Consensus Report Danish Health Final Report

The Danish Health Care System: An Analysis of Strengths, Weaknesses, Opportunities and Threats

Kjeld Møller Pedersen, University of Southern Denmark

Mickael Bech, University of Southern Denmark

Karsten Vrangbæk, AKF Danish Institute of Governmental Research

The Consensus Report

TheDanishHealthCareSystem:AnAnalysisofStrengths,Weaknesses,OpportunitiesandThreats

KjeldMøllerPedersen,MickaelBech,KarstenVrangbæk

TableofContents

TableofContents ................................................................................................................................2

Summary.............................................................................................................................................6

AsnapshotoftheDanishhealthsystem ..............................................................................................8

Framework........................................................................................................................................10

Overviewofchallenges(threats)andopportunities ..........................................................................12

Challenges .............................................................................................................................................12

Opportunities ........................................................................................................................................12

Overviewofstrengthsandweaknesses .............................................................................................13

Strengths ...............................................................................................................................................13

Weaknesses...........................................................................................................................................13

ObjectivesoftheDanishhealthsystem................................................................................................14

Solutions................................................................................................................................................15

Challenges.........................................................................................................................................16

Demographicdevelopment:Agingandstagnatingnumberofoccupationallyactive ..........................16

Themanpowersituation:shortage .......................................................................................................18

Fiscalsustainability:difficulttofinancethehealthsystemofthefuture .............................................18

Expendituredevelopment1999‐2008 ...............................................................................................18

Determinantsofgrowthinhealthexpenditures ...............................................................................20

Prognosisforhealthcareexpenditures .............................................................................................21

(In)equityissues ....................................................................................................................................24

Inequityinlifestyle/riskfactors ........................................................................................................27

Inequityinaccess ..............................................................................................................................29

Highexpectations..............................................................................................................................29

Globalization/Europeanizationofhealthcaremarkets&healthtourism...........................................31

Integrationofprivateprovidersandfinancingwithauniversalandcomprehensivepublichealthcare

systemandthecreationofalevelplayingfieldforcompetition..........................................................31

Opportunities....................................................................................................................................33

Personalizedmedicine ..........................................................................................................................34

Newtechnologies..................................................................................................................................35

Expectationsandcompetenciesofthepopulationparticipationandselfcare ....................................35

Strengths...........................................................................................................................................36

Patientrights .........................................................................................................................................36

Choiceandwaitingtimeguarantees.....................................................................................................36

Choiceofprimarycare ......................................................................................................................36

Choiceofhospitals.............................................................................................................................37

Highpatientsatisfactionandtrust ........................................................................................................37

Easyaccessinprimarycare,incl.gatekeeperrole ................................................................................38

(Reasonable)expenditurecontrol,includingefficiencyandreimbursementsystems .........................38

Introductionof‘packages’forcancerandcertaincardiacconditionsandfasttrackissue ..................39

Workinprogresson(coherent)patientpathways ...............................................................................40

Increasedfocusonpalliativecare/endoflifecare ...............................................................................40

Considerableinvestmentsinnewhospitals ..........................................................................................41

Strengtheningofpre‐hospitaltreatment/care .....................................................................................42

Qualityassuranceandmonitoring ........................................................................................................43

Wellfunctioningmulti‐leveldemocraticstructuresforintegrateddecisionmakingandimplementation.....................................................................................................................................46

Weaknesses ......................................................................................................................................47

Tensionswithinthedemocraticmultilevelgovernancestructure:Limitedvoterinterestandunclear

roleforpoliticiansatdecentralizedlevels.............................................................................................47

Ambivalencetowardsstrengtheningofpreventionandhealthpromotion .........................................48

Ambivalentattitudetowardsexplicitpoliticalprioritysetting..............................................................49

Tightbudgetsand/orwrongallocationandactivitybasedfinancing ...................................................50

Lifeexpectancyandhealthstatus .........................................................................................................51

Slowintroductionofnewtreatments? .................................................................................................53

Lackofvisionfornewhospitals,i.e.‘hospitalsofthefuture’andavisionforprimarycare ................55

Tooslowtakeupofthechroniccaremodel? .......................................................................................56

Cooperationbetweenmunicipalities–GPs–hospitals ........................................................................59

Lackoffocusonrehabilitation ..............................................................................................................59

Inequity .................................................................................................................................................60

Solutions ...........................................................................................................................................61

Whatisanaddedlifeyearworth? ........................................................................................................62

Telemedicine:Largescalepilotprojectsformonitoringthechronicallyill...........................................63

Proposal.............................................................................................................................................66

Methodsforprioritizationandproposalforaninstituteforprioritysettinganalyses .........................67

Co‐payment...........................................................................................................................................70

Co‐paymentinDenmarkandtheNordiccountries ..............................................................................70

Proposal.............................................................................................................................................71

Improveequityinhealth/useofhealthcare.........................................................................................73

Proposal.............................................................................................................................................74

Reducingthenumberofinfectionsandadverseevents.......................................................................75

Proposal.............................................................................................................................................75

Screeningfordiabetesandhealthcheckupingeneralpractice...........................................................76

Proposal.............................................................................................................................................76

Improvedpsychiatry..............................................................................................................................77

Proposals ...........................................................................................................................................77

Endoflife ..............................................................................................................................................78

Proposal.............................................................................................................................................80

Diagnosticcenters/fasttrackdiagnosingandevaluation .....................................................................80

Summaryforsolutions ..........................................................................................................................82

Endnotes ...........................................................................................................................................84

References ........................................................................................................................................94

SummaryTheorganizingframeworkforthisessayisananalysisofstrengthsandweaknessesoftheDanishhealth

systemalongwiththreats(challenges)andopportunities–aso‐calledSWOT‐analysis.Thisisfollowedby10proposals(‘solutions’)tothecombinedsetofissues.

Itiseasytocomeupwithproposalsthatwillincreasethebenefitscopeandlevelsofhealthservicesprovidedandhenceincreaseexpenditures.However,thewholepointoftheSWOTanalysisistoidentify

areasworthyofattackbecausetheythreatenthesustainabilityofthehealthsystemasweknowit,runcountertotheobjectivesofthesystem,e.g.equity,orareglaringweaknesses.RationaldecisionsaboutimprovementsmustbebasednotonlyonahelicopterviewofthehealthcaresystemviatheSWOT

analysis,butimprovementsmustbeselectedsothattheyhavethebiggestimpactpermonetaryunitexpended.Therefore,wheneverpossibleandrelevantithasbeenattemptedtoprovideaveryroughestimateofthecost‐benefitratioofparticularsolutions.NumerousreferencessupportboththeSWOT‐

analysisandthesolutionsectiontounderpinthefactualbasisofthereport.

Thethreemajorchallengesareinterrelated:1.Demography(aging,morechronicallyill),2.Themanpowersituation(adecliningworkforce),and3.Fiscalsustainabilityinviewofnotonlythedemographicdevelopmentbutalsothewelfareeffectofasteadilyincreasingincomelevel:Whengross

domesticproduct,GDP,increasesbyonepercent,healthexpendituresincreaseby1.2‐1.3%,hencegraduallycapturingagreatershareofGDP.Thefiscalchallengemaythreatenthetaxfinancedhealthsystem.Thequestionofmid‐andlong‐termsustainabilitywillrequireastrongpoliticalwilltoestablish

prioritieswithinverynarrowfiscallimits.Anotherconsiderablechallengeisrelatedto(in)equityinhealthoutcome(mortality/lifeexpectancyandmorbidity).Asregardsinequityinhealthoutcomeit

shouldberememberedthatitisinfluencedbymanyotherfactorsotherthanthehealthcaresystem,forinstancetheworkenvironment.‐Yetanotherchallengerelatestorisingexpectationsaboutwhatcanandshouldbeprovidedbythehealthcaresystem(freeatthepointofuse).

Ontheopportunitysidenewtreatmentsareatthecoreofattention,inparticularopportunitiesthatat

oneandthesametimeprovidebettertreatmentanddonotincreasecosts(verymuch).Telemedicineisanexample.Thepotentialisconsiderable,butthecost‐savingpotentialremainstobedemonstratedconvincingly.‐Thehospitalinvestmentplanprovidesanopportunityforrethinkingthehospitalofthe

future,logisticsetc.

Patientrights,freechoice,ahighdegreeofpatientsatisfaction,theambitioushospitalinvestmentplan,productivitygains,andqualitymonitoringareexamplesofstrengthsoftheDanishhealthcaresystem.Ontheweaknesssideambivalencetowardspreventionandhealthpromotion,possiblytooslow

introductionofnewtreatments,ambivalencetowardsexplicitprioritysetting,lowlifeexpectancy,andaneedforimprovedcooperationbetweenhospitals,GPs,andthemunicipalitiescanbementioned.

The10chosensolutionsinthetablebelowarechosenbasedonhowwelltheytakentogetheraddressthechallengesandtheweaknessesidentifiedintheSWOT‐analysis.Asnotedaboveveryrough

estimatesofthecost‐benefitratioformostofthesolutionshavebeenincludedintherighthand

column.Theyarenotbasedondetailedcalculations–andinthecaseofsolution10(diagnosticcenters)

itreallyisaguesstimate.

Solution ThesolutionaddressesthefollowingSWOT‐elementsand

objectives

Cost‐benefitratioand/orcostsperqualityadjustedlife

years,QALY

1. Increaseduseoftelemedicine:

Projectwithbrief‐casefortele‐monitoring/advisingthechronicallyill

Demographicchallenge(the

chronicallyill),thefiscalchallengeandpopulationexpectations

CBAratio1:1‐2

2. Cost‐effectivepreventiveactivities/healthpromotion:

HealthtestsandhealthconsultationsadmodumEbeltoft

Demographicchallenge(thechronicallyill)andthelowlife

expectancy

CBA‐ratio:1:26(anet‐benefitperparticipantofDKK

26,000)

3. Hospitalpalliativecare–hospiceatendoflife

Demographicchallengeandthepopulation’sexpectations

Cost‐minimizationanalysispointstopalliative

care/hospicecare

4. Improveequityinhealth/useofhealthcare

Inequityissues SomewhatmeaninglesstodevelopaCBA‐ratio

5. NationalInstituteforPrioritySetting,NIPS,Methodsfor(explicit)prioritysetting

Fiscalchallengeandlegitimacyofthepublichealthcaresystem

CBA‐ratio:atleast1:1andmostlikely1:>1

6. Expensivemedicine Institutionforprioritysetting CBA‐ratio:atleast1:1andmostlikely1:>1

7. Reducingthenumberofinfectionsandadverseevents’

Fiscalchallengeandqualityofcare

CBA‐ratio:atleast1:17

8. Co‐payment Fiscalchallenge CBA‐ratio:1:13

9. Improvedpsychiatrictreatment/care

Weakness,psychiatryhasfallenbehind

FordepressionthecostsperQALYrangesfrom$15‐35,000

‐whichis‘goodvalue’.Nocost‐benefitratiohasbeenestimated.

10. Diagnosticcenters/fasttrackdiagnosing

Accessandcoherentpatientpathways

GuesstimateCBA‐ratio:1:1andlikely1:>1

AsnapshotoftheDanishhealthsystemADuringatypicalyearalmostallDanesusehealthcareservices1:

• in200690%ofthepopulationusedhealthservicesi.e.consultedaGP,washospitalized,usedhospitaloutpatientservicesetc.

Comparedtomostotherpublicservices,healthcareisusedthroughoutlife,notjustsomestageoflife

likeschoolsornursinghomes.Thisinturnmeansthateverybodyisaffectedbyhowwellthehealthsystemworks.Inopinionpollsabouthighconcernpoliticaltopicshealthcarealwaysratesamongthetopfive.

Theservicesareprovidedbyahealthworkforceofabout2102,000fulltimeequivalents–about4%of

thetotalworkforce.

Publicexpenditureforhealthcareprovidedbyhospitals,GPs,etc.anddrugsin2008was2:

• Dkr.18,100percitizens(publicexpenditures)peryearofwhichDkr.13,500isusedforhospitalservicesperyear

• TheaverageDaneprivatelypaysDkr.4,100peryearoutofpocket(co‐payment)

• Totalhealthexpenditureshaveincreasedannuallyby2.8%inrealtermsforthepast10years

• InternationallytheDanishspendinglevelandgrowthrateislow.

Patientsexpressahighdegreeofsatisfactionwithhospitalcare.The2009surveyofabout70,000hospitalizedpatientsand160,000outpatientsshowed3

• that90%ofhospitalizedpatientsfoundtheoverallexperienceeitherverygoodorgood

• that95%ofpatientsreceivingambulatoryhospitalcarefoundtheoverallexperienceeither

verygoodorgood.

PatientsatisfactionwithGPsisalsohigh(StatensInstitutforFolkesundhed,2011):

• 89%wereveryorsomewhatsatisfied–satisfactionincreasingwithage

Waitingtimeforelectivesurgeryforthemostcommon17operations,e.g.hipandkneereplacement,cataract,hernia,andkidneystone4isrelativelylowcomparedtoothertaxfinancedhealthsystems:

• anexperiencedaveragetimeof63days(calculatedJanuary–August2010)

Theextendedfreehospitalchoicegivescitizenstherighttouseprivatelyrunfacilitiesfreeofchargeif

waitingtimeatpublichospitalsexceedsonemonth.Fromfourthquarter2009tothirdquarter2010

A The200+referencesappearintwoformats:themajorityappearassuperscripts,butanumberappearinroundedbrackets,e.g.(Jensen2011).Theformerarefoundunder‘Endnotes’whilethelatterarelistedalphabeticallyunder‘References’.

• about123,000usedthischoice

Apossiblesideeffectofhospitalizationishospitalacquiredinfections,e.g.woundinfections.In2009‐

2010closetooneofevery10hospitalizedpatientshadahospitalacquiredinfection5

• aprevalenceofbetween8.2–10.1%forhospitalacquiredinfections.

Thereportingsystemforadverseevents/unintendedconsequencesinconnectionwithhospitaltreatmentin2009received

• about25,000reportsfromtheregions–ofwhich1.3%weregradedasveryserious

Lifeexpectancyisofteninterpretedasasuccessmeasureforahealthsystem.Lifeexpectancyisinfluencedbymanyotherthingsthantheconsumptionofhealthcareservices,forinstancelifestyle.

Thissaid,however:

• LifeexpectancyforDanishmalesandfemalesisamongthelowestamongtheEuropeanOECDcountries.

Itisdifficulttopassjudgmentonhowwellahealthsystemisworking.Inpartbecausetheunderlyingobjectivesonwhichtoevaluatethesystemmaydifferacrossdifferentparties,inpartbecausethere

shouldbesomebasisforcomparison,e.g.othercountriesoraclearlydelimitedbaseline,andindependentobservers.

Inthe2008OECDSurveyofDenmark6achapterof57pageswasdedicatedtoanevaluationofthe

healthsystemandimportantchallenges.Thesummarywasclear:

“Overthepastfewyears,theDanishhealthsystemhasimproved.Yetwhenlookingahead,furtherpressuresshouldbeexpectedfromnewcostlymedicaltechnologiesexpandingtherangeofconditionsthatcanbetreated,aswellasfromcontinueddemandforshorterwaitingtimes

andcarethatrespondstoindividualneeds.Managinghealthcarespendingmaywellbethelargestfiscalchallengeoverthecomingdecades.Sustaininguniversalpublichealthinsurancefinancedbygeneraltaxationshouldbefeasible,butitwillrequirecontinuedeffortstoenhance

efficiencyviaorganizationaladjustments,refinedeconomicincentivesandtheadoptionofcost‐savingtreatmentpractices.Atthesametime,promotinghealthynutritionandlifestylesshouldhavehigherpriority,andthesystemasawholeshouldbemoreengagedinhelpingtoprevent

peoplewithhealthproblemsendingupbeingexcludedfromthelabourmarket.”(p.123).

TheMinistryofHealthinFebruary2010publishedanin‐houseproducedbenchmarkingoftheDanishhospitalsystem7.Thecomparisonwasmadevis‐à‐vissevenEuropeancountries:Sweden,Norway,

Finland,theUK,Germany,theNetherlandsandFrance.Itwasconcludedthat

“Generally,thebenchmarkingstudyshowsthattheDanishhospitalsectorperformswellinmostareascomparedwiththesevencountriesinthepublicationandwiththeaverageoftheOECDcountries.WithrespecttoDenmark,itshouldbeunderlinedthataccesstohealthcareisgood

withrelativelyshortwaitingtimes,andthatDenmarkhasthelowestproportionofcitizenswho

experienceunmetneedsformedicalexaminationamongthecountriesbenchmarked.Intheareaofheartdiseasetreatmentthequalityishigh,whereasDenmarkperformslesswellintheareaofcancertreatment.”(p.5)

FrameworkThebriefforthisanalysissaysthattheauthorshavetodeveloppossibleandrealisticsolutionstothe

problemsandchallengesthattheDanishhealthcarewillfaceoverthecomingyears.Ithasbeenindicatedthatabout10‘solutions’shouldbedeveloped.Theproposalsshouldnotbenarrow,e.g.onlyfocusingonhospitalsorgeneralpractice,butcoverimportantdimensionsofhealthcare.However,in

ordertocomeupwithtimelyandrelevantsolutionsitisnecessarytosketchsomeofthechallengestheDanishhealthcaresystemfacesoverthenextcoupleofdecades.TothisendaSWOTanalysiswillbedeveloped.

SWOTanalysesarenotnew.Forinstance,afewyearsbackagroupofforeignscholarsvisitedDenmark

andundertookaSWOT‐analysisoftheDanishHealthCareSystemasof1998/19998.ASWOTanalysisisastrategicplanningmethodusedtoevaluatetheStrengths,Weaknesses,Opportunities,andThreatsforanorganization–orinthiscase,thewholehealthcaresystem.Itinvolvesspecifyingtheobjectives

ofthebusinessunit/healthcaresystemandidentifyinginternalandexternalfactorsthatarefavorableandunfavorabletoachievingthesystemobjectives,namelySWOT.

Thefourletterscover:

Strengths:areinternalcharacteristicsofthebusinessorthesystem.Ideallyitshouldbecomparedto

othersystemstogainanimpressionoftherelativestrength.However,thiscomparativeaspectwillonlybetoucheduponmarginallyinthefollowing..

Weaknesses:areinternalcharacteristicsthatneedtobeaddressed.

Opportunities:externalchancestomakegreatersalesorprofitsintheenvironment.

Threats:externalelementsintheenvironmentthatcouldcausetroubleforthebusiness/healthsystem.

IdentificationofSWOTsisessentialbecausesubsequentstepsintheprocessofplanningforachievementoftheselectedobjectiveideallyshouldbederivedfromtheSWOTs.

ThefigurebelowshowshowtheSWOT‐analysiscanbeturnedinto(strategic)solutionsbydeveloping

adequateandrelevantresponsestothefourSWOTdimensions.Italsoclarifiesinalogicalmannerwhichproblemsspecificsolutionsareaimedat.Insomecasesathreat,e.g.afiscalexternalthreatmayactuallyblockothersolutions.Ifthegrowthrateinhealthexpendituresisconstrained,ittoa

considerableextentlimitssometypesofsolutions,namelythosethatrequireanexpansionoftheoverallhealthbudget.

Table1:CombinedSWOTanalysisandproposedsolutions(1…Nmeansitems/topics)

Internalcharacteristics

Strengths(S)

Weaknesses(W)

1...NOpportunities(O)

(SO)Solutions

(WO)Solutions

External

characteristics

Threats(T)

(ST)Solutions

(WT)Solutions

Ofcourseitisonlyaframework.Insomecaseswewilldeviatefromit,forinstancebecausesomesolutionsbothfurtherdeveloppositionsofstrengthandalleviateweaknessesorthatsomethreatsoropportunitiesmaybeinternalandnotexternal.

TheSWOTanalysistakesplacewithinthe(figurative)frameworkofthefigurebelow:

InthespaceallocatedforthepresentanalysisonlysomeoftheareasshowninFigure1willbetouched

Overviewofchallenges(threats)andopportunities

Challengesa) demographicdevelopment(elderly,morechronicallyill)

b) lifestyleinducedillnessesinthewelfaresocietyandequityissues

c) fiscalchallenges;inpartduetothedemographicchallenge.–Theoverarchingissueisthelong‐termsustainabilityofataxfundedhealthsystem

d) manpowershortageandthechallengeofeducatingandrecruitingstaffwiththerightmixof

knowledgeandskillsinallpartsofthesystem

e) inequityinaccess,utilizationofservice,andinhealthoutcome

f) highexpectationsinthepopulationandsustaininglegitimacyandtrustofthepublicinthehealthsysteminthelongrun

g) globalization/Europeanizationofhealthcaremarkets&healthtourism

h) howtointegrateprivateprovidersandfinancingwithinauniversalandcomprehensivepublichealthcaresystemandhowtocreatealevelplayingfieldforcompetition.

Opportunitiesi) newtreatments,e.g.personalizedmedicine..

j) newtechnology,e.g.telemedicine,digitalinfrastructure(EPR,patientmanagement,qualityassessment)ortransitionto(more)ambulatorycare

k) expectationsandcompetenciesofthepopulationparticipationandselfcare

l) redesignofworkprocessesinthewholehealthsystem(inpartduetothefiscalpressure,butalsoduetonewhospitalfacilities).Fasttrackprocedures,patientpathways

m) ‘hospitalofthefuture’–newhospitalfacilitiesandorganizationsalongwith‘primarycareof

thefuture’.

n) Interactionwithprivatesector(businessandNGO)fordevelopmentofneworganizationalforms,medicalpracticesandtechnologies

OverviewofstrengthsandweaknessesStrengthsandweaknessesisaslidingscaleandclassificationofparticularphenomenadependsonthe

‘cut‐off’pointonthisscale.Furthermore,strengthsandweaknessesarerelativeconceptsandthereforerequiresomekindofbaseofcomparison.HeretheobjectivesoftheDanishhealthcaresystemareused.

Strengthsa) qualityassurancesystem(almost)inplace,including‘unintendedconsequences’

b) (apparently)goodtreatmentquality(NIP)(butlimitedevidenceforrelativeperformance

comparedtoothercountries)

c) patientrights

d) highpatientsatisfaction

e) easyaccessinprimarycare

f) freehospitalchoice–andlowwaitingtime

g) (reasonable)expenditurecontrol

h) introductionof‘packages’forcancerandcertaincardiacconditions

i) workinprogresson(coherent)patientpathways

j) increasedfocusonpalliativecare/endoflifecare

k) considerableinvestmentsinnewhospitals

l) strengtheningofpre‐hospitaltreatment/care

m) balanceofpublic‐private(providesanopportunitytodiscuss‘privatization’)

n) reasonablywellfunctioningmulti‐leveldemocraticstructuresforintegrateddecisionmakingandimplementation

o) averyeffectivegeneralpracticesectorandareasonablewellorganizedprimarycaresectorin

general

Weaknessesa) lowlifeexpectancy

b) (too)slowintroductionofnewtreatments

c) ambivalencetowardsstrengtheningofprevention/healthpromotion

d) ambivalentattitudetowardsexplicitprioritysetting

e) tooslowintroductionofthechroniccaremodel

f) lackofvisionfornewhospitals,i.e.‘hospitalsofthefuture’,andprimarycareofthefuture

g) tootightbudgets(?).

h) haspsychiatryinadvertentlybeenleftabitbehind?(fairlylowgrowthratecomparedto

somatichospitalcare)

i) cooperationbetweenmunicipalities–GPs–hospitals

j) lackoffocusonrehabilitation

k) cooperationwith/integrationofprivatedeliveryorganizationsandthecreationofalevelplayingfieldforcompetition

l) relativelypoorresultsinsomeareas(e.g.breastandcolorectalcancer)

m) introductionofABFandothernewincentivestendtoweakenexpenditurecontrol

n) tensionswithinthedemocraticmultilevelgovernancestructure:Limitedvoterinterestandunclearroleforpoliticiansatdecentralizedlevels.

o) Somegeographicaldifferencesinaccesstohealthcare

p) Misc.inequityissues

ObjectivesoftheDanishhealthsystemAsmentionedearliertheSWOT‐elementsshouldbeevaluatedinthelightoftheobjectivesofthehealthcaresystem.TheHealthActof2007consolidatedanumberofexistingactsandwaspassedbytheFolketinget(theDanishParliament)andhencecanbeconsideredastheofficiallystatedobjectives

ofDanishhealthcare.

IntheHealthActof2007thefirsttwoarticlessetouttheobjectivesoftheDanishhealthcaresystem.Atthegeneralleveltheoverallobjectiveistoimprovepopulationhealthandattheindividualleveltopreventandtreatillnessandalleviatesufferingandfunctionalrestrictions.Article2ismorespecific:

• easyandequalaccesstohealthcare,

• treatmentofhighquality

• coherentandlinkedservices

• freechoiceofhealthcareprovider

• easyaccesstoinformation

• atransparenthealthcaresystem

• shortwaitingtimefortreatment.

SolutionsSolutionsshouldbedevelopedsothattheyaddressrelevantSWOT‐elementsandfurthermoreshould

contributetofulfillmentofthesystemobjectivesabove,cf.thetableabovewiththestrategiccontentoftheSWOT.

Solution ThesolutionaddressesthefollowingSWOT‐elementsandobjectives

1. Increaseduseoftelemedicine Demographicchallenge(thechronicallyill),thefiscalchallengeandthepopulation’sexpectations

2. Cost‐effectivepreventiveactivities/healthpromotion/healthpromotionintheworkplace

Demographicchallenge(thechronicallyill)andthelowlifeexpectancy

3. Hospitalpalliativecare–hospiceatendoflife Demographicchallengeandthepopulation’sexpectations

4. Improveequityinhealth/useofhealthcare Inequityissues

5. Methodsfor(explicit)prioritysetting Fiscalchallengeandlegitimacyofthe

publichealthcaresystem

6. Expensivemedicine Institutionforprioritysetting

Fiscalchallengeandqualityofcare

8. Co‐payment Fiscalchallenge

9. Improvedpsychiatrictreatment/care Weakness,psychiatryhasfallenbehind

10. Diagnosticcenters/fasttrackdiagnosing Accessandcoherentpatientpathways

ChallengesThebiggestchallengefacingtheDanishhealthsystemisthedemographicdevelopment.Ithasbeenrecognizedforthepast10‐15years,butreallyfirstcameintofocusinthenewmillenium9,10.If

overlooked,observerswillnotunderstandthedilemmasandtheneedforchangefacingthehealthsystemoverthenext1–2decades.Assuchitconcernsthewholesociety,butherewelimitourselvestotheramificationsforhealthcare:

• Expenditureconsequencesofanincreasingnumberofelderlyandincreasedlifeexpectancy

• Manpowersituation

• Financing:erodingtaxbaseforincometaxationwhichisthemainsourceoffinancingforthe

healthsystem

Demographicdevelopment:AgingandstagnatingnumberofoccupationallyactiveThereistruthtothesayingthatinthelongrunwearealldead.However,inordertobuildasustainablehealthsystemwehavetotakestockofimportantfuturedevelopments.Thedemographicdevelopmentprobablyisthemostimportant,andevenifwelook30‐40yearsintothefuturewecannothopefor

reversalsofthepredictedtrends.Itmayappearabstracttolookjust20‐30yearsintothefuture,butcurrentwoesinthehealthsystemwillworsenifnocorrectiveactionistaken.

