Creating an Integrated Health Care System in Greece: A Primary Care Perspective

Over the past few years Greece has undergone several endeavors, aimed at modernizing and improving the national health care services. A Health Care Reform Act seeking quality improvement and coordination of outpatient and hospital services at the
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   Journal of Medical Systems, Vol. 28, No. 6, December 2004 (  C   2004) Creating an Integrated Health Care System in Greece:A Primary Care Perspective K. Souliotis 1,3 and C. Lionis 2 Over the past few years Greece has undergone several endeavors, aimed at moderniz-ingandimprovingthenationalhealthcareservices.AHealthCareReformActseekingquality improvement and coordination of outpatient and hospital services at the Re- gional level, through the enhancement of primary care, has been recently approved.This paper reports a proposal for integrated health system in the primary care sys-tem in Greece with a major focus on equity, quality, and outcomes. The equity andquality framework of this proposal will possess the main components focusing on the provision of essential services, clinical, and organizational standards. KEY WORDS:  health policy; primary health care; integrated health care; personal doctor; Greece. INTRODUCTION Over the last few years, Greece has undergone several endeavors to modernizeand improve national health services. A Health Care Reform seeking quality im-provementandcoordinationofoutpatientandhospitalservicesattheregionallevel,through the enhancement of Primary Care (PC), has been recently approved. (1) Thislatest Health Act strives to improve the quality of care throughout the implemen-tation of Regional Health Systems (RHS). Although several endeavors were madeto develop an effective PC in Greece, there are still many concerns and it remainsa question whether the new Health Care Reform could possibly develop a unifiedframework accountable continually by all citizens in the near future.The Greek Minister of Health and Welfare addressed an invitation to a smallgroup of experts and academics with the main task of the committee being to reviewthe situation and suggest effective changes in the current system. In the frameworkof this Committee, the two authors made a proposal, and part of this proposal wasinitially published in a Greek medical journal. (2) 1 Ministry of Health and Welfare, National School of Public Health, Athens, Greece. 2 University of Crete, The Regional Health and Welfare System of Crete, Greece. 3 Towhomcorrespondenceshouldbeaddressedat5,28thOctoberStreet,12461,Haidari,Athens,Greece;e-mail: soulioti@hol.gr. 643 0148-5598/04/1200-0643/0  C  2004 Springer Science + Business Media, Inc.  644 Souliotis and Lionis The present report outlines brie fl y the existing PHC situation in Greece and itsfunding framework, with the aim to illustrate to an international readership not onlystrengths and weaknesses, but to outline a theoretical model of an integrated healthsystem based on strategic alliances while attempting to develop an inexpensive pro-posalinimprovingthePCquality,anddevelopserviceswithanexplicitaccountabilityto meeting the health needs of their local communities. Primary Care in Greece: Infrastructure and Services As far as public infrastructure is concerned, production and distribution of careareaccomplishedprimarilyviaa “ network ” consistingofapproximately200NationalHealth Service (NHS) health centers that are serving semiurban and rural areas, andapproximately250SocialSecurityInstitution(SSI)polyclinicsmostlyinurbanareas.PC centers in rural areas are accountable for curative and preventive services for allpeoplelivingintheircatchmentareasandtheyservetheirvisitorsinboth,healthcarecenter,acentralstation,thatisstaffedbyGPsandinternists,nurses,andlabassistants,and other health and administrative personnel, and satellite practice staffed by onephysician, usually a GP.The SSI is the largest insurance organization in Greece and represents approxi-mately55%oftheinsuredpopulation.Itisconsideredthatthisinformal “ network ” inmostcasesenjoysarationalplanningdistribution,gooddensityofmedicalpersonnel,and satisfactory technological level. The PC units of the SSI, cover the insured pop-ulation of the SSI for primary medical care and diagnostic services. They are staffedwith about 7500 doctors of almost all specialties, 4000 nurses, and other health carepersonnel.Mostofthedoctorsarepart-timesalariedemployees,whosimultaneouslymaintain their private practices. (3) That sector portion of the insured population belonging to the insurance fundswithouttheirownhealthservicesiscoveredbywayofcontractswithprivateschemesandprivatephysicians,butwithoutensuringtheadequacyandthequalityofservices,while insuf  fi cient provisions for prevention and health promotion and for posthos-pitalization care. Of course these conditions are also noted