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Health systems in transition <strong>Latvia</strong> • • practice allowance; indicator scale-dependent allowances for: o number of chronically ill patient visits o density of the population in the catchment area o distance from practice to emergency post o number of children on the register list. Resource allocation for secondary-level ambulatory care and GP fund holding According to government regulations, funding for secondary-level ambulatory care is split in two major parts in terms of planning and allocation. The first part is calculated for each GP practice according to the number of registered patients, amounting to €1 per patient per month, which is a form of fund holding. The second part applies to more costly procedures and is allocated directly to ambulatory care providers (e.g. health centres, outpatient departments, polyclinics, specialist consultants) through contract negotiations. These are based on tariffs for specialist consultant episodes and a procedure tariff list. The target recipients of the GP-controlled funds are secondary-level ambulatory care providers, as mentioned above, to whom patients are directly referred by GPs. The secondary-level ambulatory care providers earn their income according to tariffs of specialist consultant episodes and a procedure tariff list. The tariff list contains predominantly simple and non-costly procedures. Up to the end of 2006, GPs were allowed to keep 75% of the unused funds, after assessment of the GP practice’s operational indicators. This seems to promote inappropriate incentives for GPs with regard to underreferring patients to specialist services (Stuburs 2007 [unpublished data]). Since 2007, GPs are permitted to keep unused money for secondary care only up to a maximum of 30% of the funds for secondary care (GP-controlled fund). If the quarterly unused portion is equal to or less than 30% of the GPcontrolled fund for the quarter, the SCHIA pays out 75% of this remainder to the respective GP. If the quarterly remainder in the fund is above 30%, the SCHIA must make an assessment on whether the low spending on specialist consultations and diagnostic tests is appropriate to the needs of patients. As there is no further detailed methodology within the relevant government regulation regarding what criteria the assessment should include, the SCHIA has considered that GPs’ comparative activity indicators (such as the number of self-performed procedures and very high patient appointment rates) can be the indicators for GPs to qualify for the bonus payments from the fund. 101
Health systems in transition <strong>Latvia</strong> Criteria for GP assessment have become the subject of discussions and arguments between the GPs’ associations and the SCHIA. The associations strongly object to the criteria used by the SCHIA and propose a reconsideration of the mechanism of a GP-controlled fund. The objective behind the present arrangement has been to ensure that GP practices increase their responsibilities and service volume provided, and to promote cost-containment by offering GPs the incentive to keep patients at the primary level. On the other hand, these very incentives may hold a risk of not referring patients when it is clinically sensible to do so. In addition, there is a perceived need to equalize differences in responsibility levels among PHC practices, and the provision of financial incentives would appear to be a mechanism that can help to achieve this objective. Differences persist between GPs in rural and urban areas in terms of the range of services they provide for patients, with GPs in rural areas more often performing small surgical operations, providing pregnancy care and carrying out diagnostic tests, as opposed to referring patients to specialists for these services. Prior to 2005, different approaches to secondary-level ambulatory care provider payment mechanisms had been adopted by Riga City and the rest of the country. In Riga, GPs were not in charge of any funds targeted for ambulatory service provision, and secondary care providers received their allocations directly from the SCHIA; this was known as the “Riga model”. By contrast, in the rest of the country GPs were charged with holding the full capitation fund that was intended for ambulatory service payment, and this fund was proportionately twice as large as it is in the current, nationwide model that has been implemented since 2005; this was known as the “rural model”. In the Riga model, GPs faced the incentive to minimize their workload by referring patients to specialists, as they had no control over capitation funds intended for specialists, with the result that there were significant increases in waiting lists for specialists. By contrast, in the rural model, GPs faced the incentive to minimize referrals so as to retain as much as possible of the capitation fund themselves. The current model, as described above, is a compromise between the Riga and rural models, and is meant to be an improvement on the two previous models, incorporating lessons learned and building on the strengths of each, while at the same time improving the situation for all stakeholders. • The GP-controlled fund for purchase of secondary-level services is currently about half the size of the former one under the rural model, and relates to far fewer and less expensive secondary care services; therefore, the GP does not face as great an incentive to keep patients at the primary care level. 102
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Keywords: DELIVERY OF HEALTH CARE E
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Health systems in transition Denmar
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2. Organizational structure 2.1 Ove
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6. Provision of services 6.1 Public
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9. Conclusions In the early years o
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10. Appendices 10.1 References Apin
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