Figure1:Development1992‐2060forthreeage

groups:0‐14(blue),80+(green)and+65(red)

Figure2:Development1992‐2060forthe

occupationallyactive(15‐64,redlineatthetop)andoccupationallyinactive(0‐14,65+)

Source:DREAMmodel(Hansen,2010)

Figure1illustratesthedevelopmentforthreeagegroupsfrom1992anduntil2060.Overthenext30yearsthenumberofpersons65yearsofageandabovewillincreaseinabsolutetermsbyapprox.400,000persons.

Ifwelookatthe80+yeargroupinisolation,thisgroupwillincreasebyapprox.200,000overthesame

period.TheDanishpopulationisintruthaging.Forhealthandsocialservicesthisingeneraltermsimpliesanincreasingneedfortreatment,nursing,andsupport.Thegroupwithchronicdiseaseswillincreasebecausetheincidenceofanumberofdiseasesincreaseswithage,i.e.diabetes,cardiovasculardiseases,

rheumaticdiseasesetc.Manywillhaveseveraldiseases,socalledco‐morbidities.Thehealthsystemwillhavetodevelopcopingstrategiesnowandinthecourseoffewyears.

Atthesametime,however,theoccupationallyactivegroup,traditionallydefinedastheagegroup15‐64)isslightlydeclining,Figure2.Hence,withastagnatingordecreasingworkforcethehealthsystematthesame

facesanincreasingneedformanpower.Therearealsoeconomicramificationsofthis.

Thedemographicsupportfractiondefinedasthenumberofoccupationallyinactive(0‐14,64+)dividedbythenumberofoccupationallyactive(15‐65)isakeyfigure.Inawelfaresystemlargelybasedon‘pay‐asyougo’wherethisyear’staxespayforthisyear’sexpenses,e.g.healthcare,oldagepensions,andnursing

homes,thedevelopmentinthisfractionisofgreateconomicimportance.Thisisduetothesimplefactthatthemaincontributorstotaxincomearetheoccupationallyactive.

Measuredthisway,todaywehaveasituationwheretwooccupationallyactivepersons’support’oneoccupationallyinactiveperson,afractionof0.50.However,around2040therewilllikelybefour

occupationallyactivetosupportthreeoccupationallyinactive,afractionofcloseto0.75.

Lifeexpectancywillincreasesteadilyinthecomingyears.ThelatestavailableprojectionsarepresentedinFigure3and4formalesandfemalesrespectively.

Figure3:Lifeexpectancy,males

Source:DREAMModel(Hansen,2010)

Figure4:Lifeexpectancy,females

Theimportanceoflifeexpectancyisthatthelongerpeoplelive,thelongerthey–orsomeofthem–needhealthandsocialcare.

Themanpowersituation:shortageWithastagnatingworkforcetherewillbeageneralshortagesituationinthelabormarket–despitecurrentunemployment–andhenceintensecompetitionforexistingandfuturemanpower.Lookedatfrom

anarrowhealthsystemperspectivetheshortagesituationcanbeoutlinedasfollows:

By2015theshortagewillbeabout12‐14%ofthecurrentworkforceandaround2020theshortagewillhavegrownto15‐16%.For2015theexpectedshortageinabsolutenumberswillbe12,13:

• nursingassistants,about5,700

• nurses,about5,600

• physicians,about2,600

Thisiscalculatedbasedonunchangeddemand,andonlythreekeygroupshavebeenmentioned.Therewillmostlikelybeshortagesinotherareas.Hence,thenumberislikelytobehigher.Fornursingassistantsand

nursesitshouldberecalledthatthereiscompetitionfromnursinghomesandhomenursing,whereashortageakintotheonedescribedwillmostlikelyalsobecomevisible.

Thissituationwillmostlikelysetinmotionanumberofactivities:1.Makinghealthcareanattractiveworkplace,inparttoretain,inparttorecruit,2.probablywagepressure,3.internallyathospitalsitislikelyto

increasethefocusintwoareas:redesigningworkflowand‘taskshifting’,i.e.thatnursingassistantstakeoversomenursingtasks,nursestakeoversomephysiciantasksinordertomakesurethatcorecompetenciesareputtoeffectiveuse–becauseitiseasierintheshorttomediumtermtorecruitandtrain

nursingassistantsandnursescomparedtophysicianspecialists,4.asconcernsgeneralpracticeinnovativeorganizationalmodelswill/mustbedeveloped.

Fiscalsustainability:difficulttofinancethehealthsystemofthefutureLikewithmanpowerthequestionofshort‐,mid‐termandlong‐termfinancingofthehealthsystemisrootedinthedemographicdevelopment.Therearetwosourcesthattogetherwillcreateafiscalchallenge

ofconsiderablesize:Agingcombinedwithincreasedlifeexpectancyandthestagnatingworkforceandinconsequencehereof,a(partial)erosionofthetaxableincomebase.OntopofthisthecurrentcrisisandEUrulesconcerning‘allowable’deficitofpublicfinances,namelyamaximumof3%ofGDP(grossdomestic

product),roughlythevalueoftheproductiveoutput,willstrainthefiscalsustainability.

Expendituredevelopment19992008Thefollowingkeynumberscapturetheexpendituredevelopmentoverthepast10years14:

• overallannualgrowthrateperyear1999‐2008inrealterms(correctedforinflation):2.8%

• theannualgrowthrateforhospitalexpendituresperyear1999‐2008:3,3%

• thegrowthrateforpsychiatryhasbeenverylow,atotalofabout5%from2000to200812.

• theannualgrowthrateforprimarycare(GPs,practicingphysicianspecialists,physiotherapistsetc.)peryear1999‐2008:4.1%

• theannualgrowthrateofdrugsexpenditureperyear:5.1%

Inotherwords,steadyandcontinualgrowth–despitetheimpressiononegetsfromthenewsthat‘savings’havebeentheorderoftheday.Whetherthegrowthrateshavebeensufficient,howeverdefined,is

anothermattertobediscussedlater.

Internationallythegrowthrateisamongthelowestifcomparedtocountriesweoftencompareourselvesto.ItisacommonprocedureforinternationalcomparisonstolookatexpendituresaspercentageofGDP(grossdomesticproduct).Figure5and6togetherpaintapictureofDenmarkbeinga‘fairlylowspender’

(figure5)anda‘lowgrowthrate’country(figure6).

Figure5:HealthexpendituresaspercentageofGDP1970‐200714

Notes:1.Kvartilistheexpenditureinthe¼lowestspendingcountriesinOECDwhereas3.Kvartilisthe

¼highestspendingcountriesonhealthcareasapercentageofGDP

FrombeingwellabovetheOECDaverageDenmarktodayisonlyslightlyabove.BasicallythismeansthattheDanishgrowthratehasbeenslowerthaninmanyotherOECDcountries,Figure6.

Thereareseveralcontradictoryinterpretationsofthesenumbers.Ontheonehand,thatcostcontainmenthasbeensuccessfulinDenmark.Ontheotherhandanalternativeinterpretationisthatthehealthsystem

hasbeenunderfunded–atleastcomparedtoothercountries.Bothextremesareprobablybiasedtowardsfittinginwithcertaininterests.Beforepassingjudgment,severalquestionsmustbeclarified,andafterthatitwillstillbedifficulttopassjudgment:Typesandscopeoftreatmentsoffered;howefficientlythehealth

systemoperates(howmanyserviceslikebeddays,hospitalization,GPconsultationsareprovidedpermillionDkr.),andwhataretheadministrativecostsofrunningthesystem.Itisdifficulttoanswerthesequestions,anduntilthenitisprobablybesttotaketheinformationinFigure5and6asinteresting‘facts’

withoutgoingintotoomuchinterpretation.

Figure6:GrowthintheGDP‐percentagegoingtohealthexpenditurescomparedto1970‐level14

DeterminantsofgrowthinhealthexpendituresWhatdeterminesgrowthinhealthcareexpenditures?Averygeneral,butsomewhatsuperficial

explanation,istonotenotonlythathealthexpendituresgrowwhenGDPgrows,butthatindevelopedcountriesthegrowthrateofhealthexpendituresexceedsthatofGDP.Figure7showsthisclearly.Nocountryisbelowthe45‐degreeline,showinganoverproportionalgrowthrateforhealthcare

expenditures.

Economistsexpressthisphenomenoninthefollowingway:WhenGDPgrowsby1%,healthexpendituresgrowbymorethan1%.Overthepast15yearsthis‘additionalgrowth’,aswecallitlater,hasbeen0.3%,i.e.healthexpendituresgrowby1.3%whenGDPgrowby1%.

Onewayofcharacterizingthiswouldbetoocallit‘welfareeffect’,inthatitisnotassuchdrivenbyfor

instancedemographicdevelopmentbutbyincreasingincomelevels.Thereasoninggoesasfollows:Aswegetricher,wewanttospendmoreonhealthcare.However,asanexplanationthisisnotverysatisfactory.Somepremisesshouldbeintroduced,forinstancethatovertimethepossibilitiesfornewtreatmentsare

increasingrapidly,i.e.treatmentavailability,alongwithanapparentlyincreasingpoliticalwillingnesstopayintaxfinancesystems.However,fewanalysesareavailablethatshowthisindetail.

Figure7:AnnualrealgrowthratepercapitainhealthexpendituresandGDP,1970‐200614

InviewofhowtaxfinancefundingofhealthcareinDenmarkandothercountries,namelytaxfinanced,oneshouldstressthatthisdevelopmentisa‘willed’developmentinthesensethatithasbeenpoliticallyapproved.However,itdoesnotmeanthatthereistotalpoliticalcontroloverthedevelopment.Oftenthe

developmentisconsidered‘inevitable’,i.e.itseemsimpossibletosaynotointroduceanewandproventreatmentthatatthesametimeincreasescosts.Tocontaincostsinvolvesprioritysettingandalsoaviewtotheoverallmacroeconomy,i.e.whatisthe‘fiscalhealth’ofthenation.

PrognosisforhealthcareexpendituresTurningtothefuture,futuregrowthinhealthexpenditurescanbedividedintoademographiccomponent(overallagingofthepopulation,longerlifeexpectancy,andpossiblychangedmorbiditypattern)andanon‐

demographiccomponent(increasingwelfare,newtreatments,anddevelopmentinproductivity…the‘addedgrowth’componentmentionedabove).

Thepointofdepartureforthedemographiccomponentistheaveragepublichealthexpendituresperperson.Thisisshowninfigure7.Averageannualexpendituresvaryconsiderablyacrossthelifecycle.From

aroundtheageof60thereisastrongincrease.The‘top’aroundtheageof30ismainlyduetowomengivingbirthtochildren.

Basedonanumberofassumptions,forinstance’healthyaging’tobediscussedlater,thefuturedevelopmentinpublichealthexpenditures,i.e.privateexpendituresthatamounttoaround16‐17%of

totalexpendituresarenotincluded),areshowninfigure8,indexedatthe2008level.

Severalscenariosareshownfromthemostconservative(noincreaseinlifeexpectancyovertheperiod)toanadded‘additionalgrowth’(welfareeffects)duetoincreasedwealthupto0.6%peryear.

Figure7:Averagepublicexpendituresperperson,year200015

Intheanalyses‘Additionalgrowth’isdefinedasnon‐demographicgrowthoverandaboveproductivitygrowthintheeconomy(i.e.overgrowthinGDP),wherethescenariowith0.3%additionalgrowthisanaverageoftheexperienceoverthepast15yearsasmentionedearlier.

Withinthenexttwodecadespubliclyfinancedhealthexpenditureswillincreasewithbetweenan(unlikely)

20%andamorelikely35%inrealterms.Tothisshouldbeaddedanincreaseinsocialexpendituresofapp.13%undertheassumptionof0.3%additionalgrowth.

Figure8:Prognosisfordevelopmentinfuturehealthexpenditures,indexedat1000in2008.

TheEconomicCouncilnotesthattheuncertaintyoftheprognosisisconsiderable.However,thegreatestuncertaintyisaboutthe‘additionalgrowth’,notthedemographiccomponent.‘Additionalgrowth’depends

amongotherthingsonpoliticalprioritysettingandthewilltocarryoutprioritysetting.Inadditiontheassumptionsabout‘additionalgrowth’arecrucialwhenlookingatfiscalsustainabilitydiscussedbelow.

Anotheruncertaintyisabout‘healthaging’thatissofteningtheeconomicconsequencesofthedemographicchangesconsiderably.Thedemographicallydeterminedhealthexpendituresdependonaging

andproximitytodeath(reflectingwhatistermedterminalcostsofdying).Whenlifeexpectancyincreases,theterminalcostsarepostponed,i.e.occurbydefinitionlaterinlife,andtheincreasesinhealthexpenditurethatfollowfromlongerlifeexpectancyarenotaslargeastheincreaseinthenumberof

elderlypersonswouldsuggest.Thisphenomenonisreferredtoas“healthyageing”15.ArnbjergandBjørner,whosecalculationsunderlietheabove,foundthatbasedontheempiricalestimatesfortheperiod2000‐2007,seefigure9,thathealthyagingisexpectedtoreducetheimpactofincreasedlifeexpectancyonreal

healthexpendituresby50percentcomparedtoasituationwithouthealthyageing.TheEconomicCouncilsgivestheexampleofan85yearoldwomaninyear2050.Comparedtoan85yearoldwomenin2006her2050counterpartwillhavehealthexpendituresthatare13%lower(simplybecauseshedieslaterdueto

increasedlifeexpectancyandhenceattheageof85is‘healthier’andusefewerhealthservicesthanher

2006counterpart).Itisobviousthattotheextenttheassumptionsabouthealthagingdonotholdup,thentheexpendituregrowthwillbe(considerably?)higherthatindicatedabove.

Figure9:Averagehealthexpendituresin2000forpersonswithdifferenttimedistancetodeath11

Thegrowthratesdepictedinfigure8,apartfromthelowestcurve,meanthathealthexpenditureswillgrowfasterthantheeconomy(growthinGDP).Thequestioniswhatthismeansforfiscalsustainability.

Fiscalsustainabilityisbasicallythemediumandlongrunbalanceofoverallpublicfinancemustbalance,i.e.thatincomeandexpenditureshould‘equal’eachother(inthelongrun).HansenandPedersen11findsthat

fiscalsustainabilityisrobustwithrespecttogrowthinhealthcareexpendituresduetofutureincreasesinlifeexpectancy.Thisisaconsequenceofhealthyageingandtheindexationofthestatutoryretirementagetolifeexpectancythatfollowsfromthe2006‐welfarereform.Fiscalsustainabilityremainsverysensitiveto

non‐demographicfactors:Anincreaseinnon‐demographic(‘additionalgrowth)expendituregrowthof0.3pct.inexcessoftheproductivitygrowthincreasesthefiscalsustainabilityproblemby2.1pct.ofGDP.Doublingtheexpendituregrowthrelativetoproductivitygrowthto0.6pct.increasesthefiscal

sustainabilityproblemby4.8pct.ofGDP.ThesenumbersshouldalsobeseeninthelightofEUfiscalrulesofamax.deficitof3%ofGDP.Thismeansthathealthcarealonecouldthreatenthisobjective.

TheEconomicCouncilhashighernumbersthanHansenandPedersen.With‘additionalgrowth’of0.3%peryearthecouncilconcludesthatthiswillleadtoasustainabilityproblemof3.0%ofGDP,equivalentto54

billionDkr.measuredin2009Dkr,andwith‘additionalgrowth’of0.6thisincreasesto5.7%ofGDPwhichisequivalentto102billionDkr.in2009DKr.

HansenandPedersen–andalongwiththemtheEconomicCouncil‐concludethatthecurrentgrowthinnon‐demographic(‘additionalgrowth)healthcareexpendituresof0,3%cannotbemaintained/sustained

foraprolongedperiodwithoutchallengingthepublicfinancingofhealthcareexpendituresinDenmark.Ontheotherhanditisdifficulttoseehowthepopulationandwiththempoliticianwillstop‘changing’incomeincreasesinto,amongotherthings,morehealthcare.Laterinthepaperwewilllookatprioritysetting

TheEconomicCouncilnotesthatinessencethereareonlythreepossible(andcombinationsthereof)ways

offinancingthefuturehealthexpendituresif‘additionalgrowth’moreorlessisafactoflife:

• publicexpendituresinotherareasthanhealthhavetogrowatalowerratethaneconomicgrowthintheeconomy,i.e.allowhealthexpenditurestogrowfasterthanGDP,forinstanceatleast0.3%asforthepast15years.

o inessence,however,thisisalreadytakingplace(recallthegrowthratesmentionedearlier).

• taxrevenueshavetogrowfasterthegrowthrateoftheeconomy,i.e.increasethetaxburden

• userpayment/increasedco‐payment.

TheEconomicCouncil(p.226ff)illustratestheconsequencesforthetaxrateifthe‘deficit’istobefinance

entirelythroughtaxes.Anannualincreaseofthelowtaxrateofabout¼%(thetaxrateappliedtothebaseincome)isneededtofinancethe‘additionalgrowth’of0.3%inhealthcareexpenditures.However,thiswillonlyreducethesustainabilityproblemfrom3%ofGDPto1.7%becausethereisaconcomitantneedto

financeelderlycareinthesocialsector.

TheEconomicCouncilalsoproposedanearmarkedhealthtax(‘healthcontribution’)asameanstomakevisiblehealthcarecostsandasapossiblemeansofdiscipliningcostexpansion–andlast,butnotleasttoensurethatcostincreasesarefinancedhere‐andnowandnotbyincreasinggovernmentdebt.Increasesin

thehealthcontributionshouldmatchoverallincreases(demographicandwelfareeffect)inthehealthexpenditures.However,anumberofissuesinrelationtoear‐markedtaxationwerenotdiscussedindetail.

(In)equityissuesEquityissuesareofgreatconcernintheDanishhealthsystem.NotonlydoestheHealthActstatethatDaneshaveequalaccess,butinverygeneraltermstherationalefortheDanishhealthsystemisequityin

theseveralsensesoftheword.Inparticular,‘equalaccessindependentofeconomicmeans’isanimportantpartofthejustificationforthetaxfinancedhealthsystemwhereuseofhospitalsandGPservicesarefreeatthepointofuse.Equityisanimportantgoalinofficialdocumentslikethenationalstrategyfor

preventionandhealthpromotion,wherethecurrentversioncarriesthetitle:Healthythroughoutlife16.

Equityinhealthhastobedistinguishedfromequityinaccesstohealthcare,andequityinthedistributionandutilizationofhealthcareresources,basicallycoveringthreestages:1.access,2.useand3.outcome.Therearetwomainissues:1.Howtomeasureanddocumentthedegreeofinequityand2.howtoreduce

inequity.Thelatterwillbeaddressedinmoredetailinthesectiononsolutions.

Muchofthedebateisframedintermsofequityinhealthandinmanycasesimplyingthatthehealthcaresystemisthemaindeterminantof(in)equityinhealth.However,theclassicdiagramillustratingthatthemechanismsarefarmorecomplicatedstillstands,figure10.Theimportantpointinfigure10isthatshows

thatintermsofpolicychangesmuchchangeneedtotakeplaceoutsidethehealthcaresystemtraditionallydefined,e.g.workenvironmentorstructuralchanges,e.g.taxationoftobaccooralcohol.

Figure10:Aconceptualmodelofthemaindeterminantsofhealth17

Morbidityvaries–notonlyaccordingtoageandgender,whichisnatural–butalsoaccordingtoschoolingandeducationwhichgivesrisetoequityconcerns.Thelattervariationistermed‘socialgradient.Thisisillustratedinfigure11for(selfreported)diabetesandlongtermillnesswithseverefunctionalrestrictions.

Ageandgenderdifferenceshaveeliminatedsothateducationaldifferenceareclearlyseen.

Figure11:Illustrationofsocialgradientfordiabetesandlongstandingillness

Thetrendisclearandunambiguous:

• thelesseducationthehigherthepercentagewithdiabetesorlongstandingillness.

o thispictureholdsinmanyotherareas

Thenextquestioniswhetherinequityincreasesovertime,i.e.overtheperiodof18and11yearsrespectivelyinfigure11fordiabetesandlongtermillness?Fordiabetesitisvisuallyclear:therehasbeenanover‐proportionalgrowthamongpersonswithashorteducationcomparedtothosewithalong

education.Thenumberscarryitout:In19872.2%ofpersonswith13+yearsofeducationreporteddiabetescomparedto2.4%forthosewithlessthan10yearsofeducation.In2005thiswasdramaticallydifferent:2.8%comparedto5.8%:

• forseveralillnessesthereseemstobeincreasinginequity.

Brønnum‐Hansen18recentlyreportedonthedevelopmentinhealthoutcomemeasuressuchaslifeexpectancyandselfreportedhealthstatusinDenmark,figure12.Theresultsdocumentthatsocialinequalityinhealthexpectancyhaswidenedsincethemid‐1990s.Thereisastrikingconsistencyin

differencesbetweenpeoplewithalowandahigheducationallevel,whateverindicatorwaschosen.Thehealthexpectancyofpeoplewithamediumeducationallevelwasconsistentlyinbetweenthatofpeoplewithalowandahighlevel.Nosystematicchangeintheproportionofexpectedlifetimeingoodhealthwas

seen.Inparticular,thelifeyearsgainedduringtheperiod1994–2005wereingeneralnotexclusivelyyearsingoodhealth.

Inasocietywithalongstandingconcernforequityadevelopmentliketheonedocumentedinfigures11and12isaconsiderablechallenge.However,themechanismsbehindthisdevelopmentarenoteasily

changed,seefigure10.andtheworkbyJacobNielsenArendt19Arendtdistinguishesbetweendown‐andupstreamelements.Downstreamintermsoffigure10meansfocusingonindividualbehavior,whileup‐streamarestructuralmechanismsinsocietylikeeducationalstructure.

Figure12:Illustrationofinequity20for30yearoldmenandwomen(intermsofremainingexpectedlife

years):lifeexpectancyandselfassessedhealthstatus

Iftheunderlyingcausesareeducation,doesitthenhelptoworkwithindividualhealthbehavior.Healsoasks:Shouldinequitybereducedatanyprice?Itisaloteasiertopointoutanddocumentanegativedevelopmentinequitythanprovidinganeffectivecure.

Inequityinlifestyle/riskfactorsMuchillnessdependsonlifestyleandhealthbehavior,e.g.smoking,exercise,and/ornutritionalhabits.Thereisastrongandpersistentsocialgradientinlifestyle.Hence,thereundoubtedlyisarelationship

betweenthesocialgradientinlifestyleand(thesocialgradient)inillnessesrelatedtoparticularlifestyles/healthbehavior–andtheninturnfeedingintoandbecomingpartoftheexplanationforinequityinhealthoutcome.However,theexactrelationshipisfarmorecomplicatedthatindicatedhere,butthere

mustbearelationship.

Figure13showsclearlythatthosewiththelowesteducationandschoolingalsoarethosewithhealthhabitsthatarenotconducivetogoodhealth(‘unhealthylifestyle’).

Figure13:Socialgradientsintwolifestyle/healthhabitareas20

Thesamepatternisseeninfigure14,whereitisextendedtoincludeworkinglife.Heavyphysicalworkissomethingthatisfarmoreprevalentamongpersonswiththefewestyearsofeducationandschooling.

Thepatternseeninthetwopreviousfiguresisfoundinmanyotherareasandiswelldocumented21.

Figure14::Thesocialgradientinexerciseandworklife

Itisverydifficulttolookintothefutureasregardsdevelopmentinhealthhabitsandsomeoftheconsequencesinthewakeof(un)healthybehavior/habits.AbraveattempthasbeenmadebyJuelandDavidsenatTheNationalInstituteofPublicHealth22.Pastdevelopment–forinstancefrom1987to2005is

analyzed,e.g.theleftpartoffigure15,andthenputintoapopulationprognosisasusedabove,resultinginaprognosis,therightpartoffigure15.Suchprognosesareinherentlydifficulttomake,butwithashorttimehorizontheystillmakeindicatealikelydevelopment.Suchdevelopments–andtheconsequencesfor

themorbiditypanorama,e.g.diabetes–werenotincludedintheprognosisabovefordevelopmentinhealthexpenditures.

Figure15:Developmentinoverweightandaprognosisfor2020

Inequityinaccess“Equalaccess”meaningaccessaccordingtomedicalneedandnot,forinstanceincome,isakeyobjectiveof

Danishhealthcare.Thisissueisillustratedinfigure15AforvisitstoGPanddentistwithinthepastthreemonth.TheimportantdifferencebetweenthetwoprovidersisthataccesstoGPisfree,whilethereisconsiderableco‐paymentfordentalvisits–hencewithco‐paymentasapossiblebarriertoaccess–aclear

pictureemerges.

ForGPvisitsaslightly‘reverse’socialgradientisseenwithpercentwisemorepersonswithshorteducationseeingaGPinthestatedtimeperiodthanpersonswithalongeducation.Inviewofthesocialgradientinmorbidityitisnotsurprisingalbeitthereversepicturemighthavebeenstronger.Ontheotherhand,for

visitstothedentiststhewellknownsocialgradientisseen.Therealunderlyingreasonishardlyeducationpersebutratheranunderlyingdifferenceinincomeaccordingtoeducation.

Prescriptionmedicineisalsocharacterizedbyquiteabitofco‐payment.Whenlookingat‘regularuseofmedicine’usingsamethetechniqueasinfigure15A,thereisaclear‘reverse’socialgradient:Forthe

groupwith+13yearsofeducation34%saidtheywereregularusercomparedto48%forthegroupwithlessthan10yearsofeducation.Itisnotnecessarilyacontradictioncomparedtouseofdentist,butshouldcautionabouttooquickconclusionsaboutco‐payment.Oneobservationisrelevant,however:Mostofthe

regularmedicineusersundoubtedlyuseprescriptionmedicine–andhencehavereceivedadvicefromaphysician.Thesametypeofadviceisnotavailablefortheneedfordentaltreatment.

Figure15A:AccesstoGPanddentist.

