Primary care may be the magic bullet for healthcare

The US healthcare system can learn from the Danish primary care physician model - How to improve quality of care while controlling costs

By Frede Olesen and Stig Albinus

As healthcare systems internationally struggle with escalating costs due to the rising burden of aging populations and people with multiple chronic diseases, there is a lively debate about ways to address the crisis of healthcare. Some believe that advancing access to universal healthcare is the way forward, others argue for disruptive models where digital technology enables more connected, patient-centric healthcare, while others believe that employers should have a stronger role in healthcare. While several of such ideas may be part of a solution, they don’t address the underlying cause of the ailing healthcare systems.

We believe that the fundamental problems in healthcare systems are derived from their structural weakness caused by the fragmentation of health care delivery, the lack of seamless integrated patient care across social care and healthcare sectors and the predominant focus on late stage disease. According to a recent study, about half of all medical care received by Americans is being delivered by emergency care departments, which is shocking evidence of the healthcare delivery system lacking efficient primary care services that can keep patients with non-emergency conditions out of hospital.

To meet the needs of both patients and society, these challenges should be addressed. First, from a patient perspective we need person-centered care with the ability to create a trusted relationship between patient and doctor through best possible continuity of care and with the ability to handle the total disease burden (multimorbidity) in a comprehensive integrated way without fragmentation of care. Next, from a societal perspective we need to develop a sustainable, cost effective, affordable high-quality care system with a strong and balanced focus on the total disease trajectory from prevention of disease, through early diagnosis and treatment to rehabilitation after episodes of disease.

The pivotal role of primary care gatekeeping

Health services research from recent years emphasize the need for a strong primary care as a tool to meet these challenges. It has been shown that high continuity of care is important to ensure quality and that good continuity is associated with lower overall mortality. It has also been demonstrated that gatekeeping performed by GPs is associated with lower use of healthcare services and expenditure, and better quality of care.

Therefore, we believe that the healthcare model needs to be turned upside down. 

We need to reshape the healthcare system towards preventative, primary care, addressing early disease development and shift from a sick-care to a true health-care system.

New CMS model for elevating primary care

The potentially powerful role of the primary care physician is often overlooked. But lately there is an emerging discussion in the United States about the importance of elevating the role of the primary care physician.

The U.S. Center for Medicare and Medicaid Services (CMS) recently announced its Primary Care First Initiative a new model to incentivize primary care physicians to reduce hospitalizations and cost of care by rewarding them through performance-based payments. Primary Cares First, which will launch as a pilot program on January 1, 2020, is a voluntary, risk-based initiative to transform primary care to a value-based system that rewards physicians who keep patients healthy and out of hospital.

Health and Human Services Secretary Alex Azar has stated that the CMS Primary Cares will reduce administrative burdens and empower primary care providers to spend more time caring for Medicare and Medicaid patients while reducing overall healthcare costs. It has been estimated that doctors who earn $200,000 annually could earn up to $300,000 if their patients stay healthy.

The CMS initiative has been well-received by key U.S. stakeholders, for example the American Medical, the American Academy of Family Physicians and the American Hospital Association. Atul Gawande, CEO of the Amazon-J.P. Morgan-Berkshire Hathaway joint venture now called Haven, has also expressed his support.

What we can learn from the Danish primary care medicine model

The Danish way of organizing health care with a strong focus on primary practice may be the magic bullet to address the challenges of healthcare while still obtaining high quality care, affordable cost and universal health coverage. The aim of the following is to describe this system as this approach to care organization or parts of it may show a way forward in the United States.

Denmark is a small country in Northern Europe with 5.8 mill inhabitants, universal health coverage and with free access at point of care due to a national health insurance paid as a part of the general taxation. National health insurance also pays for preventive health care for children and maternity care including needed vaccinations. Denmark uses around 10.5 % of GDP on health. In the US, the percentage of GDP spent on healthcare is about 18%. Some 86 % of a Danish citizen’s total health costs are covered by public insurance (close to European average of 82 standard), while some prescriptions, parts of dental service and most physiotherapy are paid by patients and sometimes by patients private health insurance if they have chosen to have one in addition to the mandatory general insurance.

