Conference
Improving primary care in Europe and the US:
Towards patient-centered, proactive and coordinated systems of
care
The Rockefeller Foundation Bellagio Study and Conference Center, Italy
April 2 to 6, 2008
The Catalan single purchaser integrated care
experience - evaluation results
How incentives work
Josep M. Argimon
Josep M. Argimon, Divisió d'Avaluació de Serveis Sanitaris, Servei Català de la Salut,
Trav de les Corts, 131-159, Edifici Olimpia, 08028 Barcelona, Spain.
jargimon@catsalut.net, telephone: + 34 93 4038542.
Email:
Background
In the recent years changes in the ageing of the population and the concomitant
increase of citizens suffering from chronic diseases, as well as rising expectations of
both patients and health professionals have lead to a redefined mission for health care
organizations. The report “Crossing the Quality of Chasm” (1) states that is no longer
possible to provide better services only on the basis of improving skills, clinical
procedures and high technology alone. In order to achieve safe, effective, patientcentered, timely, efficient, and equitable health system the consolidation and
harmonization of its parts will yield much better benefits. In this sense, the “ecology” of
health services organizations has evolved from that of fragmented independent entities
into functional integrated organizations.
Several strategies are available to foster co-ordinated or integrated health care
organisations (2). Among them payment mechanisms have attracted a lot of attention.
Payment mechanisms have a strong influence on the behaviour of health
organisations. They give incentives to increase or decrease the activity, the type of
diagnostic and treatment procedures selected, and the referral or not of patients to
other institutions and levels of care. All existing mechanisms have their advantages or
disadvantages. Recently, capitation payment has received significant attention as a
tool to promote co-operation among providers and to facilitate the integration process
of a fragmented health system (3).
Capitation payment pilot project
In Catalonia, until now, purchase has taken place by health care line: payment for
activity adjusted by complexity, to specialized care; and on an adjusted capitation basis
for primary care. This purchasing system has positive elements. There seems to have
been a considerable (and praiseworthy) increase in cost-consciousness. There
appears to be also a wide agreement that separately identifying the purchaser role
from that of the provider has proved to be broadly successful and should remain in
some form. At the very least, the contracting process probably has forced some greater
clarity into the interchange between Catalan Health Service (Catsalut) and providers as
to what should be provided, for whom, to what standard, and at what price.
Nevertheless, under this scheme, incentives for coordination between healthcare levels
2
are scarce; any improvement on primary care’s resolution capacity has a negative
impact on the income of the reference hospital. Conversely, less control in primary care
of patients with chronic disease would result in greater activity in the hospital-based
inpatient care (4).
The purchaser (Catsalut) started in 2001 a pilot test of a capitation payment system to
contract integrated healthcare in five areas of Catalonia. The objective was to improve
healthcare equity, continuity and efficiency through the promotion of territorial alliances
among providers. It purchased a range of health services for a geographically defined
population from the providers in the territory that in exchange received a capitation
payment –Catalonia per person expenditure adjusted by a correcting factor (variables
of need). The formula used allowed purchaser and providers to share the risk for
expenditures on prescribing, transportation, and hospital care outside the territory in
order to lessen the capitation payment risks. All providers and the purchaser (Catsalut)
signed a co-operation contract in which providers accepted to hold responsibility jointly
for a percentage of deviation on the items previously mentioned and to achieve a set of
healthcare goals and objectives previously discussed.
Furthermore, the providers from an area signed between them a collaborative
agreement establishing common goals and policy guidelines, agreeing on governance
regulations and decision-making, setting transparent rules for sharing risks and
benefits, setting up how to implement adequate IT (shared electronic records, in
particular), ensuring staff qualification and developing co-operative professional culture,
clarifying organisational and network boundaries and membership issues, establishing
criteria for performance quality and procedures for quality assurance, focusing on
patient orientation, patient empowerment and co-operation with the larger community.
The project encompassed five areas of Catalonia covering 7.5% of the population.
These areas differ in population size and number of providers with different forms of
ownership: In two areas there is a dominant provider –quasi-monopoly- and in the
majority of areas multi-territorial providers –also managing health facilities in other
areas of Catalonia- are present.