HighexpectationsExpectationsfromthepopulationingeneralandpatientsinparticularchallengethepublichealthcare

systeminmanyways23.Patientsexpecttoreceivehighqualitytreatment,responsivenesstopersonalneeds,tobeinformedandtobeinvolvedindecisionmaking–andontopthattheyexpectfreeservicesastheimplicit‘payment’fortheirtaxes.Inadditionpatientsactmoreandmorelikeconsumers24,25and

considerhealthcareonparwith(some)consumergoods.Expectationsareformedinmanyways:

Knowledgeaboutavailabilityoftreatment,experiencewithservicelevelsandattitudeofprovidersinotherwalksoflife.

Thepublichealthcaresystem,however,sofaralsoseemstohavebeensuccessful,atleastintermsofhighpatientsatisfaction26.Despitethesegoodresults,thereisagrowingpublicdebateaboutthe

responsivenessofthepublichealthcaresystemtopatients’individualneedsforbeinginvolved,beinginformedandhavingindividualizedtheircontactwiththehealthcaresystem.Recentresultsofpatientsatisfactioningeneralpracticeseemtoindicatethatasignificantshareofespeciallyyoungpeoplearenot

satisfiedwiththeirtreatmentandalsoexperiencethatdoctorsactpaternalisticallyandarenotresponsivetopatients’needforinformationandinvolvement27.Thismaysignalthecomingofagenerationwithotherexpectationsanddemands.

Thepopulationingeneralexpectstohaveeasyaccesstoahighlyspecializedandhighqualityhealthcare

systemproviding‘bestpractice’treatment.Therisingexpectationstothehealthcaresystem,togetherwiththefiscalconstraintsdiscussedabovewillbeamajorchallenge.Potentially,thehighexpectationstomeetbestqualityofcareandeasyaccessmaychallengethefinancialsustainabilityandthelegitimacyofthe

publichealthcaresysteminthepopulation,inparticulariftheoutcomeofthisisanincreasednumberofvoluntaryhealthinsurancegivingaccesstoprivatehealthcarefacilities,e.g.privatehospitals.Privatefinancingandprivatehospitalsneednotbeanegativephenomenon,buttoavoidfragmentationthenature

andrulesforcooperationbetweenpublicandprivatehospitalsneedtobespecified.

TheregionshavebeenrathersuccessfulinclosingdownanumberofsmallerhospitalsinDenmarkdespitelocalprotests.However,itisquestionablewhetherthepopulation’sexpectationscanbemetwithadecreasingnumberofhospitalsandespeciallyareducednumberofacutefacilitiesinthefuture.

Furthermore,thecostofnewtreatmentswillnotonlychallengethefiscalsustainabilitybutalsochallengethepopulation’strusttothepublichealthcaresystemwhennotallnewtreatmentmaybeaffordablewithinthepublichealthcarebudget.Thelegitimacyofthepresentpublichealthcaresystemwithuniversal

coverageandeasyaccessmaybequestionedwithaneverpresent(andincreasing)needforprioritizationandcompetingprivateoptions.

Adifferencebetweenthepoliticalwillingnesstopayandtheprivatewillingnesstopaywiththelatterbeingbiggerthantheformerbutwithno‘outlet’throughthepublicsectorbudgetduetofiscalconstraintswill

mostlikelyleadtoanincreaseinprivatehealthinsurance.

Inthehealthinsuranceliteratureitiscommontodistinguishbetweencomplementary,supplementaryorduplicatehealthinsuranceinrelationtothetax‐financedsystem28,29:1.Complementaryvoluntaryprivatehealthinsurancecoversco‐paymentsfortreatmentsthatareonlypartlycoveredbythetax‐financedhealth

caresystem.2.Supplementaryvoluntaryprivatehealthinsurancecoverstreatmentsthatareexcludedfromthetax‐financedhealthcaresystem.3.Duplicatevoluntaryprivatehealthinsurancecoversdiagnosticsandelectivesurgeryatprivatehospitalsandforinstancephysiotherapyorofficevisitsto

medicalspecialists–servicesthatarealsoprovidedbythetax‐financedpublichealthcaresystem.

Theincreaseinprivatehealthinsurancewillmostlikelyoccurintheareaofduplicatevoluntaryinsuranceforelectivetreatment.Inviewoftheexpectedsizeofinsurancepremiumsitisratherdifficulttoimagine

thataninsurancemarketforacuteprivatehealthcarewillemerge.

Globalization/Europeanizationofhealthcaremarkets&healthtourismAnimportantexternalfactorwithgrowinginfluenceontheDanishhealthsystemistheongoingand

gradualintegrationwithintheEUandglobalmarketsforhealthservices,workforceandcapital.TheimplementationoftheEU“InternalMarket”impliesthathealthpersonnel,healthservicesandcapitalforhealthserviceinvestmentscanmovefreelyacrossnationalborderswithintheUnion.Theactual

developmentofEU‐widemarketsisagradualprocesswhereparticularlytheEUcourtsystemandtheCommissionispushingtheboundariesfortheinternalmarketintothefieldofhealthcare,whilemanymemberstates,andthustheCouncilofMinisterswanttomaintaintheorganizationofhealthcareasa

nationalprerogativeaccordingtotheTreaty(theprincipleofsubsidiarity).TheongoingtensionbetweenthetwopositionscreatesaratherundeterminedpathforthefuturewhereEUcourtdecisionsinrealitybecomethedriversforamoreintegratedmarket30,31.

Whyisfreemovementofpatientsachallenge?First,becausenationstatesmaylosetheirabilityto

determinenationalservicelevelsandthuswillhavelessroomtoestablishnationalpriorities–andhencealsolesscontrolovernationalcoststhanpreviously.Second,becauseoftheeconomicchallengeofhavingtopayfortreatmentabroad,whileatthesametimebeingobligatedtoprovideserviceandservice

infrastructurenationally.Therearealsounresolvedissuesofqualitycontrolacrossnationalbordersandlegalobligationsincaseofmalpracticeoraccidents.Theactualnumberofpatientstravelingabroadisstillverylimited,butcanbeexpectedtoincreaseinthefuture.–TheDanishregionshadagreementswith6

privatetreatmentfacilitiesabroadin2009.

Whyisfreemovementofcapitalandservicesachallenge?ThereisariskthatmajorinternationalcapitalfundsorhospitalchainsmoveintotheDanishmarketashasalreadybeenwitnessedbyforinstancetheacquisitionof‘DanishPrivateHospitals’bythecapitalfundAleriswhichisasubsidiaryofthehugefund

EQT.Thiscanbeseenasanadvantage,asitcreatesacapacitybuffer.Yet,italsocreatesissuesofplanningandcoordinationacrossthepublicandprivatesectors,aswellascompetitionforpersonnel,whichforinstancemaydriveupwages.

TheissueofinternationalizationofhealthcareextendsbeyondtheEUarea.Thereisagrowing

internationalmarketfortreatmentsforinstanceinplasticsurgeryandforseriousillnessessuchascancer–givingrisetoso‐called‘healthtourism’(medicaltourism).Althoughthiscanbebeneficialtotheindividualtherearealsosignificantrisksanduncertaintiesrelatedtothequalityoftreatmentabroad,andthe

obligationincaseofmalpracticeoraccidents.However,fromaDanishperspectiveveryfewofthehealthtouristsareDanes.Ontheotherhand:Theincreasedtransparencyabouttreatmentsavailableabroad–andmaybenoteasilyaccessibleinDenmark–mayfuelmorehealthtourismthanseentoday.

Integrationofprivateprovidersandfinancingwithauniversalandcomprehensivepublichealthcaresystemandthecreationofalevelplayingfieldforcompetition.TheDanishhealthsystemwasdesignedandhasdevelopedasapublicintegratedstructurewhereplanning,expenditurecontrolanddeliverywaslargelyintegratedinamulti‐levelpublicgovernancestructurewiththeregionallevelasakeyplayer.PrimarycareproviderslikeGPs,practicingspecialists,physiotherapists

etc.havehistoricallybeenself‐employedbutstronglyintegratedintothepublicsystem,andalmostexclusivelyfinancedbypublicfunds.

Starting1989,butacceleratingaftertheturnofthemillenniumanincreasingnumberofsmallprivatehospitalsprovidingmainlyelectivesurgeryhaveenteredthemarket.Thegrowthwasfueledbythetax

exemptstatusforemployerpaidhealthinsurancegivingaccesstotreatmentintheprivatesector,andthegovernment’swaitingtimeguarantee.Initially(fromJuly2002toOctober2007)itwasatwomonthguaranteeandafterOctober2007itwasreducedtoonemonth.Theguaranteemeansthatafterwaiting

two/onemonthfortreatmentatpublichospitals,patientsacquiretherighttotreatmentintheprivatesectorfinancedoutofthepublichealthbudget.

Theprivatehospitalsectorissmallbutattractsconsiderableattentioninthepublicdebate.Unfortunatelythereisatendencytoconfuseprivatehospitalswithbedsforovernightpatientsandsinglepractitioners

withincertainspecialties,e.g.eye,ear,nose,throat.Thereareabout20private(forprofit)hospitals.Privatehospitalsinparticularprovideelectiveorthopedicsurgery(hip‐knee‐replacementetc.).Privatehospitalsonaveragehave9‐10beds(asofJuly1,2010)andmosthave5‐10beds.Thetotalbedcapacityin

theprivatehospitalsectoris50032.Thisshouldbecomparedtoabout16,000somaticbedsinpublichospitalsofwhich6,000bedsarebedswithinthesurgicalspecialties’33.

Themanpowersituationforprivatehospitalsisasfollows32

• 500FTEnurses,equaltoabout850persons,ofwhichabout20%holdapositionatapublichospital.Thereareabout33,000FTEnursesatpublichospitals.

• About200full‐timeemployedphysiciansandanumberofparttimeemployedphysicianssothat

thetotalnumberofphysiciansisaround800ofwhich70%alsoholdajobatapublichospital.Thisnumberofphysiciansshouldbecomparedtoatotalof13,000physiciansatpublichospitals.

Theturnoverofprivatehospitalsin2009was2.2billionDkr.ofwhichabout1.2billionDkr.waspaymentfor‘guarantee’patientspaidforbythepublicsector.Therestcamefromhealthinsuranceandpatients

whopaythemselves.

Themarketforhealthinsurancein2009wasasfollows

• 900,000holdersofemployerpaidhealthinsurance,andabout1.1millioncovered(spousesoftenarecovered).Thismarkethasbasicallyemergedsincemid2002.

• 1.8millionmembersof‘denmark’ofwhichabout25%carrysurgerybenefits

Theintroductionofprivatefinancing/healthinsuranceandprivateproviders,inparticularprivatehospitals,ascompetitorstopublichospitalsraisesanumberofissues.First,privatefinancingthroughvoluntary

healthinsuranceforelectivetreatmentpaidbytheemployerandtaxexemptfortheemployeechallengesthebasicprincipleofsocialequity,asittendstofavorpeopleincertainprivateindustries,andisalmosttotallyabsentinthepublicsector.Second,privateproviderscreateissuesofcoordinationastheyarenot

partoftheordinaryhierarchicalchainofcommand,andoftennotwellintegratedintermsofinformationsharingsystems.Third,theambitionofcreatingcompetitionbetweenpublicandprivateprovidersinvolves

anumberofissuesinregardstosettingalevelplayingfield.Publicprovidersareobligedtoprovideacutecareandthewholespectrumoftreatment,beitacuteorelective.Publichospitalscannotdecidetoclosedownunprofitableservices.Theprivatesectorontheotherhandcanselecttheiractivityareasanddonot

haveextendedobligationstomaintainacutecareorlong‐termcareservices.Publichospitalshaveobligationsintermsofresearchandeducation,whichprivateactorsdonot.Thesegeneralfactorscontributetoahighercoststructureinthepublicsector,andthusunevencompetitionterms.Thecurrent

configurationofthepaymentsystemtohospitalswithacombinationofactivitybasedfundingandaglobalbudgetimpliesthatpublichospitalsareonlyrewardedforextraactivityuptoacertainpoint.Beyondthisthresholdlevel,theyhavenoincentivetoincreaseactivity.Privatehospitalsontheotherhanddonothave

similarconstraints.Extraactivitymeansextraincomeforthisgroupofproviders.

OpportunitiesInteractionwithprivatesector(businessandNGO)fordevelopmentofneworganizationalforms,medicalpracticesandtechnologies.

Intheprevioussectionwehavedescribedanumberofchallengesinregardstotheinteractionbetweenthepublicandtheprivatesectorinhealthcare.However,itisevidentthatinteractionwiththeprivatesector

canalsobeseenasanopportunityinseveralways.First,theprivateproviderscanrepresentaconvenientbuffertosupplementthepublicsectorinsituationsofextrapressures.Havingaprivatesectoralleviatesthepublicfrominvestmentcosts,andreducestheriskofoverinvestinginpublicresourcesthatmay

becomeredundant.Second,theexistenceofaprivatesectorandthecreationofanexitoptionforcitizenscanprovidepersonalutilityaswellaspressureonthepublicsectortoimproveserviceandquality.Themechanismforservice‐qualityimprovementiscomplexanddependsonthefinancingsystem.Yetthereis

reasontobelievethatthemereexistenceofanalternativeoptionandtheinherentcontestabilityofpublicserviceswhenprovidinganexitoptioncansharpentheattentiontoservice‐qualitydimensions34.Third,theprivatesectormayprovideopportunitiesforlearningandorganizationaldevelopment.Privateactorswork

underdifferentconditionsthanpublicones,andmaythushavedifferentincentivestodevelopneworganizationalsolutions.Thepublicsectormaytakeadvantageofthisbyselectivelycopyingprivatesectorpractices.Finally,theremaybebenefitsinestablishingcooperationwithprivatefirmsfordevelopingand

testingnewpharmaceuticalsandmedicaldevices.Theprivatesectorhasexpertiseandlivesettingsfordevelopmentofproducts,whiletheprivatesectorhasknowledgeofmarketconditionsandcapitaltofunddevelopment.Developmentandresearchcanbenefitboth.

Aspecifictypeofpublic‐privateinteractioninvolvesvoluntaryorganizationsorNGOs.Thereareseveral

examplesofthisalready.Patientorganizationsprovideexpertiseandknowledgeoftheconditionsforspecificpatientgroups.Largerpatientorganizationsalsofundresearchandprovidefacilitiesfortheirmemberstosupplementthepublicservicesupply.Notforprofitorganizationsdelivercareservicesto

elderlyandlongtermcarepatients.Amorerecentphenomenonattheindividuallevelistheuseofprivatevolunteersashelpersinhospitalsettings.Sofar,theirrolehasmostlybeentosupportandhelpoutwithpracticalissues,butitisnotunlikelytheirrolecanbeextendedinthefutureinboththehospitalsectorand

inlongtermcare.

PersonalizedmedicineAnumberofadvancesine.g.thefieldofhumangeneticsandmolecularmedicinehavemadeitpossibletodevelopnewtreatmentandpreventionstrategies.Thequestisopenedtowardsindividualized(personalizedortargeted)medicinewithhugeinterestsinbiomarkers,andpharmaco‐genetics.

Personalizedmedicineisaconceptwherepatientcarebecomeindividualizedbasedondistinctivecharacteristicswithhealthcareservicestailoredtoindividualvariationinriskandtreatmentresponse.Individualizedmedicineinvolvesthatpredictedtreatmentresponsestotreatmentwillbebasedonthe

individual’sgeneticmakeup.Individualswillbeclassifiedbeyondtheirbasicdiagnosisaccordingtodiseasesusceptibilityorexpectedresponsivenesstotreatmentenablingtargetedinterventionspotentiallyprovidingbetterefficiencyofexistingtreatmentsandfewerorlesssevereside‐effects.Medicinewillbe

givenmoreeffectivelyandnewtreatmentstrategiesingeneralcanbeinvestigatedreducingcostormakingtreatmentprogramsmorecost‐effective.However,personalizedmedicinerequiresmorespecializedandmoreintensivediagnosticproceduresandmayinducecostsforgeneticcounselingandnewtypesof

medicalcare35.Also,thereremainsaconsiderableneedforresearchbeforepromisingtechnologieshaveprovidedevidencetobeimplementedincommonpractice36.Advancesinstratifiedtherapeuticanddiagnostictestsinvolvedevelopmentofnewtherapeuticapproacheswithuseofinnovativecompounds

usuallyincreasingcosts(andimprovingquality)oftreatment.Itisunsurehowcostlyandcost‐effectivethedevelopmentpersonalizedmedicineisbutitwillsurelybeoneofthechallengesinthefuturehealthcaresystemintermsofcost,cost‐effectiveness,needforprioritizationanddemandforspecializedresources.

Anotherchallengewillbethepotentialfuturedevelopmentswithincelltherapy,treatmentswithstemcellsandnewdrugsfacilitatingnewtreatmentsputtingevenmorepressureonthefundingofthepublichealthcaresystem.

Diagnosticsisthekeytopersonalizedmedicine37,38,atailoredapproachtotreatmentbasedonthe

molecularanalysisofgenes,proteins,andmetabolites.Yetalthoughthisapproachhasgeneratedmuchexcitement,fewpersonalized‐medicinetestshaveachievedhighlevelsofclinicaladoption.Wearealreadyseeingthatnewdepartmentsofmolecularmedicinearebeingaddedtotheeverincreasingnumberof

specialties.Forinstance,theuniversityhospitalinSkejbyinMarch2009openedamolecularmedicaldepartment39providing,amongotherthingsdiagnosticmoleculartests.Similarly,itispossibletoobtainauniversitydegreeinmolecularmedicine,e.g.attheUniversityofAarhus40.Massspectrometryisan

analyticaltechniquethatisusedfordeterminingtheelementalcompositionofforinstancemoleculesandforelucidatingthechemicalstructuresofmolecules.Hence,accesstosuchtechniquesisanimportantprerequisite.Inotherwords:thefutureisalreadyhereandnewtreatmentpossibilitiesarereadytotake

Inarecentarticle37itwasnotedthattherearethreemainobstaclestotheadvancementofpersonalizedmedicine:scientificchallenges(apoorunderstandingofmolecularmechanismsoralackofmolecular

markersassociatedwithsomediseases,forexample),economicchallenges(poorlyalignedincentives),andoperationalissues.Althoughscientificdifficultiesremain,theeconomicchallengesandoperationalquestionsnowseemtobethebiggesthurdle.

Davisetal37notesthatinvestorsandanalystshavesuggestedthatpersonalizedmedicinecandramatically

reducehealthcarecosts.Yetmostpayershavebeenslowtoinvestinpersonalizedmedicine.Leadersinpayerorganizationssaythatseveralfactorscouldexplainthisreluctance.First,itishardtoidentifywhich

teststrulysavecosts.Second,thebeliefthatitisdifficulttotrackmuchearlier‐stageandexperimentaltestingleadstofearsthatalthoughindividualtestsmaynotbeveryexpensive,theoveralleventualcostscouldbeunjustifiablyhigh.Athirdconcernisthedifficultyofenforcingstandardprotocolstoensurethat

physiciansfollowthroughwithappropriatepatientcarebasedontestresults.Fourth,testinformationcouldbemisused—particularlyintheearlystagesofinvestigationanddevelopment—whichcouldharmpatients.Finally,thereisnolongitudinalaccounting,whichwouldenablepayerstocapturelong‐termcost

savingsfromnear‐termtesting.

NewtechnologiesThereducednumberofhospitalbedexperienceinallwesterncountrieshasbeenenabledbybetterplanningoftreatmentsandlatelybynewtreatmenttechnologiesfacilitatinglessinvasivetreatmentwherepatientscanbedischargesearlierortreatedinoutpatientsettings.Thelasttwodecadeshavealsooffered

newdevelopmentsoftelemedicineandnewITinfrastructuresassistingmoreefficienttreatmentpatterns.Withanagingpopulationwithfewerpeopleintheworkingforcemoreagreatershareofthepopulationwithneedoftreatmentthesenewtechnologies,whereonlyafewoftheexistingtechnologiesare

implementedatthemoment,maybeoneofthefuturecontributionstosustaininganefficientandsustainablepublichealthcaresector.Theseassistingtechnologiesmayaddressdifferenttypeofissues.1)Onetypeoftechnologyisrelateddirectlytotreatmentofpatientssuchastelemedicinewithdirector

indirectcommunicationbetweenpatientandhealthcareprofessionalswhichmayreducecostorincreasequalityofcareefficientlyaddressingnotonlythelongerdistancestohospitalsbutalsothepopulations’risingexpectationsforresponsiveness.Anothertypeoftechnologyisforinstancerobotassisted

surgery(Barbash,2010;Lotan,2004;Patel,2009).2)Anothertypeoftechnologyfacilitateefficientuseofexistingresourcesbymoreefficientcommunicationormoreefficientuseofcapacityacrossdifferentgeographicalsits.3)FinallynewITtechnologiesmayfacilitatemoreefficientuseofinformationforpresent

treatmentbutalsofortreatmentplanningandcommunication.Sincethisareawillbedescribedasoneofoursolutionswewillnotcommentthisfurtherhereexceptfortheobservation,thatthereappearstobesignificantpotentialasonlyalimitednumberofexistingtechnologieshavebeenimplementedsofar.

Newtechnologiescanbeofthreetypesfromaneconomicperspective:a.Dotheysubstituteexisting

treatments,i.e.better(andlesscostly?),b)aretheycomplementarytoexistingtreatmentenhancingtheclinicaland/oreconomicvalue,andc)newinthesensethattheyhavenotbeenavailableearlier.Thereisnodoubtthatthefuturewillholdexamplesofallthree,butmostlikelywithfocusonc)withlikelycost‐

expansionofhealthcareexpenditures.However,inviewoftheideaofthepresentSWOT‐analysis,itwouldbedesirablethatopportunitiescanalsobeseenaspartofthesolutiontothechallengeslisted.Thismeansthatfromthisperspectivetheinterestingnewtechnologiesshouldbesubstitutes,pointainthelist.

ExpectationsandcompetenciesofthepopulationparticipationandselfcareInlinewiththetechnologicaldevelopment,thepopulations’competencies,willingnessandexpectationstobeinvolvedintreatmenthaveincreased.Foranincreasingnumberofchronicpatientstreatmentsaretoahighdegreedependentonpatients’self‐careandactiveparticipationinnotonlytreatmentbutinactively

changinglifestyle.Thewillingnessandexpectationtoparticipateactivelyhaveresultedinmanynewtreatmentandpreventivestrategiesinvolvingindividualcoaching,grouptraining,selfcaretechnologiesfor

monitoringetc.whichempowerpatientswithcompetenciesandself‐caretoadegreewheretheydonotconsiderthemselvesas‘patients’41.

Havingemphasizedthemanygooddevelopmentsintheseareasthereisstillneedforprovidingevidenceformanyofthesetreatmentstrategiesaswellasaneedfordevelopmentofstrategieswhichwork

efficientlyforlowersocialgroupswhichseemnottobeefficientlytargetedwiththepresentinitiatives.

Strengths

PatientrightsAnumberofinitiativeshavebeenintroducedtostrengthenpatientrightsinthehealthsystem42.The

NationalBoardofHealthisinchargeofsecuringthepatients’dignity,integrityandrightofself‐determination43.In1992,alawwaspassedonpatientrights,whichobligesdoctorstoinformpatientsoftheircondition,treatmentoptions,andtheriskofcomplications.Italsoprohibitsdoctorsfrominitiating,or

proceedingwith,anygiventreatmentthatisagainstthewillofthepatient(unlessmandatedbylaw).Inaddition,thepatienthastherightnottoreceiveinformation.Thislawwasextendedin1998,regulatingthebasicandgeneralprinciplesoftheindividualpatient’srightofself‐determinationandpublicsecurity

relatedtothehealthsystemandregardingmedicalexamination,treatmentandcare.Issuescoveredarethepatient’srighttocontinuousinformation,whichisadaptedaccordingtoageandthedisease(s),giventhroughoutexaminationsandtreatmentandcommunicatedwithrespecttothepatient.Furthermore,the

rulesalsodeterminedoctors’rightstoshareinformationwiththirdparties,togivepatientsrightofaccesstodocuments,toholdcaserecordsandtohavetotalprofessionalconfidentiality44.

Thegeneralaimsofthepatientrightsregulationaretohelpensurethatthepatient’sdignity,integrityandself‐determinationarerespected;andtosupportthetrustrelationshipsbetweenthepatient,thehealth

systemandthevariouspersonnelinvolved.Theactalsocontainsrulesoninformationaboutconsentandlifetestimonials,andinformationregardingpatientcasesandprofessionalconfidentiality,alongwithaccesstohealthinformation45.

Thechoiceandwaitingtimeguaranteesarepatientrightsofadifferentkind.

Choiceandwaitingtimeguarantees

ChoiceofprimarycareSince1973residentsovertheageof16havebeenabletochoosebetweentwocoverageoptionsknownasGroup1andGroup2.ThedefaultisGroup1andapproximately99%oftheDanishpopulationwereinthisgroupin200446.Group1membershavefreeaccesstogeneralpreventive,diagnosticandcurativeservices.

Patientsayconsultemergencywards,dentists,chiropractors,ear,noseandthroatspecialistsorophthalmologistswithoutpriorreferral,buttheirGPmustreferthemforaccesstoallothermedicalspecialties,physiotherapyandhospitaltreatments.ConsultationwithaGPorspecialistisfreeofcharge,

whiledentalcare,podiatry,psychologyconsultations,chiropracticsandphysiotherapyaresubsidized.Patientsseekingcarefromspecialistsotherthanear,noseandthroatspecialistsorophthalmologists,andwithoutaGPreferral,areliabletopaythefullfee.AnindividualmaychangeGPsforanominalfeeatany

InGroup2,individualsarefreetoconsultanyGPandanyspecialistwithoutreferral.TheregionwillsubsidizetheexpensesuptothecostofthecorrespondingtreatmentforapatientinGroup1.Thesamerulesapplytotreatmentbypodiatrists,psychologists,dentists,chiropractorsandphysiotherapists.Hospital

treatmentsarefree.Onlyaminorityofthepopulation(1%)choosesthisgroup,probablyduetothelevelofgeneralsatisfactionwiththereferralsystem.

ChoiceofhospitalsAlegislativereformin1993gavepatientsthefreedomtochoosetobetreatedatanyhospitalinthecountryaslongastreatmenttakesplaceatthesamelevelofspecialization.Thisisinaccordancewiththefundamentalprinciplethathealthservicesshouldbeprovidedatthemostappropriatelevelof

specialization(i.e.lessspecializedcasesshouldnotbereferredtomorehighlyspecializedunits).Thislegislativereformwasakeysteptowardsallowingpatientsmoreinfluenceovertheircareandtreatment.However,accordingtoanationalstudy,whichassessedtheimpactofthereform,patientsprefertreatment

closetotheirplaceofresidence,whichcontradictstheoriginalintentionofthereform47.

