Creating an Integrated Health Care System in Greece - Springer Link

P1: IZO Journal of Medical Systems [joms]

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Style file version June 5th, 2002

C 2004) Journal of Medical Systems, Vol. 28, No. 6, December 2004 (

Creating an Integrated Health Care System in Greece: A Primary Care Perspective K. Souliotis1,3 and C. Lionis2

Over the past few years Greece has undergone several endeavors, aimed at modernizing and improving the national health care services. A Health Care Reform Act seeking quality improvement and coordination of outpatient and hospital services at the Regional level, through the enhancement of primary care, has been recently approved. This paper reports a proposal for integrated health system in the primary care system in Greece with a major focus on equity, quality, and outcomes. The equity and quality framework of this proposal will possess the main components focusing on the provision of essential services, clinical, and organizational standards. KEY WORDS: health policy; primary health care; integrated health care; personal doctor; Greece.

INTRODUCTION Over the last few years, Greece has undergone several endeavors to modernize and improve national health services. A Health Care Reform seeking quality improvement and coordination of outpatient and hospital services at the regional level, through the enhancement of Primary Care (PC), has been recently approved.(1) This latest Health Act strives to improve the quality of care throughout the implementation of Regional Health Systems (RHS). Although several endeavors were made to develop an effective PC in Greece, there are still many concerns and it remains a question whether the new Health Care Reform could possibly develop a unified framework accountable continually by all citizens in the near future. The Greek Minister of Health and Welfare addressed an invitation to a small group of experts and academics with the main task of the committee being to review the situation and suggest effective changes in the current system. In the framework of this Committee, the two authors made a proposal, and part of this proposal was initially published in a Greek medical journal.(2) 1 Ministry

of Health and Welfare, National School of Public Health, Athens, Greece. of Crete, The Regional Health and Welfare System of Crete, Greece. 3 To whom correspondence should be addressed at 5, 28th October Street, 124 61, Haidari, Athens, Greece; e-mail: [email protected]. 2 University

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The present report outlines briefly the existing PHC situation in Greece and its funding framework, with the aim to illustrate to an international readership not only strengths and weaknesses, but to outline a theoretical model of an integrated health system based on strategic alliances while attempting to develop an inexpensive proposal in improving the PC quality, and develop services with an explicit accountability to meeting the health needs of their local communities. Primary Care in Greece: Infrastructure and Services As far as public infrastructure is concerned, production and distribution of care are accomplished primarily via a “network” consisting of approximately 200 National Health Service (NHS) health centers that are serving semiurban and rural areas, and approximately 250 Social Security Institution (SSI) polyclinics mostly in urban areas. PC centers in rural areas are accountable for curative and preventive services for all people living in their catchment areas and they serve their visitors in both, health care center, a central station, that is staffed by GPs and internists, nurses, and lab assistants, and other health and administrative personnel, and satellite practice staffed by one physician, usually a GP. The SSI is the largest insurance organization in Greece and represents approximately 55% of the insured population. It is considered that this informal “network” in most cases enjoys a rational planning distribution, good density of medical personnel, and satisfactory technological level. The PC units of the SSI, cover the insured population of the SSI for primary medical care and diagnostic services. They are staffed with about 7500 doctors of almost all specialties, 4000 nurses, and other health care personnel. Most of the doctors are part-time salaried employees, who simultaneously maintain their private practices.(3) That sector portion of the insured population belonging to the insurance funds without their own health services is covered by way of contracts with private schemes and private physicians, but without ensuring the adequacy and the quality of services, while insufficient provisions for prevention and health promotion and for posthospitalization care. Of course these conditions are also noted in the realm of public providers. This gap in state production of PC services is due not only to a lack of funds as to their limited temporal availability to the public. This fact together with the possibility of public funding by way of contracts with the various insurance funds resulted in pronounced investment activity by the private sector in outpatient care through the establishment of private diagnostic centers, now numbering over 400 throughout Greece.(4) Primary Care in Greece: The Existing Funding Framework The funding framework governing the functioning of the health sector in Greece over the last years has been characterized by a continual increase in health expenditure. Recent research, show that total health expenditure in Greece reached 9.1% of GDP in 2000, of which 42% was private spending.(5) Indeed, given the limited acceptance by the public insurance coverage through private health schemes, the