Despite a growing number of patients with life-style provoked chronic diseases and multimorbidity, Denmark has an overall increase in life expectancy and a life expectancy 81 years at birth, a little below EU average due to a relatively high number of smokers (compared to the US at almost 79 years). Standard immunizations for children are free and the coverage rate is high – typically more than 80%.

The total number of doctors are high and rated as number four in developed countries. Around 20 % of all doctors are general practitioners (GPs) – the latter figure has been quite stable in recent years.

Three levels of organization

Danish health care is organized at three levels. The parliament and government set the general professional and economic frames, and quality standards are set and supervised by The National Board of Health. Five regions run the hospitals – around 25 hospitals in Denmark – and manage the contract with family physicians while 98 municipalities take care of rehabilitation, home care nurses and nursing homes for elderly as well as general health promotion and population-focused primary prevention. Regions and municipalities are paid a fixed annual budget after yearly negotiations with the national health insurance.

GPs have a contract with the national health insurance

Four principles have been essential in the development in Denmark. First, the GPs who have a contract with the health insurance should be spread all over the country to ensure access to health coverage for all. Next, the postgraduate training to become a licensed GP should be around the same length as to become other types of medical specialists. Third, it has been a tradition, which also has guided the negotiations with the medical association, that the annual income for an average GP and an average specialist should be nearly the same. Finally, GPs act as gate keepers to the rest of the health care system and therefore act as the chief coordinator of a patients care and disease trajectory.

The number of GPs who can have a contract with the regional health service are political decided based on national negotiations with the doctors’ association. There is one GP per around 1,600 citizens. Patients are to have at least one GP setting within a distance of 15 km. Most GPs now work in partnership practices – often 2-5 doctors in a partnership.

GPs with a contract with the regional health care are paid by the region in a mixed fee for service per encounter (around 70% - including payment for special procedures) and capitation (30%). Thus, a GP is an independent contractor with a contract with the regional health insurance authority. GPs employ their staff, own or rent their premises and have the total economic responsibility for their small business even if more than 90% of their annual income comes from the region. There is close to none GPs working on total private basis without a contract with the health insurance.

Citizens choose their own practice setting, a so-called list-based system where patients chose their preferred practice and sign on to the practice’s patient list. The 3,400 GPs work in around 1,900 practices spread over the country, and as stated thereby ensuring easy access and around 1,600 patients per practice. Typically, a patient stays on the same list for years unless he or she moves to another region, which enables a high degree of continuity of care.

The GP as gatekeeper

As mentioned above, the Danish GPs act as gate-keepers for their patients, providing the general preventative care, coordinating referrals to specialist and hospital care as well as the follow-up after specialist procedures and care. This gate-keeper, or even better, gate-advisor role, helps ensure that patients are offered early, preventative care before disease escalates, and that patients are guided to the most appropriate healthcare services when they need them.

Some have expressed concerns that the gatekeeper role of the GP limits patients’ freedom to choose the services they want. In Denmark, patients are actually free to choose between two groups of health insurance: Group 1 and Group 2. In Group 1, all access to GPs is free of any co-pay, but people must sign on a GP list and accept the GP as gate-keeper. In Group 2, patients are free to choose a GP setting for each contact without being on a list but with a modest co-payment and with free access to specialists outside hospital where there also is copayment. The fact that nearly all citizens (more than 95%) now use Group 1 is evidence of the great satisfaction with being on a GPs list and having free access with no co-payment.

University and postgraduate education and income

Access to university education in Denmark is free of cost to the student. There is a limited number of yearly medical students, and the number of new students is determined by the government and The National Board of Health. Students are allowed access to university based on their high school grades. As stated, GPs in Denmark have a mandatory 5 year postgraduate training to become a certified family physician enabling them to have a contract with the health insurance if there is an open position. National statistics have shown only small differences in income between hospital specialists and GPs, but there may be some variations when GPs compare their income among each other.

Quality of care and care coordination and medical insurance

From a quality point of view, a comprehensive set of guidelines ensure the national standard and quality.

To ensure a seamless care with best possible use of equipment and investigations, hospitals and private specialists have to send discharge information to a patient’s GP during a treatment session and at the end of the episode of care, which enables the GP to be coordinator of care.