In2002,anewpieceoflegislationregardingwaitingtimeguaranteeswasimplemented.Patientswhoarenotofferedtreatmentatpublichospitalswithintwomonthsofreferralarefreetochoosetreatmentatprivatehospitalsorclinicsanywhereinthecountryandathospitalsabroad.In2007,thisguaranteewas

changedtoonemonthasof1October.Thenon‐publictreatmentexpensesarepaidbythepatient’sregion.Asapreconditionfortheuseoftheextendedfreechoice,thechosennon‐publichospitalorclinichastohaveanagreementwiththeregion46.

Average”experienced”waitingtimesforplannedhospitaloperationshavefallenfrom90to57daysinthe

period2001‐2005andhasbeenrelativelystableatthislevelsincethen,althoughwithaslightincreasein2008and2009.Themeasureof”experienced”waitingtimeisafterthediagnosisisdeterminedandwithoutpatientinducedwaitingtime2.

Waitingtimesforlifethreateningdiseasessuchascancerareconsiderablylowerastheyareinessence

treatedasacuteconditions,andalsosubjecttospecific“carepackages”definingthemaximumwaitingtimeforallpartsofthetreatment.

87%ofthepatientsadmittedtohospitalforplannedproceduresin2006wereawareoftheirrighttochoosehospital.–46%indicatedinasurveyin2006thattheyhadactivelychosenthehospitalonwhich

theyweretreated(thisincludeschoiceoflocalhospitals)2.

Around60.000patientsweretreatedaccordingtothewaitingtimeguaranteein2009.Thetotalnumberofplannedoperationsin2009was660.0002.

Highpatientsatisfactionandtrust Patientsatisfactionisgenerallyhighandhasremainedonahighlevel,andisalsohighcomparedtootherpublicsectors.Around90%aresatisfiedwiththeirinpatientstayoroutpatientvisit26.Around20%ofthe

populationhascontactwithhospitalthroughoutayearandthehighlevelofsatisfactionforpublichospitalthereforeprovidesgreatlegitimacytothepublichospitalsinthepublicdebate.However,thepublicdebate

alsocontainstheindividualcasewithcriticalanderroneoushandlingoftreatmentorcommunication.InadditionthenumberofpatientcomplaintshandledbythenationalPatients’BoardofComplaints’has

increasedfrome.g.3,312newcasesin2005to4,235newcasesin200948.Thisincreasingnumberofcomplaintscannotunambiguouslyinterpretedwhiletheincreasingratemayillustratenotonlychangesinexpectationstotreatment,treatmentoutcomesandcommunication;changesingeneraltrusttothehealth

caresystem;changesinpopulation’sattitudestoauthoritiesandchangesinactualdeliveredquality.Thenumberofpatientcomplaintsis,however,stillconsideredtobeonalowlevelcomparedtotheoverallnumberofcontacts.

Easyaccessinprimarycare,incl.gatekeeperrole

OneofthemajorstrengthsemphasizedinaSWOTanalysisbyaninternationalteamin1999wastheeasy

accesstogeneralpractice49‐51.Theefficientmixoffee‐for‐serviceandcapitationreimbursement,thewell‐organizedpatient‐listsystemandthegatekeepingbyGPswereemphasizedtoprovidenotonlyeasyandquickaccesstoprimarycareservicesbutalsotocontributetokeepingtreatmentonthelowesteffective

costlevel.ThecurrentGPsystemhasexperiencesveryfewandonlyevolutionarychangesinthelastfourdecadesandhasonlyrecentlybeenchallengeswithminorchangesduetolackofGPsinsomeareasofDenmark.Thenumberofconsultationshasincreasedwitharound2%yearly(adjustedforpopulationsize

anddemographics)overalongperiodandthishasincreasedtheexpenditureforGPs.TheexpenditureforGPsasrelativeashareoftotalhealthcareexpenditurehasremainedrelativestable.

Thelatest2011contractwithGPsopensupforregionstosetuptheirownclinicswithpubliclyemployedGPstocopewiththeshortageofGPsinoutlyingareas.SofarGPsexclusivelyhaveworkedasprivate

entrepreneurswithapubliccontract.Thismaysignalachangeintheinstitutionalorganizationofthissectorbutthechangeswillonlyhavemarginalinfluenceintheshort‐runonthegeneralorganizationofGPswhiletheprivateentrepreneurialsystemstillisconsideredtobeaverycostefficientsystemcomparedto

otherinstitutionalorganizationofmodeofprovision.Also,thesamecontractopenedupfortheselfemployedGPstoestablishbranchfacilities,typicallyinoutlyingareas,andtostaffthemwith‘employee‐GPs’,i.e.changingtherulethatGPsshouldbeself‐employed.Thischangemaycounteractthepossiblyfor

publicrunGPsurgeries.

(Reasonable)expenditurecontrol,includingefficiencyandreimbursementsystemsThereisastrongandunrelentingpressureonthecostofhealthcaresystemsallovertheworld.Risingincomelevelsandeverimprovingornewmethodsoftreatmentarethemainexplanations,butnotuptillnowdemography.ByinternationalstandardsthegrowthrateforhealthexpendituresinDenmark,

however,islow.Figure6and7carrythisoutclearly.Thisraisesseveralquestions:Hastheannualincreasesbeentoolow–onaverage2.8%forthepast10years?Whatarethelikelyexplanationsofthe

tightexpenditurecontrol?

Astothefirstquestionitisimpossibletoansweryesorno.Theanswerdependsnotonlyontheperspective,i.e.pressuregroups,politicians,theaverageuseretc.,butalsoonassessmentofwhethernewandimprovedtreatmentshavebeenmadeavailablenottoolongafterinternationalavailability.Overall

thereisnoreasontobelievethatDenmarkhasbeenfarbehindintheintroductionofnewtreatments,althoughexceptionscanbefound.Seealso‘weaknesses’wherethequestionoftootightbudgetsisalsodiscussed.

Takentogetherthreemainexplanationsofthelowgrowthratecanbegiven:

• budgetcapsnegotiatedannuallybetweenthegovernmentandtheregionalauthorities

• productivityincreases

• reasonablywellfunctioningreimbursementsystems.

Intaxfinancedsystemsthedevelopmentofhealthexpendituretoaconsiderableextentistiedtothemacroeconomicdevelopment.Thisisreflectedinannualbudgetnegotiationsbetweengovernmentandtheregionsabouttheeconomicframes/budgetcapsfortheupcoming.Basicallygovernmentwillenterthe

negotiationswithaneyetooveralleconomyandthelevelandgrowthrateofpublicexpendituresingeneral.Fromtheperspectiveofeconomiststhisisastrengtheventhoughthegrowthratehasexceededthatoftheeconomyformanyyears.Inadditionitistoaconsiderableextentabindingbudgetconstraintin

thesensethatbudgetoverrunstypicallyhavetobepickedupthefollowingyear.

Intheannualbudgetnegotiationsannualproductivityincreasesarealsoestablished:Usuallytwopercentperyear,meaningthatinthiswaymoreroomiscreatedforanincreasedactivitylevelinadditiontotherealincreaseofresourcesavailable.

Thecappedsectoralbudget,a‘hard’budgetconstraint,andproductivityrequirementhasledtoa

reasonablegoodproductivityrecordforthehospitals,figure16.

Figure16:Cumulativeproductivitygrowth2003‐209forhospitals(strikein2008)52

Introductionof‘packages’forcancerandcertaincardiacconditionsandfasttrackissueThefasttrackapproachforhospitalcareforcancerpatientsandcertaingroupsofpatientswithcardiovasculardiseaseshasimprovedpatientsatisfactionandqualityoftreatment,becausethefasttrackapproachisbasedonminimizingdelaybetweenservicesandcareistightlycoordinated53.

Inbothcasesthefasttrackapproachwasintroducedbecauseitwasfairlycommonknowledgethatfor

bothgroupsofpatientwaitingtimemightbeharmfultohealth(diseaseprogress).Itisnoteworthythatthechangewasbroughtaboutbyalawmakingitapatientright,althoughoneprovincialhospital(VejleSygehus)hadpioneeredtheapproach,buttakeupatotherhospitalswasslow.

Atthecoreofthefasttrackthinkingislogisticthinking,includingbookingacrossdepartmentalboundariestoensurecoordination.Professionallyitrequiresadescriptionofwhichservicesshouldbeprovidedandthetimesequenceoftheseservices.

InMarch2010ariderwasaddedtothefasttrack,namelythatpatientsnowhavetherighttohavea

‘pathwaycoordinator’,i.e.apersonwhocoordinatescareforthepatient

Asmentionedthisapproachisanimprovementfromthepatientperspectiveandalsosupportedbyscientificevidence.Otherareascouldtakeadvantageofthesamethinking.

Workinprogresson(coherent)patientpathwaysMuchtreatmentandrehabilitationconstituteachainofservicesofferedbydifferentprovidersandauthorities.Typicallythereisatriangle:Hospital–generalpractice–municipality‐occasionallycalledthe

BermudaTriangletoindicatepoorlycoordinatedcare.Inthe2009surveyofpatientexperiencealmost20%ofthepatientsfoundthattheirGPhasbeentoobadlyinformedbythehospitalandforthecooperationhospital–municipality17%foundthatcooperationhadbeenverybadorbad54.Unfortunatelythereisno

informationonhowmunicipalitiesandGPscooperatedwiththehospital.

The2007healthcarereform(amalgamationofthecountiesinto5regionsandmoremunicipalinvolvementinhealthcare)alsointroducedtheso‐called‘healthagreements’wherehospitals‐‐GPsandmunicipalitiesagreeonforinstancestandardsfordischargefromhospitals,onproceduresforhospitaladmissionetc.All

ofthishasthepotentialforbettercoordinationofpatientpathwayswhentreatmentbymentionedproviderisinvolvedinthepatientpathway.

Coordinationgraduallybecomebetterandtheuseofhealthagreementsand‘pathwaycoordinators’maybethewayforwardinareawherethepast25yearshaveseenvariousinitiatives–mostwithoutgreat

effect.

Increasedfocusonpalliativecare/endoflifecareTheterminalstagesoflifeareattractingincreasingattentionaswitnessedbypalliativeteamsandhospices.Thefirsthospicewasestablishedin1992atSkt.LucasStiftelsen.AsofOctober2010therewere17hospiceswithatotalof196beds55.Todayhospiceiscoveredbythefreechoiceofhospitalanditisfreeto

thepatientprovidedthatreferralcriteriaarefulfilled.In2009thepriceperbeddayatahospicewasaroundDkr.4,500(DanskeDiakonhjem).

WHOdefinespalliativecareasanapproachthatimprovesthequalityoflifeofpatientsandtheirfamiliesfacingtheproblemassociatedwithlife‐threateningillness,throughthepreventionandreliefofsufferingby

meansofearlyidentificationandimpeccableassessmentandtreatmentofpainandotherproblems,physical,psychosocialandspiritual.Palliativecare:

• providesrelieffrompainandotherdistressingsymptoms;

• affirmslifeandregardsdyingasanormalprocess;

• intendsneithertohastenorpostponedeath;

• integratesthepsychologicalandspiritualaspectsofpatientcare;

• offersasupportsystemtohelppatientsliveasactivelyaspossibleuntildeath;

• offersasupportsystemtohelpthefamilycopeduringthepatientsillnessandintheirownbereavement;

• usesateamapproachtoaddresstheneedsofpatientsandtheirfamilies,includingbereavementcounseling,ifindicated;

• willenhancequalityoflife,andmayalsopositivelyinfluencethecourseofillness;

• isapplicableearlyinthecourseofillness,inconjunctionwithothertherapiesthatareintendedto

prolonglife,suchaschemotherapyorradiationtherapy,andincludesthoseinvestigationsneededtobetterunderstandandmanagedistressingclinicalcomplications.

Palliativecareisespeciallydirectedatpatientswithcancer,althoughtheprinciplesareapplicableforotherdiseases.Atpresentthereare16palliativeteamsandtwohospital‐basedpalliativeunits.

Theideaofpalliativeteamsandhospicescanbeboileddowntothetitleofarecentarticlebythe

acknowledgedwriterDr.AtulGawande:‘Lettinggo.Whatshouldmedicinedowhenitcan’tsavelives’56.Inarecentreportitwasnotedthatfewnations,includingrichoneswithcutting‐edgehealthcaresystems,incorporatepalliativecarestrategiesintotheiroverallhealthcarepolicy—despitethefactthatinmanyof

thesecountries,increasinglongevityandageingpopulationsmeandemandforend‐of‐lifecareislikelytorisesharply57.

Althoughmuchhashappenedthepast10yearsarecentanalysisofwhatmanywouldfindanoffendingterm,thequalityofdeathindex(essentially,whathasbeencalledpalliativecareabove9placedDenmark

on22ndplace57.

Oneofdilemmasiswhereterminalcarebesttakesplace:inthehomesupportedbyapalliativeteam;inanursinghome;inahospiceorinaspecialhospitaldepartment.ThereportfromtheEconomistsIntelligenceunit57alsonotesthatfewnations,includingrichoneswithcutting‐edgehealthcaresystems,incorporate

palliativecarestrategiesintotheiroverallhealthcarepolicy—despitethefactthatinmanyofthesecountries,increasinglongevityandageingpopulationsmeandemandforend‐of‐lifecareislikelytorisesharply.InviewoftheDanishdemographicdevelopmentandthesocial,healthcostsduringthefinalyears

oflifeandthesomewhatunclearlocationoftheresponsibilityforprovidingpalliativecareanationalstrategyisneeded.

ConsiderableinvestmentsinnewhospitalsThegovernmentin2007announcedthat25billionDkr.hadbeenreservedforbuildingofnewhospitalsandrenovationofexistingfacilities.Thisisthelargestinvestmentprogrameverforhospitals.Inadditionto

the25billioncameanestimated15billionfromtheregionsfromsalesofoftencentrallylocatedproperties.Thusatotalof40billionDkr.willbeinvestedoverthecomingdecade.

ThebackgroundforthismassiveinfusionofmoneywasthereorganizationJanuary1,2007leadingtotheamalgamationofthe14countiesinto5regions.Thecountiesandnowtheregionshad/havethemainresponsibilityforrunningthehealthservice.Thereorganizationnaturallyledtoregionalreorganizationsof

thehospitals.ThisinturnwasnecessitatedbyabrandnewmodelforemergencycarefromtheNationalBoardofHealth.Inthefuturefewerhospitalsshouldhave24/7/366emergencyadmission;Areductionfromaround40hospitalswithemergencyadmissionin2007to21inthecourseof5‐10years.

Figure17showshowtheinvestmentfundshavebeendistributedacross16hospitalprojects.Basically

threenewuniversityhospitalswillbebuilt(replacingexistingones)andtwonewmid‐sizehospitalswillalsobebuilt,andintwootherexistinghospitalfacilitieswillbeextendedsothattheyessentiallyare‘new’.

ThereisnodoubtthatthiswillstrengthentheDanishhospitalsystem.Therearecleardemandsforimprovedproductivityduetobetterphysicalfacilities,butthiscanonlybeachievedbycriticallylookingat

workroutines,patientpathwaysandpatientlogisticsingeneral.Hence,manyinterestingopportunitiesopenupwiththemassiveinvestmentprogram.Thechallengeforhospitalmanagementandclinicalmanagementistotakefulladvantageofthisuniquechanceforreorganizingahospital.

Figure17:Investmentsinneworrenovatedhospitals.Redmarksindicatehospitalwithemergency

admission

Strengtheningofprehospitaltreatment/careInthewakeofthehospitalrestructuringseveralhospitalswillclose–andmoreimportantly–withthe

centralizationofemergencyadmissionstheaveragedistancetoanemergencyhospitalhasincreasedconsiderably.Thisinturnhasledtoastrengtheningofthepre‐hospitalservice.

Overfewyearsthesystemhasbeenoverhauledandreorganized.Nolonger–andnotreallyforseveral

years–doesanambulancejustsignifypatienttransport.Treatmentstartsintheambulance–eitherbyaparamedic,anurseoraphysician–andtheambulanceislinkedtothedesignatedemergencyhospitalso

thatthehospitalisadvisedabouttheconditionoftheincomingpatientortheambulancestaffcandialoguewithhospitalstaff.

‘Rendezvousmodelshavebeendevelopedasalternativetoambulancesstaffedwithphysicians,i.e.anambulancewithapatientismetbyamobileunitstaffedwithaparamedicorphysician.

Servicelevelshavebeenestablished,e.g.max.15minutesforanambulancetorespondtoanemergency

call.Thisismonitoredcloselybyallregions.

Anewset‐upfordispatchingambulanceandmobileunitshasalsobeendeveloped.Therehasbeenconsiderableattentiontodevelopingmodelsofpre‐hospitalservicetooutlyingareas,includingahelicopterset‐up.

Anissuenotyetresolvedwellisthecooperationwith24/7servicesprovidedbyGPs(out‐of‐hoursservice,

from4.p.m.to8.a.monweekendsand24hoursonweek‐endsandholidays).ThisisasystemorganizedbytheGPsthemselves,buttheco‐operationbetweenthissystemandthelargelyhospitalbasessystemoutlinedaboveneedtobeimprove.

QualityassuranceandmonitoringOverthepasttwodecadesqualityissuesinhealthcarehascometothefore.Thebackgroundwasa

negativeone,namelythatiswasrealizedthatmanypatientsdiedorhadtheirhospitalizationprolongedbecauseoflowtreatmentquality(wrong,insufficientornotstateofthearttreatment).Towitness:InDenmarkitwasestimatedthat1,500–2,000personsdiedduetoadverseevents,thatmedicationerrors

notonlycausesuntimelydeathsbutalsoprolongedhospitalstaywithupto7daysontheaverage,andthat8‐10%ofhospitalizedpatientsacquireaninfection.58TodayDenmarkisintheforefrontregardingqualityassuranceandmonitoring–butnotnecessarilyintermsofactuallymeasurablequalityoftreatment.

Anationalprogramhasbeenestablished.TheDanishHealthcareQualityProgram,DDKM,isamethodto

generatepersistentqualitydevelopmentacrosstheentirehealthcaresectorinDenmark.TheDanishHealthcareQualityProgram,DDKM,providesforstandardsofgoodquality–andofmethodstomeasureandcontrolthisquality.Assuch,DDKMdoesnotguaranteeahighlevelofquality,butenablesprovidersof

healthcaretomonitorand(partially)controltheirqualitylevel.

TheobjectivesoftheDanishHealthcareQualityProgramare59:

• Toavoiderrorscausinglossoflives,qualityoflifeandresources

• Toensurethatknowledgeachievedviaresearchandexperienceisutilizedinallbranchesofthehealthcaresector

• Todocumentworkperformed

• Toachievethesamehighqualityacrossgeographicalboundariesandsectors

• Togeneratecoherenceincitizens’pathwaysacrosssectors–e.g.inthetransitionfromhospitaltolocalhealthcare

• Torenderqualitywithinthehealthcaresectormorevisible

• Toavoidthatallinstitutionsmustinventtheirownqualityassurancesystem

• Tostrivetowardsexcellence–allthetime

TheDanishHealthcareQualityProgramisbasedonthequalitymethodknownasaccreditation.Thebasicprincipleofaccreditationistodetermineaminimumlevelofgoodqualitywithinanumberofareas,whicharefollowedupfortheirlevelofcompliance.Thefaultsandomissionsdiscoveredintheprocessareused

asanempiricalbasistoimprovequality.AllprivateandpublicDanishhospitalsmustbeaccredited–andthefirstoneshavesuccessfullypassedtheaccreditationprocess.

Therehasbeendebateaboutthevalueofaccreditation,inpartbecausethe(economicandclinical)benefitsarehardtodocument,inpartbecauseitinvolvesquiteabitofpaperwork(“bureaucracy”)60,61.A

roughestimateofthecostsofimplementingtheDDKMisbetween0.7–1billionDKr.‐equaltolessthan1.5%oftotalhospitalexpenditures62.Thebenefits–tobedocumentedsystematically–willcomefromthesavingsduetobetterqualityofcare.

TheDanishNationalIndicatorProject,NIP,willbeintegratedintoDDKM,aswilltheannualsurveysof

patientexperiencedquality3sothatmuchofsignificantongoingqualityinitiativeswillgraduallybecomeanintegratedpartofDDKM.

TheDanishNationalIndicatorProject,NIP,63,64wasestablishedin2000asanationwidemultidisciplinaryqualityimprovementproject.From2000to2002,disease‐specificclinicalindicatorsandstandardswere

developedforsixdiseases(stroke,hipfracture,schizophrenia,acutegastrointestinalsurgery,heartfailure,andlungcancer).Todaydiabetes,depression,birthandchronicobstructivepulmonarydisease(COPD)havebeenadded.TheNIPmodelwillbecomeanintegratedpartoftheDanishHealthcareQualityProgram,

Indicatorsandstandards,seefigurebelow,havebeendevelopedandimplementedinallclinicalunitsanddepartmentsinDenmarktreatingpatientswiththesediseases,andparticipationismandatory.Allclinicalunitsanddepartmentsreceivetheirresultseverymonth.Nationalandregionalauditprocessesare

organizedtoexplaintheresultsandtoprepareimplementationofimprovements.Allresultsarepublishedviawww.sundhed.dkinordertoinformthepublic,andtogivepatientsandrelativestheopportunitytomakeinformedchoices.

Anoteworthyfeatureofthesystemisseenintherighthandcolumnofthefigure.Alltheindicators(of

goodcare/treatment)arebasedongradedscientificevidence.Thepictureforstrokeisnotunusual,i.e.noteverythingthatisdone–andoughttobedone–isfirmlybasedonscientificevidence.Itisnotanargumentagainstdoingitbutcautionsustowardthelackofsolidevidenceandwheremoreresearchis

needed.

ReportingfromNIPtakesplaceinaframeworkliketheoneshowninfigure17Awithinformationfromthepreviousreportingperiodstobeabletotrackchanges.Table2hasbeenpulledtogetherfromthe2009reportonstroke65,66,includingnewindicatorscomparedtofigure17A.Thesystemiscontinuallybeing

refinedandimproved.Table2hasincludedasanillustrationonly.Theoriginalsourcesshouldbeconsulted

forfullexplanationoftheindicators.‘Standard’istheprofessionaljudgmentofhowmanypatientsideallyshouldreceivetheserviceinquestion(insomeareasitisasubsetofstrokepatients).

Figure17A:Theframeworkforthenationalindicatorproject,NIP

Source:Mainzetal.63

Table2:Qualityreportingforstroke,2009and200765,66.

Indicator StandardFulfilled(2009) 2009 2007

Strokeunit(within48hours) 95% yes 91 85

Antiplatelettherapywithin48hours 95% no 88 87

Oralanticoagulanttherapy 95% no 73 77CT/MRIscanatdayofhospitalization 80% no 71 62

AssessmentbyPhysiotherapistwithin48hours 90% no 75 70Assessmentbyoccupationaltherapistwhitin48hours 90% no 72 66

Nutritionalriskevaluation 90% no 69 66Waterswallowingtestatdayofhospitalization 90% no 61 55Ultrasound/CT‐angiography,neckartery,withinfourdays 90% no 52 35

Mortalitywithin30days 15% yes 11 11

All‐or‐none 25 21(in2008)Note:thenumberofpatientsincludedvariesbyindicator.Atotalof11,421wasavailable,

i.e.asubstantialnumberofpatients.‐11,281wasusedforthefirstindicatorwhilethesubsetofrelevantpatientsofindicatornumber2was7,441etc.All‐or‐none’referstopatientswhoreceivedthefirst9services.

Thegoodnewsisthatoverallthereareimprovementsfrom2007to2009.Atamorenegativelevelonlytwostandardsoutof10arefulfilled.Now,insensationaljournalism,thiswouldbepresentedas‘scandalous’.Butbeforetoohastyconclusionsoneshouldforinstanceconsidertheevidencelevel,the

circumstancesthatoccasionallymakesitdifficultifnotimpossibletocarryouttheproceduresetc.Notinorderto‘apologize’butinordertounderstand.

Thenextquestionis:Whatistheeffectofcompliance(fullorpartial)withthestandards?Atageneralleveltheanswerisbetterpatienttreatmentandcare.Atamoredetailedandrelevantlevelonewouldwantto

know:Doesitsave/increaseuseofresources?Itisoftenclaimedthatgood/betterqualitycostsmore–butisitsosimple?Secondly,doesmortalitydecrease,andifnotmortalitydoesthephysicalandmentalfunctioningincreaseifall9pointsintable2arefulfilled.Atpresentallofthisitisnotwellexplored,butfor

strokethereareatleasttwoarticlesaddressit.Svendsenetal67lookedattherelationshipbetweendegreeoffulfillmentofstandardsandlengthofstay,LOS..TheyconcludedthatthemedianLOSwas13days.MeetingeachqualityofcarecriteriawasassociatedwithshorterLOS.Thesizeofthereductionwas

between13‐33%.TheassociationbetweenmeetingmorequalityofcarecriteriaandLOSfollowedadose‐responseeffect,thatis,patientswhofulfilledbetween75%and100%ofthequalityofcarecriteriawerehospitalizedaboutone‐halfaslongaspatientswhofulfilledbetween0%and24%ofthecriteria.Palnumet

al68lookedatqualityofcareandshort‐termmortalityforstrokepatients.Theirfindingscanbesummarizedsothat:elderlystrokepatientsinDenmarkreceivealowerqualityofcarethandoyoungerstrokepatients,however,theage‐relateddifferencesaremodestformostexaminedquality‐of‐carecriteriaanddonot

appeartoexplainthehighermortalityamongolderpatients

Withthisextendedstrokeexamplewehaveattemptedtoshowhowqualityismonitored,resultsandimprovement,andconsequencesintermsoflengthofstayandmortality.ThereisnodoubtthatDenmarkisinfront.Therehasbeensomecriticismabout‘bureaucracy’surroundingqualitymonitoring.Itistruethat

collectingthedatadoesconsumeresources.However,inviewofthebenefitstopatientsandthehospitalsthereisnodoubtthatincost‐benefittermsitismoneywellinvested.However,itisimportantwithmoreresearchofthetypementionedintheprecedingparagraph.

