Background
A market-oriented health care system was introduced in 2006 together with a new system of basic health insurance replacing the previous distinction between private and public insurance. Adult citizens are obliged to choose a health insurance, for which they pay around € 1100,- per year (with only slight differences between insurers) plus additional taxation guaranteeing basic health care coverage and free access to the GP, but excluding € 350,- co-payment for specialist care (children’s healthcare is free). It amounts to an average family spending € 11.000,- or around 23 % of its income on healthcare. Insurers got purchasing power and the government withdrew from healthcare, but set strict regulations for insurers and providers. Regulated competition between healthcare providers and between health insurers was introduced for specialist care, but General Practice was exempted from this competition. General Practice income has increased since 2006 and GPs invested in premises, staff and infrastructure, including ICT and communication equipment. Their personal income increased as well. Along with the change to market-oriented financing the total budget for GP-care rose from € 1.922 in 2006 to 2.372 million in 2010, an increase of 14 %. In 2011 all insurers invested another 10 %. Before 2006 the macro budget for GP care had been constant. Until 2006 GPs received capitation payments for their public patients (2/3), and fees per consultation for their private patients (1/3). From January 2006, GPs are being paid according to a uniform, mixed payment scheme. GPs receive a partial capitation for each patient per year plus fees per consultation for basic day care. They receive ancillary payments (mainly on a fee-for-service basis) for additional or special therapeutic and diagnostic services and for the care for chronic diseases. They are compensated on an hourly basis for care during out-of-office-hours (evening, night and weekend care). The income of self-employed Dutch GPs was ± € 96.000 in 2005 and of GPs employed by other GPs € ± 73.000. |
- GPs started to be organized in large care groups contracting chronic care in disease management programs. From 2006 onwards the availability of a nurse practitioner for chronic disease management rose from a few percent to over 90 % (treating chronic diseases: Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Cardiovascular Disease, Mental Care), accounting for part of the rise in practice income. Between 2007 and 2012 practice nurses’ time rose from 5.5 to 11.0 h per 1000 patients per week. - Broadening the diagnostic and therapeutic scope of the practice followed the selective incentives for extra services (± € 50 per service for minor surgery, spirometry, EKG, Cyriax injection, etc.). - Primary care practices became larger with more GPs working in one center. The number of single handed practices dropped between 2006 and 2012 from 46 % to 39 %. The number of GPs rose slightly from 8612 in 2006 to 8879 in 2012 (3 %) and patients per fte GP decreased slightly. Self-reported GP-time rose from 21 to 28 h per 1000 patients per week. - In 2008, the Dutch Association of Family Medicine (LHV) accepted new guidelines on availability and accessibility. Insurers offered € 4,- for each patient when the guidelines were met. Practices should minimally be open 6 h a day, 5 days a week and address emergency calls by a medically trained person within 30 s. The GP had to visit the emergency patients within 15 min. It was incentivized but also checked by the Dutch Inspection of Health Care and subsequent failure to meet the standard was financially penalized (in practices of > 2500 patients over € 10.000, - could be missed). Only 3 practices finally did not meet the target. (personal communication L. Rijkers, LHV) - A 5 year extensive project to renew the FM-training including training the trainers was completed in 2006 with a focus on assessing and improving consultation skills. The vocational training program of GPs involved ± 1600 trainers and ± 3000 trainees. Nearly half of the GP-population thus got extra education in communication and in treating according to clinical guidelines in a new curriculum of 8 days every year. |
Method
Study design and setting
Participants
Measures
