THE ITALIAN CASE OF GP CONTRACTING, A FOCUS ON EMILIA ROMAGNA REGION

1. THE ITALIAN CASE OF GP CONTRACTING, A FOCUS ON EMILIA ROMAGNA REGION Maria Pia Fantini Department of Medicine and Public Health Alma Mater Studiorum University of Bologna Rennes, 11 MARCH 2009

2. In the Alma Ata Declaration, Primary Care was defined a gate for access, a first step of contact for people, families and communities with the National Health System.Within Primary Care we can recognize Pediatric and general practitioner assistance Consulting assistance Pharmaceutical aid/assistance Services for elderly and rehabilitation Specialistic assistance A determinantrolewithinPrimary Care isplayedby the GeneralPractitioners(GP)

3. THE OVERCOMING OF THE HEALTH INSURANCE SYSTEM The first mutual aid associations were born in Italy at the beginning of XIX century. They were first established as workers association with the aim of raising funds through auto-contribution for the assistance of workers in case of illness. During the Fascism this workers sickness fund became obbligatory; at the beginning for single categories (“sea and air people”,1929) or for single pathology and professional diseases (1935) later in a general system with the creation of the National Health Insurance for workers (1943) which will become INAM in 1947 after the inclusion of many other minor assurances. The current organization of National Health System can be considered as the result of a process started in the middle of 70’s which has required /leading two radical changes: THE OVERCOMING OF THE MUTUAL SYSTEM THE ATTRIBUTION OF AUTORITY TO THE REGIONS

4. NATIONAL HEALTH INSURANCE This system based on assurances was cause of many problems : Citizens had the right to the health assistance as workers (different kind of assistance for different workers) Different level of assistance between workers within the same categories and different level of assistance between workers belonging to many different sickness funds companies An increasing gap between national income and payments caused by the constant requests by mutual practicioner (national health doctor were payed fee for service) together with the relevant costs of visits,drugs,diagnostics prescriptions and admissions to hospitals.

5. In the postwar period (1948), Constitution declares in the article.32 “ The Italian Republic considers health as a fundamental right for people and a duty for the community,and guarantees free healthcare to poor (…)”THE PUBLIC ACTION IN HEALTH POLICY WERE GRANTED TO: Minister of health (established in the 1958 Public sickness funds INAM,INPS,INAIL,ENPAS, ENPDEDP, INADEL and private Provinces Hospitals Municipalities Other national assurance providers (OMNI)

6. BEFORE THE 1978……. Medical officers National health service doctors Independent physicians

7. THE FOUNDATION OF ITALIAN NATIONAL HEALTH SYSTEMINHS 1978 • Basic principles: universal coverage and free access(without co-payments,except for specific services or population categories) for all residents,funded on general taxation • Pervasive political control: centrally the Ministry of Health: total fund set every year in the state financial law locally the municipalities:real decision maker on health expenditure • Goal was integration of healthcare services in LHU (primary care,acute care, hospitals, rehabilitation) accountable to local municipalities which manage social services

8. 1978:THE INSTITUTION OF GENERAL MEDICINE AND THE BIRTH OF THE GENERAL PRACTICIONER (GP) Independent but agreed exclusively with the NHS GP remuneration based on capitation payment Free choise by the citizen (in a relationship of confidence) Widespread distribution on territory

9. 1992: A FIRST REFORM OF THE INHS • First comprehensiveplanpresentation in 1989, finalreformapproved in 1992 and amended in 1993 • Simplificationof the institutionalstructure: Regionalization • Quasi markets • ManagerialsystemsforLHAs and IHs • LHAs and lHs under regionalcontrol (GM ofLHAs/lHsappointedbyregionalgovernement)

10. A NEW INSTITUTIONAL STRUCTURE • Relevant action to delegate powers to regions • Region are made responsible to guarantee “ a basic level of care” given fixed funding from national governement • LHUs and self-governing hospitals become “public enterprises” under regional control • Primary care and discussion about the role of GP are still at a marginal position

11. THE 1999 REFORM (DGL 229/99) AND THE NEW ROLES OF GP • Main contents of the reform concern Primary Care organization with better definition of GP roles : • Evaluation of citizens needs • Regulation on patient access to secondary care (gate-keeping function) • Taking care of chronic conditions and terminal patients • Quality control on their own work

12. THE CONSTITUTIONAL REFORM OF 2001 • Regionalization goes ahead • Definition of the Essential Levels of Care (ELCs) with possible regional integrations • Italian health Authorities are integrated delivery system (IDS). They regroup services provided at different levels: prevention, primary care (GPs), secondary care (ambulatories specialistic), tertiary care (general hospital), rehabilitation (nursing homes, rehabilitation centers), long term care (centers or home care). They are in charge of delivering/purchasing services for the residents of a defined geographical area. • Tertiary and quaternary care is also provided by independent hospitals and academic medical center,both public (mostly)and private(few large,many small clinics)

13. Institution of S.S.R.E.R. Better answer to complex needs of the population (social and healthcare integration) complete reorganization of health services increased professional participation to healthcare management Districts indicate the “Primary Care Units” (NCP) as main centers for delivery of healthcare REGIONAL LAW OF 2004 (L.R. 29/2004) “generallaws on organization and functionsof the Regionalhealthcare system” newdefinitionof the Emilia Romagna regionalHealthcare system accordingto the newfederalist vision

14. THE GP CONTRACTS: DEVELOPMENT AND EVOLUTION ACROSS THE YEARS The normative agreement which regulate the relationships between the NHS and the general medicine is called “Accordo Collettivo Nazionale”(national collective agreement) it is stipulated between Governement, Regions and main Trade Union Organizations representing GP; its basic principles from 1978 regard The optimal Gp/patient ratio in order to define the number of GP in agreement for each LHUs ( 1:1000, in Emilia Romagna 1:1300) The maximum number of patients for each GP: according to patient’s choice, every GP has a list of patients with the limit of 1500 registered GP remuneration based on capitation payment

