Valorização Social e Política da APS Valorização Social e Política da APS Inovações no MundoInovações no Mundo

5º Seminário Internacional 5º Seminário Internacional de Atenção Primária à Saúdede Atenção Primária à Saúde

26 de março de 201026 de março de 2010

Rio de Janeiro, Rio de Janeiro, BrasilBrasil

Richard G. Roberts, MD, JD, FAAFP, FCLMRichard G. Roberts, MD, JD, FAAFP, FCLMProfessor of Family MedicineProfessor of Family Medicine

University of Wisconsin School of Medicine & Public HealthUniversity of Wisconsin School of Medicine & Public Health1100 1100 DelaplaineDelaplaine Court, Madison, WI 53715Court, Madison, WI 53715

TEL: +1 608 263 3598; FAX: +1 608 263 5813TEL: +1 608 263 3598; FAX: +1 608 263 5813Email: richard.roberts@fammed.wisc.eduEmail: richard.roberts@fammed.wisc.edu

P l C itPersonal Health

CommunityHealth

PersonalPersonal ProfessionalProfessional

Primary Health CarePrimary Health Care

PopulationPopulationPublicPublic pp

The ChallengesThe Challenges

•• Access access accessAccess access access•• Access, access, accessAccess, access, access•• Chronic conditionsChronic conditions•• Personal care in complex systemPersonal care in complex system•• Comprehensive careComprehensive care

Aligning payment with prioritiesAligning payment with priorities•• Aligning payment with prioritiesAligning payment with priorities

Family doctor demographicsFamily doctor demographics

•• 1 in 3 are women1 in 3 are women•• 1 in 3 are women1 in 3 are women•• Half are over age 50Half are over age 50gg

S h t l H lth Aff i 2006 25 555S h t l H lth Aff i 2006 25 555 571571Schoen et al. Health Affairs 2006;25:w555Schoen et al. Health Affairs 2006;25:w555--w571.w571.

Family Physician VisitsFamily Physician Visits

47%47% Acute problemAcute problem47%47% Acute problemAcute problem25%25% Chronic problem routineChronic problem routinepp15% Preventive care15% Preventive care8%8% Chronic problem unstableChronic problem unstable1%1% Pre or post surgery/injury follow upPre or post surgery/injury follow up1%1% Pre or post surgery/injury follow upPre or post surgery/injury follow up

Ti R i tTi R i tTime RequirementsTime Requirements

•• 10.6 hrs/day10.6 hrs/day –– chronic conditionschronic conditions1, 21, 210.6 hrs/day 10.6 hrs/day chronic conditionschronic conditions•• 7.4 hrs/day 7.4 hrs/day –– preventive servicespreventive services33

P ti t d ?P ti t d ?•• Patient agenda?Patient agenda?•• Acute care?Acute care?•• Administrative issues?Administrative issues?

11 ØØstbye T Ann Famed Med 2005; 3:209stbye T Ann Famed Med 2005; 3:209--2142141.1. ØØstbye T. Ann Famed Med 2005; 3:209stbye T. Ann Famed Med 2005; 3:209 214.214.

2.2. Tsai et al. Am J Man Care 2005;11:478Tsai et al. Am J Man Care 2005;11:478--88.88.

33 Yarnall KHS AJPH 2003;43:635Yarnall KHS AJPH 2003;43:635 6416413.3. Yarnall KHS. AJPH 2003;43:635Yarnall KHS. AJPH 2003;43:635--641.641.

4.4. Bodenheimer T. NEJM 2006:355:861Bodenheimer T. NEJM 2006:355:861--864.864.

ComplexityComplexity

•• Average visit: 1 4Average visit: 1 4 8 problems8 problems•• Average visit: 1.4 Average visit: 1.4 –– 8 problems8 problems•• Diagnoses: top 25 = 60% total Diagnoses: top 25 = 60% total g pg p

Stange KC, et al. J Fam Pract 1998;46(5):363Stange KC, et al. J Fam Pract 1998;46(5):363--8.8.g , ; ( )g , ; ( )

Primar Health CarePrimar Health CarePrimary Health Care Primary Health Care InnovationsInnovationsInnovationsInnovations

•• AccessAccessAccessAccess•• OutcomesOutcomesOutcomesOutcomes•• PaymentPaymentPaymentPayment•• StandardsStandardsSta da dsSta da ds•• SystemsSystemsyy

Access Access –– after hoursafter hours

•• AustraliaAustralia special paymentspecial payment•• Australia Australia –– special paymentspecial payment•• Canada Canada –– family health networksfamily health networksyy•• Netherlands Netherlands –– coop, RN callcoop, RN call--in linein line•• UK UK –– 2424--hr nurse line, walkhr nurse line, walk--in centresin centres

AccessAccess –– after hours,after hours, not EDnot EDAccess Access after hours, after hours, not EDnot EDBase: Adults with any chronic condition who needed afterBase: Adults with any chronic condition who needed after--hours carehours care

