- Email: [email protected]
Paying for the expanding role of primary care in cancer control
Comment
A series of measures have been undertaken to promote the development of primary care in China. The Chinese Society of General Practice was founded in 1993—a first step towards the recognition of general medical practice in China. The basic framework of the primary care medical education system was constructed in 2000 and a fairly comprehensive general medical education system was in place by 2010 to meet the needs of health reform and of community health services. China’s national medical insurance system, covering the whole country, was established in 2008 and is broadly divided into three types: basic medical insurance for urban employees, basic medical insurance for urban residents, and rural cooperative medical insurance for farmers. Other people who live in rural areas are entitled to the same basic medical insurance as urban employees. To further improve the medical insurance system and reduce the economic burden for people who have serious diseases such as cancer, the catastrophic medical insurance system was set up in 2012 and is now available in more than 90% of cities and counties as of June, 2015. Therefore, patients who have serious diseases can be reimbursed for more than 50% of the additional cost after the original reimbursement. All of these insurance systems are accepted at all levels of hospitals to ensure the referral channels are unimpeded. The Key Tasks of Health Reform in 2015 of the State Council report4 stressed that the Chinese Government would need
to continue to support construction of the community health-service system and enhance the comprehensive ability of community health services. Furthermore, to improve the medical capacity of PCPs, standardised training of junior doctors would need to be fully implemented, and about 50 000 new junior physicians will receive such training in 2015. With an increased emphasis on cancer control services in community hospitals, the diagnosis and treatment of patients should be improved. The key findings of The Lancet Oncology Commission1 provide valuable information to help to improve the health-care system in China. Yuankai Shi National Cancer Center; Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing 100021, China [email protected] I declare no competing interests. 1 2
3 4
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72. Aging Society and the Pension Insurance Development report. 2014. http://www.cnki.net/KCMS/detail/detail.aspx?QueryID=0&CurRec=1&recid =&filename=JJZK2015Z1017&dbname=CJFDLAST2015&dbcode=CJFQ&pr =&urlid=&yx=&v=MjY1MDBGckNVUkwrZmJ1WnRGeXpnVTc3Qkx5ZlJaYkc 0SDlTbXJvOUVZNFI4ZVgxTHV4WVM3RGgxVDNxVHJXTTE= (accessed Feb 23, 2015; in Chinese). Chen W, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer in China, 2011. Chin J Cancer Res 2015; 27: 2–12 The Key Tasks of Health Reform in 2015 of the State Council. April 26, 2015. http://www.gov.cn/zhengce/content/2015-05/09/content_9716. htm (accessed May 5, 2015).
Tek Image/Science Photo Library
Paying for the expanding role of primary care in cancer control
See The Lancet Oncology Commission page 1231
1228
Advances in cancer detection and treatment pose a challenge to traditional cancer services focused on the acute delivery of specialist care. In The Lancet Oncology Commission,1 Greg Rubin and colleagues set out an exhaustive charter for the role of primary care services, and the primary care physician (PCP). The authors suggest 18 action points for a greater role for the PCP from detection to palliation. Effective PCP involvement in cancer care will depend on the identification of appropriate PCP roles and the development of skills, which the Commission does address, and also on the provision of the right financial incentives, which the Commission mentions only briefly. At a fundamental level, how PCPs are paid affects the type and volume of care they provide. Australia, as
in the UK and several other European countries, has a strong primary care system with a gatekeeping role. Unlike the UK, Australian PCPs are funded on a fee-forservice basis, and patients are not registered to specific PCPs or primary care organisations.2 Incentive payments for PCPs have been targeted to specific interventions such as cervical screening.3 But if each specific cancerrelated behaviour outlined in the Commission were to attract its own payment, the funding system would soon become overwhelmingly complex. In general, a reliance on fee-for-service provides an incentive for PCPs to increase the volume of care and to generate revenue, rather than to provide continuity and integration of patient care. This is becoming an increasing challenge with the growing incidence of complex and www.thelancet.com/oncology Vol 16 September 2015
Comment
