1. Pay for Performance – a critical assessment (using recent Estonian experience) “Improving primary care in Europe and the US: Towards patient- centered, proactive and coordinated systems of care” April 3, 2008 Ain Aaviksoo, MD MPH PRAXIS – Center for Policy Studies

2. Why? Encourage most rapid feasible performance improvement by all providers. Support innovation and constructive change throughout the health care system. Promote better outcomes of care, especially through coordination of care across provider settings and time. IOM. Rewarding provider performance: aligning incentives in Medicare. (2006) Motivate family physicians to actively engage in disease prevention and monitoring of chronic patients, and to provide the insured with a broad health service (monitoring of pregnant women, perform minor surgeries, etc.). Estonian Health Insurance Fund Annual Report 2006

3. The Context (Estonia) Area 45 000 sqkm ~1.4M inhabitants GDP per capita 12 300 EUR (2006) Health expenditure per capita 496 EUR; 5% of GDP (2006) Single public Health Insurance Fund (85% of public and 63% of total HC costs) ~800 family doctors practicing as private entepreneurs (61% in solo practices) Map source: www.parks.it

4. High penetration of ICT in primary care Source: Development of the information society in Estonia as mirrored in European surveys in 2003. Estonian Informatics Centre. Data from „eEurope+ Health Survey”, June 2003. http://www.ria.ee/atp/?id=762 (Accessed January 12, 2006) http://www.ria.ee/atp/?id=762

5. Everything grows... and some grow even more

6. The case of Estonia (timeline) 2002 Family Doctors’ Association started accreditation 2003 no payment differentiation by accreditation possible 2005 concept for P4P agreed between family doctors and Health Insurance Fund (based on NHS example) 2006 first year of reporting on performance 2007 first payment according to results from 2006 (max 8% of annual revenues); second year of reporting; adjustment of criteria

7. How does P4P work in Estonia?

8. Results from 2006

9. CRITICAL ANALYSIS

10. Organisation matters Solo practice (N=35) Group practice (N=65) Polyclinic type practice(N=13) Total sample (N=113) Proportion of bonus payment recipients 66%52%85%60% Proportion of higher bonus payment recipients 4%24%0%13% Bonus payment by capital area family physicians in 2006

11. Confounders and facilitators Introduction of the P4P parallel to robust growth of overall healthcare and primary care budget Initiative of family doctors’ leaders to praise the colleagues who do good job Universal ICT backup

12. Challenges Decreasing participation trend plus differentiation(?) by performance Financial reward very small Future improvements of the programme planned “carefully” and resistance is growing Integration of overall health care system is rather poor

13. Observations Large scale implementation of P4P: USA, UK, Estonia Ideas evolving in most countries Actively promoted by the World Bank (P. Schneider. “Provider Payment Reforms: Lessons from Europe and America for South Eastern Europe”. WB Policy Note. October 2007)

14. International comparison Lessons learnt (by P Schneider)“Trial” in Estonia Cost and administrative burden are key barriers Relatively low (ICT already implemented), but still the issue causing most resistance Careful monitoring needed to avoid unexpected side effects Ongoing; some independent analysis and evaluation embedded Incremental introduction to reduce risks Easy to start, but missing the final (even if temporary) goal Public information to put pressure Results publicly available; local media covers extensively Supporting wider health strategy necessary Health insurance fund leadership is there, but general health policy is too scattered Performance effect is probably relatively smallInitial results vary promising among those who participated voluntarily. Overall effect – too close to call …

15. Back to basics Adapted from M Roberts et al. “Getting health reforms right”. OUP 2004 Control knobs FinancingPaymentOrganizationRegulationBehaviour Intermediate goals Efficiency Quality Access Final goals Health statusSatisfacion Risk protection POLITICAL DECISIONS

16. Risks & recommendations Feasibility of implementation Sufficiency of reward Precision/predictability of outcomes Adequacy of the tool for given goal ES Fisher, NEJM Nov 2006