Transcript Health care reforms in Europe and their implications for Japan

Health care reforms in Europe and their
implications for Japan
Peter C. Smith
Centre for Health Economics
University of York
Structure of presentation
• Introduction
• Promoting cost-effectiveness
– Cost containment
– Markets and competition
– Quality improvement
• Other aspects of reform
• Implications for Japan
An acknowledgement:
the WHO European Health Observatory
• Surveys of individual countries Healthcare
Systems in Transition profiles
• Books on important topics:
–
–
–
–
Financing
Hospitals
Social insurance
Purchasing
• Web site: http://www.euro.who.int/observatory
Common features of western European
Health Systems
• A broad package of insured health care, embracing most
mainstream health interventions (not always long term care)
• Universal coverage of all citizens, regardless of financial or
health status;
• Low reliance on direct user charges
• Financial contributions according to ability to pay,
independent of health status (tax or social insurance)
• High levels of regulation of providers
• A unifying principle of ‘solidarity’ - the health risks of all
citizens are pooled, with contributions to the risk pool
unrelated to health status
Four broad types of health system
• Social insurance: unreformed
– France, Austria
• Social insurance: competitive
– Netherlands, Germany
• Public sector: devolved
– Sweden, Spain
• Public sector: centralized
– United Kingdom, Italy
Figure 1: Public and private health expenditure as a percent
of GDP, 2001 (Source: OECD Health Data)
JAPAN
United Kingdom
Sweden
Spain
Italy
Ireland
Germany
France
Finland
Denmark
Belgium
Austria
Public
Private
0
2
4
6
8
10
12
Life expectancy 2000
(Source: OECD Health Data)
Austria
78.1
Belgium
77.7
Denmark
76.9
Finland
77.6
France
79.0
Germany
78.0
Greece
78.1
Ireland
76.5
Italy
79.6
Netherlands
78.0
Portugal
76.6
Spain
79.1
Sweden
79.7
United Kingdom
77.9
JAPAN
81.2
Preoccupations of European health systems
• 1980s: Cost containment
• 1990s: Efficiency and markets
• 2000s: Quality
1. Cost containment
a) Gatekeeping
b) Copayments
c) Community care
1a) Gatekeeping
• Traditional feature of public European systems
(UK, Scandinavia, Italy)
• In some respects, directed at enhancing quality
of care
• But main focus is on containing costs
• Some evidence of success
• Social insurance countries seeking to
encourage gatekeeping through payment
mechanism (France, Germany)
Figure 2: Average number of doctor consultations
per capita, 2000 (Source: OECD Health Data)
JAPAN
United Kingdom
Sweden
Netherlands
Italy
Germany
France
Finland
Denmark
Belgium
Austria
0
5
10
15
General practice fundholding UK
•
•
•
•
•
•
•
•
In force 1991 to 1998
Voluntary participation by general practices
Average practice size 7,500
By 1997, 50% of patients had a fundholding general
practitioner
Fundholders received budgets from health authority to
purchase routine non-emergency surgery and prescribing
for patients
Emergency and complex surgery paid by health authority
Fundholding abolished April 1999
To be reintroduced April 2005?
Difference between fundholder and
non-fundholder hospital admission rates
Admissions per 1000
0.5
0
-0.5
Emergency
-1
-1.5
-2
-2.5
-3
-3.5
Elective
-4
-4.5
97/98
98/99
99/00
00/01
Gatekeeping principles
•
•
•
•
Limiting access to specialist care
Persuading citizens to use preferred providers
Potential lever to improve costs and quality
Needs to be implemented alongside many
other policies
• Very different effectiveness in different
systems.
1b) Copayments
• Traditionally low levels of copayment in European
systems
• Widespread voluntary insurance against copayments
in some systems, diluting incentive effect (France,
Ireland)
• Tentative experimentation with copayments in public
systems (Sweden, Netherlands)
• Reference pricing as a form of copayment for
pharmaceuticals (Germany, Spain etc.)
• Differential copayments according to lifestyle? Not
yet tried.
Figure 3: Percentage of total health care expenditure in the
form of out-of pocket payments (Source: OECD Health Data)
JAPAN
Spain
Netherlands
Italy
Ireland
Germany
France
Finland
Denmark
Austria
0
5
10
15
20
25
Copayments for physician visits:
German example 2004
• €10 fee for each first appointment with a
doctor in a three month period
• Some evidence of an effect on demand, but
reform may distort the pattern of utilization
• Concern that the poor and chronically sick will
be disadvantaged
• No market in voluntary copayment insurance
yet.
Reference pricing
• Designed to encourage use of cheaper generic substitute drugs
• Involves setting a fixed ‘reference price’ for all drugs within a
cluster
• Patients must pay difference between drug price and reference
price
• Complex technical issues (choice of clusters, choice of
referenceprice)
• Widespread use in Europe (Sweden, Germany, Spain, Italy),
but Norway abandoned because ineffective.
Reference:
Kanavos, P and Reinhardt, U (2003), “Reference Pricing For Drugs: Is It
CompatibleWith U.S. Health Care?”, Health Affairs, 22(3), 16-30.
