Version 2010

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1 ^rs

ion 2010

Position, remuneration and income of General Practitioners in Germany, England, The

Netherlands, Belgium and France

Prof. Dr. J. van der Zee,

Maastricht University, Dep. of International Health Dr. M. Kroneman

NIVEL, Utrecht, The Netherlands

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General structure of the lecture

PART I

• 2 families of health care systems

• gate-keeping or free access: that’s the question

PART II

• GP incomes and remuneration 1975- 2005

• Recent update of GP-incomes in D, UK

NL, F, B 2005-2009

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PART I

• 2 families of health care systems:

Health care systems in Europe can be subdivided into 2 ‘families’:

–

Bismarck systems (German family)

–

Beveridge systems (UK family)

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Characterization:

• Bismarck:

–

‘Family’ of social security based healthcare systems (SHI)

– German health care system belongs to

and is founder of this type of systems

• Beveridge

– ‘Family’ of National Health Systems

(NHS)

– Founder: United Kingdom

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Differences Bismarck/Beveridge

Organisation •Far less strict

organisation •Strictly hierarchical (pyramid)

Role of state •Legal conditions, supervision

•no provision of health care

•Funding, spending and regulating

•Often providing health care

SSH NHS

Funding •Earmarked

premiums •General taxation

Role of GP •No gatekeeper

•No listed patients

•Remunerated fee-for-service

•Gatekeeper

•Patients listed

•Often salaried

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Bismarck versus Beveridge:

• Ok, these are the differences, but…….. so what?

• Van der Zee and Kroneman studied differences between Bismarck (SSH),

Beveridge (NHS) in Europe* versus USA in:

1. health outcomes

2. health care utilization 3. health care expenditure 4. user evaluation

*J van der Zee, M Kroneman. Bismarck or Beveridge: a beauty contest between

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Health indicators

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Mortality

Standardized death rates per 100,000

400.00 500.00 600.00 700.00 800.00 900.00 1000.00 1100.00

1975 1980 1985 1990 1995 2000 2005

Average SSH (8-12 countries) Average NHS (6-10 countries) US

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Health care expenditure

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Total health care expenditure per capita (PPP-US$)

0 1000 2000 3000 4000 5000 6000 7000

Average SSH (8-12 countries) Average NHS (6-10 countries) United States

Total health care expenditure per capita (pppUS$)

Source: OECD health data files 2006/2009

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Health care utilization

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Average length of stay in acute care hospitals (days)

0 2 4 6 8 10 12 14 16

Average SSH (7- 9 countries)

Average NHS (8-10 countries) US

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Hospital discharges per 100 inhabitants

0 5 10 15 20 25

1980 1985 1990 1995 2000 2005

Average SSH (7-9 countries) Average NHS (7-10 countries) US

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User evaluation

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0 10 20 30 40 50 60 70 80

1996 1998 1999 2002

Average SSH (6 countries) Average NHS (9 countries)

%

Consumer evaluation of health care system

(% satisfied)

Source:

Eurobarometer 44.3 (1996), 49 (1998), 52.1 (1999) and 57.2 (2002)

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Conclusions SSH versus NHS

• Neglectable (hardly any) differences in health outcomes

• Higher utilization rates in Bismarck/SSH systems

• Lower costs and better cost containment in Beveridge/NHS

• Higher user satisfaction in Bismarck/SSH

• Both Bismarck and Beveridge perform far better than USA

• In short: trade off between user satisfaction and health care expenditures

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Part I

• Gate-keeping or free access:

– What is the key to the lower satisfaction

scores for Beveridge/NHS health care systems?

– Could it be the gate-keeping position of

GPs?

Some results of an explanatory study

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Direct accessibility and patient evaluation

• Establish relationship between

accessibility of specific health services in EU and the evaluation of (GP-)care by the population

M.W. Kroneman, J.A.M. Maarse, J. van der Zee.Direct access in primary care and patient satisfaction: A European study, Health Policy, 76 (2006) 72-79

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Methods

• E-mail questionnaire about accessibility of 17 health care services (in 18

countries), resulting in scale of direct accessibility varying from 0% to 100%

of the services

• Data from EUROPEP-study into patient evaluation of GP-care (14 countries) (Grol R, Wensing M. Nijmegen:

Mediagroup KUN/UMC, 2000 )

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Direct accessibility and gate-keeping