WellfunctioningmultileveldemocraticstructuresforintegrateddecisionmakingandimplementationAllpublichealthsystemsneedasteeringstructureforallocationofresources,implementationofpolicy

initiativesandcontrolofaccountability.TheDanishsystemisorganizedasamultilevelgovernancestructurewithstate,regionsandmunicipalities.Theregionsplayacrucialroleinorganizinganddeliveringspecializedcurativehealthcareservices,whilethemunicipalitiesareinchargeofmostpublichealth,

rehabilitationandlongtermcareservices.Thestatesetstheformalframeworklegislationandfinanceshealthcare.Inadditiontolegislativemeasuresthereisalongtraditionforinteractionbetweenthelevels

throughannualnegotiationsandagreementsonbudgetarymatters.Thebudgetaryagreementsdefinetheoverallexpenditurelevels,andspecifymorespecificinitiativesandtargets.Thereareregularfollowupmeetingsonimplementationprogressandresultsin‐betweenagreements.Theprocessofentering

agreementshasservedrelativelywellasamechanismforcoordinatingcentralfinancingandregional/municipalactivitylevels.Theagreementsalsoserveasaplatformforconsensus‐buildingonneworganizationalprioritiesinthesector.Theformalnegotiationstructureissupplementedbyageneral

traditionforinvolvingdecentralizedauthoritiesincommitteesandcouncilsforreorganizationanddevelopmentofguidelinesandrecommendationsforthesector.Someobserversarguethatthestatehastakenonastrongerhandinsuchnegotiationprocessesoverthepastdecades,yetitstillappearsthatthe

variousnegotiationarenasandprocessesbetweenthestateandregional/municipalactorsrepresentareasonablywellfunctioningmechanismforco‐developmentandcoordinationofpolicyinitiatives.

Thefollowingexamplesofpolicyimplementationsillustratetherelativelywell‐functioningmultileveldecisionstructures:1)theimplementationofacomprehensive“TheDanishHealthcareQualityProgram,

seeabove.Themodelamalgamatedseveraldecentralizedinitiativesintoacomprehensivenationalmodelbasedonacombinationofaccreditationandnationalqualitydatabases.Theannualbudgetnegotiationswereimportantarenasforthedecisionprocessonthe“DanishModelforQualityAssessment”69,2)the

extensivetransformationfromin‐hospitalcaretooutpatientservices,whichhasledtosignificantreductionsinbedtime,andcost.Thetransformationhasbeenimplementedbytheregions,butsupportedbynationallevelpolicy,3)theimplementationofanewhospitalinfrastructure.Inacomparativelightthe

Danishhealthsectorhasshownagreaterabilitytomakestructuraladjustmentsthanseveraloftheneighboring.Thechangeshavetakenplaceafterdialoguebetweenthenationalandregionalauthorities,albeitwitharelativelystronghandfromthestatelevel.

TheStructuralreformof2007alsointroducednewinstitutionalstructuresforcoordinationbetween

regionsandmunicipalities.Theregionsarenowrequiredtoenteragreementswiththemunicipalitieswithintheregiononinteractioninregardstohealthcare–calledHealthAgreements.Theagreementsincludemandatoryelementsonadmissiontoanddischargefromhospitals,informationsharing,

coordinationofrehabilitationetc.TheagreementsarecurrentlybeingevaluatedbytheNationalBoardofHealthbutaregenerallyconsideredimportanttoolsforcoordinationinspiteofconflictingincentivesatthetwolevels70.

Weaknesses

Tensionswithinthedemocraticmultilevelgovernancestructure:Limitedvoterinterestandunclearroleforpoliticiansatdecentralizedlevels.InaprevioussectionwecharacterizedthemultilevelgovernancestructureforDanishhealthcareasreasonablywellfunctioning.Theargumentswerethatthesystemhistoricallyhasbeenrelativelygoodat

adaptingtonewcontingenciesinordertomeetmultiplegoalsofcostcontainment,qualityimprovementandinnovation.Yet,thispictureshouldbemodifiedwiththeobservationthatthereseemstohavebeengrowingtensionswithinthesystemoverthepastdecade.Thesetensionsbetweendecentralizedautonomy

andcentralcontrolculminatedinthestructuralreformof2007.Thereformcreatedfivenewregionsinsteadofthepreviouscounties,andatthesametimestrippedtheregionsoftheirrighttofinancetheiractivitiesthroughtaxation.Theregionsthusbecamefullydependentonthenationallevel,andmunicipal

co‐financingfortheiractivities.

Thesubsequentprocessofcreatingnewhospitalstructureshasalsorevealedastrongerwillingnessfromthecentralleveltodictatedecisionsatthedecentralizedlevel.Regionallydevelopedplanswereinseveral

casesrejectedbythenationalauthoritiesthattendedtoplaceahigheremphasisonanexpertcommitteeappointedbythestate.

Suchdefactoreductioninautonomyattheregionallevelislikelytoaffectthesupportfordecentralizeddemocraticgovernancenegativelyandtomakeitmoredifficulttorecruitnewmemberstotheregional

assemblies71.Moreover,suchongoingtensionsarelikelytonegativelyaffectthebroaderlegitimacyofthepublicgovernancestructure.Thismayinturnleadtofurtherreforms,andperhapsalsoacceleratethetendencytodemandsupplementaryoralternativeprivatesolutionswiththepotentiallynegativeeffectson

equalityandintegratedplanningdescribedintheabove.

AmbivalencetowardsstrengtheningofpreventionandhealthpromotionThestructuralreformin2007changedtheresponsibilityforprevention,treatmentandrehabilitationbetweenmunicipalitiesandregions72.Oneoftheareasbeingrestructuredwaspreventionandhealthpromotionwherethemunicipalitiesweregivenresponsibilityforandsomesupportingeconomicincentive

topromoteprimary,secondaryandtertiarypreventiveinitiatives.Essentiallythemunicipalitieshavesoleresponsibilityforprimaryprevention(lifestyle–and,intheparlanceoftheActtermed‘citizenorientedprevention).Thereisasharedresponsibilityfortertiaryprevention,e.g.typicallythechronicallyill.(inthe

terminologyoftheActtermed‘patientorientedprevention’)

Atthesametimemunicipalco‐financingwasintroduced.Basicallymunicipalitiespayacertainamounteverytimeoneoftheircitizensusesregionalhealthcareservices.Thus,inthiswaythelawmakershopedtogivethemunicipalitiesanincentivetolookformunicipalalternativestocertainregionalhealthcare

services,e.g.preventrepeatedhospitalizationsbystrengtheninghomeaid,homenursing,orpatientschoolsforchronicallyill.

Mostmunicipalitieshaveintroducedsomepreventionprogramsandcarriedoutsurveys,so‐calledhealthprofiles,tobuildtheirpreventionandhealthpromotionstrategyon;however,thereisstillconsiderable

ambivalencetowardsstrengtheningpreventiveprogramsandtheoptimallevelofpreventiveinitiatives.Theambivalencehasmanyexplanationssuchaslackofevidence,lackoffundinginthemunicipalities,lackofinfrastructure,lackofknowledgeorcompetencesinthemunicipalitiesandlackofeconomicincentiveto

promoteprevention.

Anumberofreportshavetriedtopointoutcost‐effectivepreventiveinitiatives73butthereisstillaconsiderableandprobablyin‐optimalvariationbetweenthemunicipalities.Thereexistsnocompleteorcomprehensiveoverviewofthepreventiveprogramsinthemunicipalities(Due2008;Hansen2008;Hansen

2010;KommunernesLandsforening2008;Sundhedsministeriet,2008),butwebelievethatthereisaconsiderable(butnotnecessarilyoptimal)amountalreadyallocatedbuttheuseofefficientpreventiveprogramsisatanin‐optimallowlevel,toacertainextentdocumentedbytheCommissiononPrevention74.

Withthecurrentfiscalsituation(aswellasthesituationinthenearfuture)forthemunicipalitiesitishardtobelievethatthepreventiveeffortwillincreasebutonecanhopethattheexistingfundingwillbeused

moreeconomicallyrationalonefficientpreventiveprograms.

Oneoftheconsiderableobstaclesinobtainingtheoptimallevelandmixofpreventiveprogramsistheconflictingeconomicincentivesfacingthemunicipalitiesresponsibleforpreventionandregionsresponsibleforprovidinghealthcareservices.The2007structuralreformhaveaddressedthisconflictingandtriedto

aligntheincentivesbymakingmunicipalitiespartlyresponsibleforfundingofthehealthcaresystemdependingonactualutilizationbythecitizensofthemunicipality.Theideawasthatmunicipalco‐fundingwouldprovidemunicipalitieswithanincentivetotrytodevelopalternativestoregionalhealthcarefor

certainpatientgroups,forinstancepatientswithchronicdiseaseslikeCOPD.However,mostconsidertheseeconomicincentiveseithertobetoolowintherelevanttreatmentareas,ortoogeneral,astheyincludeareaswherethemunicipalitiesinrealityhaveverylittleornopossibilitiesforsubstitution,e.g.pregnancies

orbrokenlegs75‐78.

AmbivalentattitudetowardsexplicitpoliticalprioritysettingTheneedforprioritizationinthehealthcaresystemisacknowledgedbynationalaswellasregionalpoliticians,thepopulationandbyhealthcareprofessionals.DespitethisgeneralrecognitionofthenoformalinfrastructureintheDanishhealthcaresectororauthoritiesfacilitatesmoreexplicitprioritization.

Someofthenationalauthorities,e.g.theNationalBoardofHealthandTheReimbursementCommitteeinTheDanishMedicinesAgency,dotakedecisionprioritizingreimbursementandimplementationofthenewtreatmentsbuttheprioritizationisneitherexplicitnortransparent.InthevisionofTheDanishMedicines

Agencyitisstatedthat“wewillfocusonthehealthandwelfareofbothpeopleandanimalswithdueconsiderationtoaffordableandeconomictreatments”butcriticswouldclaimthatlittleemphasisispaidtocost‐effectiveness,andwhereeconomicconsiderationsaretakenintoconsiderationitisonlyintermsof

theimpactontotalexpenditureratherthancost‐effectiveness.

AsindicatedanumberofnationalDanishinstitutionscontributedirectlyorindirectlytoprioritysettingbyex‐orimplicitlydoingprioritysettingorbyprovidinginformationforprioritysetting.Thefollowingareexamplesandnotanexhaustivelistwhileregionalauthoritiesalsohavevariousinstitutionscontributingto

prioritysetting.

• Nationalboardofhealth–NationalCommitteefortheEvaluationofCancerDrugs(UVKL)Thiscommitteeisanadvisoryassemblywhosepurposeistoadvisetheregionsontheuseofcancerdrugsonanationallevel.IntheirmandateitisstatedthatHealthTechnologyAssessment(HTA)or

mini‐HTAisanappropriateframeworkforprovidingasystematicassessment.ItisstatedthatUVKLdiscussescancerdrugsonthebasisofsubmittedmini‐HTAsfromtheprofessionalassociations,oftenwithaneconomicevaluation(cost‐effectivenessanalysis)aspartoftheassessment.There

hasbeenanumberofHTAcompletedforthispurposebutatpresentnoorveryfewmini‐HTAsarebeingmade.

• TheReimbursementCommitteeinTheDanishMedicinesAgencydecidewhichprescriptiondrugscanbesubsidizedonageneralbasis(generalreimbursement),andwhenapatientcanbegranted

individualreimbursementforspecificdrugs.Thereimbursementisthedeductionfromthepricechargedatthepharmacy.Decisiononreimbursementindirectoperatesasprioritysettingwherecostandcost‐effectiveness,however,onlyisoneofparametersbeingtakenintoaccount.Thereis

noformalrequirementforincludingcost‐effectivenessanalysisinthedecisions.

• TheNordicCochraneCentre(NCC)isanindependentresearchandinformationcentrethatispartofTheCochraneCollaboration.TheNCCprovidessystematicreviewsoftheclinicaleffectsofhealth

care.Thesereviewscontributetoprioritysettingbyhelpingtoonlyimplementhealthcareserviceswhichhaveproventobeeffective.ThecenterispartoftheCochraneCollaboration.

• InstituteforRationalPharmacotherapy(IRF).TheaimoftheIRFistopromotethemostrationaluseofcurrentandfuturemedicinalproductswithrespecttobothpharmacologicalandeconomical

aspects.Thisaimisdirectedtowardsbothprimaryandhospitalcare.IRFcontributetoprioritysettingbye.g.providingreviewsofnewmedicalproducts,bypreparingpharmacotherapeuticguidelinesforselectedareasinco‐operationwiththerelevantscientificsocieties,byinitiating

projectsandscientificinvestigationsinareasofmajorpharmacotherapeuticandeconomicalconcern.

• ThenationalMini‐HTAdatabasecollectsmini‐HTAsorhospital‐basedHTAs.Thisisintendedtofacilitateprioritysettingatthehospitallevel.Themini‐HTAhasproventobeausefulframework

whichhassomeapplicabilitytohospitallevelprioritysettingbuttherearestillsomeissuesaboutthequalityofthemini‐HTAreports79

• TheUnitforHealthTechnologyAssessmentandEvaluationwithintheNationalBoardofHealthhasuntilrecentlyprovidedcomprehensivenationalHTAsonselectedtopics.

Thedebateonexplicitprioritizationisraisedtimetotimeinthepublicdebateandamonghealthcare

professionals,butnoinfrastructureoragreementshavebeenreachedlikeinothercountries,likee.g.NICEinUK.Politiciansandpublicauthoritieshavebeenreluctanttokeepprioritizationinclosedenvironmentswithlittleornotransparencytothepublic.Therelativefavorableincreaseinthepublicfundingforhealth

care,comparedtootherpublicwelfareareas,havestillcalledforprioritizationbutthecomingyearswithanexpectedlowergrowthinhealthcareexpenditurenecessitateamoretransparentandexplicitframeworkforprioritizationinthehealthcaresector.

Tightbudgetsand/orwrongallocationandactivitybasedfinancingReimbursementofhospitalswaschangedin2002goingfromglobalbudgetingtobecomepartlydependent

onactivityusingaDRGsystem80‐82.Theoverallbudgetcontrolofhospitalexpenditure,whichistheresponsibilityoftheregions,haschangedwiththeintroductionofactivity‐basedfunding(ABF)ofhospitals.ABFhavehadclearprosbypromotingmoreoverviewandcomparativemeasuresofhospitalproductionas

wellasinfluencinghealthprofessionals’mindsettobecomeincreasinglyawareofcostsandcostminimizationinitiatives.SomeperiodswithABFhave,however,alsodemonstratedsomeoftheconsintermsoflowerbudgetsafetyandchangesintheabilitiestoallocatehospitalfunding.

TheintroductionofABFtogetherwiththeintroductionofpatientsextendedfreeofproviderhas

challengedtheregions’abilitiestocontroloverallbudgets.Theregionfacethedilemmathattheyhaveincentivizetheirhospitalstorespondtodemandwhiletheextendedfreechoiceenablespatientstochoosehospitalinanotherregionoraprivatehospitaliftreatmentguarantiescannotbefulfilledbythepublic

hospital.Ontheotherhandregionshavetosafeguardtheoverallbudget,whichmeansthattheyshouldnotincentivizeactivitytoostrongly.Regionshavemanypossibilitiesofsafeguardingtheoverallbudgetfor

theirpublichospitalsbutthemechanismsbywhichtheydosohaschangedconsiderablysincethedaysofglobalbudgets.

Despitemanymechanismsforbudgetsafeguardingregions’abilitytoallocatebudgetshasbeenseverelychallengedbecauseoftheextendedfreechoicewith1monthwaitingtimeguarantyforallpatientsindependentoftypeofdisease,severityofthediseaseortypeoftreatment.Duetothiswaitingtime

guarantyregionsfacethecompetitionfromprivateproviders(privatehospitalsandclinics)whoareabletoprovidethetreatmentwithinthewaitingtimeguaranty.Regionshavethereforeverylittlecapabilityofreducingallocationoffundingtosomediseaseareasortreatmenttypes,andthishasresultedinin‐optimal

highfundingandin‐optimallowwaitingtimeforsomeminorseverdiseases.

LifeexpectancyandhealthstatusItwouldbeidealifameasureofsuccessintermsof‘health’forthehealthcaresystemexisted.However,thisisnotthecase.Insteadanumberofimperfectandconventionalmeasuresexist.Amongthemislifeexpectancyatbirth,i.e.howmanyyearscananewbornchildexpecttolivegivenexistingmortalityratesat

differentages.MeasuredbythismetrictheDanishsystemdoesnotfarewell,cf.Figure18.

Denmarkwasinthemiddleby1970–butlifeexpectancyalmoststagnated17years(1978‐1995)–andafterthislifeexpectancystartedtogrowthagain.Buttheconsequenceofthestagnationwastoputatthebottomplace,asclearlyseenintherighthandsideoffigure18.Thestagnationispuzzlingandhasbeen

analyzedintensively83,84.ItisstrikingthatSwedenconsistentlyhasbeenatthetop.InarecentarticleDenmarkandSwedenwascomparedwithaviewtothecausesofthisdifferentpattern.Juelconcludesthatlifestyleismainculprit:

“LifeexpectancyinSwedenisnowalmostthreeyearslongerthaninDenmark.Averysubstantial

partoftheDanishexcessmortalityandlowlifeexpectancycomparedtoSwedencanbeattributedtohighmortalityrelatedtoalcoholandtobaccoconsumption.Overall,alcoholandsmokingaccountforalmosttheentiredifferencebetweenDanishandSwedishmenandfor75percentofthe

differencebetweenDanishandSwedishwomen”85Figure18:Developmentinlifeexpectancyatbirth1970‐2008,andsituationin2008

Thisconclusionisbasicallythesameasemergedfromtheanalysesinthemid90ies.Manyinterestgroups

havetriedtotiethelacklusterdevelopmentinlifeexpectancytohealthcarespendingandhaveoftenreferredtotheratherlowDanishhealthcarespendinglevel,cf.above.Whileitcannotberuledoutentirely

itisnotverylikelythatthisisthemaincause86.Severalthingspointinthisdirection.Firstly,lifeexpectancyisinfluencedbymanyotherthingsthanhealthcareservices,e.g.workenvironmentandlifestyle.Secondly,muchhealthcareisnotdirectlyaimedatprolonginglife,butrathertoalleviatedfunctionallimitations,e.g.

hip‐andkneereplacement,cataractsurgery.Thirdly,lifeexpectancyisnotaverysensitiveindicatorinthesensethatonlyratherdramaticinterventionswillchangelifeexpectancyradically–thereforecastingdoubtontheuseoflifeexpectancyasagoodindicatorofsuccess.

Figure19:Decliningexcessmortalityfordiabeticpatient1997‐2008.

Thelastpointcanbeillustratedbylookingatdiabetes,figure19.Improvementsindiabetescarehasledtoadeclineinmortality(theoverproportionalmortalitythatcharacterizespersonswithdiabetes.Theimprovementsindiabetescarehavebeensosuccessfulthattheyundoubtedlyhavecontributedtothe

improveddeclineintheexcessmortality(comparedtothepopulationnorm)survival.However,thepointhereisthatsuchanobvioussuccessstoryisnotreallydetectableand/oridentifiableinoveralllifeexpectancy.

Twosupplementarymeasuresareofinterest:Selfperceivedhealthandmortalityfromamenablecauses,

figure20.

Afundamentalissuerelatestohowtoattributepopulationhealthoutcomestohealthcare,thebasicweaknessoflifeexpectancyisexactlythelackofahighdegreeofattribution.Oneapproachusesmortalitydata,whicharereadilyavailableatapopulationlevelinmanycountries,andisbasedontheconceptof

‘amenablemortality’referringtodeathsfromcertaincausesthatshouldnotoccurinthepresenceoftimelyandeffectivehealthcare87,88.Itisinnowayaperfectsmeasurebecauseonecanalwaysdebate

exactlywhatandwhatextentsomethingIamenabletohealthcare.Fromfigure19itisseenthatDenmarkdoesnotfaretoowellmeasuredthisway–butneitherdoesSweden.Forselfperceivedhealthwedobetter.

Figure20:HowisDenmarkdoingintermsofamenablemortalityandselfperceivedhealth

Slowintroductionofnewtreatments?InmanyareasDenmarkhavenotbeenontheforefrontofimplementingnewtechnologiesand

treatments89,90.Theslowadoptionofnewtechnologiesanddrugsmaybeduetothebeforementionedsuccessfulcostcontainmentbutthisisnottheonlyreason.Theawarenessandcapabilitytoimplementnewtechnologiesisanotherreasonasingeneralwhatdeterminesdiffusionofnewtreatmentswhere

economicsisonlypartoftheexplanatoryvariables.

Doauthoritiesdragtheirfeetinintroducingnewtreatments–orputdifferentlyandmoredramatic:Arepatients“denied”accesstonewtreatments,inparticulardrugs?Thisisarecurrentclaim–inparticularfromthepharmaceuticalindustry.Anexampleofsuchaclaimandthereasoningbehindcanbefoundin

oneofmanystatementsfromLIF91..Theheadingwent:‘Danesdonotgetthenewestcancerdrugs”.Referringtoarecentreport92itwasnotedthatcancersurvivalinDenmarkislow.And

“Oneofthereasonsforthesenon‐impressiveresultsisthatDenmarkonlyslowlytakesupthesenewandmoreeffectivedrugs.Thereportshowhowfasteightnewdrugsagainstcancerweremarketed

indifferentEuropeancountriesandhereDenmarksystematicallyhasbeenslowerthanSwedenandNorway.Thus,therearemoreexamplesofdrugshavingbeenusedfortwoyearsinneighboringcountriesbeforeDaneswereallowedtobenefitfromthem”

Thereareatleastthreerelevantissues.First,isittruethataccesstodrugsisslowerinDenmark?Secondly,ifanaffirmativeanswer:Doesitmatter(whatbenefitsareforegone)andthirdly:Whatarethereason?

Asregardsthefirstquestionfigures21and22provideexamplesofresearchunderpinningclaimsaboutslowintroduction.Figure21showsthatthelevelofsalesofthesebiologicaldrugsforrheumatismhave

beenratherlow,whilefigure22showsthatthetimingofmarketapprovalinDenmarkisnotfarbehindmostothercountriesinthetable.Asregardsfigure22thereissupplementaryinformationinthesourceshowingdevelopmentinsales.Marketingauthorizationisonething,actualuseisanother.

Figure21:Salesof‘biological’drugsfortreatmentofrheumatism93

Thesecondandthirdquestionsabovearebestaddressedtogether.Thereisnoquestionthatthesenewdrugshaveaneffectonthetargetedillness–thatiswhytheyhavetestedthoroughlyinrandomizedtrials.

However,thequestionishowmuchbetterthanexistingtreatmenttheyare?

Oftenimprovementsare‘marginal’,i.e.notreallyabreakthroughwithdramaticclinicalimprovements.Andifthisimprovementcomesatahighprice–whichisoftenthecasewithnew(biological)drugs–thenitisfairtoaskwhetheritshouldbeintroduced.Thisleadsdirectlytothequestionofprioritysetting.In

DenmarkwehaverecentlyseentheestablishmentoftheCouncilforExpensiveHospitaldispenseddrugs(basicallysomeoftheabovementioned),RADS,wherethetwointerlinkedissuesofeffectandcostsundoubtedlywillbediscussed.

Whetheroneunquestionablyshouldconsider‘delayed’introductionofnewtreatmentsasanegativething

isdebatably,butitshouldbediscussedseriouslytoensureanevaluationofwhetheritisrealproblem,notonlyperceivedbythepharmaceuticalindustry.Itshouldbenotedthatapartfromcanceritishardtofindexamplesoutsidetherealmofpharmaceuticals.Forcancer‘experimentaltreatment’(drugs,radiation,and

surgery)hasbeendiscussedforseveralyearsbecauseitwasbelievedthatDanishoncologistsweretooconservativeandsomewhatunwillingtoprovide‘newand/orexperimental’treatments(thatpatientshadheardwereavailableabroad).In2003thesystemwithaccesstoexperimentalcancertreatmentwasputin

placewithadvisoryboard.ThearrangementwasaimedatpatientswithlifethreateningcancerorsimilarmanifestationswheretreatmentpossibilitiesinDenmarkwereexhausted.Theboardadvisesonpatientcaseswheretheattendinghospitalphysicianhasappliedonbehalfofthepatient.Thenumberofcasesis

limited.In2009atotalof341patientshadapplied94.IncreasinglypatientsarenotsendabroadbutinsteadareenrolledintrialsatDanishhospitals.

Figure22:Nationallaunchdatesfor8cancerdrugs92

Thereversesideof‘tooslowtointroducenewtreatments’istoaskwhetherthereareareaswherewe

havefallenbehind.IntwoareasDenmarkprobablyfellbehindinthe1990ies:Heart(surgery)andcancertreatment.Inthenewmillenniumthishasbeenrectifiedby‘CancerPlanI–III’,thelatestfromNovember

201095‐100.Manyobserverswouldagreethatthecatch‐upefforthasbeensuccessfuleventhoughitisnotyetvisibleintermsof(markedly)improvedsurvivalrates.Forheartsurgerythecatchupstartedalreadyin1993withthe‘heartplan’.In2005theNationalBoardofHealthpublishedastatusreportandnotedthat

weonparwithmostothercountries101,102.

Lackofvisionfornewhospitals,i.e.‘hospitalsofthefuture’andavisionforprimarycareAsnotedinthesectiononstrengthstheDanishStateandtheRegionsarecurrentlyinvestingmorethan40billionDkrinanewhospitalinfrastructure.Thechangesaremadetoaccommodatethenewregionalstructureandfollowingoverallprinciplesofpursuingbenefitsofscaleandspecializationbyconcentrating

activitiesonfewerandlargerhospitalfacilities.Yet,itcanbearguedthatbeyondthesegeneralandsomewhatvaguelydefinedprincipleswithrelativelyweakevidenceforthebenefits,atleastineconomicterms71,thereisalackofcoherentlongtermvisionforthedevelopmentof“hospitalsofthefuture”,and

forcoordinatingsuchhospitalfacilitieswithamodernized“primarycareofthefuture”.Itisobviouslydifficulttoforeseeindetailwhatthefutureneedsandopportunitieswillbe,yetitisequallyobviousthatthereareanumberofdimensionswherecurrentdevelopmenttrendsarelikelytomakeanevenlarger

impactinthefuture,andwhereacoherentstrategyforintegratingalloftheseelementsinaflexiblesolutionhaspotentialtoimprovethefutureperformanceofthehealthsystemsignificantly.However,it

appearsthatthereisalimitedwillorcapacityinthesystemtobuildsuchacoherentlongtermvisionforhospitalsandprimarycareofthefuture.