80

Percent reported Percent reported very/somewhat difficultvery/somewhat difficult getting care on nights, weekends, getting care on nights, weekends, or holidays without going to ERor holidays without going to ER

60

Somewhat difficult

Very difficult6256 56

60

28 23 2720

40

60

36 3944

4021 15

19 2440 36

30

34 33 2915 15 20 20

401520

0

AUS CAN FR GER NETH NZ UK US

Data collection: Harris Interactive, Inc.Data collection: Harris Interactive, Inc.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

AccessAccessAccessAccess•• Same day visitSame day visit•• Same day visitSame day visit•• OnOn line schedulingline scheduling•• OnOn--line schedulingline scheduling•• Group visitsGroup visits•• Group visitsGroup visits•• EE--visitsvisits•• EE--visitsvisits•• WebWeb--based informationbased information•• WebWeb--based informationbased information•• Mobile consults & monitoringMobile consults & monitoringMobile consults & monitoringMobile consults & monitoring•• Networks: CanadaNetworks: CanadaNetworks: CanadaNetworks: Canada

OutcomesOutcomes

•• Disease managementDisease managementDisease management Disease management •• Chronic Care ModelChronic Care ModelChronic Care ModelChronic Care Model•• Guidelines: softwareGuidelines: softwareGuidelines: softwareGuidelines: software•• Payment: QOFPayment: QOFay e t QOay e t QO

United Kingdom United Kingdom -- QOFQOF

•• 20042004 146 metrics146 metrics•• 2004 2004 –– 146 metrics146 metrics•• 2006 2006 –– 135 metrics135 metrics•• ₤ 1 billion additional funds₤ 1 billion additional funds

Campbell et al. Ann Fam Med 2008;6:228Campbell et al. Ann Fam Med 2008;6:228--234234

United Kingdom United Kingdom -- QOFQOF

•• Improved diseaseImproved disease specific carespecific care•• Improved diseaseImproved disease--specific carespecific care•• Improved data captureImproved data capturep pp p•• Changed behavior regardless of valuesChanged behavior regardless of values•• Improved physician incomeImproved physician income

C b ll t l A F M d 2008 6 228C b ll t l A F M d 2008 6 228 234234Campbell et al. Ann Fam Med 2008;6:228Campbell et al. Ann Fam Med 2008;6:228--234234

United Kingdom United Kingdom -- QOFQOF

•• Dual QOFDual QOF patient agendapatient agenda•• Dual QOFDual QOF--patient agendapatient agenda•• Deskill doctorsDeskill doctors•• Decrease continuityDecrease continuity•• Disgruntled staff if not rewardedDisgruntled staff if not rewarded

Impact of performance cultureImpact of performance culture•• Impact of performance cultureImpact of performance culture

C b ll t l A F M d 2008 6 228C b ll t l A F M d 2008 6 228 234234Campbell et al. Ann Fam Med 2008;6:228Campbell et al. Ann Fam Med 2008;6:228--234234

PaymentPayment

•• SalarySalarySalarySalary•• FeeFee--forfor--serviceserviceFeeFee forfor serviceservice•• CapitationCapitationCapitationCapitation•• PerformancePerformance--basedbasede o a cee o a ce basedbased•• BlendedBlended

StandardsStandards

•• Australia Australia –– RACGPRACGPU i d SU i d S NCQA PCMHNCQA PCMH•• United States United States –– NCQA PCMHNCQA PCMH

SystemsSystems

•• Lean designLean designLean designLean design•• TeamletsTeamletsTeamletsTeamlets•• MicrosystemsMicrosystemsMicrosystemsMicrosystems•• Electronic health recordsElectronic health recordsect o c ea t eco dsect o c ea t eco ds

InformationInformationInformationInformationCountryCountry EMREMR RegistryRegistryCountryCountry EMREMR RegistryRegistryAusAus 7979 6868CanCan 2323 2626GG 9292 8181GerGer 9292 8181NetNet 9898 6363NetNet 9898 6363NZNZ 9292 8080UKUK 8989 9292USUS 2828 3737USUS 2828 3737

Schoen et al. Health Affairs 2006;25:w555Schoen et al. Health Affairs 2006;25:w555--w571.w571.

Predictors for successPredictors for success

•• Provide ready accessProvide ready access•• Provide ready accessProvide ready access•• Prevent & manage chronic conditionsPrevent & manage chronic conditionsgg•• Prove & improve performanceProve & improve performance

Aims & AssetsAims & AssetsAims & Assets Aims & Assets of Primary Health Careof Primary Health Careof Primary Health Careof Primary Health Care

•• ContinuityContinuityC h iC h i•• ComprehensiveComprehensive

It’s theIt’s the

RELATIONSHIP!RELATIONSHIP!RELATIONSHIP!RELATIONSHIP!