continuing illnesses that can be treated at a primary care practice.4 This challenge applies to cancer, from the early phases of treatment to the ongoing management of survivors. In Australia, there is now wider consideration of some form of capitation funding for these patients, which would be compatible with the goals of the Commission.5 In the UK, patients are already registered with a primary care organisation with some fund holding; therefore, changing behaviour in PCP care will require different financial changes, perhaps a change in capitation rates to make adjustment for the purchase of cancer-related services. This is a difficult task given the variable upfront population risks associated with cancer and the myriad available treatments, which have variable costs and effectiveness. Since PCPs are uniquely placed to offer ongoing care for patients who would prefer to be cared for outside the specialist setting, one of the burgeoning areas for the involvement of PCPs is survivorship care. This represents a potential challenge for PCPs and funding systems alike. For PCPs, it will involve continual learning about new cancer treatments, their sequelae, and potential effects on survivors. For funding systems, these patients represent a new group requiring care that is not already incorporated in existing capitation rates. Financial incentives will need to recognise remuneration of PCPs for the services they provide to patients directly and also the continual training and education needed to provide these services. Further, as specialists already have the major role in cancer care, moving more care to the PCP
setting will change the balance of services they provide. Therefore, the behaviour and incentives for PCPs cannot be considered in isolation of those for specialists. How physicians are paid is essential to achieving the right mix of activities and desired outcomes. Attaining the goals set by the Commission will require getting the incentives right. Effective financial incentives can be designed only with careful consideration of the system onto which they are being added. At the risk of making more work, we would suggest a 19th action point: review whether the funding of primary and specialist services creates the right incentives. Without this understanding, our capacity to enact the actions promoted by the Commission remains limited. Richard de Abreu Lourenco, *Jane Hall CHERE, University of Technology Sydney, Sydney, NSW 2000, Australia [email protected] We declare no competing interests. 1 2 3 4
5
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72. Hall J. Australian health care—the challenge of reform in a fragmented system. N Engl J Med 2015; 373: 493–97. Greene J. An examination of pay-for-performance in general practice in Australia. Health Serv Res 2013; 48: 1415–32. Wranik D, Durier-Copp M. Framework for the design of physician remuneration methods in primary health care. Soc Work Public Health 2011; 26: 231–59. Primary Health Care Advisory group. Discussion paper: better outcomes for people with chronic and complex health conditions through primary care. August 2015. http://www.health.gov.au/internet/main/publishing.nsf/ Content/2D8BCF439DE725CACA257E93001B462A/$File/discussion.pdf (accessed Aug 28, 2015).
The Lancet Oncology Commission’s discussion of the role of primary care physicians in cancer diagnosis1 provides an opportunity to reflect on the experience of the UK National Institute for Health and Care Excellence (NICE) in developing an updated guideline for the recognition and referral of suspected cancer.2 The authors of the Commission note that uncertainty remains regarding the most appropriate risk threshold for referral to secondary care—and identification of the most appropriate threshold for urgent referral of suspected cancer was indeed a challenge for NICE. Cancer survival in the UK lags behind other high-income countries, and delayed diagnosis and differences in access to treatment have been identified as the two most www.thelancet.com/oncology Vol 16 September 2015
likely causes.3 NICE can influence both the timeliness of diagnosis (through decisions about the risk threshold for urgent referral to secondary care) and access to treatment (through its cancer guidelines and technology appraisals). NICE takes cost-effectiveness into account when formulating its guidance. By applying consistent decisionmaking rules, it can help to ensure that the limited funds of the National Health Service (NHS) achieve the greatest health benefits—in this case, by recommending urgent referral thresholds that are cost effective. For new cancer treatments, sufficient data usually exist to allow estimation of their cost-effectiveness. When assessing different risk thresholds for urgent referral to secondary care, the situation is less
Aj Photo/Science Photo Library
Referral of suspected cancers: the NICE approach