Someofthedevelopmenttrendthatshouldbeconsideredinclude:1)therapiddevelopmentofITandtelecommunicationtechnology,whicharealreadytodayhavingalargeimpactonmedicalpractice.This

developmentislikelytocontinueinthefuturewithopportunitiesfordigitalizingmanyareasofthecurrentpractice.Animportantaspecthereisthedevelopmentofdigitalimagingtechnologyfordiagnostics.Thiscreatesnewopportunitiesforsharinginformationacrosstreatmentlevels,andthusforcoordinatingfast

trackdiagnosisandtreatmentpaths.2)Thedevelopmentofcustomizedmedicinebasedongenemapping,willalterthewaywethingaboutmedicationandtreatmentregimes,andwillrequirenewandmoreindividualizedinformationandtreatmentstructures.3)Thedevelopmentofnano‐technologiesfor

operationsislikelytocontinueleadingtomuchlessinvasivetypesofsurgerythantoday,andthusacontinueddevelopmenttowardsshorterhospitalstays,whichinturnrequiresmorecomprehensiveandcoordinatedeffortsintheprimarycaresector.4)thedemographictransitiontowardsmoreelderlywillin

itselfrequireareconfigurationofthefocusinboththehospitalandprimarycaresectors,andnotleastamuchstrongeremphasisoncreatingcoherentpathwaysacrossthesectorboundariesforthemanyelderlypatients,whichoftenhavemultipleconditionsandcomplexcareneeds.5)Atthesametimewecanexpect

otherpartsofthefuturepatientpopulationtohavemanymentalandeconomicresourcesthatcanbeutilizedforself‐managementandactiveinvolvementinco‐productionoftreatment.Thisrequiresinnovativewaysofinteractionbetweenhealthcarepersonnelandpatientsofthefuture.

Inmoregeneraltermsweseeaneedfordevelopingahealthsectorwithamuchstrongerfocuson

innovationandcontinuousintegrationofthemostrecentresearchintopractice.Inthissense“thehospitalofthefuture”ismuchmoreaconceptoforganizationalprocessesandknowledgemanagementthanofphysicalinfrastructure.Similarlyweneedtodevelopaconceptofthe“primarycareofthefuture”which

accommodatesthegrowingneedforintegrationofservicesandthegrowingnumberofelderlyandpatientswithlongtermcareneeds.Itisalsoofvitalimportancethatthe“primarycareofthefuture”developsastrongerfocusoneffectivepreventionandhealthpromotioninordertopreventdiseases,and

todetectconditionsatanearlystage.

Tooslowtakeupofthechroniccaremodel?TheNationalBoardofHealthrelativelyearlytookleadershipindevelopingachroniccaremodel–inpartinviewofthedemographicdevelopmentdiscussedabove,inpartbecausetheprevalenceofchronicillnesseswasincreasingindependentlyofthedemographicdevelopmentduetolifestylechanges.Inanumberof

reportsa‘chroniccare’modeldescribedbelowwasdeveloped103‐110.ItisadefinitestrengththatthechroniccaremodelisbeingpromotedvigorouslybytheNationalBoardofHealth,includingestablishmentofasteeringgroupforchroniccarewithrepresentativesfrommunicipalities,regions,andgovernment,but

unfortunatelynotwithaGPrepresentative.AdynamicprojectonchroniccarehasalsobeenestablishedbytheNationalBoardofHealth.Aweaknessisthattheuptakeofthemodelseemsratherslowandmuch

dependsonthe(good)willofthepartiesinvolvedintheoperationaldetails:Municipalities,GPsandtheRegions.GPsareformallyaregionallyfinancedentity,butrunbyself‐employedGPsoncontractwiththeregion.Therehasbeenmuchtalkandunderstandingbutnotacorrespondinglevelofcoordinatedaction

whereasmanyexamplesofindependentmunicipalandregionalprojectsareseen.Centralgovernmenthasapproved0.6billionDKr.thathasbeenallocatedtoprojectsthatrun2010‐2012.However,onemay

questionthenumberofproject.Lookingatthelistofprojects110itisclearthatanattempthasbeenmadetoconsider‘everybody’–probablyresultingintoomanyandtoosmallprojectswithnoguaranteethatgoodprojectresultswillbecomepartoftheannualbudgetonceprojectmoneyrunout.

Itisalsoastrength(andaweakness)thatchroniccareisanintegralpartofthecompulsoryhealth

agreements111betweenregions/GPsandthemunicipalities,butithasbeenhardtoobtaincommitmenttoconcertedaction.

TheNationalBoardofHealthdescribesthebackgroundfortheinitiativeasfollows:

“Duetotheemergenceofincreasinglyefficientandcostlytreatmentoptions,anageingpopulationandtheensuingincreaseinthenumberofpeopleaffectedbychronicdiseasesandproblems

recognizedinthecareofchronicconditionsitisnecessarytoidentifytheoptionsforbettercareinconnectionwithchronicconditions,p.4107

Chronicdiseasescanbedefinedbyoneormoreofthefollowingcharacteristics:theyarepermanent,leave

residualdisability,arecausedbynon‐reversiblepathologicalalteration,requirespecialtrainingofthepatientforrehabilitation,ormaybeexpectedtorequirealongperiodofsupervision,observationorcare.Thisdefinitionincludesbothsomaticandmentaldisorders.

Thelistofspecificchronicdiseasesusuallyencompasses:

• diabetes

• asthmaandallergy

• cancer

• chronicobstructivepulmonarydisease(COPD/KOL)

• cardiovasculardisease

• osteoporosis

• muscular‐skeletaldiseases,typicalrheumatism

• psychiatricdiseases

ThechroniccaremodelwasbasicallydevelopedintheUS112.Thebasicideasandissuesarecapturedin

figure23.Startingfromtheleftwehavewhatisformallythe‘chroniccare’model.Anessentialelementisthecollaborationbetweenthehealthsystemandthecommunity(inDenmarkamongotherthingsthemunicipalitiesandNGOs).Anotherimportantelementisselfcare.TheNationalBoardofHealthhasbeen

stronginstressingthiselement103,109,113,106.Animportantelementofselfcareismonitoring–wheretelemedicinemaybecomeanimportanttool.TheNationalBoardofHealthstatesthat:“Thepatients'self‐monitoringofthediseaseshouldbeenhancedandtechnologiesforself‐monitoringshouldbeevaluated

andthequalityofthemonitoringshouldbeassured”,p.7110.

ThestratificationmodelinthemiddleofFigure23stressesboththedivisionofworkandtheimportanceofprimarycare.Itisofcourseanidealizedmodelbutontheotherhanditalsoshowshowimportantitistodiscussandimplementwaysofensuringthatpatientsasmuchaspossiblearetreatedatthelocallevel.The

workwithpatientpathwaysforchronicpatientsisanimportantwaytorealizethis108.

Figure23:Asnapshotofthechroniccaremodel

TotherightinthefigureiscollaborationtriangleinDanishhealthcare.Thechroniccaremodelisageneric

model–albeitimplicitmirroringanAmericansetting.ThemodelneedstofitaDanishsettingandinparticulartocapturethethreemainparties.Muchisdoneformallythroughthehealthagreements,butmoreimportantlyisthedaytodaycollaboration.Oneparticularchallengeistodecideonwhoistolead.

Therecommendationisclear:“…thegeneralpractitioneristheprojectleaderthroughtheentirecourseofthechronicdiseaseandthatthecontentsofthefunctionareincorporatedintothedescriptionofthecourse.”Thequestioniswhetherthisisacceptedbytheotherpartiesandwhethergeneralpracticeandwill

takeonthistask.

Inviewofthepreviousrecommendationitshouldbenotedthatgeneralpracticealreadyisheavilyinvolvedwithchronicpatient,figure24.Almost50%offace‐to‐faceencountersarewithchronicpatients.

Thetotalityofthechroniccarehasnotbeensubjectedtorigorousevaluation,onlyparts,e.g.theself‐carecomponent,(Lorig1999).Hence,onemustbecarefulnottomaketoosweepinggeneralizationsorclaims.

Thechroniccaremodelcanbelookedatfromseveralperspectives:

• asawayofprovidingcareintheprimarycaresectorandavoiding‘clogging’in‐andoutpatientcare.Inthisrespectthemodelisworthlookingat–inparticularifoutcomesareequalorbetterthanfor

hospitalcare

• producingbetteroutcomes.Arecentsummaryofstudiesseemtoprovidesomesupportforthis,(Coleman2009)

• doesitcreatenetsavingsoratleastprovidecost‐effectivecarecomparedtoforinstancemainlyhospitalcare.Oneshouldprobablynotexpectnet‐savings.(Peikes2006;Peikes2009;Russel2009).

Atbestitiscostneutral.

Figure24:Chronicdiseasesandgeneralpractice114

Cooperationbetweenmunicipalities–GPs–hospitalsWellfunctioningcooperationbetweenmunicipalities,generalpracticeandhospitalsisessentialnotonlyforpatientevaluationofhealthcarebutalsofortreatmentoutcome.Despitethefactthatithasbeen

discussedforatleast25yearsthereisstillplaceforimprovement115eventthoughmuchworkisbeingdone,forinstanceinconnectionwiththehealthagreements.Inthefirst1985‐whitepaperontheissuecoordinationofchronicallyillpatientswasdiscussed–andsomeoftherecommendationsstillarenot

implemented.

Intwoareasitiscrucialthatthetriangle‐cooperationfunctions:Training/rehabilitationandchroniccare‐wherethelatterinpartoverlapswithcarefortheelderly.Thehealthagreementsalsoplayapivotalroleinthisconnection.Theproblemwiththehealthagreementsarethattheyontheonehandarecompulsory

butontheotherhandnon‐committing,i.e.withouttheconsentofthepartiesitisimpossibletodoanything,forinstancetofollowintersectoralguidelinesfromtheNationalBoardofHealthfortreatmentofthechronicallyill.Inadditiontheeconomicincentivestocooperatearenotinplace.Aso‐calledmunicipal

co‐financingforregionalhealthcareisinplacebutisnottargetedandinmanycasesconsideredveryineffective.

LackoffocusonrehabilitationItisincreasinglybeingrealizedthatrehabilitationisanintegralpartoftreatmentorthefinalpartofacourseoftreatment.Itisalsorealizedthatrehabilitationismorethan‘training’,e.g.traditional

physiotherapy.Rehabilitationcoversphysical,mentalandsocialneedsandthereforeoftenconsistsofamultidisciplinarypackageofservices.

Arecurrentthemeforcancer116,117,heart,andrheumatismpatientsandgroupswithmisc.chronicdiseasesisthattheyreceivetoolittleornorehabilitation118.Rehabilitationisalsoanintegratedpartofthechronic

caremodel.Thereisreasonableevidencefortheeffectofrehabilitation119‐122.

AccordingtotheHealthActpatientshavearighttoatrainingplanwhentheyaredischargedfromahospitalanditisfoundmedicallyrelevant123.Apartfromspecializedtraining,trainingaccordingtotheplanmustbeprovidedbythemunicipalitiesthatdecideonboththetypeandextentoftraining.Thereareat

leastthreeproblemswiththisorganization:a)asaruleitisonlytraining,notrehabilitationthatisoffered,b)economicincentivesarelargelyabsentortoosmall,andc)somemunicipalitiesaretoosmall(populationwise,andthereforeintermsofpatients)tooffertrainingdifferentiatedaccordingtoillness/problem.

OverallthelackofrehabilitationseemstobeaweaknessoftheDanishhealthsystem,althoughcancerplan

IIIshowssomepromise.TheremuchlikelyisaneednotonlytohavealookattheHealthActandsubstituterehabilitationfortraining.Furthermoretheremaybeaneedtolookateconomicincentives.

InequityInequityissueswerediscussedundertheheadingof‘challenges’inpartbecausemostoftheminasenseareoutsidethecontrolofhealthcaresystem,e.g.workenvironmentorlifestyle,withaccesstoservices

beinganexception.Nevertheless,mostlikelymanyconsiderbothinequityinhealthandinequityinmorbidityasaweaknessofthehealthsystem.Ifnot,itisatleastanissueofconsiderablesocietalconcern.

Inequityingeographicalaccesstohealthcarehasonlybeentouchedonindirectlyabove.ThecentralizationofhospitalsandtheshortageofGPsmeanthatpeopleinoutlyingareasareincreasinglyforcedtotravel

furthertoreachhealthservices.Itiswellknownthatdistancetoproviderinfluencesutilizationlevel:thelongerthedistance,thelessuse.

SolutionsItiseasytocomeupwithproposalsthatwillincreasethebenefitscopeandlevelsofhealthservicesand.

increaseexpenditures.However,thewholepointoftheSWOTanalysishasbeentoidentifyareasworthyofattackbecausetheythreatenthesustainabilityofthehealthsystemasweknowit,runcountertotheobjectivesofthesystem,e.g.equity,orareglaringweaknesses.Ifwearetomakerationaldecisionsabout

improvementsitmustbebasednotonlyonahelicopterviewofthehealthcaresystemviatheSWOTanalysisbutimprovementsmustbeselectedsothattheyhavethebiggestimpactpermonetaryunitexpendedandshouldhavearealisticchanceofbeingimplementableintheDanishhealthcaresector.

TheSWOTanalysiscanbeusedtobrieflytocomparewiththeobjectivesforDanishhealthcaresetoutin

HealthAct:

ObjectiveaccordingtotheHealthAct Comment

Easyandequalaccesstohealthcare

Basicallyfulfilled–eventhoughequalaccessindependentofeconomicmeansalwayswillbeasore

pointaslongasthereisco‐payment.However,aworldwithoutco‐paymentwouldrequireanadditional20billionDKK.oftaxmoney

Treatmentofhighquality

Seemstobefulfilledtoareasonabledegree–but

difficulttodocuments.

Coherentandlinkedservices Anareaforimprovement,inparticularintersectoral

pathways.However,theextentofproblems,i.e.howmanypatientsactuallyexperienceproblems,isunknown.

Freechoiceofhealthcareprovider Fulfilledtoahighdegree

Easyaccesstoinformation NotexplicitlyaddressedintheSWOTanalysis,butthewebsitewww.sund.dkandwww.sundhedskvalitet.dk

attesttothefactthatsomethingisbeingdone.However,thereisnoreadilyavailableinformationabouttheextentofuse

Atransparenthealthcaresystem Difficulttopassjudgment.

Shortwaitingtimefortreatment. Inviewofboththeexperiencedwaitingtimeandthe‘waitingtimeguarantees’,e.g.extendedfreehospitalchoice,thisisreasonablyfulfilled.

Twomajorchallengeswereidentifiedandwillbecoupledwiththesolutionspresentedbelow.Thesolutionswillnotinandbythemselvesputanendtothechallengesbutcontributetoacopingstrategy:

1. Fiscalsustainability:‐>mechanismsforanexplicitframeworkforprioritysettingandintroductionofco‐paymentinmoreareasofthehealthcaresector

2. Demography:‐>thetwopreviousproposalsandfasterimplementationofthechroniccaremodel

alongwithincreaseduseoftelemedicine

Inthesectiononopportunitiestelemedicinewasmentionedandthereforehasbeenincludedamongthesolutions

Asregardsweaknessestwoimportantareashavebeenidentified:

3. inequity–inparticularinequityinhealth‐>aninequityreducingprojectisproposed

4. preventionandhealthpromotion‐>healthtestandhealthconsultationwithGPisapossibility

5. adverseeventslikehospitalinfections‐>projecttoreducehospitalinfections

6. psychiatry‐>variousimprovementprojects

7. endoflife‐>increaseduseofpalliativeteams

Whatisanaddedlifeyearworth?TheConsensusmodelisbasedontheideathatacost‐benefitanalysis,CBA,iscarriedoutforimprovementproposals.InaCBAamonetaryvalueisattachedtobothbenefitsandcosts–andthemonetaryvalueof

benefits,e.g.anaddedlifeyear,ideallyshouldreflectwillingnesstopay.Asimplewaytopresenttheresultsisintermsofthecost‐benefitratio,e.g.foreveryDKKinvestedtherearebenefitsoftwoDKK.

InhealtheconomicsitisstilltheexceptiontouseCBAbecauseformanyreasonsitisverydifficulttoputamonetaryvaluetoanaddedlifeyearandingeneraltomonetarizehealthgains.Insteadanothertypeof

economicevaluationisused–theso‐calledcost‐utilityanalysiswheretheapproachistoaskhowmuchaqualityadjustedlifeyear,QALY,costsandthencompareacrosspossiblealternativeusesofmoneywithinthehealthcarefield.Forinstance,ifinvestmentsaremadefortherapyX,thecostperQALYisDKK95,000

comparedtoacostperQALYofDKK70,000ifthemoneyalternativelyisusedfortherapyY.ThesimplerulethenistochoosetherapyYbecauseinthiswayonegets‘mosthealthperDKK’.

WithoutgoingintodetailaQALYisaconstruction,whereonetriestocaptureatoneandthesametimetwooftheimportanthealthbenefits:Prolongationoflifeandaddedqualityoflifease.g.(mentaland/or

physical)functioning(“addyearstolifeandlifetoyears”).Sometreatmentsgiveaddedfunctionalabilitybutdonotprolonglife,e.g.ahipreplacement,whileothersaddyearstolife,e.g.alivertransplantation.SobyconstructingaQALYonesotospeakattemptstoamalgamatethesemeasuresintoacompositemeasure

ofhealthbenefit.Thereareatleasttwolimitationsofthisapproach.First,vis‐à‐vistheconsensusmodelonecannotcomparewithalternativeuseofthesamemoneyinothersectors,e.g.infrastructure.Inthepresentcontextthisisreallynotabigproblem.Secondly,certainprojectswithinhealthcareandproposed

below,forinstanceaninstituteforprioritysettingorintroductionofco‐payment,areverydifficult,ifnot

impossibletotranslateintoQALYies.Considerforinstancewhetherornotweknowifco‐paymentisharmful(orbeneficial)tohealth?

AsregardsthevalueofanaddedlifeaDanishestimate(Nielsen2008)ofDKK200,000perextralifeyearwillbeused.Ithasbeenestimatedbasedonthethinkingbehindwillingnesstopay.Theestimateon

purposeischosentobelowestvalueoutofseveralpossibilities.Thisisdoneinviewoftheuncertaintyofthistypeofestimates.Thismeanscost‐benefitratioslikelywillconservativeestimates.

Forcost‐utilityanalysisQALYthesimpledecisionruleistopickthealternativewiththelowestvalueofcostsperQALYgainedasillustratedabove.However,isdoesnotanswerwhatis‘goodvalue’inthesense

whatisareasonable‘price’perQALY,i.e.shouldoneforinstanceacceptanimprovementthatcostsforinstance2millionDKKperQALYgained?AruleofthumbhasbeenintroducedinEnglandbytheNationalInstituteofClinicalExcellence,NICE,thatusecost‐utilityanalysisforprioritysetting.Theheuristicruleis

thatanythingbelow£20,000isgoodvalueandoughttobeintroduced,whileprojectswithfrom£20,000to£30,000perQALYareworthwhileconsidering,whileoneshouldbeskepticalofprojectscostingmorethan£30,000perQALY.ColleaguesattheUniversityofSouthernDenmarkhavebeenworkingputtinga

monetaryvalueonaQALYakintotheideaofthevalueoflifeyear,(Gyrd‐Hansen2011).BasedonthesamedatasetbutusingdifferentmethodstheyarrivedatwillingnesstopayestimatesperQALYrangingfrom20,404DKK(€2720)perQALYto722743DKK(€96366).Forthisreasonweabstainfromputtinga

monetaryvalueonaQALY.

InsomecasesitdoesnotreallymakesenseeithertoestimateaCBA‐ratioorforthatmatteracostperaddedQALY,e.g.terminalcareorreductionofinequity.Inthisinstance,however,itstillmakessensetocarryoutacost‐minimizationanalysis.Forinstance,ifthreeoptionsareavailableforterminallyillpatients:

hospice,palliativecareandusualcare,thequestioniswhichcare/treatmentmodeistheleastcostlyassumingroughlythesamequalityoflifeforthepatient.Asimilarreasoningmaybeappliedtovariouswaysofreducinginequity.

Allestimatesofcost‐benefitratiosorcostsperQALYareveryroughestimates.Theyarenotbasedon

detailedcalculation.Thereforetheyshouldonlybetakenasanindication.

Telemedicine:Largescalepilotprojectsformonitoringthechronicallyill.Telemedicineisoneofthepossiblesolutionstothechallengesandopportunitiesinthehealthcaresectorinthefuture,inparticularvis‐à‐visthechronicallyill.Todaythereareexamplesoftelemedicinewithinmanyspecialties–fromtele‐psychiatryacrosstele‐dermatologyandtele‐radiologytotele‐rehabilitation.

Manystudiesoftelemedicineinthecurrentliterature,sometimeswithdebatablequalityofthestudydesign,concludethattelemedicinestrategiesarecostsavingorhavethepotentialtobecomecostsaving124‐126.Telemedicinemaysavevaluableresourcesprovidehighqualitytreatment/adviceandmay

compensateforlongerdistancestohospitalsinremoteareas(Medcom2010;TeknologiskInstitut2008;Alectia2010)

Thepossibletypesofinterventionsincludecare/adviceandmonitoringatadistance,informationand

communicationtechnologiesinhealthcare,internetbasedinterventionsfordiagnosisandtreatmentsandsocialcareifthisisanimportantpartofhealthcareandincollaborationwithhealthprofessionals.

Onetypeoftelemedicineissimplythattwohealthprofessionscommunicateoveradistance.Anothertypeiscommunicationorinteractionbetweenapatientandahealthcareprofessionaleitherdirectlybytalkingorvideoconferencingorindirectlybymonitoringofthepatient’sconditionwithpossiblefeedbacksfrom

thehealthprofessional.

Thedifferenttypesoftechnologieshavedifferentprosandconsandsolvedifferenttypesofissues(DanskSelskabforTelemedicin201;InternationalSocietyforTelemedicineande‐health,2011;Medcom2011;OECD2004).

Todaytherearemanyon‐goingprojects,forinstanceprojectssupportedbyABT(ABTFonden,2011)orthe

projectslistedatthewebsiteoftheDanishSocietyforTelemedicine(DanskeSelskabforTelemedicin2011).Therearealsogoodexamplesofsolutionsthathavealreadybeenintegratedintodailypractice.

Theliteratureontelemedicinehasincreasedinthelastdecadeandaconsiderablenumberofreviewsexitalready,however,themeta‐reviewprovidedbyEkelandetal2010showsthattheliteratureonevidenceon

telemedicineisstillveryheterogeneous136.Aconsiderableshareofthereviewsconcludesthatevidenceispromisingbutincompleteandaconsiderablesharealsoconcludesthattheevidenceislimitedandinconsistent136.Theneedandpotentialfortelemedicinesolutionsisobvious,however,thelimitedand

incompleteevidenceoftheeffectsoftelemedicineisoneofthemainbarriersforimplementationofthesetechnologies.

Anotherchallengefortheimplementationoftelemedicineiseconomicissues.Investmentcosts,costfortraining,reimbursementoftelemedicineservices.Oneofthenecessarypreconditionsforimplementation

oftelemedicineonalargerscaleismorethoroughdocumentationoftheeconomicconsequences.Anumberofreviewshaveconcludedthatthereislackofthoroughandstandardizedmeasuringandreportingofeconomicconsequences137.

Telemedicineisinsomecasesgoingtobecompletesubstitutesforin‐personencounters.However,inmost

casestelemedicinewillnotbeacompletesubstituteforin‐personencountersandsomecombinationwillprobablyberequired.Thisraisesanimportantquestionaboutwhatistheoptimalsubstitutionbetweenin‐personencountersandcommunicationandmonitoringbydistance.Italsoraisesquestionsabouttheneed

fordramaticreorganizationofthein‐personencounterwhilethiswillchangenotonlyinfrequencybutalsoincontent.Italsoraisesquestionsaboutorganizationoftelemedicinesolutionswhereeconomicsofscaleandjointproductioninvolveneedforcentralizationofthepersonnelsupportingthesolutionsstillsatisfying

theneedforoptimalin‐personencounters.

Thefollowingisalistofpossibleorexistingtelemedicinesolutions:

1. Communicationbetweenhealthprofessionalswiththesamedegreeofspecializationacrosstwogeographicalsiteswheretheircommunicationcanbesupportedbyvideoconferencinganddigitalpicturesandonlineaccesstothesamee.g.laboratorytestresults.Thistypeofcommunicationwill

supporthealthprofessionalsincasesoftreatmentofcomplexcaseswheredecisionsontheappropriatetreatmentmaybeimprovedbyinteraction.

Communicationbetweendistantspecializedhealthprofessionalsisnotnewbuttechnologies,e.g.

IT,digitalpicturesfromx‐ray,CTscan,onlinedatabaseswithlaboratoryresultsetc.,willimprove

thepotentialsofsparring.Thislikely,however,cannotbeexpectedtoresultinlowercostsbutpotentiallybettertreatmentdecisionsimprovingqualityoftreatment.

2. Communicationmayalsosupportlocalorregionalhospitalswhodonothaveaccesstospecialists,ormayhavedifficultiesinhavingspecialistspresentatthehospitalatalltimes.Here

communicationsfacilitiesmayallowspecializedtreatmenttotakeplaceclosetothepatients’closesthospitalwithoutaspecialistbeingpresentatthesiteatalltimes.Itmayalsoimproveflexibilityforplanninginsmallhospitalswhereitistooexpensivetohavea24‐7capacitywith

presentspecialists.Thistypeofuseoftelemedicinemaythereforefacilitatespecializedtreatmentinmoreruralareasanddecreasetheneedforcapacityofspecialistsbeingpresent.

ThistypeoftelemedicineispresentlybeingimplementedinsomeDanishhospitalswheree.g.partsofdiagnosticproceduresareperformedbyspecialistsinanotherhospitalthanwherethepatientis

present.Thereislikelypotentialsavingsofimplementingthesetypesofsolutionsinthefuturebutintheshortrunlargeinvestmentsininfrastructureandfacilitiesareneeded.

Someevidenceindicatethattelemedicinemaybeasafe,feasibleandreliablesystemforprovidingtreatmentwithine.g.acutestrokemanagement,diabetesmanagement,emergency

departments127‐129.Manymoreareaswillberelevantforthistypeoftelemedicine.

3. Yetanothertypeofcommunicationusingtelemedicinemaybebetweenprimarycaredoctorsordoctorsinlessspecializedhospitalcommunicatewithspecialistsathospitaltodecidewhetherthereisaneedforreferralofthepatientorthespecialistsmaybeabletoguidethelessspecialized

doctoronthedistance.Thiscanpotentiallyimprovequalityoftreatment,improveandreducenumberreferralsanddecreasepatients’costsfortransportation.

OneexampleofthistypeoffacilityhasbeingimplementedforcommunicationandmonitoringofnewbornbabiesatÆrøSygehuswhichisaverysmallhospitalonasmallisland.Thishospitalhas

veryfewdoctorsandnospecializedpediatrician.Thissolutionsfacilitatesthatpediatricianscanfollowandadvicehealthprofessionalsatadistancewhichmaybeimportantincriticalfacesofthedeliveryandthefirsthours.Alsoitisimportantinsituationswheretransfersareconsidered

becauseofcomplicationswherespecializedarebetteratjudgingwhetheratransferisneedandwhichtypeoftransferisoptimal.

Anotherexampleisthecommunicationusingvideoconferencingandpictureby3Gmobilephonesbetweenhomecarenursesandspecializeddoctorsjudgingdiabeticwoundsandtheneedfor

treatment.Thissolutionenablesthehomecarenursestoprovidebettercarewitheasyaccesstospecialistssupportingtheirtreatmentandeventuallyassessmentsontheneedtorefertomorespecializedcare.Thissolutionwillsavemoneybyimprovingqualityoftreatmentalsoimproving

qualityoflifeforpatients130.

