status quo of quo vadis? - KCE

More documents

Recommendations

Info

24 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 responsibility to organise the Evaluation of the Professional Practices. This evaluation by the URML is organized upon the doctor's request. The EPP is mandatory and the law describes the EPP content, the implications and practical modalities. The regional unions of sickness insurance funds (URCAM) are responsible for the coordination of the collective evaluation of the practices. Through regional programs of sick insurance, they set the priority actions for a collective evaluation of the practices (for example drop by X % of the prescriptions of statins or by Y % of the short duration medical leaves). Those quality improvement initiatives launched in 1996 had a relatively limited impact. In ‘liberal’ medicine, the installation of multiple mechanisms of quality insurance did not improve the evaluation culture: the constraining mechanisms were a failure (example of RMO) and the inciting tools such as the evaluation of the professional practices (EPP) had a limited impact on the daily practice of the 'liberal' doctors. PRACTICE GUIDELINES The 131 ‘recommandations pour la pratique clinique’ are accessible on the website from the HAS (Haute Autorité en Santé). Those guidelines are frequently linked with ‘référentiels’ for assessing the practice on specific issues. The HAS uses different development methods, mainly consensus conferences with multidisciplinary teams. 91 Recently, prescription patterns changed after the introduction of guidelines but they do not seem to have any clear macro-economic impact. 83 To date there is no systematic evaluation at the level of the individual doctor. PEER REVIEW GROUPS Only one experiment of peer review groups is that of the French Society of General Medicine in Brittany, in partnership with the regional unions of the sickness insurance funds). Some groups receive a financing (FAQSV). Other peer review groups (as the groups from the Société Française de Médecine Générale) have no financial support. The participation to those groups is an item of the EPP evaluation procedure. PRACTICE ACCREDITATION Accreditation is mandatory for the health institutions but not for the ‘liberal’ practices. Some group practices piloted experiences of accreditation of 'liberal' practices for example in Brittany. 2.4.1.3 Evidence for effectiveness There is no publication about the effectiveness of the current quality improvement mechanisms. 2.4.1.4 Future developments The evolution is towards more transparency, as illustrated by the recent law on patients' rights. Continuous medical education is increasingly on the agenda with for example the organisation of trainings that last more than one day and the design of software that integrate guidelines within the medical record. However, the resistance of French doctors to any form of control is a serious break for the development of quality initiatives.
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 25 2.4.1.5 Learning points and suggestions for Belgium The French experience illustrates some pitfalls in the implementation of a quality system at national level. First, the lack of conceptual framework underlying the initiatives entails difficulties for setting up a coherent system. Secondly, the scattered initiatives rely on the willingness of many actors with conflicting interests. The lack of an integrated quality system leads to an insufficient implementation in the practice. Finally, implementing quality initiatives is difficult when they did not involve the profession within their development. The freedom of choice for the patients, the absence of gatekeeping system and the weak structure of ‘liberal medicine’ are often identified as factors hampering the quality of care whilst increasing the financial burden for the health care system. The ‘quality steps’ in the ‘liberal’ sector remain very limited, and exclusively relies on voluntary work. Three last points are important for the French system: • The balance between the obligation (recertification process for all practitioners; responsibility of complex pathologies by health networks) and the incitation towards voluntary investment in quality (e.g., creation of a label ‘médecin engagé dans l'entretien régulier de ses connaissances’, incentive to create flexible networks of prevention or duty to assume the responsibility of specific populations); • The need for clarifying the role of each actor in quality improvement initiatives e.g. URML, Ordre des Médecins, sickness insurance funds (with a controlling section - to sanction frauds and dangerous behaviours and a counselling section - to promote quality in the practices); • The willpower of the system to empower the patient to act as a lever for promoting health care quality: practice recommendations for the patients, perspective of a ‘regional guide of he professionals of health’ listing the labelled 'liberal' experts. 2.4.2 Germany 2.4.2.1 Organisation of the health care system, with focus on family medicine/general practice AMBULATORY MEDICINE AND GENERAL PRACTICE Ambulatory health care is mainly provided by private for-profit providers. GPs/Family physicians represent 55% of the physicians working in primary care. Nowadays, most GPs work in single-handed practices also in the eastern part, which is remarkable as until 1989 public polyclinics delivered most ambulatory services. 81 About one out of three family physicians do not have any specialist qualification. With a 1,1 GP density for a thousand inhabitants Germany is in the middle of the European group. 2 Today an academic curriculum for GP exists in almost half of all (34) medical faculties. SELECTION OF A FAMILY DOCTOR BY THE PATIENT Sickness fund members are free to choose a family physician who cannot change during the quarter relevant for reimbursement of services for that patient. 92 Patients frequently choose office-based specialists directly. However, one of the experts consulted in this project (J. Stock) notices today a reverse tendency: many elderly and ill people ask for a gatekeeping system, to help them going through the jungle of the health system. REIMBURSEMENT SYSTEM Germany has a fee for service system. The statutory health insurance (SHI) is the major source financing health care, covering 88% of the population (2003). The payment of physicians involves two major steps. First, the sickness funds make global payments to the physicians’ associations for the remuneration of all SHI-affiliated doctors, instead of paying the doctors directly. The
Page 1 and 2: Kwaliteitsbevordering in de huisart
Page 3 and 4: Kwaliteitsbevordering in de huisart
Page 5: Hoe refereren naar dit document? Re
Page 8 and 9: ii Kwaliteitsbevordering in de huis
Page 10 and 11: iv Kwaliteitsbevordering in de huis
Page 12 and 13: vi Kwaliteitsbevordering in de huis
Page 15 and 16: KCE Reports 76 Quality development
Page 35 and 36: 21 Quality development in general p
Page 37: KCE Reports 76 Quality development
Page 53 and 54: KCE Reports Quality development in
Page 89 and 90:
KCE Reports 76 Quality development
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Health policy KCE Reports 76 Qualit
Page 151:
Page 154 and 155:
Wettelijk depot : D/2008/10.273/18
Page 156 and 157:
38. Baarmoederhalskankerscreening e
show all

status quo of quo vadis? - KCE

Create successful ePaper yourself

Delete template?

Save as template?