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greatest share of funding is related to out of pocket payments that burden personal and family income.(4,5) According to recent estimates the average amount spent by households in Greece on a yearly basis for PHC services, whether supplementary or in addition to their insurance coverage, is 2.45 million euros, or approximately 28% of the total (public and private) expenditures for health.(5) The above factors exist as part of the wider environment in which funding by social insurance has been limited over the last years, resulting in that it is now considered to be inadequate to completely cover the population’s needs. In addition, the ability of the state budget to subsidize reform endeavors in the health sector is considered to be limited. Also, the continuation—or the result—of recent years’ policies which were fashioned in the environment of the fiscal limitations imposed by the country’s efforts at joining the Economic and Monetary Union.

Primary Care in Greece: Some Achievements and Concerns Regarding the provision of PC in Greece the current situation has been analyzed in a number of reports that have brought attention to the factors that define it negatively. These include, inter alia:(6−8) • The exclusive involvement of General/Family Physicians (G/F) and primarycare physicians in curative activities and their absorption in dispensing of prescriptions • The failure of these practitioners to use clinical guidelines and other standards for best practice • Their small contribution to providing home care • The lack of experience from community based programs and interventions aimed at diseases’ prevention and health promotion • Their failure to diagnose mental disorders and other illnesses On the other hand it appears that the GPs and PC physicians are capable in managing effectively some clinical and health-related conditions and specifically: (a) Use suitable instruments in assessing for diagnosing dementia(9,10) and depression,(9) and making early diagnosis of treatable conditions and diseases (b) Assess the vaccination coverage of schoolchildren and high-risk individuals, and administrate these vaccinations(11,12) (c) Follow practical guidelines for diagnosing bronchial asthma and hepatitis C,(13) and effectively use these guidelines in the therapeutic management of their patients (d) Carry screening programs for specific chronic diseases and follow-up highrisk groups (e) Manage emergency cases and deal effectively with most of these.(14) Several suggestions for the further development of General/Family Medicine and PC in Greece have been recently outlined.


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A Debate for a Unified Primary Care System The discussion about an intergrated PC system is not new, but currently an important debate has evolved, with a focus on the quality improvement of PC services. SSI’s existing structures in urban centers, which in many political and scientific approaches are treated negatively regarding reform endeavors, could be the foundation upon which to construct a new PC system. In line with this reasoning proposals were presented for the development of an administratively and organically unified system for providing PC, with the basic precondition that the SSI structures relinquish their autonomy and become part of the National Health System. This proposal is supplemented by indication of the need to create a unified funding base as the prerequisite for the reasonable utilization of available funds. The first criticism to be made of the above positions is that the subordination—at least in the first phase—of SSI’s structures to the NHS, may create problems ranging from the establishment of ownership framework and use of production means, to the regulation of physicians’ employment status, in addition, the administrative cost of the transition is expected to be high. Beyond this, it is extremely uncertain whether such a primarily administrative intervention in the system will produce tangible results in terms of adequacy and quality of services that could be perceived by the users in the short term. As far as pooling of resources under one administrative entity is concerned, the effectiveness of the intervention as outlined using the rationale of high degree of representation and creation of surpluses in negotiations with producers, is controlled given that entities such as SSI already have a high degree of representation, which within the existing institutional framework (pre-established prices and products) does not allow for contractual grounds as a foundation for negotiation. As a continuation of the above speculations, it is noted that the final form of any reform proposal is called upon to answer the following questions:

• Is it possible to apply an integrated system for PC? • What is the number of general practitioners and other primary care physicians required to serve the needs of such a system, and what is the timeframe required to produce this number? • Is it possible to develop a legislative base based on the personal physician, and what is the adequate package of services to be provided to the insured population and individuals it is obliged to cover? • To what extent an ideological and domain consensus is required before any intervention?