Figure 3. Direct Access of health care services in 18 European countries

13 19

25 33 35 35 41 47 47 56 57 64 65 65 67 71 76 76

0 50 100

Portugal Italy

Finland Denm

ark Nor

way UK Net

her lands

Ireland Spain lux

em bour

g Sw

iss Aust

ria Ger

many FranceBel

gium

IcelandGreece Sweden

Percentage of services directly accessible

Gate-keeping Non gate-keeping Switzerland

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Direct access and organisation of GP-services

W nee X ja

Gatekeeping

20.00 30.00 40.00 50.00 60.00 70.00

Percentage services directly accessible

20.00 30.00 40.00 50.00 60.00

accessibility of GP-services

WW

X

W W W

X X

X

W W

X

Austria Belgium

Denmark

Finland

France Germany

Iceland

Netherlands Norway

Portugal

Spain

Sweden Switzerland

UK

accessibility of the service = 17.16 + 0.55 * percda R-Square = 0.45

% positive evaluation of organisation of GP-services

(r = 0.67, p=0.01)

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Satisfaction with specific aspects of medical care (summary)

• Satisfaction with:

– patient physician communication and – medical technical content

NO RELATIONSHIP with direct accessibility

• Satisfaction with:

– Accessibility of GP services:

SIGN. correlation with direct accessibility

(r = 0.67, p=0.01)

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Discussion

• So gate-keeping by GPs versus free

access to health services seems to be a sensitive element in satisfaction of

health care users

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PART II

• Summarizing part I:

– Bismarck/SSH systems are less strictly organised than Beveridge/NSH:

• GP less dominant/powerful

• No gate-keeper in most cases

• GP-services compete with other health care services

• Fee-for-service remuneration is typical fro

Bismarck/SSH; Salary or capitation fee typical for Beveridge/NHS

• These features influence health services utilisation (previous slides) and health care expenditures….

• Question for Part II: Do these elements influence GP-incomes in Europe?

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Incomes of General Practitioners 1975-2005

a study in eight European countries

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Introduction

Sources:

• Data for 1975-1991:

– Delnoij 1994*

• Data for 1995-2005:

– Kroneman, Van der Zee, Groot ,2009**

– Kroneman, Meeuws, Van der Zee, Groot, 2009***

• For this conference: preliminary data for 2005-2009

*Delnoij DMJ. Physician payment systems and cost control. Utrecht: NIVEL, PhD thesis Utrecht University, 1994.

**Kroneman M, Van der Zee J, Groot W. Income development of General Practitioners in eight European countries from 1975 to 2005, BMC Health Services Research, Vol 9, 2009, nr. 26 and

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Introduction

Research question:

–

How is the development in GP income over time in several European

countries?

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Methods (1)

• Countries: Belgium, Denmark, Germany,

Finland, France, The Netherlands, Sweden and the United Kingdom

• Data sources: internet, written sources,

country experts (by tailor made questionnaires)

• Data collection:

– for 1995 and 2000: in 2004/05 – For 2005: in 2006/07

• Yearly income:

– for salaried GPs: yearly salary before taxes – For service related remuneration systems:

based on data on health care utilization and tariff structure

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Methods (2)

• Comparability of the data:

– Data were corrected for international

differences in purchasing power and

inflation

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Annual GP income over time in ppp$, corrected for inflation, index year = 2000

20 40 60 80 100 120 140

Income in 1000 ppp$

UK Ger Den Net Bel Fin Fra Swe

UK 2005: 155,360

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Practice costs for ffs countries 2005

0 50 100 150 200 250

Belgium Fr

ance

Denm ark Nethe

rland s

Germ

any UK

GP practice costs 1000 ppp$

0%

20%

40%

60%

80%

100%

Percentage of turnover

ppp$ percentage of turnover

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Conclusions

• GP-incomes going down 1975-1990/95;

increasing from 1995 again;

• Dramatic increase in 2005 in UK due to quality target based income

construction;

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• What happened around 2005?