15. AGREEMENT OF ‘78 GP maximalist are called to refuse the exceeding number of patients in a gradual way. This couldn’t happen for economic reasons and led to the beginning of a conflictual relationships between parts AGREEMENT OF ‘81 The concept of Association between GP were first introduced in this agreement as alternative solution to reduce the iper-”maximalist” GPs • the “associationism” was born in this context, but it will assume a very different meaning in the following years Contracts were renewabled every four years without meaningful changes until the reforms of ‘99 and 2000

16. THE 3 LEVELS ARTICULATION OF CONTRACTS The contract at the national level deals with: • Guarantees for patients and professionists; • Responsability of the institutions (Regions and LHUs) • GP Duties , structure of remuneration The contract at regional level deals with:: • Health objective and resources share • Organizational models: functions and objectives (es. Equipe, UTAP e NCP) • Operative instruments The contract at local level deals with: • Projects • healthcare activities and pathways

17. THE NATIONAL COLLECTIVE AGREEMENT OF 2000 After the approvation of Dgl 229/1999 • The District is recognized as an independent entity as far as concerned the economic and managerial profile • Incentives for the “Associationism”

18. THE NATIONAL COLLECTIVE AGREEMENT OF 2005 • Regions acquired an important managerial autonomy • Definition of an extended system of managerial and professional experimentations • Achievement of the continuity of assistance h 24 • Attribution of wide managerial and planning responsabilities to general practicioners

19. The comparison between 2000 and 2005 agreement shows an important change of perspective regarding three elements: • A further step into the process of regionalization of healthcare policies • A focus on quality of care and clinical governance • An incentive system for the GPs tied to organizational solutions and managerial choices

20. Requirements for maintenance of the conract relationship Criteria for national, regional and local trade union representativeness Functions and objectives of the association forms; General criteria in training management, in its main areas; Structure of the payment; Conditions and workplace for independent profession RELEVANT ELEMENTS AT NATIONAL LEVEL

21. Organization of patients loadtaking by GPs; Continuous assistance 24 hours on 24 and 7 days on 7 Emergency , services medicine and social-integration forms management GPs conditions for partecipation into defining planning objectives, budget and responsabilities for their accomplishement Criteria and methods for setting up the informative system RELEVANT ELEMENTS AT REGIONAL LEVEL

22. PRIMARY CARE IN EMILIA ROMAGNA REGION: NORMATIVE REFERENCE FRAME • Regional health plan 1999/2001 (DGR 309/2000) • AIR 2001 (DGR 3085/2001) • Regional law 29/2004 “general laws about organizations and functioning of the regional health service • AIR 2006 (DGR 1328/2006) • Document “new lines for the organization of primary care, mental health, pathological dependences and public health departments (DGR 2001/2007) • Proposal of Social and Health Plan 2008/2010

23. PSSR: INTEGRATION AND INTEREST AREAS FOR THE GPs • Managerial integration :stronger collaboration with territorial departments,participation to the resources allocation process • Professional integration :promotion of the development of multiprofessional communities development (with social components)

24. AIR 2006: STRATEGIC LINES Organizational integration for the General Medicine • Organizational development of Primary Healthcare Units (NCP) • Professional coordination inside NCP • Continuity of assistance Quality of assistance • long-term conditions (multi-professional integration) • Health promotion and prevention • Prescriptions appropriatness Developement of informatic/informative systems • “Progetto Sole”

25. INCENTIVES AIR 2006

26. ANALYSIS GRID OF LOCAL AGREEMENTS(1/2)

27. ANALYSIS GRID OF LOCAL AGREEMENTS(2/2)

28. QUALITY OF CARE: PRESCRIPTIONSAND DRUGS APPROPRIATNESS AND SIMPLIFICATION OF THE ACCESS TO THE SPECIALISTIC SERVICES The analysis of local agreement has showed • A general orientation OF all the LHAs towards the increase of appropriatness in drug prescriptions • Local guidelines for the simplification of the care access (with indication of priority index and/or diagnostic query for single deseases),in order to reduce waiting list • Coordination projects between GP and ambulatory/hospital specialistics.

29. QUALITY OF CARE: CHRONIC DISEASES • The diabetes project is considered in every LHAs, even with different modalities and incentives • Other projects/care pathways concern COPD (2 LHAs), Heart failure (2 LHAs), Renal failure (2 LHAs), Hypertension (1 LHA) , Asthma (1 LHA), Psychiatric patient (steady conditions) (1 LHA) Oncologic patients follow-up (1 LHA) • On average in all LHAs there are two paths activated for each chronic disease.Only one LHA has started 5 paths. • TAO, basic diagnostic in NCP seat/ group medicine

30. QUALITY OF CARE: PREVENTION • Health promotion and correct lifestyle promotion in 4 LHAs specific projects • Vaccination programmes • Oncologic screenings

31. QUESTIONNAIRE “WEB-BASED”

33. ORGANIZATION DEVELOPMENTPRIMARY CARENCP development (questionnaire)

34. Local distribution of NCP, Groups Medicine and Network Medicine.

35. Average number, range of GP and patients for each NCP in LHUs

36. Percentage of Gp adherent to different association forms in each LHUs

37. Developed activities in each NCP, percentage on regional total.

38. Percentage of NCP on total and relating activities

39. The final aim is the quality of care achieved through quality of management But anything is manageable if we are not able to measure it” (Florence Nightingale 1820 - 1910)