See The Lancet Oncology Commission page 1231
1229
A series of measures have been undertaken to promote the development of primary care in China. The Chinese Society of General Practice was founded in 1993—a first step towards the recognition of general medical practice in China. The basic framework of the primary care medical education system was constructed in 2000 and a fairly comprehensive general medical education system was in place by 2010 to meet the needs of health reform and of community health services. China’s national medical insurance system, covering the whole country, was established in 2008 and is broadly divided into three types: basic medical insurance for urban employees, basic medical insurance for urban residents, and rural cooperative medical insurance for farmers. Other people who live in rural areas are entitled to the same basic medical insurance as urban employees. To further improve the medical insurance system and reduce the economic burden for people who have serious diseases such as cancer, the catastrophic medical insurance system was set up in 2012 and is now available in more than 90% of cities and counties as of June, 2015. Therefore, patients who have serious diseases can be reimbursed for more than 50% of the additional cost after the original reimbursement. All of these insurance systems are accepted at all levels of hospitals to ensure the referral channels are unimpeded. The Key Tasks of Health Reform in 2015 of the State Council report4 stressed that the Chinese Government would need
to continue to support construction of the community health-service system and enhance the comprehensive ability of community health services. Furthermore, to improve the medical capacity of PCPs, standardised training of junior doctors would need to be fully implemented, and about 50 000 new junior physicians will receive such training in 2015. With an increased emphasis on cancer control services in community hospitals, the diagnosis and treatment of patients should be improved. The key findings of The Lancet Oncology Commission1 provide valuable information to help to improve the health-care system in China. Yuankai Shi National Cancer Center; Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing 100021, China [email protected] I declare no competing interests. 1 2
3 4
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72. Aging Society and the Pension Insurance Development report. 2014. http://www.cnki.net/KCMS/detail/detail.aspx?QueryID=0&CurRec=1&recid =&filename=JJZK2015Z1017&dbname=CJFDLAST2015&dbcode=CJFQ&pr =&urlid=&yx=&v=MjY1MDBGckNVUkwrZmJ1WnRGeXpnVTc3Qkx5ZlJaYkc 0SDlTbXJvOUVZNFI4ZVgxTHV4WVM3RGgxVDNxVHJXTTE= (accessed Feb 23, 2015; in Chinese). Chen W, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer in China, 2011. Chin J Cancer Res 2015; 27: 2–12 The Key Tasks of Health Reform in 2015 of the State Council. April 26, 2015. http://www.gov.cn/zhengce/content/2015-05/09/content_9716. htm (accessed May 5, 2015).
Tek Image/Science Photo Library
Paying for the expanding role of primary care in cancer control
See The Lancet Oncology Commission page 1231
1228
Advances in cancer detection and treatment pose a challenge to traditional cancer services focused on the acute delivery of specialist care. In The Lancet Oncology Commission,1 Greg Rubin and colleagues set out an exhaustive charter for the role of primary care services, and the primary care physician (PCP). The authors suggest 18 action points for a greater role for the PCP from detection to palliation. Effective PCP involvement in cancer care will depend on the identification of appropriate PCP roles and the development of skills, which the Commission does address, and also on the provision of the right financial incentives, which the Commission mentions only briefly. At a fundamental level, how PCPs are paid affects the type and volume of care they provide. Australia, as
in the UK and several other European countries, has a strong primary care system with a gatekeeping role. Unlike the UK, Australian PCPs are funded on a fee-forservice basis, and patients are not registered to specific PCPs or primary care organisations.2 Incentive payments for PCPs have been targeted to specific interventions such as cervical screening.3 But if each specific cancerrelated behaviour outlined in the Commission were to attract its own payment, the funding system would soon become overwhelmingly complex. In general, a reliance on fee-for-service provides an incentive for PCPs to increase the volume of care and to generate revenue, rather than to provide continuity and integration of patient care. This is becoming an increasing challenge with the growing incidence of complex and www.thelancet.com/oncology Vol 16 September 2015
Comment