– (Changes in) the remuneration system in

UK, Netherlands, Germany, Belgium and

France

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Changes in GP remuneration

• Netherlands 2006: drastic change in remuneration system :

– Former system:

• Sickness fund patients: capitation fee,

• Private patients: fee-for-service (mainly consultations and visits);

• 35-40% of population privately insured

– New system:

• all patients: capitation fee + additional fee-for- service per contact

• fee for special services (e.g. minor surgery,

substitution secondary care) in negotiation with health insurers

NEW

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• Effects in the Netherlands:

– Declarations to health insurers necessary for all patients

– More long consultations (>20 min) declared then expected (in 2006 17% increase)

– Extra income from special services varies per health insurer (32 in 2008) and per practice, depending on negotiation outcomes

– Formerly private patients go more often to GP (is now free of charge)

– Expenditure on GP care higher than expected:

discussion on tariffs

– In short: private patients started to behave like sick fund patients

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Changes in GP remuneration

• United Kingdom 2004: drastic change in remuneration system

– Before 2004:

• Basic allowance per GP (age dependent)

• Additional income from a.o.

– number of patient on the list

– demographic characteristics of patients – out-of-hours and emergency visits

– several preventive activities

– After 2004:

• Practice based allowances, based on characteristics of patients on the list

• Additional income from reaching quality requirements

• Option to opt out for out-of-hours services (90%

of GPs took this option)

NEW

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Effects in UK

• Dramatic increase in income, British GPs become best paid in Western-Europe

• Targets: almost all practices satisfy all targets

• Almost all GPs opt out for out-of-hours services (decreases income with 6000 euro per year)

• Government freezes income

• Targets are adjusted

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Changes in GP remuneration

• Belgium:

– Fee for service

– General Medical Record allowance (since

1999), large increase in price in 2003

– Several (relatively small) allowances

(accreditation, settlement, GMF

lumpsum, informatisation)

• No fundamental changes in

remuneration system since 2000

NEW

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Effects in Belgium

• Increase results mainly from additional income via GMF (since 2003)

• Increase in 2008 result of enlargement

of insurance coverage (self employed

now included)

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Changes in GP remuneration

• France:

– Fee-for-service system – 2005 changes:

• Basis of calculation of value of service changed. From 2005 fixed fee per

consultation.

• médecin traitant: patients first visit their GP for referral to medical specialist. For registered patients with chronic

conditions, GPs receive 40 euro per year (2005)

NEW

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Changes in GP remuneration

• Germany:

– Fee-for-service system, based on value

points

– 2009 changes (data on income not yet

available):

• Fee-for-service based on monetary value, volume related caps, for volume above budget: lower monetary value

• Case related compensations increase in importance

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- 50,000 100,000 150,000

200 0

2001

200 2

2003

2004

200 5

2006

2007

200 8 Belgium Netherlands UK

Development in GP income

based on 2000 price level, corrected for purchasing power (preliminary data!)

Preliminary data,

please do not quote!

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Conclusions

• German reforms; effects cannot be shown yet (2010 earliest year) but effects will not be

spectacular and if that was the case; curbing measures will be inevitable;

• German GP incomes have been in the top range since 1975.

• Increase in NL due to abolition of private patients (started to behave like sick fund patients);

• Governments don’t like income increases and try to curb these (harder work for the same tariff or just higher targets).

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General conclusion

• GP gate-keeping:

– sensitive element

– influences satisfaction with health care system.

• However:

– listing of patients in a practice plus

– remunerating the GP for record keeping and coordination:

promising way of strengthening the (income) position of GPs in FFS based remuneration systems

• All in all:

– Bismarck based health care systems perform quite well

– But: there is a price attached to satisfied users.

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Additional information

• Detailed results of comparison between

SSH, NHS and USA

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Health indicators

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Mortality

Standardized death rates per 100,000

400 500 600 700 800 900 1000 1100 1200 1300 1400

1975 1980 1985 1990 1995 2000 2005

Austria Belgium France Germany Greece

Luxembourg Netherlands Switzerland Greece -1982 Italy -1977 Portugal -1978 Spain -1985 Average SSH Denmark

Finland Greece 1983- Ireland

Italy 1978- Norway

Portugal 1979- Spain 1986- Sweden

United Kingdom

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Infant mortality rates

Deaths per 1.000 life births

0 10 20 30 40 50 60

1970 1975 1980 1985 1990 1995 2000 2005

Austria Belgium France Germany Luxembourg Netherlands Switzerland Greece -1982 Italy -1977 Portugal -1978 Spain -1985

