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P4P for generalists: first results

Country: 
France
Partner Institute: 
Institut de Recherche et Documentation en Economie de la Sant (IRDES), Paris
Survey no: 
(16)2010
Author(s): 
Zeynep Or
Health Policy Issues: 
Remuneration / Payment
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes yes no

Abstract

In 2009 the National Health Insurance Fund introduced a new contract for generalists, offering additional payments based on their performance against a list of clinical targets. A year later, the first results suggest that the impact of this contract on GP practice has been positive yet marginal. Overall one third of the eligible generalists have signed the contract until now. Two thirds of those who signed receive a remuneration, amounting on average to 3000 Euros, end of the first year.

Recent developments

In 2009, the National Health Insurance Fund offered a new contract to individual generalists (CAPI, Contrats d'amélioration des pratiques individuelles) giving them the opportunity to increase their income based on their clinical performance. These contracts, signed on a voluntary basis, aimed to improve clinical quality of care and to encourage generic prescription, but do not alter the existing Fee-for-service scheme. They can provide up to 6000 Euros annually if 100% of the targets are achieved; those who do not fully achieve the objectives set are still paid according to the progress they made.

The targets (and contracts), set on a tri-annual basis, require respecting practice guidelines in three domains:

  1. Prevention: the target is to achieve a 75% vaccination rate for over 65 year-old patients; 80 % breast cancer screening for women aged 50 to 74 years old; to prevent the use of contraindicated drug combinations which can result in adverse reaction: reduce the prescription rates of vasodilatateurs (which are overly prescribed despite being proven ineffective) and benzodiazepine (potentially dangerous and addictive) for elderly patients.
  2. Chronic diseases: improve quality for diabetic patients by increasing the % of treatment in line with current recommendations (eye exams, HbA1c prescription, etc) and the treatment of high blood pressure (the target is to normalise blood pressure for 50% of the patients over three years).
  3. Prescriptions: for seven groups of medication (antibiotics, anti-depressors …) "generic prescription" is encouraged with varying final targets.

The first contracts were signed in July 2009 by about 5500 GPs, but this number went up to 14800 generalists (one third of the eligible GPs) by September 2010. Two thirds of the GPs who signed the contract in July 2009 will receive a remuneration in 2010. On average they receive about 3100 Euros as they reached 45% of the targets set. This represents about 5% of the annual income of an average GP.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual highly controversial highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low very low very high
Transferability strongly system-dependent system-neutral system-neutral
current current   previous previous

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes yes no

Initiators of idea/main actors

  • Providers
  • Payers
  • Private Sector or Industry

Stakeholder positions

There is no significant change regarding stakeholder's views (see survey 13/2009). The GPs and the pharmaceutical industry have been extremely critical of this contract. GP unions consider CAPI as a treat to their collective bargening power and to independance of physicians. 

Given the initial mistrust and opposition from doctor unions, the CNAMTS considers that the participation rate is "gratifying".  There are, however, more than 30000 doctors who are still not convinced by this contract, of which 9000 could have obtained at least 2500 Euros given their current results (without changing anything in their practice).

At the same time those GPs who signed the contract but did not get any payment (as they have not reached their targets) start to criticize the performance indicators used and the methods of calculating these indicators (which is rather complicated and could be misleading in some cases).

Actors and positions

Description of actors and their positions
Providers
GP Unionsvery supportivestrongly opposed strongly opposed
Specialistsvery supportiveneutral strongly opposed
Payers
National Health Insurance Fundsvery supportivevery supportive strongly opposed
Private Sector or Industry
Pharmaceutical industryvery supportivestrongly opposed strongly opposed
current current   previous previous

Influences in policy making and legislation

No development on the legistative front.

Actors and influence

Description of actors and their influence

Providers
GP Unionsvery strongneutral none
Specialistsvery strongstrong none
Payers
National Health Insurance Fundsvery strongvery strong none
Private Sector or Industry
Pharmaceutical industryvery strongstrong none
current current   previous previous
National Health Insurance FundsSpecialistsGP UnionsPharmaceutical industry

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The Health Insurance Fund monitors the results and provides information to those GPs signing the CAPI contract. Each GP participating in this scheme receives regular visits (3 times a year) from the representatives of the health insurance fund, where s/he gets the statement of his/her results and some practical help to follow up guidelines.    

