Revising Estonia’s Quality Bonus Scheme in Primary Care

Effective management of chronic conditions is Estonia’s most pressing health system challenge, alongside tackling socioeconomic and geographic inequities in health. Both challenges demand high-performing primary care. Although many measures of primary care performance in Estonia are good, there are signs of weakness. In particular, patient-centredness and care coordination could be improved to prevent unnecessary admission to hospital or attendance at hospital Emergency Departments. In order to address these challenges, the Estonian Health Insurance Fund and Estonian Society of Family Doctors launched a pay-for-performance scheme in 2006, the Quality Bonus Scheme. Specific aims of the QBS were to incentivize preventive care and management of chronic conditions. Nearly all Family Doctors in Estonia now participate in QBS. One in three, however, obtain low scores. Doctors generally perform well in the preventive care domain, but performance in the domain linked to care for chronic conditions is highly variable - with poor performance typically concentrated in Estonia’s southern counties. Performance in domain of additional professional competencies is uniformly low.

Estonia’s QBS differs in important respects from primary care P4P schemes in other countries. It has a more complex design than many schemes, rewarding relative improvement rather than absolute achievement, and is linked to a separate bonus scheme for Quality Management. QBS pays less (as a fraction of overall income) than several other schemes and feedback of results takes several months, slower than that seen in other countries. It also offers less opportunities to exempt patients from inclusion in the scheme, which may penalize Family Doctors who care for patients with unusually complex needs. The scheme also relies on claims data submitted by Family Doctors to EHIF for reimbursement. While this minimises administrative burden, it means that QBS is limited to measuring processes and activities. In contrast to primary care P4P schemes in other countries, key dimensions performance such as clinical outcomes or patient experience are not currently captured by QBS. Furthermore, most QBS incentives are directed to the individual Family Doctor. Primary care is increasingly team-based, however, meaning that there may be scope to consider wider use of group-level incentives within QBS.

The authors of this report are Ian Forde, Marvin Ploetz, Adrien Dozol and Iryna Postolovska. The support of Christoph Kurowski, Enis Baris and other managers at the World Bank Group is gratefully acknowledged.

Ten recommendations are made for modernizing QBS in light of Estonia’s priority health care needs; international experience and best practice in using pay-for-performance in primary care; and, concurrent reforms to Estonia’s primary care financing and service delivery model. Taking each of them forward will require close cooperation between EHIF and ESFD:

1. On-going revision of QBS indicators is recommended, dropping those which have high achievement or low disease burden
2. The dimensions of primary care performance captured by QBS should be expanded
3. Local elements should be developed
4. QBS should reward both improvement and absolute level target achievement
5. Consider wider application of practice-level incentives, to reflect team-base care
6. Use QBS to encourage group practice
7. Expand the criteria by which patients can be exempted from inclusion in QBS
8. Strengthen the incentives within QBS, both financial and non-financial
9. Shorten the feedback loop by which Family Doctors receive results
10. Finally, ensure that QBS is part of an overall strategy to strengthen primary care quality.



The State of Health Care Integration in Estonia

The report “The State of Health Care Integration in Estonia” summarizes an assessment of the state of health care integration in Estonia and its driving forces. In the absence of a widely accepted definition, this study defines health care integration as: i) the delivery of care in the appropriate care setting and ii) coordination and continuity of care across care settings. The study focuses on integration issues related to the prevention and treatment of chronic diseases, with particular attention to the role and functioning of primary care and equity issues. The findings of this analysis therefore do not provide a comprehensive assessment of quality within specific care settings (i.e., primary care, acute inpatient care, etc.), nor of overall health system performance. Yet, they constitute one of several inputs that may be relevant for future policy changes. These study findings are based on a quantitative analysis of health insurance claims data plus stakeholder interviews and focus group discussions as part of a joint research agenda between the Estonian Health Insurance Fund (the EHIF) and the World Bank Group (WBG).

The report was prepared by a team led by Christoph Kurowski. Team members were Amit Chandra, Elyssa Finkel, and Marvin Plötz.

