Abstract

Background. Many countries use payment for performance (P4P) in primary health care to improve quality. In 2006 Estonia launched P4P for family doctors (FD). The P4P is aimed at forcing FDs to pay more attention to the prevention and monitooring of chronic diseases.

The Estonian P4P for FDs consists of three major parts: prevention, monitoring of patients with chronic diseases according to the national guidelines and professional competence.

The FDs fulfilling all these criteria are entitled to extra payment.

Aim. The aim of the article was to present the results of two studies conducted to find out the impact of P4P on the number of FD and specialist visits and on the number of hospital bed days.

Methods. In the first retrospective study we used the data of the Estonian Health Insurance Fund for all working FDs (n = 797, 2005; n = 801, 2011) 2006–2011. The FDs were divided into two groups:those joining P4P and those not joining P4P. We compared the workload of the FDs and family nurses in these two groups. In the second longitudinal study we divided all working FDs (n = 803) into two groups based on the results in P4P (“good” and “poor” outcome) and formed a sample. We selected from 80 FDs (10%), 40 with “good” outcome and 40 with “poor” outcome plus their patients (n = 26327; n = 19865) and analysed the FDs` patients with two chronic diseases in both groups: hypertension (HT) and type 2 diabetes (DIAB2) during one calendar year (2014) to find out the impact of P4P on the number of FD and specialist visits and on the number of hospital bed days.

Results. The FDs who had joined P4P had more primary and secondary visits and a higher number of visits to family nurses compared to the FDs who had not joined P4P. In both groups the number of home visits decreased. The P4P had an impact on the number of specialist visits and on the number of hospital bed days. Comparison of the number of visits to the FDs with “poor” and “good” outcome revealed a significant difference in the average number of visits for patients with HT (6.71 and 8.18, respectively; p < 0.01) and for patients with DIAB2 (7.73 and 9.52, respectively; p < 0.01). The number of specialist consultations was (4.64 and 4.54 (p < 0.01)) for HT and (5.65 and 5.91 (p = 0.68)) for DIAB2 and the average number of hospital days was (2.30 and 2.13 (p < 0.01)) for HT and (3.35 and 3.04 (p < 0.05)) for DIAB2.

Conclusions. The P4P has a substantial impact on the workload of the primary care team and their members. The number of visits increased for both doctors and nurses while the number of visits to the nurses increased more. The P4P system increased the number of visits to FDs as well as to specialists. Although the number hospital bed days was reduced in some cases, we failed to see a clear effect of P4P on better outcomes for health care.