The above issues require investigation and clarification before any intervention is attempted. At the center of speculation is the question of how much the prospect of administrative reorganization is the only path for PC health reform in Greece, and to what degree it can be guaranteed that the quality of care offered will be better “the day after.”


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CREATING AN INTEGRATED HEALTH SYSTEM IN THE GREEK PRIMARY CARE The basic presupposition in the proposal creation of an integrated health system in PHC in Greece is that the State is required to be the guarantor of an adequate package of health services, while also ensuring their continuation in terms of follow-up. On the other hand, this choice has an ideological and technical foundation regarding administrative intervention that is the unification goal of health services, beyond the fact that it meets political, social, and economic obstacles, not offering reason based on the criteria of equity, effectiveness, and efficiency. The system suggested in the context of the present proposal must satisfy the principles set out below:(2,15,16) (a) Continuity of care, allowing for the management of acute and chronic health problems by the same physician or health team across time (b) Integrated and coordinated care that is management of the most common diseases and health problems as well as major risk factors, in the patient’s own social, cultural, and psychological environment, through the intersectional collaboration meeting the patient’s care needs at local level. (c) Patient, and their families, focused care coordinated with appropriate referral and movement of patients through the system. In such a system the role of the personal physician is also considered to be a centralized one. The personal physician must be defined by his duties that are his obligations to provide the adequate health-care package to all of the system’s beneficiaries, including management of the most common diseases in the community, the major risk factors, immunizations, and services involving social care and rehabilitation. This personal physician can preferably be specialized in General/Family Medicine, or failing this, another clinical specialty enabling him to fulfill his duties as previously outlined. Intensive training in the use of clinical protocols and basic skills foreseen by the adequate health care package must be carried out prior to his integration into the system. The time required to complete such an accelerated training program is estimated at one (1) month. Intensive on-the-job training following his employment should also be provided.(17) The referral process is a central point in the system we propose to examine. The personal physician should be the one to assume the responsibility for referring patients to other specialists or other health services. It is proposed that in the first phase bypassing the procedures should not involve patient participation in cost, but rather should be the opportunity to promote the expediency and usefulness of the personal physician as an institution. Another new element of the proposed systems is the introduction of auditing of the personal physician’s clinical effectiveness. Several methods could be used in measuring the personal doctor’s clinical effectiveness mainly through the establishment of a contract with binding provisions concerning the package of care offered (Table I). It is emphasized that without ensuring such a “package” of services that clearly include management of major risk factors and clinical assessment of the health status


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Table I. Package of Services to Be Offered by the Personal Physician to Each User of the System 1. Management of the most common diseases and health problems faced in PC based on the local epidemiological model including Arterial Hypertension, non-insulin-dependent Diabetes, Bronchial Asthma, Chronic Obstructive Pulmonary Disease, Cardiac Insufficiency, Coronary Disease, Degenerative Bone Disease, Osteoporosis, infections common in the community, senility, major depressions. 2. Management of major risk factors such as smoking, lipid disorders, obesity. 3. Vaccination of children and adults. 4. The early diagnosis of specific types of cancer, such as cancers of the breast, cervix, prostate, and colon. 5. Health-status evaluation (including cognitive and emotional disorders) in the elderly and in patients with chronic diseases and disabilities. 6. Developmental follow-up of infants and children, prenatal care. 7. Treatment of minor trauma and injuries, performance of minor surgery, and provision of First Aid, including basic cardiopulmonary resuscitation (CPR). 8. Performance of a minimum number of diagnostic and therapeutic procedures in the clinic. 9. Performance of a minimum number of diagnostic and therapeutic procedures in the patient’s home.

