Greece: Primary Care in a time of crisis. 2nd VdGM Forum, Dublin 2015

Editor's Notes

1. It ‘s a great honor for me to be here to present you the unique case of Primary Care in Greece during this time of austerity
2. The old debate about the financial sustainability of health systems has been reset from how to pay for healthcare in 30 years time to how to pay for it in the next 3 months
3. Greece was the most affected by the crisis country with a substantial and sustained fall in GDP
4. There were 5 sequential years of negative growth
5. Unemployment rocketed from 8 to 27% in 7 years, being even worst in youth
6. Unemployment and inability to pay contributions left almost 2,5 millions without health coverage
7. social spending dropped in parallel with GDP. Goverment, instead of protecting vulnerable groups, took money from the health sector to finance other areas
8. only 12% of the spending goes to health
9. Health spending from 10% of GDP in 2009 dropped to 9.3% in 2012 (the OECD average). The public share was 67%, below the average of 72%
10. The overall drop from its peak in 2008 was 25%
11. a unique number in Europe
12. The allocation of resources reveals a health system focused in hospital care, in illness and not in health
13. Outpatient care moreover suffered the bigger cut in the budget during the crisis
14. The share of the private spending remained still high, although substantially lower than the past, as it depends on the ability to pay
15. Out of pocket money, go to inpatient care and pharma spending, while it is severely cut in outpatient care
16. Unmet medical needs rise high, posing an issue of equity. They represent undetected illness and bad health for tomorrow
17. The evaluation of the Greek Health system in Euro Health Consumer, year by year worsens!
18. Health systems may cope with budget cuts for a limited period, if they are adequately publicly funded and the out-of-pocket payments are low (not the case in Greece). Policies must be implemented to gain efficiency and to support the vulnerable.
19. Efficiency gain means doing the same or more with less resources
20. Greek health system is characterized by almost all the leading causes of inefficiency. If we have a positive approach there is a lot of waste that can be addresed
21. Health promotion is poor, with high prevalence of unhealthy lifestyle factors. 1st in overweight children
22. 1st in daily smokers
23. Poor performance in prevention, like cancer screening
24. The most inappropriate staff mix. The highest number of doctors per population
25. With the lowest ratio of generalists to specialists
26. And the lowest ratio of nurses to doctors.
27. Oversupply of high teq equipment,
28. inducing demand of investigations like CT and MRIs
29. Overuse and inappropriate use of medications, like antibiotics
30. Inflating the pharmaceutical spending- #1 in 2008
31. System characterized by corruption- #1 in under the table payments to doctors
32. In the study of Kringos, about the strength of PC in Europe
33. The greek was evaluated as the worst
34. As it scored badly in almost all the dimensions of the structure and the process of Primary care
35. These dimensions were also assessed in a technical report conducted by the Task Force for GR. There was an unclear distribution of responsibilities between the various players of the system And not a broadly supported vision of Primary Care.
36. GPs were badly paid and by oldfashioned methods- salaried or on fee-for-service the share of private spending was large and often under the table
37. Lack of GPs and nurses in PC and No clear job description for them No policies to address the imbalance
38. Low patient satisfaction with the ease of access. It depends on money and waiting time.
39. The role of GP is often limited to prescribing and referring There is weak community orientation, focusing on the patients visiting the practice
40. Fragmented PC system makes personal continuity a problem, There are no referrals and usually no communication between GPs and specialists
41. Quality
42. And efficiency can not be assessed, as there is monitoring only of quantity of services and not of the value of delivered care
43. Inequity is a clear and worsening problem
44. Gain efficiency with elimination of inappropriate and ineffective services, and reallocation of the resources towards the more cost effective primary care and public health are the answers to the restricted health budgets.
45. EOPYY, the new national insurance scheme was established by the merger of the numerous funds. EOPYY formed a unified benefit package and by targeting to efficiency abandoned some services, covered by the noble funds in the past.
46. The unified benefit package restricted the range of the covered services. What happened to the share of the population entitled to coverage and to the level of the user charges for the services? Reductions in coverage shift responsibility for paying for health services on to individuals and will usually increase the role of out-of-pocket payments in the health system (direct payments for non-covered services and user charges for covered services). Cost shifting is likely to delay care seeking, increase financial hardship and unmet need, exacerbate inequalities in access to care, lower equity in financing and make the health system less transparent. It can also promote inefficiencies – for example, by skewing resources away from need or encouraging people to use resource-intensive emergency services instead of cost-effective primary care. As a result, coverage restrictions may provide a degree of short-term fiscal relief but could add to health system costs in the longer term.
47. Policies to extent entitlement to vulnerable groups were necessary. These actions were initially limited, slow and ineffective. Only since June 2014, uninsured people are covered for prescribed pharmaceuticals and for non-emergency hospital care
48. User charges increased in almost any function of care: drugs, tests, consultations, inpatient care
49. Copayment for prescription drugs raised from 12% to 29% in 2 years
50. The increased user charges undermine performance, as they have little selective effect, and deter people from appropriate care and especially preventive care. It also leads to cost increasing substitution
51. Pharmaceutical spending was confronted with a new pricing policy, e-prescribing, positive list, guidelines, budget for doctor, etc. As a result Greece is not any more an eager and early adopter of novel pharmaceuticals,
52. And the spending for drugs dropped From the high of 5,4 billions euros in 2009 to 2,1 billions in 2014
53. If we want to absorb further savings without damaging front line services, the only way is to perform Structural reforms with a focus in primary Care. Crisis poses a unique opportunity to implement the reform, that we are planning again and again since 1980, but never managed to succeed, as there was never enough political will to confront the reactions of many interest groups. It’s primary care now more than ever!
54. If we want to strengthen PC, we have to increase its funding, reform the payment methods, shift the care out of hospitals, improve the access and change the skill mix
55. Individualizing these recommendations for Greece, there must be a clear vision of PC with GPs as core profession, the access must be with the lowest cost, stepped access with mandatory referrals, personal list of patients for each GP, freedom of choice in the selection of the GP, community orientation
56. Funding matched to the needs of the population, payment of GP by a mix of capitation, fee for service and pay4p, Reimbursement of GPs in line with their role, development of guidelines
57. Development Of quality indicators, as a part of quality improvement cycles, Well developed medical records facilitating continuity of care, monitoring and evaluation
58. Clear job description of GPs that defines their educational and training needs. Short training to obtain the core competencies
59. One year ago, greece launhed a new phc law
60. That establish the development of a unified Primary Health Care Network and the Implementation of the Family Physician. Since then the MoH works on the necessary ministerial decisionsaccording to the reccomendations to activate the law
61. The full scale of the effects of the crisis in health may not be apparent for years, especially those due to suboptimal management of chronic diseases. Unemployment and financial insecurity are associated with Mental health problems. There has been an increase in deaths from suicides and limited evidence of a decrease in general health status and increases in HIV and malaria
62. Deaths from suicides in Greece increased from 328 in 2007 to 508 in 2012, a 50% increase. We have to monitor the numbers, to see if this is an established trend out of the yearly variability. Nonetheless, the suicide rate in Greece still remains the lowest in europe .
63. You all know that we have a new government in greece. Will this endanger the PHC reform?