Telemedicinewithinteractionorcommunicationbetweenhealthprofessionalsinvolveatleasttwotypesoftechnologies.Thefirsttypeinvolvesdirectcommunicationbetweenpatientandhealthprofessionswhereanothertypeinvolvesmonitoringofpatients.

4. Directpatientandhealthprofessionalcanfacilitatethatpatientsaredischargesearlierfromhospital,avoidadmission,outpatientvisitsorGPconsultationsbycommunicatingwithhealthprofessiononedistancebyinternetorvideoconferencing.

Oneexamplesofthisistelemedicineconsultationsforchronicobstructivepulmonarydisease

(COPD)patientswherepatientsreceivea“briefcase”withvideoconferenceequipmentaswellasequipmentformedicalcheck‐ups.Thisapproachhasproventoreducethenumberofbeddaysandthenumberofhospitalreadmissionsandpatientshavebeensatisfiedwithbeingdischargedearlier.

ThissolutionisnowusedinpilotprojectformanyofFunen’sCOPDpatients.Thesolutionmeetsthechronicpatient’swishtobehospitalizednolongerthannecessary.Atthesametime,itfreesupresourcesathospitalsbyreducingovercrowdingproblems,especiallyonmedicalwards.The

solutionseemsstilltoincreasetotalcostbecauseofthepriceofthe“briefcase”131.Itcould,however,beexpectedthatthepriceofthebriefcasewillbereducedinthefuturemakingthesolutioncost‐effective.

5. Monitoringofpatients,especiallychronicpatients,provideopportunitiesofdischargingpatients

earlierandavoidingoutpatientvisits.Furthermoreoptimizationoftreatmentbyfeedbackfrommonitoringpotentiallydecreasesorstabilizesdiseaseprogressionbenefitingthepatientbyincreasedqualityoflifeandfewercomplicationsinthefuture.Itisstilltobeprovenwhetherthisis

loweringcostswhichmayintuitivelybeoneoftheconsequences.

6. Yetanothertypeoftelemedicineiswhenpatientsandhealthprofessionalscommunicatewithothertypesofpersonnel.

Interpretationservicesusingvideoconferencingistestedinanationalpilotprojectatthemomentandeconomicanalysisindicatesthatthistypeofinnovationmayreduceunitcostperconsultation

withinterpretationby20‐30%.Considerableinvestmentsaretobemadeimplementingthistypeoftechnologyandthetechnologyinvolve,aswithmanyoftheothertelemedicinetechnologies,majorchangesintheorganizationalroutines132‐135.

ProposalInviewofthedemographicchallengesalargescaleprojectabouttele‐monitoringandtele‐adviceforchronicallyillpersons–andinparticularpersonswithmorethanonechronicillness–isproposed.The

objectiveistotest‘thebriefcase’approachtotele‐monitoring‐andadvicementionedabove.Ithasalreadyshownpromise,butneedsbroaderandmoresystematictestinganddevelopment,ideallywithintheframeworkofaso‐calledpragmatictrialcombinedwitharigorouseconomicevaluation.Rigorouseconomic

evaluationsshouldbeoneoftheelementsofthetesting.AseparategoalwouldbetoestimatehowmanyofthechronicallyillcanhandlethetechnologyandhowmuchIT‐supportisneededathome.

Endpointstobemeasuresare:(functional)healthstatus,useofhealthservices,easeofuseandsatisfactionwiththetechnologyprovided.

Theprojectshouldbeacollaborativeprojectinvolvingahospitalmedicaldepartment,oneormore

municipalitiesandGPs.

Itshouldbe‘longterm’–i.e.runover2‐3yearsandinvolveasubstantialnumberofpersonswithchronicdiseases.

Funding:(probably)around100milliontoensurelargescaleand‘long’term.ThemoneyshouldcomefromtheABTfund.

Expectedcost‐benefitratio(scaleupresultsfromtheproject):Atleast1:1andideally1:2

MethodsforprioritizationandproposalforaninstituteforprioritysettinganalysesTheneedforprioritizationisobviousingeneralandinviewoftheproblemswithfiscalsustainability.The

methodologyandframeworksforprioritysetting,however,arelessobviousandpresentdifferenttypesofchallenges.Healtheconomistshavelongsuggestedandperfectedeconomicevaluationstosupportdecisionmakingonprioritysetting.Therearestillfewsuccessfulexamplesoftransparentandexplicituse

ofeconomicevaluationforpriorisetting.OneexceptionmaybeNICE(NationalInstituteforClinicalExcellence)inEnglandestablished1999whichisanorganizationalframeworkforprioritysettingexplicitlyapplyingcost‐effectivenessanalysesasanexplicitpartoftheirdecisionmaking.Somereservationsforusing

cost‐effectivenessexplicitlystillremain138,139.

Inviewoftheabovediscussedambiguitytowardsprioritysettingandthefragmentedstructureandnewinstitutionissuggested.AnumberoftheelementsareinspiredbyNICEinEnglandwhereasespeciallythestructureoftheboardfortheinstitutionisverydifferent.NICEisdebatedandhasalsoshownthatthere

arenoeasysolutionstotacklethebasichealtheconomicproblemofhowtobestallocateresourcestosatisfyallhealthcareneeds140,141.Asstatedtheproblemofmakingexplicitprioritiesarenoeasy.“Toalargeextent,denyingaccesstohealthcarebyexplicitmeansisboundtoleadtodiscontent,becausethe

generalpublicinterpretthisasbenefitsbeingdenied.Theopportunitycostargument,whichimpliesthatbenefitsareonlybeingdeniedbecauseevengreaterbenefitscanbedeliveredelsewhere,ismuchmoredifficulttoconvey.Moreover,thetechnicalnatureofNICE’sworkposesapotentialbarriertobroader

publicunderstandingofitsremitandtheprocessesunderlyingitsguidance.”142.AlthoughNICEisdebated,NICEhasalsodemonstratedthatitispossibletomanageanationalframeworkforprioritizationprovidingbetterprioritizationoratleastabetterbasisforprioritization.

Thisinstitutionshouldbeanchoredwithintheexistingnationaladministrativestructurebutmore

importantlyitshouldhaveapoliticalanchoringwithaboardofnationalpoliticianstoinsureitspoliticalsupportaswellasthelegitimacythroughoutthehealthcaresectorandinthepopulationingeneral.

Theanchoringintheexistingnationaladministrativestructureshouldpromoteaquickimplementationoftheinstitutionalandits’contributionsandeasethechanceofsuccessoftheinstitution.Theanchoring

should,however,alsobefreeoftheexistinglimitationsoftheexistingnationaladministrativestructure.Theanchoringmeansthate.g.theNationalBoardofHealth,TheDanishMedicinesAgencyandtheMinistry

ofHealthshouldbeinvolved,butthenewsuggestedinstitutionshouldnotbeembeddedintheexitingauthoritieswhiletheinstitutionshouldbefreetoreachoutintothehealthsystemwithnewapproaches.

Theboardofpoliticiansshouldberesponsibleformakingstrategicdecisionsfortheinstitutionguidinganestablishedframeworkforprioritysetting.Theyshouldnotbeinvolvedinorresponsibleforspecificpriority

settingssuggestedbytheinstitutionwhilewedonotbelievethatpoliticiansareablenorwillingtosticktoprioritieswhenpressuregroupsraisequestionsthespecificpriorities.Thepoliticiansshouldbeinvolvedinsettingcriteriaforprioritizationandguidingoverallprioritizationse.g.acrosspreventionandtreatment.

ThepoliticalboardshouldhavepoliticalrepresentationfromallpoliticalpartiesintheNationalParliamentandrepresentationfromallRegionalcouncilsandmayberepresentationfrompoliticiansfrommunicipalitiesortheassociationofmunicipalities.

Thisnationalinstitutionshouldhavetwooverallvisions.Theprimaryaimistoincreasethecapacityand

capabilityforrationalprioritizationinthehealthcaresystemlocally,regionallyandnationally.Thesecondoverallaimoftheinstitutionsistosupportspecificprioritizationinitiatives.

Thefirstaimshouldbeachievedbytwotypesofactivities.Firstly,theinstitutionshouldsupportthepoliticalboardinsettingupanationalframeworkforprioritysettingwhichcanbeusedforguidingspecific

prioritysettingsatlocal,regionalandnationallevel.Thisframeworkprovidesoveralldescriptionsofthegoalsforprioritysettingsandprovidesguidelinesforgoodprocessesforprioritysettingatlocal,regionalandnationallevels.AsintheNICEframework,itcouldbeconsideredthatthisnationalprioritization

frameworkshouldincludeanumberofpermanentcommittees.Onecommittee,calledthePartnersCouncil,shouldincludemembersfromorganizationswithaspecialinterestininstitution’sworkincludingpatientgroups,healthprofessionals,NHSmanagement,qualityorganizations,industryandtradeunions.

Theothercommittee,calledCitizensCouncil,shouldhavemembersofthepublicrepresentingthepopulation.

Secondly,theinstitutionshouldofferandsupporteducation,courseactivitiesandconferenceactivitywhichwillenlargecapacityandcapabilitiestocarryoutprioritysettingatlocal,regionalandnationallevels.

Thenationalframeworkrepresentsthepoliticalwillingnessandneedfortransparencyinprioritysettingandtheeducationalactivitiesrepresenttheoperationalcapacityandcapabilitytocarryoutprioritysetting.

Thenationalframeworkshouldbedisseminatedthroughcoursesandeducation.Furthermorethereisagreatneedforeducatingpoliticians,hospitalmanagers,healthprofessionalsandadministratorstobe

acquaintedwithmethodsforprioritization.Themethodsforprioritizationsincludeknowledgeonevidence‐basedpractice,clinicalprioritysetting,economicevaluation,healthtechnologyassessment,etc.Regardlessofhighlyeducatedpersonnelinthehealthcaresectorandintheadministration,thereisstillagreatneed

foreducationandtraininginmethodsforprioritysetting.Mostoftheinstitutionsresourcesshouldbeusedfortheseeducationalactivities.

Thesecondaimoftheinstitutionistosupportspecificprioritizationinitiatives.Thisshouldbeachievedbycollectingandinsomecasescoordinatingprioritysettingfromtheexistinginstitutionsororganizationsand

byinselectedcasesassistingthespecificbasisforprioritysetting.Itisimportantthatthisinstitutionpromotestheuseofthenationalframeworkforprioritysettingbyusingtheactualprioritysettingsfromtheothernationalauthorities.Also,itisimportantthatthebasisforprioritysettingiscoordinated.

Denmarkcannotaffordtoproduceallmaterialforprioritysettingandweshouldthereforebenefitsfromasmanyreliableforeignsourcesforrelevantmaterialaspossible.Theinstitutionsshouldthereforebe

responsibleforfacilitatingreliableandeasyaccesstorelevantinformationusefulforprioritysetting.Ofspecificactivitiesonecouldimagineprofessionalassistancefordoingliteraturesearchesandassistancefor

specificevaluationslikesystematicreviews,HTAsandeconomicevaluation.Anothertypeofactivityistosupportpermanentcommitteesresponsiblefordevelopingguidanceprogramsaccordingtothenationalframework.

Thereareatleastthreetypesofcoststhatshouldbeconsideredwhenimplementingthistypeof

institutions143.First,thecostofrunningtheinstitutionitselfandthesupportforanationalframework.Second,thecostofprovidingeducationprograms,coursesandtheresourcesusedtosupportthebasisforcarryingoutprioritization,bethatreports,notesorevaluations.Third,thecostofenforcingthepriority

settingdecisions.

Thefirsttwotypesofcostsmaybeconsiderableseenthroughoutthewholehealthcaresectorbutthethirdtypeofcostshouldnotbeneglected.Thistypeofcostislessvisibleandcannotbemeasuredbutconsiderableresourcesmaybeneed(andalreadyusedinthecurrentsituation).Toreducethethirdtypeof

costitisimportantthatanationalframeworkforprioritizationisgeneratedandthatthisframeworkhavepoliticalandadministrativelegitimacy.Aninvestmentinanationalinstitutionsupportanationalprioritysettingframework,whichisaveryvisibleamountofresourcesandseeminglyanincreasetothecostofthe

healthcaresystem,maynotseemobviousinthecurrentsituationwherehospitalslackmoney.However,itisarguedherethatbycreatinganationalprioritysettingframeworkandbyincreasingthecapabilitytocarryoutprioritysettingtheseresourcesareeasilysavedbyimprovingprioritysettinginthehealthcare

sector.SomeoftheexperiencesfromNICEindicatethatprovidinganationalframeworkforprioritysettingiscost‐effectiveandinsomecasescostsaving,seehttp://www.nice.org.uk/aboutnice/whatwedo/niceandthenhs/CostSaving.jsp.

Establishingamoretransparentandsystematicnationalprioritysettingframeworkisintuitivelyappealing

andwillprobablyalsoleadtomoreefficientuseofresourcesandmorelegitimateprioritysetting,Yet,itshouldbeemphasizedthatthereislimitedsolidevidencethatsuchanexplicitnationalframeworkforprioritysettinghasactuallyimprovedtheefficiencyandlegitimacyinthecountrieswhereithasbeen

established.Someoftheconcernsincludethecostandlogisticsofprovidingupdatedinformationforalltypesoftreatments,therelativelylengthyprocessofcollectingandevaluatingevidence,thefactthattheactualcost/effectivenessofhealthtechnologiesvariesconsiderablyaccordingtotheorganizationalchoices

forimplementation,andthatthemethodsforevaluatingpreventionandhealthpromotionactivitiestendtobeunderdeveloped.

AnationalinstitutionwithanannualbudgetofaroundDKK50millionissuggested–enablingastaffinglevelof15‐20personsandfundsforcommissioningstudiesfromoutsideanalysts.Inviewofthetotal

publicexpenditurebudgetthiswillbelessthan0.5%.

Itisveryhardtoestimatetheeconomicbenefitsofaninstitutionforanalysessupportingprioritysettingbecausemuchdependsontheimpactoftheanalyses,i.e.willtherecommendationsbefollowed.Therearenumerousstudiesshowingnet‐savingsifforinstancesuggestedtreatmentguidelinesarefollowed.Hence,

itdoesnotstretchtheimaginationtoassumethatatleast50millionDKKcanbesavedbyfollowingadviceoncost‐effectivenessoradviceontreatmentguidelines.Inotherwordstherewillbeatleastacost‐benefit

ratioof1:1andmostlikelymuchhigher.However,itwouldbeirresponsibletotrytobemoreexactbecausenumerousun‐testableassumptionswouldhavetobemade.Thereisnodoubtthatifonelookedat

theestablishmentoftheInstituteofRationalPharmacoTherapywithabout10employees(IRF2011)fromacost‐benefitperspectivethecost‐benefitratioishigh.

CopaymentThereisnowayaroundnotaddressingfiscalsustainability.Inthesectiononchallengesitwasnotedthattherewerebasicallythreewaysofcopingwithfiscalsustainability:1.‘overproportional’growthofpublic

expendituresforhealth(atthecostofotherpublicexpenditureareas),2.taxincreases,3.co‐payment,and4.acombinationofthefour.Itisunlikelythatthechallengecanandwillbemetbyjustoneofthefirstthree.

Tomostpoliticalpartiesco‐paymentisasacredcow,soittakesconsiderablecouragetocomeupwitha

proposal.Thecuewordinthedebateis‘inequityinaccesstohealthcare’followedbyargumentlikemanycannotaffordit(orisitthatmanydon’tgiveithighenoughpriorityinthehouseholdbudget?)orthatpostponementofuseofhealthcarebecauseofco‐paymentmayharmhealth.

CopaymentinDenmarkandtheNordiccountriesIn2008privateexpenditures(=co‐payment)amountedto21.8billionDkr.Thisisequalto15%ofthetotal

sumofhealthexpenditures,upfrom12%in19992.Itisdebatablewhatthebasisforthiscalculationshouldbebecausepartsofmunicipalnursinghomeexpendituresarepartofthebase.Iftheprivateexpendituresarecalculatedfromabaseofregionalpublichealthexpendituresthepercentagein2008

wouldbearound18%.

Figure25:Co‐paymentinDenmark:Categoriesanddevelopment1993‐2007144

Themaincategorieswithco‐paymentinDenmarkareseeninFigure25.Themaincategoriesaredrugsandadultdentaltreatmentwitharound30%eachoftotalco‐payment.Physiotherapyhasbeenincreasingovertheperiod.Aspercentageofdisposableincometherehasbeenanincreasefrom2.2%to2.4%in2007.

HospitalizationexistsinFinland,NorwayandSweden,Figure26.Itshouldbenotedthatthereisasimilar

concernforequityintheotherNordiccountriesasinDenmark.

Figure26:Co‐paymentintheNordiccountriesasofJanuary2010145

ProposalTheessentialelementsofthisproposalhavebeenliftedfromtheWelfareCommission’sproposalfrom

2006146.Theessentialelementsoftheproposalhasbeenpulledtogetherintable3(tables15.1and15.2intheWelfareCommissionsreport)(Velfærdskommissionen2005)

Thismeansthatservicesthathavebeenfreeatthepointofconsumptionformorethanacenturyormorewillbecoveredbyco‐payment.Thelevelofpayment,column2intable3,doesnotdeviatefromtheother

Scandinaviancountries,ifanythingslightlylower.

Thenetcontributiontofinancingofhealthcarewillbearound2billionDkr.However,therewillsomenetsavingsbecausedemandedservicevolumewilldecreaseasthepricerisesfrom0to20‐150Dkr.pervisit.Thedecreaseinexpenditureswillbearound1.3billionDkr.(column4).Thisisimportantforanother

reason,namelythatitfreesupcapacityinthatthetotalvolumeofservicesisexpectedtodecreaseby25%(maybeabitoveroptimistic.Thedecreasemorelikelywillbeinrangeof15‐25%).The‘excess’capacitywillcreateroomfortheincreaseddemandthatovertheyearswillcomefromtheagingpopulation,butinthe

shorttermalsomeansadecreaseinincomeforGPsandspecialists.

Table3:Co‐paymentproposalbytheWelfareCommission:feeandtotaleffects

Co‐payment,Dkr.

TotaleffectBillionDkr.

Ofwhichvolumedecrease Revenue

Generalpractice 1.4 0.6 0.8

*consultation 75

*telephoneore‐mailcontact 20 *homevisit 150

Out‐of‐hoursservice,GP 0.3 0.1 0.1*consultation 100 *telephonecontactandhomevisit 20

*telephonecontact 50

*homevisit 150 Consultationwithspecialist 100 1.0 0.5 0.4

A&Evisit 150 0.2 0.1 0.1Visitout‐patientdep. 125 0.4 0.0 0.4

Hospitalization 50/perday 0.2 0.0 0.2TOTAL 3.4 1.3 2.0

Note:ItisassumedthatutilizationofGPservices,specialistconsultations,andA&Evisits

decreaseby25%aftertheintroductionofco‐payment.Hospitalizationsandvisitstooutpatientdepartmentsarenotaffectedbyco‐payment.‐Numbersdonotaddupduetorounding‐off.

TocounterinequityissuestheWelfareCommissionintroduceaceilingforco‐paymentequivalentto1%of

income,i.e.whentotalpaymentduringayearreached1%ofincome,servicesagainbecomefree.Thepriceforthisceilingisareductionofrevenuebyalmost38%(thisreductionhasbeenincludedinthenumbersincolumn5intable3.The1%ceilingmeansthathighincomegroupspaymoreinabsolutetermsthanlow

incomegroups.Thereareotherwaystominimizedistributionalconsequences,forinstanceanabsoluteceilingforeverybodylikeinSweden,forinstanceDr.1,500butsuchasystemwouldbemoreunfairthananincomeceilingbecauseitwouldweighheavieronlowincomegroupsthanhighincomegroups.Another

approachwouldbetofollowthemodelforsubsidiestoprescriptionmedicine,whereco‐paymentdecreasesbyincreasinglevelofuseandbecomezeroafteracut‐offlevelhasbeenreached.

TheWelfareCommissiondidnotincludethecostsofadministeringtheco‐paymentscheme.Itobviouslywillnotbefree.Administrationcostswilldependonhowtheco‐paymentschemeisadministered.Ifitis

donebyusingtheexistingsystemsforreimbursementofGPsandspecialists,e.g.thataninvoiceissenttopatientseveryquarterbasedontheelectronicallysubmittedreimbursementclaimsfromGPsandspecialists,thenitcanbeadministeredatfairlylowcosts.Forthehospitalsaco‐paymentmodulecanbe

addedtotheelectronicpatientrecordsystem.BoththeGP/specialistsystemsandthenewco‐paymentmoduleforhospitalcarecanbelinkedtothetaxsystemtomonitorthepercentageofincomegoingtoco‐payment.Itisassumedthattheadministrationcostswillbe100‐150millionDkr.

Ifweassume150millionDkr.peryear,thismeansthata“cost‐benefitratio”of13willbetheresult.However,itshouldbenotedthatitisnotacost‐benefitratiointheusualsenseofthewordbecausethebenefits(=revenues)cannotbyanystretchofimaginationbeinterpretedaswillingnesstopay.Inaddition

thebenefitsstemmingforcreatingmorefiscalsustainabilityhasnotbeencalculatedeither.

WithintheDanishsystemofvoluntaryhealthinsurancetheintroductionofco‐paymentwillleadtoincreaseddemandforinsurancein‘denmark’thatessentiallyisa‘co‐paymentinsurance’thatreimbursespatientsforpartoftheirco‐payment.Fromatheoreticalandempiricalpointofviewthiswouldlessenthe

volumeimpactofco‐paymentandhencethe‘savings’duetodecreasedvolumeofutilization.

Improveequityinhealth/useofhealthcareAsnotedinthechallengesection,therearethreedifferentequityissues:Access,utilization,andoutcome(mortalityandmorbidity).TheHealthActonlymentionsequityinaccesswhilethenationalpolicyonpreventionalsomentionsequityinoutcomes.Asshownabovetherearenoseriousproblemswithequityin

accesswhilethereareclearsocialgradientsinoutcomeandunderlyinglifestyle.

Theissueofinequityinhealthisanimportantanddifficultchallenge.Persistinginequityisproblematicinandbyitself,asitrepresentsfailuretoliveuptothebasicgoalsofourhealthsystem(totheextentthatthehealthcaresystemistherelevantcausalparty).Yet,thereareotherreasonsforfocusingonhealth

inequity,asthepartofthepopulationwithworsthealthstatusaccountforamajorpartofthehealthexpenditure.Bytargetingthisgroupwemaythusachieverelativemorehealthgainforourinterventionthanbyabroaderstrategy.However,theproblemisthatthereismuchlessagreementonpossiblemeans

toimprovingequityinhealthbecausethecausalmechanismsaredifficulttoattackandinmanycasesarelocatedoutsidethehealthsystemnarrowlydefined.

Publichealthstudiesindicatethatthedeterminantsofhealthareverycomplex,e.g.figure10above,andincludetheinteractionbetweengeneticendowments,physicalandsocialenvironments,prosperity,

personallifestyleandperceivedwellbeingalongwiththehealthcaresystem(Evans1994;Marmot2004).Thedifficultyindesigninginterventionsisthatwedonotknowtheexactinteractionbetweenthesefactors,andthatindividualresponsestointerventionstendtovary.Yet,onethingiscertain.Itisnotenoughto

introducechangestothehealthcaresystemperseinordertoaffectinequitiesinhealth.Arangeofsupplementaryinterventionsshouldbeconsidered.First,itiswellknownthatlifestyleinducedillnessesaremoreprevalentinsomepartsofthepopulationthaninothers.Obesity,smokingandalcohol

consumption,andtherelatedillnessesofthecardio‐vascularsystemandvariousformsofcanceraremoreprevalentinsomesocialgroupsthaninother.Itthereforeseemsthatatargetedinterventioninthisgroupmighthavesignificantpotentialforpositiveimpactonhealthequity.Yet,theimpactwilldependonhow

theinterventionisdesignedandhowthegroupresponds.Themostradicalinterventionwouldbetobanaccesstocertaintypesofsubstances(alcohol,tobacco,fattyfoods),ortomandateexercise.However,suchinterventionsarehardlyfeasibleordesirable.Alessradicalroutewouldbetorestrictaccesseitherby

makingitdifficulttoobtainthesubstancese.g.bylimitationsinsalesoutlets,ortobanuseofthesubstancesinparticularareasandatparticulartimes.Anotherwayofrestrictingaccessisviaprice

mechanisms,wheretaxescanmakethesubstancerelativelymorecostly.Alloftheseinterventionsarealreadyusedtosomeextent,althoughDenmarktendstohavefairlyliberalaccess.Wepredominantlyrelyonthepricemechanism,andlatelyalsorestrictionsinuseatparticulartimes.Theproblemwithrelyingon

pricemechanismsisthatitcanhaveunintendedconsequencesforotherlifestylechoices.Highpriceofalcoholandtobaccomayleadtolowerconsumptionofhealthyandmoreexpensivefood.

Restrictionsinaccesstofattyfoodsareverydifficulttoenforce.Anotherroutecouldbetomakehealthierfoodsmoreeasilyavailablee.g.byreducingtheVATonselectedtypesofgoods.Thismightinducesome

consumerstoshifttheirconsumption.However,wedonotknowtheexacteffect,asfoodconsumptionisdeterminedbyarangeofculturalfactorsinadditiontopricerelations.Itisthereforelikelythatsuchaninterventionmustbecombinedwithtargetedinformationcampaignsetctohavefullimpact.

Inequitiesinuseofhealthcaremayappeareasiertochange.Yet,likefoodconsumptiontheuseofhealth

servicesdependonarangeofculturalfactorsinadditiontothepracticalavailability.Culturalfactorsaffectboththedemandside,e.g.intermsofhowoftentheindividualwantstoseeahealthprofessional,andthesupplysideintermsofhoweasyitisforthehealthprofessionaltoassesspotentialhealthproblemsand

thusmaketherightdiagnosticandtreatmentchoices.Culturalfactorsalsoaffectissueslikecompliancewithtreatmentregimesandwhetherornotthepersonengagesinlifestylechangesthatcansupport(orworsen)thetreatmenteffects.

