Croatia - new method of financing family medicine

As of May this year, family doctors were financed mainly through capitation – based on the number of patients in care. Only a smaller part of income (10%) was financed through undertaking additional therapeutic procedures.

Doctors who work as employees in public health centers comprise about 25% of the total number of doctors in family medicine clinics. The rest are in private practices contracted to the Croatian Health Insurance Fund (CHIF).

With previous type of financing, there was almost no motivation for improvement of the health service provided by family doctors. Also, until this year, the Croatian Health Insurance Fund (CHIF) relationship with family doctors was not based on partnership – doctors were financially penalised, for administrative faults and there was no control of quality of work. Added to this, statistical data analyses, were flawed with data collected only for first and control examinations and home visits.

A pilot project was initiated, headed by CHIF director, Sinisa Varga, with implementation as of May 1, 2013. Through this project an entirely new model of financing was introduced.

The smallest part of practice financial turnover is now based on number of patients - capitation is now a quarter of the financial reimbursement of what it was previously.

I would say it better in this way: Previously, the number/value of patients (capitation), was the major source of income. New model still has capitation as part of income, but it is only around 1/4th thus stimulating GP/FDs to work in other directions to obtain similar or even greater income (more different procedures, quality of work elements, less refferals and more cases solved, preventive measures etc).

Reducing the impact capitation finances bring to a practice, the "whims" of patients and subsequent "switchings" from one family doctor to another in order to get what they wish will certainly be reduced. The trend has already been observed in some practices, and the patients recognize the new relations. Unfortunately, doctors were „hostages“ of patients for far too long.

Part of the new financing was the introduction of fixed sums for paying of nurse wages, utilities, purchase of medications and expendable material.

Expenses of education are still not in the fixed money allotment and doctors still heavily rely on help from pharmaceutical companies with all the pros and cons it brings.

Remaining income is made through additional treatments. The list of procedures performed by practitioners (currently, ear syringing, suture removal, wound treatment, spirometry and similar) has expanded. tremendously.

Home visits, palliative home visits, patient consultations via phone and/or e-mail, initiation of insulin, consultation with district nurses and physical therapy are increasingly valued. What is important, especially for rural areas, is the inclusion of joint and fracture repositioning and immobilisation, home childbirth deliveries, liquid nitrogen cryotherapy (warts and similar), ultrasound, examination of tourists, and preparation of patients for telemedical consultations (due to huge diversity of Croatia, most remote parts in mountains and islands have access to state of the art IT technical connectivity with the Croatian institute for telemedicine, for educational and consultational purposes – doctor and other health staff educational courses, telemetric secondary care consultation, even psychiatric consultations with patient in front of camera). In this way practice income is increased and it is possible to acquire new equipment and participate in education. To purchase specific equipment a longer period of time is needed to accumulate funds.

Alongside this, additional (smaller) income is made if blood samples are taken in the practice as well as other microbiological samples; if patients can make appointments for consultations rather than be seen on a first-come-first-served basis; if staff make appointments for secondary care consutlations; if there is a book of complaints and impressions; and if doctors form an official group practice with special obligations and availability for patients which didn't exist so far.

Regarding preventive activities, computerized 'panel' reports (special program pop-up screens) were introduced to enable fast preventive measures in opportunistic screening during our daily work. There are four 'panels' presently: primary prevention, COPD, diabetes and hypertension. These 'panels' could be a hugely important thing since they reduce human interaction by using computer logic to filter individuals for screening out of a whole population. The computer 'panel' synthesizes all diagnosis-related (or specific panel related) health record data from many sources and presents it in a simple way in one place referenced to normal values, curves and to recommended procedures and controls for lab results, spirometry values, anthropometric values etc.

Most doctors (about 85%) have accepted this sort of finance system, while 15% of doctors kept the old finance system. One of the main complaints is that the new system is highly unstable, depending on "whims" of the health fund and being valid for only one year, while old contracts were valid up to 2021. In this way, teams with a large number of patients (more than 2100) find a result in a loss of part of their income or requiring more procedures to get similar income; while teams with smaller numbers of patients are paid more. Group practice is also being introduced which is currently functioning only as improved accessibility for patients in case of vacations and sick days by their chosen doctors.

In the end the vast majority of practitioners are satisfied with the new finance system, and also with the fact that everything they do in practices can be displayed in reports (previously, we could not put into records what were the procedures we performed). This is an improvement as the perception of the general public and colleagues was that general practitioners serve only for menial routine work and that most of their work comes down to handing out prescriptions and referral. On the other hand, this new reimbursement system stimulates doctors towards additional education and acquiring additional skills while not being very dependent on total number of patients. This will hopefuly lead to an increase in medical care diversity and availability in PHC to Croatia's population and cutting back on unnecessary secondary care costs within the healthcare system.

What needs to be improved, and a space where we see the role of the health ministry and family medicine organizations, is the education of doctors and team members, as well as improving practice equipment. The ultimate aim we all hope for is improved availability and diversity of health care as well as improved outcomes, especially in rural areas.

Dr Tanja Pekez-Pavlisko on behalf of KoHOM