continuing illnesses that can be treated at a primary care practice.4 This challenge applies to cancer, from the early phases of treatment to the ongoing management of survivors. In Australia, there is now wider consideration of some form of capitation funding for these patients, which would be compatible with the goals of the Commission.5 In the UK, patients are already registered with a primary care organisation with some fund holding; therefore, changing behaviour in PCP care will require different financial changes, perhaps a change in capitation rates to make adjustment for the purchase of cancer-related services. This is a difficult task given the variable upfront population risks associated with cancer and the myriad available treatments, which have variable costs and effectiveness. Since PCPs are uniquely placed to offer ongoing care for patients who would prefer to be cared for outside the specialist setting, one of the burgeoning areas for the involvement of PCPs is survivorship care. This represents a potential challenge for PCPs and funding systems alike. For PCPs, it will involve continual learning about new cancer treatments, their sequelae, and potential effects on survivors. For funding systems, these patients represent a new group requiring care that is not already incorporated in existing capitation rates. Financial incentives will need to recognise remuneration of PCPs for the services they provide to patients directly and also the continual training and education needed to provide these services. Further, as specialists already have the major role in cancer care, moving more care to the PCP
setting will change the balance of services they provide. Therefore, the behaviour and incentives for PCPs cannot be considered in isolation of those for specialists. How physicians are paid is essential to achieving the right mix of activities and desired outcomes. Attaining the goals set by the Commission will require getting the incentives right. Effective financial incentives can be designed only with careful consideration of the system onto which they are being added. At the risk of making more work, we would suggest a 19th action point: review whether the funding of primary and specialist services creates the right incentives. Without this understanding, our capacity to enact the actions promoted by the Commission remains limited. Richard de Abreu Lourenco, *Jane Hall CHERE, University of Technology Sydney, Sydney, NSW 2000, Australia [email protected] We declare no competing interests. 1 2 3 4
5
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72. Hall J. Australian health care—the challenge of reform in a fragmented system. N Engl J Med 2015; 373: 493–97. Greene J. An examination of pay-for-performance in general practice in Australia. Health Serv Res 2013; 48: 1415–32. Wranik D, Durier-Copp M. Framework for the design of physician remuneration methods in primary health care. Soc Work Public Health 2011; 26: 231–59. Primary Health Care Advisory group. Discussion paper: better outcomes for people with chronic and complex health conditions through primary care. August 2015. http://www.health.gov.au/internet/main/publishing.nsf/ Content/2D8BCF439DE725CACA257E93001B462A/$File/discussion.pdf (accessed Aug 28, 2015).
The Lancet Oncology Commission’s discussion of the role of primary care physicians in cancer diagnosis1 provides an opportunity to reflect on the experience of the UK National Institute for Health and Care Excellence (NICE) in developing an updated guideline for the recognition and referral of suspected cancer.2 The authors of the Commission note that uncertainty remains regarding the most appropriate risk threshold for referral to secondary care—and identification of the most appropriate threshold for urgent referral of suspected cancer was indeed a challenge for NICE. Cancer survival in the UK lags behind other high-income countries, and delayed diagnosis and differences in access to treatment have been identified as the two most www.thelancet.com/oncology Vol 16 September 2015
likely causes.3 NICE can influence both the timeliness of diagnosis (through decisions about the risk threshold for urgent referral to secondary care) and access to treatment (through its cancer guidelines and technology appraisals). NICE takes cost-effectiveness into account when formulating its guidance. By applying consistent decisionmaking rules, it can help to ensure that the limited funds of the National Health Service (NHS) achieve the greatest health benefits—in this case, by recommending urgent referral thresholds that are cost effective. For new cancer treatments, sufficient data usually exist to allow estimation of their cost-effectiveness. When assessing different risk thresholds for urgent referral to secondary care, the situation is less
Aj Photo/Science Photo Library
Referral of suspected cancers: the NICE approach
See The Lancet Oncology Commission page 1231
1229