Average SSH

Denmark Finland Greece 1983- Ireland

Italy 1978- Norway

United Kingdom

Average NHS

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Life expectancy at birth

68 69 70 71 72 73 74 75 76 77 78 79 80 81 82

83 _Austria

Belgium France Germany Luxembourg Netherlands Switzerland Greece -1982 Italy -1978 Portugal -1979 Spain -1985 Average SSH Denmark

Italy -1978 Norway

Portugal -1979 Spain -1985 Sweden

years

Source: WHO-HFA 2006/2009

US: OECD health data files 2006/2009

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Health care expenditure

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Total health care expenditure per capita (pppUS$)

Total health care expenditure per capita (PPP-US$)

0 1000 2000 3000 4000 5000 6000 7000

Austria Belgium France Germany Luxembourg Netherlands Switzerland Portugal -1978 Spain -1985

Average SSH

Denmark Finland Greece 1983- Ireland

Italy Norway

United Kingdom

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Total health care expenditure as percentage of GDP

3 4 5 6 7 8 9 10 11 12 13 14 15 16

1970 1975 1980 1985 1990 1995 2000 2005

Austria Belgium France Germany Luxembourg Netherlands Switzerland Portugal-1978 Spain-1985 Average SSH Denmark

Finland Greece Ireland Italy Norway

United Kingdom Average NHS United States

%

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Health care utilization

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Doctor's consultations per capita

0 1 2 3 4 5 6 7 8 9 10

1980 1985 1990 1995 2000 2005

Austria Belgium France Germany Luxembourg Netherlands Switzerland Greece -1982 Average SSH Denmark

Finland Greece 1983- Italy 1978- Norway

United Kingdom Average NHS

Source: OECD health data 2009 US

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Average length of stay in acute care hospitals

2 4 6 8 10 12 14 16

18 _Austria

Belgium France Germany Luxembourg Netherlands Switzerland Greece -1982 Portugal -1979 Spain -1985 Average SSH Denmark

Norway

Portugal -1979 Spain -1985 Sweden UK

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Hospital discharges per 100 inhabitants

0 5 10 15 20 25 30 35

1980 1985 1990 1995 2000 2005

Austria Belgium France Germany Luxembourg Netherlands Switzerland Greece -1982 Spain -1985 Average SSH Denmark

Italy 1978- Norway

Portugal 1979- Spain 1986- Sweden UK

Average NHS US

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User evaluation

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0 10 20 30 40 50 60 70 80 90 100

Austria Belgium France Germany Luxembourg Netherlands

Average SSH

Denmark Finland Greece Ireland Italy Portugal Spain Sweden

United Kingdom

%

Consumer evaluation of health care system

(% satisfied)

Denmark Finland

Source: Eurobarometer 44.3 (1996), 49 (1998), 52.1 (1999) and 57.2 (2002)

Austria

Portugal Greece

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Direct access and overall patient evaluation of GP services

W no X yes

Gate-keeping

20 30 40 50 60 70

20 30 40 50 60

Patient satisfaction with GP-care overall (%)

WW

X

W W

W

X X

X

W W

X

Austria

Belgium

Denmark

Finland

Iceland

Portugal

Spain

UK

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Direct access and evaluation of medical technical aspects of GP care

W nee X ja

Gatekeeping

20.00 30.00 40.00 50.00 60.00 70.00

medical technical aspects

W W

X

W W

W

X X X

X

W W

X

Austria Belgium

Denmark

Finland

Iceland

Portugal

Spain

UK

medical technical aspects = 32.28 + 0.29 * percda R-Square = 0.17

% positive evaluation of

Naar achteren

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Bismarck-Beveridge

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Infant mortality rates

Deaths per 1.000 life births

0.00 5.00 10.00 15.00 20.00 25.00 30.00

1970 1975 1980 1985 1990 1995 2000 2005

Source: OECD health data files 2009

(64)

Life expectancy at birth

68 70 72 74 76 78 80 82

Average SSH (8- 12 countries) Average NHS (6-10 countries) US

Years

Source: WHO-HFA 2006/2009

US: OECD health data files 2006/2009

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Doctor's consultations per capita

0 1 2 3 4 5 6 7 8

1980 1985 1990 1995 2000 2005

Source: OECD health data 2009

Included are ambulatory care physician

contacts plus contacts in out- patient wards (excl. US)

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Total health care expenditure as percentage of GDP

3 4 5 6 7 8 9 10 11 12 13 14 15 16

Average SSH (8-12 countries) Average NHS (6-10 countries) United States

%