Financial incentives in France: from CAPI to public health targets

Financial incentives in France:
from CAPI to public health targets
Isabelle Durand-Zaleski
Special thanks to Ms Dominique Polton, from the National health insurance
fund for salaried workers
CAPI:
contract for the improvement of Individual practice
2009, financial incentives for GPs
Contracted individually with the SHI
Initial resistance from national stakeholders
Physicians’ Unions (vs tradition of collective contracting)
National Council of the Physicians Association
Union of drug manufacturers
National health authority
CAPI criteria
Prevention
Flu immunization
Breast cancer screening
Monitoring & risk factors control
Diabetes
Hypertension
Outcome
Hypertension
Limit useless and potentially harmful prescriptions
Vasodialtors
Benzodiapzepines
Control expenditues
Generic prescription: PPI, statins, antidepressants, antihypertensives,
antibiotics
Choose the cheap statins, antihypertensives, anti platelet agregants
http://www.fmfpro.com/IMG/pdf/dp_convention_medicale_2011_vdef.pdf
CAPI= Current practice and CAPI targets
80
70
60
50
40
30
20
10
0
ic
n
in
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ro
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co
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ne
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ia
od
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be
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to
in
la
en
di
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so
sc
va
er
nc
ca
st
n
ea
io
br
at
iz
un
m
flu
target
current
CAPI= KOL opinion and independent GP journal
Prescrire
KOL
ge
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pr
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ns
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or
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es
in
br
cr
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ee
in
flu
g
im
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un
iz
io
at
n
20
15
10
5
0
Despite opposition from their Unions, GPs enroled
Évolution du nombre de signataires du CAPI
18 000
16 000
14 000
12 000
10 000
8 000
6 000
4 000
2 000
16,067 (38% of eligible physicians) individually contracted CAPI.
201111
201110
201109
201108
201107
201106
201105
201104
201103
201102
201101
201012
201011
201010
201009
201008
201007
201006
201005
201004
201003
201002
201001
200912
200911
200910
200909
200908
200907
200906
200905
0
Results for them:
70% received a bonus
Average bonus of 3 100 € for the first year
Max ≈ 8,000 €
And for their patients (2009 vs 2012)
50
45
40
35
30
25
20
15
10
5
0
2009
contracting
2010
contracting
2009 non
contracting
2010 non
contracting
HbA1C x3 eye exam
aspirin
At the macro level:
Appropriate diabetes management by # enrolees
Taux de patients diabétiques ayant eu 3 ou 4 dosages d'HbA1c
1400
Effectif de signataires
1200
1000
800
600
400
200
0
5
10
15
20
25
30
35
40
45
50
taux à fin juin 2009
CNAMTS - DSES – DEOS
55
60
65
70
75
taux à fin mars 2012
80
85
90
95 100
Appropriate risk factor management by # enrolees
Taux de patients diabétiques à haut risque cardio-vasculaire
sous statines
2500
Effectif de signataires
2000
1500
1000
500
0
5
10
15
20
25
30
35
40
45
50
taux à fin juin 2009
CNAMTS - DSES – DEOS
55
60
65
70
75
taux à fin mars 2012
80
85
90
95 100
Taux de patients diabétiques à haut risque cardio-vasculaire
sous statines et sous aspirine à faible dose
1600
Effectif de signataires
1400
1200
1000
800
600
400
200
0
5
10
15
20
25
30
35
40
45
50
taux à fin juin 2009
CNAMTS - DSES – DEOS
55
60
65
70
75
taux à fin mars 2012
80
85
90
95 100
Use of asprin vs other anti platelets
Taux de patients sous AAP traités par aspirine à faible dose
3500
Effectif de signataires
3000
2500
2000
1500
1000
500
0
25
30
35
40
45
50
55
60
taux à fin juin 2009
CNAMTS - DSES – DEOS
65
70
75
80
taux à fin mars 2012
85
90
95
100
2012 changes: Public Health targets
Chronic diseases and prevention: 500 points
Efficient prescribing (reduce overuse, misuse and increase
generic prescribing): 400 points
Office management, computerized records: 400 points
For each indicator the SHI defines the current level,
intermediate and final target levels
Each point is worth 7 €
The maximum number of points is 1,300
The expected average bonus is 4,500 € per physician per
year
The 2011 Act on social security has allowed the contract to be integrated
in the new collective agreement to be negotiated in 2011.
Quality and efficiency of
care
Prevention / screening
+ New target for flu immunisation, cervical
cancer screening, antibiotic use, duration of
prescription for benzodiazepines
Follow up of chronic
care patiens
+ Level of Hb1C & LDL cholesterol for
diabetic patients
Efficiency of drug
prescription
Same indicators
Organisation of the practice
Use of EMR, use of a software labelled by
HAS for prescribing, electronic exchanges
with NHI, information for patients, annual
synthesis of the medical record
29 indicators – 1300 points – 1 point = 7€ for 800 patients registered (>
16 years old)
Potential bonus = 9 000 euros (for 800 patients)
Other agendas for the SHI
P4P is now part of the basic remuneration of
physicians (fee level frozen until 2016)
SHI acquires legitimacy for guidelines
implementation
SHI has developed academic detailing vs pharma
reps.
New deal in the relationship with Unions
When financial incentives do more good than harm: a checklist
BMJ 2012;345:e5047
1. Does the desired clinical action improve patient
outcomes?
2. Will undesirable clinical behaviour persist without
intervention?
3. Are there valid, reliable, and practical measures of the
desired clinical behaviour?
4. Have the barriers and enablers to improving clinical
behaviour been assessed?
5. Will financial incentives work, and better than other
interventions to change behaviour, and why?
6. Will benefits clearly outweigh any unintended harmful
effects, and at an acceptable cost?