription, investigation and referral rates will all
be higher in FFS vs capitation
Rx:
FFS OR 0.75
95%CI 0.66-0.85
Ix:
FFS OR 2.26
95%CI 1.50-3.40
Referral:



3. That satisfaction with communication will be higher in
FFS in comparison to capitation
 FFS OR 0.79
95%CI 0.66-0.95
32
Why so ?
Madden and Nolan (2005)
Use of Rx and Ix by GP’s
Omission of confounders from previous
work, Scott (1995)
Stable Irish system vs US ‘before + after’
Uni-dimensional economical approach –
‘businessman with licences’- insufficent
33
Incentivisation vs professionalism
Timmins, 2005
– ‘the professionalism of
GP’s will have to be
played off against their
financial self interest’
120
100
80
60
Marshall, 2005
40
– ‘crowding out’
20
Score
0
0
1
2
3
4
5
6
34
Conclusions
Prescription and investigation patterns indicate
that the method of GP remuneration does impact
upon the process of the consultation.
SID does not appear to explain the differences
between payment status; rather GPs may be
more concerned with their patients’ ability to pay,
than with opportunities for income generation.
35
Dissemination issues
JE Pirkis, GA Blashki, A W Murphy, JC
Richards, IB Hickie, L Ciechomski. The
contribution of general practice based
research to the development of national
policy: Two international case studies.
Submitted AusNZ Health Policy Journal
36
Publishing record
Question 1.
Does health status differ between patients ?
Rejected: Eur J Pub Hlth, Soc Sci Med Currently: IJMS
Question 2.
How do patients view the issue of cost?
Rejected: Health Affairs
Currently: Hth Economics
Question 3.
Does a co-payment effect health seeking behaviour?
Rejected: BMJ, Family Practice
Currently: EJGP
Question 4.
Does patient satisfaction differ ?
Currently: Family Practice
37
Research into policy
Lavis, 2003
– ‘producer-push’
(where producers of research actively push
research knowledge out to users of research),
– ‘user-pull’
(where users of research actively pull in research
when faced with a decision that they believe could
be informed by research knowledge) and
– ‘knowledge exchange’
(where producers and users of research are jointly
responsible for transferring and facilitating the
uptake of research knowledge, and elements of
‘producer push’ and ‘user pull’ approaches occur)
38
Dissemination
Innvaer (2002): systematic review of of policy-makers’ views on
using research evidence for policy decisions.
Facilitators x7
–
–
–
–
–
–
–
personal contact between researchers and policy-makers
timeliness and relevance of the research
summary with clear recommendations
good quality research
confirmed current policy or endorsed self-interest
community pressure or client demand for research
included effectiveness data
Barriers x6
– absence of personal contact between researchers and policymakers
– lack of timeliness or relevance
– mutual mistrust, including perceived political naivety of scientists
and scientific naivety of policy-makers
– power and budget struggles
– poor quality of research
– political instability or high turnover of policy-makers
39
FFS vs capitation paper
Where to send to ?
– Probably a secondary issue, for us ?
Have decided not to wait for publication
– attempted to get HRB to sponsor meeting
– will persist with some prior dissemination
Sustenance from Int Cmmttee Med
– http://www.icmje.org/
The ideal is Lomas, 2000
– ‘linkage and exchange’, that routine and ongoing involvement of
policy-makers in the activities of research organisations will
improve the likelihood of research influencing policy.
40
Acknowledgements
HRB
Participating GP’s and practices
41