in the realm of publicproviders.This gap in state production of PC services is due not only to a lack of fundsas to their limited temporal availability to the public. This fact together with thepossibility of public funding by way of contracts with the various insurance fundsresulted in pronounced investment activity by the private sector in outpatient carethrough the establishment of private diagnostic centers, now numbering over 400throughout Greece. (4) Primary Care in Greece: The Existing Funding Framework ThefundingframeworkgoverningthefunctioningofthehealthsectorinGreeceover the last years has been characterized by a continual increase in health expen-diture. Recent research, show that total health expenditure in Greece reached 9.1%of GDP in 2000, of which 42% was private spending. (5) Indeed, given the limitedacceptance by the public insurance coverage through private health schemes, the  Creating an Integrated Health Care System in Greece 645 greatest share of funding is related to  out of pocket   payments that burden personaland family income. (4,5) According to recent estimates the average amount spent byhouseholds in Greece on a yearly basis for PHC services, whether supplementary orin addition to their insurance coverage, is 2.45 million euros, or approximately 28%of the total (public and private) expenditures for health. (5) The above factors exist as part of the wider environment in which funding bysocial insurance has been limited over the last years, resulting in that it is now con-sidered to be inadequate to completely cover the population ’ s needs. In addition,the ability of the state budget to subsidize reform endeavors in the health sectoris considered to be limited. Also, the continuation — or the result — of recent years ’ policies which were fashioned in the environment of the  fi scal limitations imposedby the country ’ s efforts at joining the Economic and Monetary Union. Primary Care in Greece: Some Achievements and Concerns Regarding the provision of PC in Greece the current situation has been ana-lyzed in a number of reports that have brought attention to the factors that de fi ne itnegatively. These include, inter alia: (6 − 8) •  The exclusive involvement of General/Family Physicians (G/F) and primary-care physicians in curative activities and their absorption in dispensing of prescriptions •  Thefailureofthesepractitionerstouseclinicalguidelinesandotherstandardsfor best practice •  Their small contribution to providing home care •  The lack of experience from community based programs and interventionsaimed at diseases ’  prevention and health promotion •  Their failure to diagnose mental disorders and other illnessesOn the other hand it appears that the GPs and PC physicians are capable inmanaging effectively some clinical and health-related conditions and speci fi cally:(a) Use suitable instruments in assessing for diagnosing dementia (9,10) and dep-ression, (9) and making early diagnosis of treatable conditions and diseases(b) Assessthevaccinationcoverageofschoolchildrenandhigh-riskindividuals,and administrate these vaccinations (11,12) (c) Follow practical guidelines for diagnosing bronchial asthma and hepatitisC, (13) and effectively use these guidelines in the therapeutic management of their patients(d) Carry screening programs for speci fi c chronic diseases and follow-up high-risk groups(e) Manage emergency cases and deal effectively with most of these. (14) Several suggestions for the further development of General/Family Medicineand PC in Greece have been recently outlined.  646 Souliotis and Lionis A Debate for a Unified Primary Care System The discussion about an intergrated PC system is not new, but currently animportantdebatehasevolved,withafocusonthequalityimprovementofPCservices.SSI ’ s existing structures in urban centers, which in many political and scienti fi capproaches are treated negatively regarding reform endeavors, could be the founda-tion upon which to construct a new PC system. In line with this reasoning proposalswere presented for the development of an administratively and organically uni fi edsystem for providing PC, with the basic precondition that the SSI structures relin-quishtheirautonomyandbecomepartoftheNationalHealthSystem.Thisproposalis supplemented by indication of the need to create a uni fi ed funding base as theprerequisite for the reasonable utilization of available funds.The fi rstcriticismtobemadeoftheabovepositionsisthatthesubordination — atleast in the  fi rst phase — of SSI ’ s structures to the NHS, may create problems rang-ing from the establishment of ownership framework and use of production means,to the regulation of physicians ’  employment status, in addition, the administrativecost of the transition is expected to be high. Beyond this, it is extremely uncertainwhether such a primarily administrative intervention in the system will produce