It was expected that the introduction of the capitation payment would lead providers
into greater levels of clinical integration: by establishing alliances, shared objectives
and strategies, organic structures with mainstreaming elements, and shared clinical coordination mechanisms.
3
Other expected results were substitution between care levels, and redistribution of
resources between providers. As far as capitation payment entails transferring the risk
to the entity that receives the capita –as the payment is independent from the volume
of activity- it provides an incentive to deliver healthcare efficiently (5). When using a
capitation payment to assign resources to a network of providers, it provides an
incentive to searching ways for clinical and functional integration that allows them to
align their individual interests in order to achieve the network’s overall objectives (6). In
theory, providers perceive that they are receiving a shared budget and that any action
on a specific point of the network will impact the overall results. Hence, network
providers have the incentive to deal with the health problem in the most cost-effective
point of the healthcare continuum (5,6). Therefore, it was expected to shift the balance
from secondary to primary care.
Evaluation of the project
Several indicators intimately associated with healthcare process were selected and
defined for monitoring the project. Since the optimal degree of integration varies
between different health care units and depends mainly on the need for integration to
deal with common patient groups, those chronic conditions where clinical networking
have been proved successful for patients were prioritized (i.e, heart failure, chronic
pulmonary obstructive disease, stroke).
Key evaluation questions were: Do pilot areas have outcomes that are different from
other similar areas? Do pilot areas improve the results over those of the previous year?
Do pilot areas achieve better results with respect to standard goals? Different areas
were selected through cluster analysis to mirror each other with respect to
demographic and environment variables. The results of the pilot areas were compared
with those of the mirror areas, as well as with the results achieved in the previous year
in the same area.
Some of the indicators are related with preventive services such as CV risk
assessment and geriatric assessment: Others belong to the field of resolution: control
of high blood pressure or diabetes control or ambulatory care sensitive conditions. A
third group relates to coordination between health care levels: for instance, heath
failure re-admissions and COPD re-admissions; or the contact with primary health care
liaison nurse 24-48 hours before the discharge from hospital or the convalescence
4
clinic. The results were promising and, in general terms, pilot areas perform better than
control areas or the rest of Catalonia.
We also performed a survey about patient satisfaction. The results did not show any
difference between pilot areas, control areas or the rest of Catalonia.
After five years of the pilot test, in 2006, Catsalut promoted also a qualitative,
exploratory and descriptive study that was carried out by means of document analysis
and individual semi-structured interviews (with a topic guide). Topic guides included a
general for all interviewees and a specific part for the different groups of informants
(managers, health professionals). Interviews were conducted in order to elicit
informants’ perspectives and opinions on the capitation payment system. The
interviews, between 40 and 90 minutes long, were recorded and fully transcribed (7).
A criterion sample of documents containing information on strategies and co-ordination
mechanisms and of three groups of stakeholders in direct contact with the project
searching a variety of discourses was selected. Criteria to select informants were: a)
managers of the providers (territorial and multi-territory at head office, regional and
territorial level), b) health professionals, and c) managers of the purchaser (head office
and regional services).
A narrative content analysis was conducted. Data from interviews were segmented by
informant groups and themes and from documents by areas and themes, with a mix
generation of categories from the topic guide and emerging from the data.
Triangulation of results took place by comparing different sources, techniques and
groups of informants in order to ensure its quality. Three researchers with different
background and in-depth knowledge of the context participated in the analysis.
Whereas the health indicators analysis gave us promising results, the qualitative
evaluation shows that the implementation of the pilot project achieved few and limited
results, both geographically and temporarily. Compared with the expected results a
great variability was found. Whereas a clear progress towards clinical integration was
made in some territories, in others the goals and strategies agreed in the collaborative
agreement were poorly implemented. The analysis of factors influencing the pilot
project implementation found an important imbalance between the few enabling
factors and a great number of hindering elements. According to informants, the main
and facilitating factor of the pilot project development was the human factor: providers’
5
will to collaborate and good relationship among providers’ representatives in the area.
Other identified factors were: to have shared objectives and strategies (clearly defined
in a specific report); strong leadership; clearly defined roles for the members of each
institution; existence of primary care, hospital care and convalescence/long-term care
facilities in a defined territory; and a shared clinical records/integrated information
systems (7).
