Integrating medical education and pay for-performance in primary care
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Transcript of Integrating medical education and pay for-performance in primary care
Integrating Medical Education and Pay-for-Performance in Primary Care: An Option for National Health Coverage
Ahmad Fuady
Department of Community Medicine, Faculty of Medicine, Universitas Indonesia
January 2014
Background•The implementation of Jaminan Kesehatan
Nasional (JKN) in 2014 challenge to strengthen primary care; roles as gate keeper, quality and cost controller.
•Problems in primary-level care: poor quality, shortage and discrepancy of healthworkers.
•Medical Education Act of 2013: introducing the term of Dokter Layanan Primer (DLP) a better quality of primary care?
(1) DLP• Currently zero-state of DLP; how to produce? • Additional professional education • Shifting ‘general physician’ to DLP?
(2) Payment system in primary care• Capitation system; criticized for a low basis fare
per capita and its uncertain mechanism for promotion and prevention.
• Pay-for-performance (P4P) system; an option? ▫ Some limitations ▫ Assessment of performance for payment; combined
for medical training? ▫ Quite similar concept with workplace based
assessment.
Idea• Integrating postgraduate training with
workplace-based assessment and the P4P system
Financial incentive better education better quality of care efficiency ?
Aim•Exploring the feasibility for the integration
and its potential to support the national health coverage.
The DLP in Indonesian health system•Family physician vs general physician vs
DLP?•Leave the debate!
•Focusing on how to produce a better quality of primary-level physician▫Postgraduate, master program?▫Postgraduate, professional specialist training?▫Not a conventional strategy workplace-
based
Workplace based assessment on quality of practice and education
•Recent reforms: “the assessment of day-to-day practices undertaken in the working environment”.
•Evaluating performance in context, re-coupling teaching and testing, formative potential, and more valid assessment.
•For licensing
Swanwick, 2005; Miller, 2010
Tools for assessment
•Multisource feedback, triangulation•Mini-clinical evaluation exercise•Direct observation of procedural skills•Multiple assessment method, a portofolio
Goal
Miller, 2010
Integrating with Pay-for-Performance?•Financial incentives improvement of
quality and continuity of care
de Bruin, 2011; Campbell, 2007
Pay for performance
“Both economic theory and common sense support the notion that payment for health care should be determined, at least in part, based on meaningful indicators of quality or value.”
Rosenthal, 2007
Providing explicit financial incentives to care providers based on their scores on preset performance measures with the goal of improving the quality and efficiency of care.
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Pay for performance: rationale1. Deficiencies in the quality and efficiency of care;2. Improving performance ultimately requires
changes in the behavior of physicians;3. Providers are responsive to financial incentives;4. Base payment methods have disadvantages and do
not explicitly stimulate good performance;5. Performance measurements have become more
accurate and sophisticated.
Therefore, it seems natural to tie a portion of providers’ income to their performance
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•Also, improvement on education?•Tools for assessment and certification
Some indications, for a more effective system:•Payment on the basis of scoring on process-
based incentives. •Blending of individual- and group-level
incentives. •Mixed of absolute and relative performance
de Bruin, 2011
Considerations
Conrad and Perry, 2010; de Bruin, 2011
Limitations
•Not the solely assessment for postgraduate training.
•Mixed evidence on the P4P.•“Distortion effect”: discourage efforts on
aspects of healthcare performance not included and rewarded by the scheme, tunnel vision.
•Gaming, risk selection. •Better recording of care rather than better
care. Rosenthal and Frank, 2006; van Herck, 2010;Chen, 2011; Conrad and Perry, 2010; de Bruin, 2011
How to design: current proposal• Integration, as a part of training
assessment• Episode-based/bundled payment: rewarding
patient management and outcomes (rather than volume) across the entire continuum of care.
• Global capitation + performance incentives.• Preparing a massive number, qualified
assessors.
Conclusions
•The integration of medical education and pay-for-performance in primary care is feasible with some limitations.
•Pilot project and good design of integration are required.