tan-gible results in terms of adequacy and quality of services that could be perceived bythe users in the short term. As far as pooling of resources under one administrativeentity is concerned, the effectiveness of the intervention as outlined using the ratio-nale of high degree of representation and creation of surpluses in negotiations withproducers, is controlled given that entities such as SSI already have a high degree of representation, which within the existing institutional framework (pre-establishedprices and products) does not allow for contractual grounds as a foundation fornegotiation.As a continuation of the above speculations, it is noted that the  fi nal form of anyreform proposal is called upon to answer the following questions: •  Is it possible to apply an integrated system for PC? •  What is the number of general practitioners and other primary care physi-cians required to serve the needs of such a system, and what is the timeframerequired to produce this number? •  Is it possible to develop a legislative base based on the personal physician,and what is the adequate package of services to be provided to the insuredpopulation and individuals it is obliged to cover? •  To what extent an ideological and domain consensus is required before anyintervention?The above issues require investigation and clari fi cation before any interventionis attempted. At the center of speculation is the question of how much the prospectofadministrativereorganizationistheonlypathforPChealthreforminGreece,andto what degree it can be guaranteed that the quality of care offered will be better “ the day after. ”  Creating an Integrated Health Care System in Greece 647 CREATING AN INTEGRATED HEALTH SYSTEM IN THE GREEKPRIMARY CARE ThebasicpresuppositionintheproposalcreationofanintegratedhealthsysteminPHCinGreeceisthattheStateisrequiredtobetheguarantorofanadequatepack-age of health services, while also ensuring their continuation in terms of follow-up.On the other hand, this choice has an ideological and technical foundation re-garding administrative intervention that is the uni fi cation goal of health services,beyond the fact that it meets political, social, and economic obstacles, not offeringreason based on the criteria of equity, effectiveness, and ef  fi ciency.The system suggested in the context of the present proposal must satisfy theprinciples set out below: (2,15,16) (a) Continuityofcare,allowingforthemanagementofacuteandchronichealthproblems by the same physician or health team across time(b) Integrated and coordinated care that is management of the most commondiseases and health problems as well as major risk factors, in the patient ’ sown social, cultural, and psychological environment, through the intersec-tional collaboration meeting the patient ’ s care needs at local level.(c) Patient, and their families, focused care coordinated with appropriate refer-ral and movement of patients through the system.In such a system the role of the personal physician is also considered to be acentralized one. The personal physician must be de fi ned by his duties that are hisobligations to provide the adequate health-care package to all of the system ’ s ben-e fi ciaries, including management of the most common diseases in the community,the major risk factors, immunizations, and services involving social care and reha-bilitation. This personal physician can preferably be specialized in General/FamilyMedicine, or failing this, another clinical specialty enabling him to ful fi ll his duties aspreviously outlined. Intensive training in the use of clinical protocols and basic skillsforeseen by the adequate health care package must be carried out prior to his inte-gration into the system. The time required to complete such an accelerated trainingprogram is estimated at one (1) month. Intensive on-the-job training following hisemployment should also be provided. (17) The referral process is a central point in the system we propose to examine.The personal physician should be the one to assume the responsibility for referringpatients to other specialists or other health services. It is proposed that in the  fi rstphase bypassing the procedures should not involve patient participation in cost, butrather should be the opportunity to promote the expediency and usefulness of thepersonal physician as an institution.Another new element of the proposed systems is the introduction of auditingof the personal physician ’ s clinical effectiveness. Several methods could be used inmeasuring the personal doctor ’ s clinical effectiveness mainly through the establish-ment of a contract with binding provisions concerning the package of care offered(Table I).It is emphasized that without ensuring such a  “ package ”  of services that clearlyincludemanagementofmajorriskfactorsandclinicalassessmentofthehealthstatus
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