Estonian care management program pilot

In 2015, the Estonian Health Insurance Fund signed a cooperation agreement with the WorldBank to continue analysis for the purposes of disease prevention, and improving access to health services; and the development of the health care system. One of the goals of stage II of the study is to develop a model that would help family physicians identify in their lists, the patients whom the implementation of the preventive, advisory and monitoring activities, would most benefit, a) patient's health and quality of life, b) at the same time supporting the optimal use of health insurance resources. Today, the WorldBank in cooperation with the Health Insurance Fund, and with the family physicians participating in the project, have developed an evidence-based model of risk patients and started piloting the model on 15 February 2017. The piloting of the model is planned in the practice of the family physicians participating in the WorldBank project. In total, the projects involve eleven family physicians from different regions of Estonia. The pilot project is scheduled to last six months, the final deadline being 31 August 2017. Developing the evidence-based model of risk patients is targeted especially for Estonian family physicians using international studies and international experience, linking it to the Estonian studies and experience. The aim of the model is to create a tool for primary health care workers (family physician and a family nurse) to identify better and manage the treatment process of chronically ill patients, integrating them with specialist medical care and social systems.

This is in order, through a monitoring system of chronically ill patients, to prevent as much as possible the exacerbation of the disease and thus to minimize hospitalization (including the importance of cooperation in primary and specialized medical care), thereby improving health outcomes, as well as to support mutual cooperation of social and health care systems.

In the first stage of the preparation of the pilot project (January - February 2017), a patient monitoring web environment was developed for family physicians. This means that important data for family physicians (consisting of the health indicators and the medical history of the risk patients, as well as of the reference to the patient's socio-economic background) is located in the online environment, where the family physician and the family nurse will have an overview of the health indicators of the so-called risk patients, and of the set treatment goals, based on planned activities, and can then monitor the implementation of the treatment plan.

The activities of the family physician and the family nurse include the following activities:

a) assessment of the risk patients’ needs and planning of treatment;

b) the coordination of health-related activities;

c) the coordination of the issues of social assistance (cooperation with a social worker).

In the course of the pilot project, family physicians may need to cooperate with hospitals in order to better monitor the course of the treatment of the patients on their list.

At the final stage, a project evaluation will be carried out in order to obtain feedback on the possible applicability of the project in all the family health organizations in Estonia.

What is Treatment Management?

Treatment Management is a means of improving the coordination of the treatment of the patients with complex and increased medical needs, both between the various levels of the health care, the social system, and between various providers of health care and social services. Treatment Management includes directional and preventive actions to a small portion of patients who are at high risk of health deterioration, or the risk of the increased use of health care services. Such actions may include, for example, patient monitoring after hospitalization, monitoring of referral to a medical specialist, and the results of the examinations; monitoring of the performance of the goals described in the family physicians’ quality system; ensuring the drug compatibility control and the usage; and monitoring of patients between scheduled appointments. Treatment Management is designed to address the needs of complicated patients in order to improve their health outcomes and reduce their need for more extensive health care services.  

Upon developing the evidence-based model of risk patients, targeted especially for Estonian family physicians, the Estonian Health Insurance Fund and the WorldBank used international studies and international experience, linking it to the Estonian studies and experience.

Why is Treatment Management necessary?

All over the world, those who have a difficult socio-economic background make up only a small part of primary care patients, whereas the disease burden and health care costs of the people with lower socio-economic backgrounds account for a disproportionately large percentage. Many of these patients have multiple chronic diseases at one time, and they are confronted with major socio-economic problems, and/or simultaneously, they also have behavioral health comorbidities. They are likely to consume many different medications, visit several different medical specialists, and/or have significant functional restrictions.  Such characteristics may make coordination of the patient’s care difficult for primary health care providers, but failure to do so could lead to serious problems including unnecessary deterioration of health, duplication of examinations, mutual conflicts of the medication prescribed for treatment, and treatment errors. Treatment Management programs have a great potential for the improvement of  treatment coordination and patient’s treatment outcomes, and these programs are increasingly used by many different national health care systems.

The objectives of this pilot project are:

a.     To assess the applicability of the risk patients’ Treatment Management model developed under the pilot project;

b.    To understand the impact of the pilot project on the Treatment Management processes, and on the treatment results of patients enrolled in the program;

c.     Based on the experience gained, to develop risk patients’ Treatment Management models and solutions that will function in Estonia, and their application.

The ultimate goal of the Treatment Management program is to improve the health outcomes of patients with chronic diseases and complex needs and to reduce their need for health care services.


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