Among the factors that hinder coordination the most prominent were the following:
different organisations providing the same services in the same territory; fear of the
organisations to loose identity; lack of interest of managers working for organisations
multi-territory; health workers with different wages performing the similar tasks;
different training of health workers among organisations; lack of transparency in the
calculation of the formula; lack of knowledge among health workers (7).
For a good performance of a capitation payment system, providers, managers and
health professionals need to be involved. A good knowledge on the pilot test elements
only emerged from the discourse of managerial level informants of purchasers and
providers and only local level managers knew about joint actions in the territory. In
spite of managers’ claim that the pilot test had been widely disseminated throughout
their institutions, the interviewed health professionals expressed limited awareness.
Nonetheless, health professionals that knew about it did not perceive any benefits to
health care, only managerial efforts to control expenditures. This seems to reflect a
current common situation within health systems, whereby a swelled managerial class
focuses its attention into managing resources, at the expense of its productive core –
health personnel- and of the final health care recipients. An increase in health
professionals’ involvement will probably entail that they perceived it to be beneficial to
clinical work. Furthermore, during the pilot test, the purchaser fulfilled just one of its
functions -purchasing services- against the providers’ claim for a strong and clear
leadership from the purchaser, along with an increased participation in the
methodological development of the test.
Although recognizing quite a few limitations, interviewees coincided on considering a
capitation payment system as a good alternative to resources allocation by product
line, which leads to an increase in acute hospital activity. Nonetheless, they indicated
possible risks derived from the selection of expensive pathologies, and the absorption
of minor providers. Interviewees also believed that the pilot test had in general fostered
dialogue and increased trust and transparency among providers. Interviewees also
6
agreed that the pilot project represented a decisive shift against competition introduced
in the early nineties as the instrument for service quality improvement.
The results of this qualitative study have been very helpful for reshaping the experience
before extending it to other areas. Firstly, even if the payment mechanism is one of the
purchaser’s most powerful tools to influence provider’s behaviour, it is not the only one.
In order to introduce changes considered necessary to improve essential aspects such
as care continuity, efficiency, equity, the purchaser must exercise its policy making
capacity and to implement reforms instead of solely rely on the creation of economic
incentives. Secondly, integrated networks essentially consist of fair, balanced and well
organised arrangements, regulations, contracts between organisations on the basis of
negotiations on central values and policies, leadership and decision making, and the
co-ordination and co-operation of healthcare activities, and the evaluation of sharing
costs, benefits and risks. Thirdly, it demands that numerous organisations see their role
as but one part of a larger whole when there are strong local and organisational
identities. Integration is not simply an issue of well-organised co-ordination in a
fragmented system. Above all requires a culture of trust and co-operation which cannot
be created overnight; it will take time to mature. Finally, for a good performance of a
capitation payment system, providers, managers and health professionals need to be
involved.
7
References
1. Institute of Medicine. Crossing the quality of chasm. A new health system for the 21st
century. Washington: National Academy Press; 2001.
2. Hauck K, Shaw R, Smith PC. Reducing avoidable inequalities in health: a new
criterion for setting health care capitation payments. Health Econ. 2002; 11(8):667-77.
3. Puig Junoy J. Integración asistencial y capitación. Economía y Salud. 2002; 15:1-2.
4. Agustí E, Casas C, Brosa F, Argimon JM. Aplicación de un sistema de pago en la
población de Cataluña. In: Ibern P, editor. Integración asistencial: fundamentos,
experiencias y vías de avance. Barcelona: Masson; 2006.
5. Monrad Aas IH. Incentives and financing methods. Health Policy. 1995; 34: 205-220.
6. Shortell SM, Schmittdiel J. Prepaid groups and organized delivery systems. Promise,
performance and potential. In: Enthoven A, Tollen LA, editors: Toward a 21st Century
Health System. The contributions and promise of prepaid group practice. San
Francisco: John Wiley & Sons; 2004.
7. Vargas I, Vazquez ML, Terraza R, Agusti E, Brosa F, Casas C. El impacto de un
sistema de compra capitativo en la coordinación asistencial: resultados de una prueba
piloto en Cataluña. Gac Sanit 2008 (in press).
8
9