How to strengthen primary care and pay for quality, not volume? The Croatian experience shows it can be done if goals are set clearly, doctors are fairly incentivized, and we rely on data. The expert discussion also indicated what steps Slovakia is preparing.
How to persuade doctors: co-creation, choice, and long debates
The reform was not devised only by the authorities but by the doctors themselves: they helped select elements that make sense in practice. Instead of pressure came choice—those who did not want to could remain with the original model, but full participation meant approximately a 10 % income increase upon meeting all criteria (e.g., KPI and QI at 7,5 % each). The “roadshow” was also important: a series of about ten full-day meetings around the country, where leadership of the insurer and the ministry answered questions from thousands of doctors and built trust.
Results came quickly for clearly measurable indicators. In half a year, the number of antibiotic packs fell by roughly 8 % and spending by 20 %, as older, more appropriate agents were chosen more often—a benefit also for the fight against antimicrobial resistance. Strengthened gatekeeping thus did not rest on sanctions but on rewarding good practice and a sensible division of competencies between GPs and hospitals.
Quality, equity, and Slovakia’s plans
Some changes had a direct impact on mortality: after GPs gained the authority to initiate anticoagulant therapy, deaths fell in the relevant population. Equity of access, however, requires targeted solutions—Croatia has 60 inhabited islands without doctors, so it involved nurses for field visits and telemedicine (e.g., ECG or early detection of stroke). Similarly, teams that work specifically with marginalized groups could be incentivized; crucial here are high-quality, aggregated data on each physician’s patient population. Croatia also introduced some quality-based payments in hospitals: for example, use of reserve antibiotics is monitored, and through DRG budgets approximately 20 % of the budget is tied to performance and meeting criteria.
Slovakia has announced changes in payments for outpatient specialized care so that it is more worthwhile to accept a new patient and shorten waiting times, not just repeatedly schedule the same ones. In prevention, three screening programs will be added and a national screening center will be established with its own coordination and incentives for both doctors and patients. Incentives for participation in screenings are also to be increased, for example through gynecologists, and the more efficient day hospitalization regime will be strengthened by increasing its reimbursements. The common denominator of success remains the same: clear goals, measurable indicators, fair remuneration, and trust built on open communication and data.
