Is primary care losing out to the hospital?

Is primary care losing out to the hospital?

Healthcare is in a period of drastic change. Healthcare organisations must increasingly position themselves as value-driven enterprises. Governments and health insurers are experimenting with new costing models, in which health care providers are running ever greater financial risks. New organisational models are being developed to better manage these financial risks. In practice, this means a far-reaching integration of first and second line care. This will not happen without a struggle, as is evident from the discussions currently taking place about chain care and emergency care. Integration of care is difficult to achieve in the Netherlands because we continue to work with sector-specific and therefore fragmented budgets and organisation models. In this blog I will discuss which integral organisation models can work in the Netherlands!

Beyond fragmentation

The integration of care for people with complex care needs is a problem in the Netherlands. The introduction of integrated care ended in failure. There is a lack of integration between primary and secondary care in both chain care and emergency care. This is because chain care for chronic conditions is not integrated with the medical specialists in the hospital. In addition, there is an ongoing discussion about emergency care. The construction with the GP Centre on the one hand and the Casualty department on the other hand is far from efficient. The discussion in chain care and emergency care is yet another example of the game of shyster in the Dutch healthcare system. There is a constant failure to establish a truly integrated working relationship between general practitioner and medical specialist and to link governance and financing to this. This has led to a fragmentation of care, which has particularly affected the group of complex patients with multiple chronic conditions – a group that is only growing in the Netherlands. These people need integrated care, in which first- and second-line care providers cooperate to a far-reaching degree.

Examples abroad show how we can break this deadlock in the Netherlands. Using two value-driven care organisation models from the US, we show that it is time to take a different approach. Both models have been scientifically proven to bring about significant improvements in quality and cost savings. They have therefore proven their worth and could easily serve as a starting point for the Dutch situation.

Patient Centred Medical Home

The first model, Patient Centred Medical Home (PCHM), dates back to 1967, making it one of the oldest value driven care models. It resembles the health centers as we know them in the Netherlands. The model is based on the ideas of the American professor Barbara Starfield, who was the first to demonstrate conclusively that well-organized primary care contributes to better health outcomes, higher life expectancy and lower costs. She fought for a people-oriented approach to patients and for a strong primary care system that guides people through the jungle of facilities. And that’s what happens in a PCMH. In this model, a general practitioner or other primary care provider selected by the patient is responsible for planning, delivering, coordinating and monitoring patient care, both within the organization and across the continuum of prevention, care and well-being. The needs of the patient are central to this.

Within a PCMH, care is provided 24/7 by a multidisciplinary team of care providers (Figure 1). The focus is not only on the medical care question, but also on a people-oriented approach. This means, for example, that (care) programmes that focus on the social domain, such as combating poverty, also run. So a total package is offered with the aim of keeping people as healthy as possible. Patients are actively involved in managing their own health.

A PCMH is based on the principles of population management and continuous process improvement. In addition, proactive data management takes place. This means that everything surrounding the patient is monitored: laboratory results, hospital admissions, referrals, etc. Everything is laid down in clear guidelines, protocols and checklists. There is a lot of research that demonstrates the added value of PCMH in terms of cost, care use and health.

Accountable Care Organisation

An Accountable Care Organisation (ACO) is formed and governed by various healthcare providers from primary and secondary care. Care is provided across the entire chain. In terms of legal entity it resembles the care groups as we know them in the Netherlands. An ACO can be governed by, for example, general practitioners, independent medical specialists and/or health insurers. The parties working together in an ACO are jointly responsible for the total care of a patient population with respect to quality and costs. The two are inextricably linked. The improvement in care as a result of improved quality, leads to better outcomes, which in turn leads to lower costs. The focus on cost regulation stems from the origins of this model of care: the Obama Care Act. This healthcare law required Americans to sign up for health insurance.

An ACO operates on the basis of quality, cost and coordination indicators that have been jointly defined (Figure 2). The benchmark was determined for these indicators, after which quality criteria and rates were established. In addition to a payment by operation contract, providers participating in an ACO also enter into an outcome costing contract (i.e. bundled payment or shared savings/shared risk contract). This means that they are exposed to financial risk, but also share in the profits. Proactive data management is used to keep track of how individual healthcare providers perform on the various indicators. Finally, ACOs benefit from well-organized primary care. After all, the more efficiently primary care is organised – for example by setting up a good gatekeeper function – the more you will earn as an ACO.

The difference between a PCMH & ACO

If you compare a PCMH and an ACO, you will see that a PCMH is much more focused on care-related collaboration and an ACO is more focused on collaboration between organizations. Table 1 below shows the differences between the PCMH and the ACO.

Table 1: Comparison PCMH and ACO

Regional organisational strength

The PCMH and ACO concepts are good examples of value-driven care models that can also be applied in the Netherlands. Both models show that the answer to better outcomes must be sought in an integrated approach. In the transition towards this goal, the question is whether the (regional) hospital or primary care will soon be in the lead. Actually, this discussion should not take place, because what should matter is striving for the best, most efficient and people-oriented care for the patient. This is achieved by better coordination of prevention, care and welfare. Research has repeatedly shown that a strong first line is and remains the foundation for a value-driven approach.

The first line Calimero complex

However, primary care providers in the Netherlands seem to be increasingly sidelined, because their internal organisation leaves much to be desired. Primary care organisations have too little mandate from their members and allow themselves to be steered too much by the issues of the day and experienced work pressure. The hospital has a head start in this respect, which is why healthcare financiers are now moving more in their direction. But the approach that the financiers have in mind is not going to solve the problems. What is needed is a step back. Back to the drawing board and start at the basics. For secondary care, the ACO is a very interesting model for a regional care approach, but first the primary care must be better organized.

On the road to equality

Value-driven care is impossible without a well-organised first line. The concept of PCMH can save primary care. It lays the foundation for well-coordinated and organized 24-hour care and offers many concrete handles on how to improve the organizational power of primary care. First-line organizational strength is a prerequisite for experimenting with a concept like an ACO. Only then will primary care be an equal partner for the hospital and the medical specialist.

Read more about how the two care models can be used to shape value-driven care in the white paper.