Quality in Primary Care Open Access

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The impact of pay-for-performance on the workload of family practices in Estonia

Ruth Kalda, Eero Merilind, Katrin V?stra, Rauno Salupere, Anastassia Kolde

Background The quality system in Estonia is a payfor- performance scheme, rewarding family doctors for the quality of care they provide. This study examines the impact of the quality system on the workload of family doctors in Estonia. Aim The aim of this study was to explore differences in the workload of family doctors participating in the clinical quality system and those not participating. Methods The study was conducted using a database from the Estonian Health Insurance Fund, which consists of health-related data for 96% of the Estonian population. The study compared the workload of Estonian family physicians in two groups: those participating in the quality system and those not. Results During the observation period 2005–2011, the proportion of family doctors participating in the clinical quality system increased from 48.2% to 69.2%. The total number of visits in primary care increased also and there was a difference in workload between the two groups. Doctors participating in the quality system performed more primary (initial) and secondary (follow-up) visits. The number of visits per doctor was also higher for those participating in the quality system. There was a shift to visits carried out by nurses, which showed an increased workload for nurses in the quality system during the observation period compared with a stable workload for those outside the system. The number of home visits decreased in both groups. Conclusion Pay-for-performance had a notable impact on the workload of the primary care team and its members. Paying more attention to detecting chronic diseases in their early stages, recalling patients for general health check-ups and immunizing children may have an effect on health status, but also requires increased staff levels.