To strengthen the quality of care, GPs have incentives in their contracts to ensure formal postgraduate courses each year, and most GPs now collaborate on postgraduate training where they organize themselves in quality clusters of 20-30 doctors. In these clusters, the doctors discuss implementation of, for instance, national guidelines for the management of different chronic diseases and they work on quality improvement based on data provided by the health insurance and pharmacy databases with the goal of reducing unnecessary practice variations. These initiatives are also economically incentivized by the regions.

In the last few years, hospitals have been asked as part of their contracts with the regions, to extend their investigation and information services to primary care, thereby stimulating the dialogue between hospitals and primary care. This initiative has helped improve the connection between primary care and larger, specialized hospitals that in the recent past have been focused less on primary care and population health due to their growing specialization.

Most GPs also have a close collaboration with district nurses and the municipalities to ensure connectivity and seamless health and social care, in particular for elderly and frail patient populations.

On a regional and a national basis, patients can complain about perceived lack of quality and these complains are judged by different consensus boards, which also may give patients economic compensation in case of medical errors. This system has ensured that it is very rare that a complaint reaches the formal legal system and the court. For the same reason, costs to medical insurances have been kept low and contributing to low total cost of health care.

A new proposed Danish healthcare reform

Denmark is on its way to further enhance the role of the primary care physician as part of the new healthcare reform. An agreement for a reform that was made on March 26, 2019, between the conservative government and its coalition parties. The proposed reform, which is called “A Stronger Healthcare System – Close to You” stipulates several new steps that are designed to improve the primary care services, and advance more connected, preventative care services for the Danish population.

The upcoming parliamentary election in Denmark on June 5 may lead to changes in some elements of the reform, but it is likely that a healthcare reform will take place and will follow many of the principles suggested in the current agreement.

A key element in the proposed reform is to further elevate the role of the primary care physician as a cornerstone in the Danish healthcare system. Some of the key initiatives include: 100 more physicians and 160 additional primary care trainees will be added each year in 2019 and 2020. Key aspects of care for patients with chronic diseases will also be moved from the acute hospital care setting to the primary care sector for diseases, such as, COPD, type 2 diabetes, cardiovascular disease, musculoskeletal disease and light-to-moderate mental health conditions. Furthermore, primary care physicians will have greater responsibility for vulnerable patients after discharge from hospital. In addition, home visits by doctors to patients will be a higher priority. Finally, primary care practices will focus more on ensuring the quality of patient care. In the future, all practicing physicians will be part of so-called quality clusters that will work on reducing clinical variations and ensuring consistent quality of care based on documented clinical quality measures. The clusters will meet regularly to work on the quality of care in their own practices as well as collaboration with other sectors in the healthcare system.

What US healthcare can learn from the Danish primary care model

The Danish primary care model should be a great source of inspiration for the US healthcare system, as well as other international health systems, that need change. Despite differences in the funding of healthcare – private, public or a mix – there are some valuable learnings that should be considered across all systems:

• Primary care is essential to ensuring population health along all stages of the patient care journey, avoiding unnecessary hospitalizations of patients and offering services to more vulnerable patient groups.
• With growing aging and multi-morbid patient populations, hospitals will not be able to carry the burden of care in the future, and many chronic conditions, such as type 2-diabetes, COPD, chronic heart failure, etc., will be managed better and more efficiently in primary care outside of the hospital.  
• Making physicians employees often take away their motivation and incentives to engage in their practice. Other models for better connecting primary care services with secondary hospital services should be pursued while maintaining the independent nature of physician practices.
• Primary care physicians should be given more responsibilities, resources and financial incentives to play the important role of coordinators of care for patients.

We are only at the beginning of an important transformation from a healthcare model focused on sick-care in the secondary hospital setting to a preventative, primary healthcare model. Sharing knowledge and evidence from new models of care, including from Denmark and CMS, will help drive successful transformation.

About the authors:

Frede Olesen, Professor, The Research Unit for General Practice, Aarhus University, Denmark [email protected]>

Stig Albinus, Senior Director, Global Healthcare Practice, APCO Worldwide, New York, U.S.A. [email protected]