of the system’s users—in cases where documentation exists for effective action and intervention—not only is the concept of complete and total coverage of the population nullified, but in addition estimating the cost of transition becomes exceptionally difficult. Emphasis should also be made of mechanisms that ought to be created by the system in order to support existing knowledge and guide the customary practice of the personal physicians and other health workers in the PC sector, with guidelines and evidence-based information, contributing to the effective and efficient use of resources. Agreements that will serve the needs of health-care personnel, development of electronic and other guides that will govern diagnosis, therapy, and dispensing of prescriptions, availability of on-line support mechanisms, auditing compliance as well as evaluating the effectiveness of these interventions, are among the prime elements that should form part of a total PC system. Reference to the role and function of nursing personnel in the community is essential and must follow European models. We are proposing to assign concrete roles to nurses who will assist personal physicians, and especially in home-care activities. In addition, this functional reorganization of PC in Greece demands a series of supportive interventions, such as: (a) Establishing the required infrastructure for providing the system with the necessary information regarding the evolution of the health-status model of the population and maintenance of medical records (b) Extending the working hours of the facilities and organizing specialties within the framework of coordinated networking among the various facilities as well as in relation to hospital inpatient care (c) Introducing a mixed compensation system (salary and per-capita remuneration) that will be common to all PHC units physicians regardless of specialty (d) Certifying providers of services, in both the public and the private sector


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DISCUSSION Our proposal seems to be coming timely. A health care reform is in progress, the legislative framework seems to be efficient in General Practice/Family Medicine, although they are still seeking recognition within the Greek context. It introduces a new technique for public management, enriching the function of the PC health sector with institutional adjustments, ensuring the clear limits of the various actors’ responsibilities. The advantage of this contractual reasoning lies in the fact that it separates administrative from functional responsibility in the system and in addition is by nature dynamic, which contributes to the ability taking advantage of all existing structures. It is profound that our proposal’s main endeavor is to see a model of integrated delivery systems to be implemented in primary care in Greece. An interest in the concept of integrated or organized delivery system has been seen in USA at the beginning of the last decade,(18,19) with the goal and objective of a coordinated costeffective care to be achieved. Vertical integration in our proposed model implies the coordination in capacities or infrastructure (equipment, supplies, human resources, high technology) and the process of care (clinical protocols, medical audit, assessment of quality assurance) in order to achieve the best care at the personal level. Thus, we expect to provide the Regional Health and Welfare System with a more pluralistic character, enriching the mixture of provided care with services extending beyond the traditional curative approach including services of disease prevention and health promotion, and management of major risk factors. In addition, the central coordination of the system and the central role of the personal physician are expected to restore continuity of care, introducing barriers to the system not based on a rationale of limitation (gate-keeping), but rather on improvement of existing structures and conditions under which health care is provided. Thus, at the implementation level, the proposal resembles the model of Health Maintenance Organizations in the USA, through the “exploitation” and improvement of SSI services in urban centers, taking advantage of private infrastructure and the formation of a functional framework for the health care market based on a complex of contracts and agreements.(20,21) Our approach presents some similarities with the American definition, offered by the Institute of Medicine, defining PHC as “the provision of integrated, accessible health care services, by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”(22) Thus, the Greek proposal meets the integrated dimension of the primary care services provision since it discusses the concepts of comprehensiveness, coordination, and continuity. It also defines the role of personal doctor who will be accountable for addressing a range of health services according to the identified needs, within the community or local level. The terms “personal physician” or “personal care” are not unknown in the relevant literature. Recent publications document the value of the personal relationship between doctor and patient, along with the role of the personal physician, which is considered important in treating most of the health problems for which the


