Financial incentives and disincentives for providing mental health care in general practice – a survey of nine European countries

Background/Objectives: It is evident from numerous studies that a high proportion of patients attending general practices suffer from mental health problems. Reasons for this probably include the easier geographical accessibility of primary care services, physical comorbidity, and patients’ fear of being stigmatised when contacting specialised psychiatric services. While training GPs in recognizing and managing mental disorders among their patients is an approach already well documented in the literature, little is known which incentives and disincentives, especially concerning the reimbursement procedures for actually attending to these patients, exist in general practice. The present study, which is still ongoing, analyses such financial incentives and disincentives.

Methods: The analysis is carried out in two steps. First, the different payment systems for GPs were analysed from available information in the literature and on the web. In this step also the implications of different payment systems for attending or not attending to the GPs’ patients with mental disorders were analysed. In a second step, a detailed survey was carried out in a 7th Framework project of the European Commission (REFINEMENT) with local experts collecting information on the more specific implications of the respective payment systems.

Results: Eight of nine countries have a capitation (or ‘list’) system in primary care, with flat rates being paid for all persons on the list of the GP, irrespective of whether they used the service or not. However, the flat rates may be differently weighted, with, in one instance, higher flat rates for children and for the elderly on the list. In one country, a flat rate is paid only for patients actually attending the GP during a given time period (one or three months, depending on the insurance company). In all countries, additional fees for services (FFS) are paid, but in very different ways and to a different extent. While in one instance very few such FFS payments are possible (vaccination and pregnancy), in another an extensive catalogue of extra FFS extra payments exists (with even ‘masked depression’ included). The organisation of primary care (solo practices vs. group practices/primary care centres; self-employed vs. employed), the gate keeping function (in some countries but not in others), the general funding system (tax vs. insurance) also matter and are analysed.

Discussion/Conclusions: Payment systems of GPs have important motivational functions for caring for specific groups of patients, including those with mental disorders. Capitation (or ‘list’) systems as such do not have an incentive to provide more than what is absolutely necessary. Together with the limited training of GPs concerning the recognition and management of mental disorder in most countries, this means that mental disorders of GP patients remain under-recognized and under-treated. In order to improve the situation, financial incentives should be built into the remuneration system, in addition to an adequate training at medical school and in postgraduate training. This may prove as a cost-effective measure with the financial gains for society larger than the costs for increasing respective financial incentives for general practitioners.

Funding: EC Seventh Framework Programme project “Financing systems’ effects on the Quality of Mental health care in Europe“ (REFINEMENT, grant no. 261459).

Keywords: Cost of illness, financial incentives, general practice.