Practice characteristics | Study population, percentage | National Average b
| ||||||
---|---|---|---|---|---|---|---|---|
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | Total | ||
Practice type | ||||||||
Single handed | 26.5 % | 23.2 % | 29.9 % | 31.7 % | 27.2 % | 12.5 % | 24.3 % | 39.5 % |
Duo or group | 73.5 % | 76.8 % | 70.1 % | 68.3 % | 72.8 % | 87.5 % | 75.7 % | 60.5 % |
Urbanization degree | ||||||||
- High urbanisation
d
| 45.5 % | 42.5 % | 43.8 % | 42.3 % | 44.6 % | - | 44.2 % | 47.7 % |
- Moderate urbanisation
d
| 44.0 % | 37.2 % | 43.2 % | 46.3 % | 42.7 % | - | 43.1 % | 40.7 % |
- Rural
d
| 10.5 % | 20.3 % | 13.0 % | 11.4 % | 12.7 % | - | 12.7 % | 11.6 % |
Mean N of pats/ practice | 4228 | 4882 | 4699 | 4545 | 4714 | 5171 | 4767 | 4055 a
|
Training practice | 52.2 % | 42.5 % | 48.4 % | 69.7 % | 66.5 % | 53.9 % | 57.5 % | 33 % c
|
Number of practices | 323 | 323 | 265 | 237 | 230 | 279 | 1657 | |
Number of GPs | 323 | 323 | 435 | 602 | 540 | 743 | 2966 |
Characteristics of the respondents | Study population, percentage or average (SD) | National average a
| ||||||
---|---|---|---|---|---|---|---|---|
2007 | 2008 | 2009 | 2010 | 2011 | 2012 | Total | ||
n | - | - | 8506 | 17,661 | 15,695 | 15,079 | 56.941 | |
Age | - | - | 51 (16) | 51 (17) | 52 (17) | 52 (17) | 52 (17) | 39 |
Percentage women | - | - | 65.5 % | 64.8 % | 64.5 % | 64.4 % | 64.6 % | 50.5 % |
Percentage w. chronic illness | - | - | 24.1 % | 23.8 % | 24.6 % | 24.7 % | 24.4 % | 31.8 % |
Consultation rate | - | - | 4.3 (4.1) | 4.4 (4.3) | 4.3 (4.0) | 4.3 (4.4) | 4.4 (4.3) | 4.2 b
|
Analysis
Results
Study population
General trend in patient experiences
GP-score
What is your opinion of the GP and/or general practice over the last 12 months with respect to: | ||||
---|---|---|---|---|
Aspect/item | Score in 2009 % | bèta |
p
| |
Composite GP score, n = 2713 GPs for each item
|
84.8
| .096
| .0000
| |
1 | making you feel you had time during consultations? | 87.6 | .085 | .0001 |
2 | interest in your personal situation? | 83.3 | .060 | .0078 |
3 | making it easy for you to tell him or her about your problems? | 87.5 | .080 | .0004 |
4 | involving you in decisions about your medical care? | 84.9 | .081 | .0003 |
5 | listening to you | 91.4 | .067 | .0029 |
6 | keeping your records and data confidential? | 93.3 | .078 | .0005 |
7 | quick relief of your symptoms | 76.5 | .069 | .0020 |
8 | helping you to feel well so that you can perform your normal daily activities? | 81.0 | .107 | .0001 |
9 | thoroughness | 85.9 | .105 | .0001 |
10 | physical examination of you? | 87.6 | .078 | .0005 |
11 | offering you services for preventing diseases? | 79.3 | .054 | .0127 |
12 | explaining the purpose of tests & treatments (screening, health checks? | 87.0 | .082 | .0003 |
13 | telling you what you wanted to know about your symptoms and/or illness? | 87.7 | .081 | .0003 |
14 | helping you deal with emotional problems related to your health status? | 80.0 | .058 | .0098 |
15 | helping you understand the importance of following his or her advice? | 83.5 | .061 | .0063 |
16 | knowing what he or she had done or told you during contacts? | 81.0 | .076 | .0007 |
17 | preparing you for what to expect from specialist or hospital care? | 75.6 | .142 | .0001 |
Composite practice score, n = 1527 practices for each item
|
67.8
| .097
| .0039
| |
18 | the helpfulness of the staff (other than doctor) to you? | 82.7 | .106 | .0025 |
19 | getting an appointment to suit you? | 74.6 | .079 | .0206 |
20 | getting through to the practice on the telephone? | 61.0 | .081 | .0220 |
21 | being able to talk to the general practitioner on the telephone? | 58.6 | .041 | .2403 |
22 | Waiting time in the waiting room? | 48.3 | .062 | .0670 |
23 | Providing quick services for urgent health problems? | 81.8 | .114 | .0010 |
Practice score
Factors associated with patient experiences
Variable | GP Performance | Practice Performance | ||
---|---|---|---|---|
bèta |
p
| bèta |
p
| |
Visitation year | .096 | .0001 | .097 | .004 |
Mean age of the GP | .204 | .0001 | .250 | .0001 |
%female patients | .018 | .443 | −.056 | .098 |
% Patients with chronic illness | −.066 | .007 | −.117 | .001 |
Mean practice consult frequency | .181 | .0001 | .103 | .003 |
Single handed vs other practice | .035 | .111 | .269 | .0001 |
R2 = .078 | R2 = .170 |