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patient visits the doctor.(23) Such physicians may be effective for patients with minor or acute problems when a quick access is required. Of course this reference concerns the British Health System, a system that emphasizes clinical management, a framework that includes all measures for improving quality of care, as well as improving effectiveness. Our approach is not far from the new definition of General Practice/Family Medicine and core competences of General Practitioners that WONCA Europe has recently advocated.(24) Strengthening of support mechanisms contributes to rational use of resources and improvement of the system’s effectiveness, while indicators’ measure for controlling clinical effectiveness (medical audit) are also expected to contribute to this end. The British experience in PHC change can highlight a series of measures supporting the everyday tasks of General Physicians, especially with the adoption of guidelines but also rapidly available information in newly published documentation. Thus, the National Health System, has established a Centre for Reviews and Dissemination, at the University of York and a recent bulletin of Effectiveness Matters provides a guide on how to search available resources on evidence of clinical effectiveness.(25) An initiative has also been undertaken in Crete, Greece, where the Regional Health and Welfare Authorities in collaboration with the Clinic of Social and Family Medicine have developed a website that provides immediate information regarding practical guidance in the areas of general medical consensus results or systematic review of the literature (www.cgrg.gr). The methods that these authorities are using in order to measure clinical effectiveness in primary care have been recently discussed in an International Conference at Catvat, Croatia.(26) The formation of a flexible compensation system provides additional motivation for increased productivity and controlling the facilities’ “clients”— without, however, voiding the right of free choice—and on the other hand contributes to controlling costs for care since it allows gradual application of global budgets. In conclusion, the choice of functional intervention in the provision of PHC appears to combine the following advantages: i It constitutes a realistic solution applicable in the medium term. ii It utilizes the existing infrastructure and thus avoids wasting resources in order to create new structures or make transition to a new framework (overviewed by the Ministry of Health). In addition, maintaining the funding apparatus and strengthening the viewpoint of the buyer (the insurance funds), ensures the greatest possible social consensus, avoiding upheavals with uncertain outcomes. The same is foreseen in the case of physicians who are already manning the existing structures. iii Ensures improvements in the quality of services by way of procedures that guarantee universal acceptance, whereas in addition it introduces into the system the concept of the personal physician which on the one hand has been the goal of health policy for a number of years, and on the other hand is an additional—after central administration—potential guarantor of the adequacy of provided services. iv It can be a first stage, a precursor of a major administrative innovation in the system—if its advisability is confirmed—which in accordance with the relevant


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proposals foresees development of a unified system in the areas of both funding and provision of services. In conclusion, the proposed approach seems to be suitable for the development of a proper network that will offer a full continuum of care and minimize service duplication.