1c) Community care
• Objective is to keep patients out of
unnecessary hospital care, and to minimize
length of stay
• Some crude attempts to limit very long lengths
of stay (bed blocking) (Belgium)
• Some discussion of introducing ‘no claims’
insurance premium discount (Netherlands)
• Incentives for local government to arrange for
community care (England)
Figure 4: Trends in average length of stay, all acute episodes
(Source: OECD Health Data)
30
Austria
Denmark
Finland
25
Days
20
France
Germany
Ireland
15
10
Netherlands
5
Portugal
0
Sweden
1960
1970
1980
1990
2000
United Kingdom
2. Markets and efficiency
a)
b)
c)
d)
e)
Provider markets
Payment mechanisms
Purchaser markets
Information and markets
Health technology assessment
2a) Provider markets
• Major efforts to make provider markets more
competitive and contestable
• Clearly relevant to some aspects of acute care,
but concerns at implications for chronic care
• Little evidence on effectiveness of provider
markets
• Little evidence on relevance of ownership of
providers
2b) Payment mechanisms
• Almost all systems reimburse providers according to
some sort of DRG payment
• Most DRG fee schedules are set passively, according
to expected average costs
• DRG systems are augmented by numerous other
payment mechanisms
• Payment mechanisms less well developed in
ambulatory care
• Key issue is sharing risk within the health system.
Adjustments to payment mechanisms
• In Norway, funding of local governments is partly on the basis
of DRGs (that is, actual activity) and partly on the basis of
risk-adjusted capitation (that is, expected activity).
• In the Netherlands, some cost-sharing between the payer and
the provider occurs once provider costs on a particular patient
exceed some threshold.
• Many systems augment the pure DRG payment with other
sources of finance, such as local government subsidies for
capital resources (Austria) and tax subsidies (Belgium).
• In Germany, patients in registered chronic disease programmes
attract additional capitation payments for sickness funds [23].
2c) Purchaser markets
• Payers for health care (local governments or insurance funds)
have tended to reimburse passively
• Major efforts to make sickness funds competitive in social
insurance systems (Netherlands, Germany, Belgium)
• Early experience suggests the a concern with the risk
adjustment process, needed to create a fair market and prevent
cream skimming of rich, healthy patients
• Little evidence of benefits in terms of quality or efficiency
• Key issue: how to reconcile active purchasing with the
patient’s traditional freedom to use any provider and fixed fee
schedule.
Risk Adjustment 1:
Age and sex: English Acute sector
600
Cost per person (£)
500
400
300
200
100
0
0 10 20 30 40 50 60 70 80
Age
Male
Female
Risk Adjustment 2:
Additional needs: English Acute Sector
•
•
•
•
•
Limiting long-standing illness (under 75)
Mortality (under 75)
Unemployment
Older people living alone
Single parent households.
The outcome of the English redistributive system
Percentage gain (loss) from equalization grant,
183 English health districts
183
157
131
105
79
53
27
1
-30
-20
-10
0
10
20
30
40
50
How much greater should the funding gap
be?
Under-75
Mortality rate
Funding
per capita
(% national)
Manchester
135.4
133.1
West Surrey
79.5
81.7
ENGLAND
100.0
100.0
2d) Markets and information
• Information is a key resource in the
functioning of health care markets
• Traditionally poor level of information on
costs and quality
• Great opportunity to enhance information base
for patients and collective purchasers
• Concern about distortions induced by public
reporting.
English performance ratings:
acute hospitals
***
**
*
!
Hospitals with the highest levels of
performance
Hospitals that are performing well
overall, but have not quite reached the
same consistently high standards
Hospitals where there is some cause for
concern regarding particular key targets
Hospitals that have shown the poorest
levels of performance against key targets
http://www.doh.gov.uk/performanceratings/2002/
Performance ratings –
key targets 2002
1. no patients waiting more than 18 months for inpatient treatment
2. fewer patients waiting more than 15 months for inpatient
treatment
3. no patients waiting more than 26 weeks for outpatient treatment
4. fewer patients waiting on trolleys (gurneys) for more than 12
hours
5. less than 1% of operations cancelled on the day
6. no patients with suspected cancer waiting more than two weeks
to be seen in hospital
7. improvement to the working lives of staff
8. hospital cleanliness
9. a satisfactory financial position
Plus…
… a satisfactory quality inspection.
York Hospital Performance Rating 2002
www.doh.gov.uk/performanceratings
York Hospital Performance Rating 2002
continued
Effect of performance ratings
• Positive impact on ‘key targets’
• Some concern that gaming or fraud has
distorted the information provided by
organizations
• Also concern about unintended side-effects on
unmeasured aspects of health care
2e) Health technology assessment
• Universal move towards defining an ‘essential’
package of care
• Principal criterion for inclusion in package is costeffectiveness of interventions
• Experience at a very early stage
• An enormous task, with numerous methodological
and practical complexities
• Many countries setting up health technology
assessment institutes (England, Finland, Germany,
Sweden)
3. Quality improvement
a) Professional improvement
b) Patient empowerment
c) Incentives for quality
3a) Professional improvement
• Two distinct perspectives:
– Supporting professional best practice (e.g.