In parallel, the Health Insurance Fund is preparing support for doctors via booklets providing information for patients with diabetes and on the iatrogenic risk of using multiple drugs, etc. to encourage the respect to practice guidelines.

Before the end of the year, representatives of the Health Insurance Fund will start visiting the GPs who did not sign this contract, to convince them to join this scheme. These doctors will also have access to their own results with respect to the targets set in CAPI.

More generally, the Health Insurance Fund is highly motivated for pushing further this scheme by extending the contracts to cover other public health priorities such as improving the rate of treatment in line with guidelines for moderate/severe depression and detection of osteoporosis. There are also intentions for proposing the same kind of contracts for other healthcare providers (specialists, paramedics, etc.) and/or for integrating the targets in the national convention between sickness funs and generalists.

Monitoring and evaluation

Based on the first year results from about 5500 GPs who signed the contract in July 2009, the Health Insurance Fund considers that GPs who signed the contract have improved their practice, in particular with respect to follow-up of patients with diabetes and prevention. CNAMTS, the biggest health insurer in France, also notes progress for generic prescription, while it is recognized that there is still a big margin for improvement.

Looking at these results more closely gives however a more nuanced picture:

Prevention: There has been a slight reduction in vasodilatator (2 percentage points) and benzodiazepine prescription (1% point). But there has not been any significant change in flu vaccination rates for elderly (less than 1% point) and no change in breast cancer screening.

Chronic diseases: The share of diabetic patients having 3 or 4 doses of HbA1c in the year has increased 4 percentage points, while recommended eye exams increased about 2 percentage points. Statine prescription for diabetic patients with high cardiovascular risk has increased about 4 percentage points, while that of low aspirin has increased 5 percentage points.

However, data from CNAMTS show that these indicators for prevention and diabetic care have been improving for all of the generalists, but the progress is stronger, in particular for diabetes, for those who signed the contract.

Prescriptions: Concerning generic prescriptions, in two therapeutic groups generic prescription has improved: Proton-pump inhibitors (+ 19 % points against 15.3 % points for those GPs who did not sign the contract) and drugs for high blood pressure (11.9 % points against 11.4% for other GPs).

On the other hand, generic prescriptions for antibiotics and antidepressants have declined over the period both for those GPs who signed this contract and for others.

Expected outcome

The CAPI contracts, while marginally, may help to improve healthcare provision and quality by encouraging GPs to respect practice guidelines. However, the cost effectiveness of this contract is questionable. Moreover, while it is too early for any firm conclusions on the success or failure of these contracts, there seems to be little change in GP behaviour due to these contracts. The results presented above suggest that the CAPI contract did not have a significant impact on GP behavior. It seems that the GPs who have signed the contract behave quite similarly to those who did not and the areas where progress is observed are those where there has been an improvement in general. Also, GPs who first signed CAPI were amongst those who are already close to the targets set. It is likely that they are more receptive to quality guidelines, with or without CAPI, compared with the average.

Ultimately, P4P reforms built on the current FFS system do not seem to have enough potential to change the way care is delivered by generalists in France. Global payment models (such as risk adjusted capitation) paying for patients rather than services provided could be more effective for improving quality and cost-efficiency.

Impact of this policy

Quality of Health Care Services marginal marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low low very high
current current   previous previous

It is difficult to judge or isolate the impact of these contracts on care quality with respect to other policy/programs which has been implemented recently. For example, concerning diabetes care where there seem to be a progress in terms of respecting guidelines, there has been several national and regional initiatives targeting to improve care coordination and quality of care for diabetic patients. These include introduction and promotion of National guideliness by High Health Authority (HAS) and establishing care networks for diabetes.

References

Sources of Information

Assurance maladie, 16 septembre 2010, available at www.ameli.fr/fileadmin/user_upload/documents/Dp_capi_16_09_2010_vdef.pdf

http://www.lettreauxmedecins.ameli.fr/Media/nl35/LettreCNAM35sr2.pdf

Author/s and/or contributors to this survey

Zeynep Or

Suggested citation for this online article

Zeynep Or. "P4P for generalists: first results". Health Policy Monitor, October 2010. Available at http://www.hpm.org/survey/fr/a16/3