ACKNOWLEDGMENTS We are grateful to the former Minister of Health and Welfare, Professor Costas Stefanis, for inspiring and encouraging us to bring all these ideas to a paper. REFERENCES 1. Lionis, Ch., and Mercouris, M.-P., Views on today’s situation in primary health care and proposals for its improvement. Prim. Health Care 12:7–9, 2000 (in Greek). 2. Souliotis, K., and Lionis, C., Functional reconstruction for the primary health care : A proposal for the rise of the impassable. Arch. Hellenic Med. 20(5):466–476, 2003 (in Greek). 3. Ministry of Health and Welfare of Greece, Health, Health Care and Welfare in Greece, Athens, Greece, 2003. 4. Souliotis, K., The Role of the Private Sector in the Greek Health Care System, Papazisis, Athens, Greece, 2000 (in Greek). 5. Souliotis, K., Analysis of health expenditure in Greece 1989–2000. Methodological clarifications and discoveries regarding the health care system. In Kyriopoulos, K, and Souliotis, K. (eds.), Health Expenditures in Greece. Methodological Problems in Measurement and Consequencies for Health Policies, Papazisis, Athens, Greece, 2002 (in Greek). 6. Kyriopoulos, J., Georgoussi, E., Andrioti, D., Boerma, W., and Mercouris, M. P., The involvement of General-Medicine physicians in Preventive Medicine. Prim. Health Care 7:21–28, 1995 (in Greek). 7. Georgoussi, E., Andrioti, D., Kyriopoulos, J., Boerma, W., and Mercouris, P. M. The characteristics of General-Medicine physicians’ services in Greece, in comparison with other European countries. Prim. Health Care 4:193–202, 1999 (in Greek). 8. Lionis, Ch., and Kyriopoulos, J., Primary health care and General Medicine: The safety valve for high quality in health care. Prim. Health Care 12:167–168, 2000 (in Greek). 9. Arguriadou, S., Melissaropoulou, H., Krania, E., Karagiannidou, A., Vlachonikolis, J., and Lionis, C., Dementia and depression: Two frequent disorders of the aged in primary health care in Greece. Fam. Pract. 18:87–91, 2001. 10. Lionis, C., Tzagournissakis, M., Iatraki, E., Kozyraki, M., Antonakis, N., and Plaitakis, A., Are primary care physicians able to assess dementia? An estimation of their capacity after a short-term training program in rural Crete. Am. J. Geriatr. Psychiatry 9:3, 2001. 11. Lionis, C., Chatziarsenis, M., Antonakis, N., Gianoulis, Y., and Fioretos, M., Assessment of vaccine coverage of school children in three primary health care areas in rural Crete, Greece. Fam. Pract. 15:443–448, 1998. 12. Chatziarsenis, M., Miyakis, S., Faresjo, ¨ T., Fioretos, M., Vlachonicolis, J., Trell, E., and Lionis, C., Is there room for General Practice in penitentiary institutions: Screening and vaccinating high risk groups against hepatitis. Fam. Pract. 16:366–368, 1999. 13. Lionis, C., Frangoulis, E., Skliros, S., Alexandrakis, G., and Kouroumalis, E., How Greek GPs manage hepatitis C infected patients: Experiences gained from a primary health care district in rural Crete. Aust. J. Fam. Phys. 28:207, 1999. 14. Evrenidou, K., Mylonakis, M., Mittas, E., Vlachonikolis, I., and Lionis, C., Visits to a General Practitioner in a tourist area of Crete during one night. Medicine 78:261–265, 2000 (in Greek). 15. Kyriopoulos, J., Lionis, C., Dimoliatis, G., Mercouris, M. P., Economou, C., Tsakos, G., and Philalithis, A., Primary health care as the foundation of health reform. Prim. Health Care 12:169–188, 2000 (in Greek). 16. Lionis, C., The draft law in primary health care—A challenge in health care reform. Prim. Health Care 14:11–12, 2002 (in Greek).


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17. Lionis, C., and Mercouris, M.-P., General/Family Medicine at the crossroads: Necessary prerequisites for its establishment in Greece. Prim. Health Care 13:8–9, 2001 (in Greek). 18. Anderson, S. T., How healthcare organization can achieve true integration. Health Finance Manage. 52:31–34, 1998. 19. Devers, K. J., Mitchell, J. B., and Erickson, K. L., Implementing organized delivery systems: An integration score card. Health Care Manage. Rev. 19:7–20, 1994. 20. Luft, H. S., Health Maintenance Organizations: Dimensions and Performance, Wiley, New York, 1981. 21. Luft, H. S., Translating the U.S. HMO experience to other health systems. Health Aff. 10:172–186, 1991. 22. Donaldson, M., Yordy, K., and Vanselow, N. (eds.), Institute of Medicine: Defining primary care: An interim report, National Academy Press, Washington, DC, 1994, p. 16. 23. Kearly, K., Freeman, G., and Heatth, A., An exploration of the value of the personal doctor–patient relationship in General Practice. Br. J. Gen. Pract. 51:712–718, 2001. 24. WONCA Europe,The European Definition of General Practice/Family Medicine, WONCA Europe, 2002, (www.medisin.ntnu.no/wonca). 25. NHS Centre for Reviews and Dissemination, the University of York, Assessing the evidence on clinical effectiveness. Effectiveness Matters 5:1–7, 2001 (http://www.york.ac.uk) 26. Lionis, C., Seeking the clinical effectiveness in primary care within the regional health system in Greece. In The Abstract Book, in the 6th International Conference Biotechnology and Public Health, Catvat, Croatia, October 10, 2003.