Netherlands, Sweden)
– Identifying unsafe practitioners (e.g. England)
SWEDEN
Some active quality registries
• Cancer
•
•
•
•
•
Rectal Cancer Surgery
Prostate Cancer
Bladder Cancer
Sarcoma Group
Esophageal and Gastric
Cardia Cancer
• Cervical Cancer
Screening
• Stomach Cancer
• Malignant Melanoma of
Skin
• Musculoskeletal
•
•
•
•
•
•
•
Hip-Fracture
Total Hip Replacement
Knee Replacement
Rheumatoid Arthritis
Lumbar Spine Surgery
Spinal Cord Injury
Pain Rehabilitation
…. about 50 in total.
Source: Rehnqvist, N. (2002), "Improving accountability in a
decentralised system", in P. Smith, Measuring up: improving health
systems performance in OECD countries, Paris: OECD.
Identifying unsafe practitioners:
could surveillance have detected Bristol early?
HES
CSR
10
alpha = beta = 0.0001
alpha = beta = 0.001
5
alpha = beta = 0.01
alpha = beta = 0.1
0
Zero
alpha = beta = 0.1
-5
alpha = beta = 0.01
alpha = beta = 0.001
-10
alpha = beta = 0.0001
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
-15
1985
Cumulative LLR:
as expected <- > increased risk
15
Year
DJ Spiegelhalter, R Kinsman, O Grigg and T Treasure. (2003) ‘Risk-adjusted
sequential probability ratio tests: applications to Bristol, Shipman, and adult
cardiac surgery’, International Journal for Quality in Health Care 15:7–13.
3b) Patient empowerment
• Contradictory pressures within Europe
• Some public systems seeking to enhance patient choice
(Denmark, England)
– Purpose is to enhance quality (principally waiting times)
• Some social insurance systems seeking to circumscribe patient
choice (France, Germany)
– Purpose is to encourage use of ‘preferred providers’ (quality and cost)
• Information for patients is a key resource in promoting choice
• Notion of giving a voucher (or cash payment) to chronic
patients – some tentative experiments.
http://www.drfoster.co.uk
3c) Incentives for quality
• Increased evidence of wide variations in
clinical quality
• New ability to measure quality
• Publication of quality data not enough to
secure improvement in clinical performance
• Direct incentives needed to secure
improvement.
New General Practitioner contract
• Each practice can earn ‘quality points’ according to
reported performance
• 146 performance indicators
• 1,050 points distributed across indicators according to
perceived importance
• Points based on absolute level of attainment (not
adjusted for local difficulty)
• About €110 per point for an average practice, but
increasing if a difficult environment
• Minimum income guarantee (no loss of earnings)
GP Contract:
Indicators and points at risk
Area of practice
Clinical
Organizational
Additional services
Patient experience
Holistic care (balanced clinical care)
Quality payments (balanced quality)
Access bonus
Maximum
PIs Points
76
550
56
10
4
184
36
100
-
100
30
50
146
1050
GP Contract: Clinical indicators
Domain
CHD including LVD etc
PIs Points
15
121
Stroke or transient ischaemic attack
Cancer
Hypothyroidism
10
2
2
31
12
8
Diabetes
Hypertension
Mental health
Asthma
18
5
5
7
99
105
41
72
COPD
Epilepsy
Clinical maximum
8
4
76
45
16
550
Hypertension:
indicators, scale and points at risk
Records
Min
Max Points
BP 1. The practice can produce a register of patients with
established hypertension
9
Diagnosis and initial management
BP 2.The percentage of patients with hypertension whose
notes record smoking status at least once
25
90
10
BP 3.The % of patients with hypertension who smoke,
whose notes contain a record that smoking cessation advice
has been offered at least once
25
90
10
BP 4.The % of patients with hypertension in which there is
a record of the blood pressure in the past 9 months
25
90
20
BP 5. The % of patients with hypertension in whom the last
blood pressure (in last 9 months) is 150/90 or less
25
70
56
Ongoing Management
Some other European concerns
•
•
•
•
Sustainability of finance sources
Manpower
Pharmaceutical regulation
Aging population
Implications for Japan
• General themes from Europe
• Lessons from reform
• Relevance to Japan
Four weaknesses of social insurance systems
•
•
•
•
The narrow finance base;
Sickness funds securing quality or cost
control over providers;
Lack of control over expenditure growth;
Lack of accountability of providers to
insurers and patients.
Some reforms that can address weaknesses
•
•
•
•
•
•
•
Cross subsidy from general taxation or other
sources of finance
More active purchasing of health services by
insurers
Incentives for patients to use preferred providers
Increased application of health technology
assessment
Gatekeeping
Reform of copayment policy
Enhanced information, particularly on the quality
and costs of providers
Three ‘headline’ issues for Japanese policy?
•
•
•
Improvement of comparative information on
the quality and efficiency of providers and
insurers.
Experimentation with financial incentives for
patients.
Encouragement of more active and flexible
purchasing by sickness funds.