Duetothecomplexitiesanduncertaintiesofbothdirectandindirecteffectsitisinherentlydifficulttomake

preciseestimatesofcostandbenefitsofpublichealthinterventions.ThenationalDanishCommissiononPrevention74notedthispointintheirreportfrom2009.Yet,theycalculatedcost‐effectivenessofanumberofinterventions,andconcludedthate.g.adoublingofthetaxationlevelfortobaccoandalcoholwaslikely

tohavenetbenefits.Andmoregenerallythatacarefullydesignedsetofinterventionsagainstthemainpublichealthproblemsofsmoking,drinking,excessiveeatingandlackofphysicalexercisecouldprovideoverallnetbenefit.TheCommissiondidnotanalyzeconsequencesforhealthequity,butasstatedinthe

abovethereareinequitiesintheengagementinriskybehavioracrossdifferentsocialgroups,andinterventionstargetingsuchbehaviorarethuslikelytohaveaninequityreducingeffect.

ProposalTheonlywaytogatherevidenceonhowtopossiblychangethesocialgradientinlifestyleandhealthistoconductsomekindofexperiment.Itisnoteasy,butstillfeasibleisaconcertedeffortisputintoitfromforinstancedepartmentsofoccupationalmedicine,GPs,municipalitiesandleastbutnotlast:companies.Itis

importanttomovefrommeasuringandtalkingaboutinequityandtrytodosomethingaboutit.

Aprojectisaimedatlow‐education,low‐incomegroupsthatareoccupationallyactive;typicallyun‐skilledandtoacertainextentskilledpersons.Theaimisinfluencethelifestyleandhealthstatus.Themostlikelysettingisanumberofcompanieswithrelativelymanyemployeesinthisgroup.

Theprojectshouldbelongterm,i.e.2‐3years,inordertobeabletodetectdifferences–andshouldbe

coupledwithaanadditional2‐3yearsoffollowuptoevaluatewhetherapossiblychangedlifestyleislasting.

Aprojecttoabout150millionDKKisenvisaged.Agoodevaluationshouldbeincluded,alsoincludinganeconomicevaluation.However,theimportantthingsassuchisnoteconomicbenefits,butratherwhat

doesitcosttochangethesocialgradient.Hence,inmanyrespectsitwouldbeabsurdtothinkintermsofa

cost‐benefitratio.Therelevantapproachwouldbeacost‐utilityapproachbasedonqualityadjustedlifeyears.

Itisimportantthatthemoneyconcentrateonafewsubstantialprojectsandnot‘spreadthin’onmanyprojects.Ifthelatterapproachisfollowed–alltoocommoninpubliclyfinancedprojects–thenitis

unlikelythanitispossibletodetectdifferences.

ReducingthenumberofinfectionsandadverseeventsThereismuchfocusonneworimprovedtreatmentsandtheirclinicalbenefits.However,inmanyrespectsthereareevenbiggerbenefitstobegainedintermsofimprovedsurvivalorbetterfunctionalstatustobegainedbyimproveorganizationalquality.Andevenmoreinteresting:Whilenewandimprovedtreatments

mostlikelywillleadtoincreasingexpenditurelevel–despite‘good’cost‐effectivenessratios–improvedorganizationalqualitymostlikelywillleadtonetsavings.

Therearethreetypesofquality:Patientexperience/satisfaction,professionalqualitylikeNIPdiscussedabove,andorganizationalquality.Organizationalqualityisaboutworkprocesses,structure,and

organization.Inmanyinstancesorganizationalqualityisaprerequisiteforbothprofessionalandpatientexperiencequality:wellorganizedprocessescanhelpsupporttimelyandprofessionallycorrecttreatmentandmuchofwhatpatientsexperiencedependshowwellthingsareorganized.

Toaconsiderableextenttheunderlyingreasonsforinfectionsandadverseeventsisrelatedto

organizationalqualityinthesensedescribe.Hygiene–personalandwithinthehospital(cleaning,sterilizationofutensilsetc.)isverymuchaboutworkprocesses.Soareissuessurroundingmedicationerrors.Itisincreasinglybeingrealizedthatimprovingorganizationalqualitymaysavemoneyaswitnessed

byarecentheadingonthewebsiteoftheprojectSafePatient:“Thehealthsystemofthefuturecannotaffordwasteanderrors.Patientsafetycanbepartofthesolutiontoeconomicchallengefacingthehealthsystem”(SikkerPatient2011).

ProposalTheinterestingthingaboutdecreasingthefrequencyofhospitalinfectionsandadverseeventsisthatatthetechnologicallevelitisnotverydemanding.Thehurdleistochangebehaviorandingrainedworkroutines.

WHOhasshownintheproject“SafeSurgerySavesLives”adherencetoprovenstandardsintheformofasimplechecklistwith19itemshasimprovedcompliancewithstandardsanddecreasedcomplicationsfromsurgeryineightpilothospitalswhereiswasevaluated,(Gawande2009;WHO2009;Haynes2009).

HospitalscurrentlyusingtheWHOSurgicalSafetyChecklisthavebeguntocollectlocalevidencethattheChecklistmakesadifferenceinsurgicalcareapartfromwhatwasdocumentedintheHaynesarticleintheNewEnglandJournalofMedicine.AccordingtotheWHOwebsiterecentlyStanfordUniversitypresented

theirfindingsatthe2010AmericanCollegeofSurgeonsAnnualClinicalCongressheldinWashingtonD.C.ResearchersatStanfordfoundthattheobserved/expectedmortalityratiodeclinedfrom.88inquarteroneto.80inquartertwowiththeuseofamodifiedversionoftheWHOSurgicalSafetyChecklist.Moreover,

theyfoundthattheuseoftheChecklistincreasedthefrequencyinwhichstaffreported"PatientSafetyNeverEvents"whilethenumberofPatientSafetyNeverEventsthatwererelatedtoerrorsor

complicationsdecreasedfrom35.2%to24.3%.Overall,theChecklisthasnotonlyimpactedoutcomes,butithasalsoimprovedcommunicationamongthesurgicalteam,andthusqualityofcare.

Similarly,againandagainithasbeendocumentedthatimprovedhandhygieneleadstoadecreaseinhospitalinfections.

Theoverallproposalissimplytoimplementinitiativesofthekindjustdescribed.Onemightevencontemplatetomaketheuseofchecklistscompulsory.Suchprojectswouldbeself‐financingwithinayear.

Ithasbeenestimated(veryroughly)thatreducingadverseeventsandinfectionswouldyieldacost‐benefitratiointheorderof1:17andlikelyevenhigher,(Pedersen2009).

ScreeningfordiabetesandhealthcheckupingeneralpracticeCloseto85%ofDanesseetheirGPduringatypicalyear.Thereforeiswouldbenaturaltousethisfactinasystematicwaybyintroducingbi‐annualcheckupscombinedwithscreeningfordiabetes(type2).The

check‐up–called‘healthtestandhealthconsultation’’–hasbeenshowntobecost‐effectiveintheEbeltof‐experiment(Jacobsen2001;Larsen2006;Rasmussen2006;Lauritzen2008)forthe30‐49yearsold.Theexactageinterval,e.g.inclusionofthe50‐65yearsold,shouldbeconsideredinconnectionwithactual

implementation.

ProposalAfewdetailsontheexperimentareinplace,inparttoelucidatethecontentsofthehealthtestandthe

healthconsultationwiththeGP,alongwithprovidingdocumentationfortheidea.

Thetargetgroupwas30‐49yearsold.Theyweredividedintothreegroupsbyrandomization(lottery):Acontrolgroupthatonlyansweredquestionnaires.Interventiongroup1hada

• broadhealthtestwithwrittenadvicefollowedbyanormal10–15minuteconsultationondemand.Interventiongroup2alsohadabroadhealthtestwithwrittenadvice,followedhoweverbya

planned45minutepatient‐centeredconsultation.

Participantsinthetwointerventiongroupswereofferedacomprehensivebiomedicalhealthtest.Healthtestswereperformedbyspeciallytrainedlaboratorytechniciansinoneoftheparticipatingclinics.2–3weeksafterthehealthtestallparticipantsreceivedwritteninformationfromtheirGPonthetestresults.

Adviceandpossibilitiesforlifestylechangesweregivenifthetestresultswereoutsideapre‐definednon‐risk‐range.Participantsininterventiongroup1wereadvisedtomakeanappointmentforanormalconsultationiftheresultswereconsideredtobeserious,i.e.elevatedbloodglucoseorhighriskof

cardiovasculardiseases.Allparticipantsininterventiongroup2wereofferedanappointmentfora45minutepatient‐centeredconsultation.Aonepagequestionnairewasincludedwiththewrittenadviceaskingparticipantstoconsidertheirhealthandwhattheycoulddotoimproveit.Theparticipantswere

askedtofillitinanddecidewhattotalkaboutwiththeirGP.AttheendofthehealthtalktheGPaskedeachindividualtosetamaximumofthreelifestyle‐relatedgoals.Ifneeded,furtherannualhealthconsultationslasting30minutescouldbeagreedupon.

Theprincipalfindingsofthe5‐yearfollow‐upofwere:

• Ahighparticipationratetohealthtestsandhealthconsultations.

• Arelevant,absolutereductionintheprevalenceofpeoplewithelevatedriskofCVDinthe

• interventiongroupscomparedtothecontrolgroup.

• Nopsychologicalreaction.

• Aninitialincreaseinhealthcarecontactsfollowedbyadecreasingtrend.Therewasnooverallincreaseinhealthcarecontacts.

Aneconomicallydominanteffect,i.e.healthtestsandconsultationsproducesignificantlybetterlifeexpectancywithoutextradirectandtotalcosts.

Estimatedlife‐yearsgainedperparticipantwere0.24and0.3yearsforinterventiongroup1and2

respectively‐comparedto0.16yearsforthecontrolgroup.Comparedtothecontrolgroupthedifferencewasstatisticallysignificant.

Anoverallpositiveperceptionbyparticipantsofhavinghealthtestsandhealthconsultations.

Fromahealtheconomicsperspectivetheresultswereinteresting:therewerenonet‐addedcostoverasixyearperiodofprovidingthetwointerventiongroupswithadditionalservices(healthtestandhealth

consultation).Inotherwords,thegainsinestimatedlifeexpectancycameatnonetcost.Theaveragenet‐gaininlifeexpectancyintwointerventiongroupswas0.13comparedtothecontrolgroup.IfweapplythevalueofanextralifeyearofDKK200,000thisanet‐benefitofDKK26,000(200,000*0.13)

Asaminimumhealthconsultationsandhealthtestsshouldbeintroducedforthe30‐49yearsold–the

targetgroupfortheoriginalexperiment.Inclusionofthe50‐65yearsoldshouldbeconsidered,butshouldbecarefullyevaluated.

ImprovedpsychiatryApsychiatricdisordercanbedefinedinavarietyofways.Thereforetheestimateofthenumberofpersonssufferingfromapsychiatricdisordervariesfrom10‐20%ofthepopulation(Sundhedsstyrelsen2009)andin

absolutenumbersfrom500,000to700,000(DanskPsykiatriskSelskab2004).ThiscoverseverythingfromschizophreniaoverADHDandautismtodepressionandanxiety.

AnincreasingnumberofDanesexperiencepsychiatricdisordersduringtheirlifetime.Psychiatriccarehasgenerallyreceivedlessattentionfrompoliticiansthansomaticcare,cf.abovewheregrowthinpsychiatry

relatedexpenditureslaggedbehindsomaticexpenditures.Theremaythereforeexistopportunitiesfor‘valueformoney’withinpsychiatryinthesensethathealthreturnsmaybehigh.Thequestioniswhereandhowtoinvest?Thereareseveralpossibilities.

Proposals1. Increasedfocusondepressionandanxiety.AccordingtotheDanishMentalHealthFund

(Psykiatrifonden2011)atanytimeabout200,000personssufferfromsomekindofdepressionof

whichabout120,000arerelativelyserious(gradedfrommediumtoserious).Duringtheirlifetimeabout15%oftheadultpopulationatsometimewillsufferfromdepression.Intermsofnumbersthisisonlysurpassedbyanxietywhereitisestimatedthat200,000+personsatanytimesuffer

fromanxiety,(Christensen2007).

Thesegroupsofcoursereceivetreatment.However,thereisnodoubtthattheirsituationcanbeimprovedconsiderably.

TherearenoDanishcost‐effectivenessanalyseseitheroftreatmentorpreventionofdepressionoranxiety.AtliteraturesurveybyWHO(WHO2004),anAustraliananalysis(Issakidis2004)anda

Swedishanalysisofdepressionorienteddrugsandanxiety(Wessling2008)togetherleavelittledoubtaboutthecost‐effectivenessoftreatment,i.e.thatthecostsperQALYiswithinnormallyacceptedbounds.Forinstance,theWHOsurveyshowedfrom$15,463to$36,434perQALY

gainedfortreatmentofferedintheprimaryhealthcaresector.Itshouldalsobenotedthatthesocietalcostsofdepressionandanxietyintermsofnotonlytreatmentbutalsolosttimefromworkordisabilitypensioningareconsiderable,

(Donohue2007).About50%ofallnewcasesofdisabilitypensionhaveapsychiatricdisorder(8,000

+)asthestatedreason,(Ankestyrelsen2011),butnopubliclyavailableinformationisavailableabouttheexactpsychiatricdiagnosis.Thereisnodoubtthatanumberofsuicidesarerelatedtodepression.However,theexactnumberisnotknownwithanydegreeofcertainty,although

professorLarsKessingclaimsthatabout20%ofthosewithrecurringdepressioneventuallycommitsuicide,(Kessing2011).Iftheywereandtherewashardevidenceofthepreventiveeffectonecouldestimateacost‐benefitratio.However,weabstainfromthishereandrelyonthecostsper

2. Increasedfocusonearlyinterventionagainstnon‐psychoticdiseases(e.g.depressionandanxietydisorders):Evidencepointstopositivelong‐termeffectsofearlyintervention.Wesuggestinitiatingapilotprojectfocusingonearlyinterventionmethodsingeneralpracticeandmunicipalhealthcare

assistedbyhospitalspecialists.Theinterventionconsistsoftrainingandresourcesforincreasedopportunisticscreening,andearlyreferraltospecializedcare.

3. Easieraccesstotreatmentandfollowupviahomecareteams:Theinterventionistoscaleuptheeffortthatisalreadydoneinmanyregionstoinstitutionalizethecapacityforambulatorytreatment

andfollowupinhomecareteams,andparticularlytoexpandthehomecareteamstoalsocovernon‐psychoticconditionsandcriminalpsychiatry.Homecareteamshaveprovensuccessfulinhelpingpatientsincreasecompliancewithtreatmentregimesandtoreducetheriskofalcoholor

substanceabuse.

Inthelattertwocasesitisverydifficulttoassessthecost/benefitratio.Particularlythebenefitsideappearsproblematic,asbothshorttermandlongtermbenefitsshouldbeincluded.Itshouldthereforebeanexplicitpartoftheprojecttodevelopeconomicevaluationsthatcancreateaclearerpictureofcostsand

benefitsinaDanishsetting.

EndoflifeEnd‐of‐lifeissuesareemotionallycharged,butneverthelessneedtobeaddressedinalevel‐headedfashion.Abovethedevelopmentinthenumberofhospicebedsandpalliativeteamshasbeendescribed,

hereweturntothepossibilityofexpandingthisareafurther.However,thereareotherissuesaswell,namelydrugsforterminallyillpatients.

Thequestionisnotwhetherterminallyillpatientsattheend‐of‐lifeshouldbe‘denied’treatment,butratherhowandwherecareshouldbeprovidedandthecost‐effectivenessofthesealternatives.Thenumberofpersonswillbeincreasingandthepossibilitiesforcontinuingactivetreatmenttotheverylast

However,inordertoprovidepossibleanswerthedelineationof‘terminallyilland‘end‐of‐life’needtoberesolved.

Terminalillnessisusedtodescribeanillness/diseasethatcannotbecuredoradequatelytreatedandthatisreasonablyexpectedtoresultinthedeathofthepatientwithinarelativelyshortperiodoftime.Thisterm

isoftenusedforprogressivediseasessuchascancerandadvancedheartdisease.Inpopularuse,itindicatesadiseasewhichwillendthelifeofthesufferer.Often,apatientisconsideredtobeterminallyillwhenthelifeexpectancyisestimatedtobesixmonthsorless,undertheassumptionthatthediseasewill

runitsnormalcourse.Thecaveatisthatitisaprediction–andtherewillbeexceptionssothatthepersonsinquestionlivelonger.InDenmarkpatientsareusuallyadmittedtohospicewhentheyareexpectedtohaveonemonthremaininglifetime.

ArecentarticleinthehighlyprestigiousNewEnglandJournalofMedicinereportedonalotterybasedtrial

wherepatientswithnewlydiagnosedmetastaticnon‐small‐celllungcancerwererandomlyassignedtoreceiveeitherearlypalliativecareintegratedwithstandardoncologiccareorstandardoncologiccarealone.Theresultsareinteresting.Amongpatientswithmetastaticnon‐small‐celllungcancer,early

palliativecareledtosignificantimprovementsinbothqualityoflifeandmood.Ascomparedwithpatientsreceivingstandardcare,patientsreceivingearlypalliativecarehadlessaggressivecareattheendoflifebutlongersurvival(Temel2010).Noeconomicevaluationhasbeencarriedout,butthearticleraisesmany

interestingquestions.Forinstance,‘aggressivetreatmenttotheveryend’vs.palliativecaretowardstheend.Inanaccompanyingeditorialitwasnotedthat

“DespitetheincreasingavailabilityofpalliativecareservicesinU.S.hospitalsandthebodyofevidenceshowingthegreatdistresstopatientscausedbysymptomsoftheillness,theburdenson

familycaregivers,andtheoveruseofcostly,ineffectivetherapiesduringadvancedchronicillness,theuseofpalliativecareservicesbyphysiciansfortheirpatientsremainslow.Physicianstendtoperceivepalliativecareasthealternativetolife‐prolongingorcurativecare—whatwedowhen

thereisnothingmorethatwecando—ratherthanasasimultaneouslydeliveredadjuncttodisease‐focusedtreatment”,(Kelley2010)

Therearenotverymanyeconomicevaluationswherestandardcare,palliativecare,andhospicecareis

comparedheadtohead.Acoupleofstudieslookingatin‐homepalliativecarevs.standardcareshowthatprovisionofinterdisciplinaryhome‐basedpalliativecareatendoflifeforpatientswithCHF,COPD,andcancercanleadtosignificantcostsavings,(Brumley2007;Enguidanos2005;Morrison2008;Penrod2006;

Penrod2010;Stephens2008).

Denmarkhasrecently(January2011)experiencedadebateaboutsomethingakintoterminallyillpatients,namelytheso‐called‘secretcodes’inthepatientfiles.Secretcodesarecodesunknowntothepatient(and

strictlyagainstthelaw)thatindicatethatincaseofaworseningofthepatient’ssituationthereshouldbenotransfertointensivecareorresuscitationbasicallyindicatingthatadditional/intensivetreatmentatbest

wouldincreaselifemarginally.Apartfromthelegalityoftheprocedureusedthereisbothanethicalandeconomicissue.

TheEnglishpriority‐settinginstituteNICE(NationalInstituteofClinicalExcellence)in2009introducedsupplementaryappraisalrulesforlifeextendingdrugstoterminallyillpatients.Thiscaseillustratesseveral

things:ingeneralhowdifficultprioritysettingaroundend‐of‐lifeissuesisandspecificallythatitseemsthatNICEsoftenedtherulesestablishedbythecostsperQALYthinking.

Thebackgroundwasthatanumberofdrugsforrenalcarcinoma(cancer)intermsofcost/QALYwerenotevenclosetothe£30000.Inaddition,incomparing2ofthedrugsunderconsideration,anextra£31,185

onlyextendspatient’slifeby5months.TheseconclusionsweresubsequentlyendorsedbyNICEwhoimmediatelybecamethetargetofintenseorganizedlobbyingfromstakeholders.Thecriticismwasintensefrompressandpoliticians.

InviewofthecriticismNICEissuedasupplementaryguidelineconcerning‘end‐of‐life’relateddruguse.The

supplementaryadviceistobeappliedinthefollowingcircumstancesandwhenallthecriteriareferredtobelowaresatisfied:

• forpatientswithashortlifeexpectancy,normallylessthan24monthsand;

• sufficientevidencetoindicatethatthetreatmentoffersanextensiontolife,normallyofatleast

• anadditional3months,comparedtocurrentNHStreatment,and;

• islicensedorotherwiseindicated,forsmallpatientpopulations

Whentheconditionsdescribedabovearemet,theNICEAppraisalCommitteewillconsider:

• TheimpactofgivinggreaterweighttoQALYsachievedinthelaterstagesofterminaldiseases,usingtheassumptionthattheextendedsurvivalperiodisexperiencedatthefullqualityoflife

anticipatedforahealthyindividualofthesameage,and

• ThemagnitudeoftheadditionalweightthatwouldneedtobeassignedtotheQALYbenefitsinthispatientgroupforthecost‐effectivenessofthetechnologytofallwithinthecurrentthresholdrange

ProposalFormanyreasonsitisimportanttostartfocusingonendoflifeissuesdespitethefactthatitisahighlyemotionalsubject.Apointofdeparturemaybetheterminallyillandhowtocareandtreatthisgroup.Three,notnecessarilyexclusive,alternativesneedtobeconsidered:Normal(moreorlessaggressive)

hospitaltreatment,palliativecare(invariousforms)andhospicecare.Lookedatfromacost‐minimizingperspective–assumingequalqualityoflife/lifeexpectancy‐theremaybeanadvantagetopalliativecare/hospicecare,cf.studiesreferredtoabove.However,thisverymuchneedstobesubjectedtoa

rigorouscost‐effectivenessstudy.

Diagnosticcenters/fasttrackdiagnosingandevaluationDelayofdiagnosticprocedureshasatleasttwoconsequences.Foranumberofdiseasesthediseasemayprogressfurtherwhilewaitingforaspecificdiagnosis,e.g.cancer,andinmostcasesdelaysindiagnosis

leadtopatientanxietyandworry.Ithasalsobeenshownthatlongtermsicknessabsencecanbeshortenedbycoordinatedandfastdiagnosing(Kilsgaard2006).Heretheissueforinstanceiswaitingtimeformedicalcertificationby(practicing)specialists(KAD2002).Diagnosingofteninvolvesseveralparties:GP,practicing

specialist,andthehospitalshowingthatcoordinatedandconcertedactionsareneeded.Fasttrackevaluationanddiagnosismay(toacertainextent)alleviatethetwomentionedproblems.Fasttrackevaluationanddiagnosingisalreadyinplaceforcancerandcertainheartdiseases,butmaytoadvantage

beextendedfurther.A‘diagnosisguarantee’hasbeenproposedsimilartotheguaranteeabouttreatment,(Eriksen2009;Bundgaard2009).However,theinitialenthusiasmapparentlyhasdampenedandapartfromthetwomentioneddiseasesnotmuchhashappenedapartfromaparliamentaryproposalbytheSocial

democratsaboutcreatingdiagnosticcenters(Andersen2010).

Fasttrackdiagnosingandevaluationisnotanunconditionalblessing.Firstofall,unlessitisavailabletoallpatientgroups,apossiblesideeffectmaybethatpatientgroupsnotcoveredbyfasttrackproceduresareneglected/pushedaside.Onemightarguethatfasttrackdiagnosisonlyshouldbeavailableforpatients

with‘seriousdiseases’.However,thequestionishowtodefine‘seriousdisease’.Itisdefinitelymorethanlifethreateningdiseases,e.g.therecentlyapprovedFinanceActfor2011hasresourcesfordiagnosisof‘murky/unclearindicationsofcancer’(diagnosticpackage),forinstancealsopatientswithrheumatism

whereearlyinterventionhasbeenshowntobeimportant,howeverlogicallyrequiringearlydiagnosis(Deighton2010).Secondly,tomakesensefasttrackdiagnosingobviouslyrequiresthattreatmentisavailableafterdiagnosing.Byfasttrackingthediagnosticprocessthewholeideaistoinitiatetreatmentas

fastaspossible.Thus,ifthebottleneckinrealityisnotthediagnosticphasebuttreatmenttherewillbeaneedtolookatthisbottlenecktoharvestsomeoftheimportantbenefitsoffastdiagnosing.Fasttrackingalsodecreasespatientanxietyindependentofpossiblehealthbenefits:‘WhatamIsufferingfrom?’Many

patientscomplainthattheworstiswaitingtimewithuncertainty.Forpatientsfearingcanceritturnsoutthatmanydonothavecancer,but‘only’anotherlessseriousdisease.

ArecentDanishstudyoffasttrackdiagnosingofneckandheadcancershowedthatitwaspossibletoreducewaitingtimesinheadandneckcancer.Throughlogisticchanges,employmentofafull‐timecase

manager,strengtheningthemultidisciplinarytumorboardandgivinghigherpriorityforheadandneckcancerpatients,theoveralltimefromfirstsuspicionofcanceruntiltreatmentstartwasreducedfrom57calendardaysto29calendardays,(Toustrup2011).

Asthisexampleshowsanimportanttoolforfasttrackingislogisticsandefficientclinicalpathwayswhich

includecoordinatedbookingofandavailabilityofspecialistsanddiagnosticfacilitylikeimagingandlaboratoryfacilities.Assumingthatthequestionmoreisaquestionaboutefficientuseofexistingmanpowerandfacilitiesratherthanshortageofthesamethereshouldbenodoubtthatfasttracking

shouldbecost‐effective.However,ithasnotbeenpossibletoidentifycost‐effectiveorcost‐benefitanalysesofeitherfasttrackdiagnosingordedicateddiagnosticcenters.However,thereareseveralstudiesonfasttracktreatment(searchPubmedusing‘fast‐track’)showingfavorableeconomicresultsandeven

resourcesavings.Inviewoftheoftenlowcostsofestablishingfasttrackprocedures,e.g.improvedlogisticsand/oracriticallookatbottlenecks,aguesstimateofacost‐benefitratioisatleast1:1andmost

likely1:>1.

SummaryforsolutionsTable4showsasummaryofthesolutions,theissuestheyaddressandtheroughcost‐benefitratiosand/orcostsperQALY.

Table4:Summaryofthe10solutions

Solution ThesolutionaddressesthefollowingSWOT‐elementsand

objectives

Cost‐benefitratioand/orcostsperqualityadjustedlifeyears,

1. Increaseduseoftelemedicine:

Projectwithbrief‐casefortele‐monitoring/advisingthe

chronicallyill

chronicallyill),thefiscalchallengeandpopulationexpectations

CBAratio1:1‐2

2. Cost‐effectivepreventive

activities/healthpromotion:Healthtestsandhealth

consultationsadmodumEbeltoft

chronicallyill)andthelowlifeexpectancy

CBA‐ratio:1:26(anet‐benefitper

participantofDKK26,000)

3. Hospitalpalliativecare–hospiceatendoflife

Demographicchallengeandthepopulation’sexpectations

Cost‐minimizationanalysispointstopalliativecare/hospicecare.

4. Improveequityinhealth/useofhealthcare

Inequityissues SomewhatmeaninglesstodevelopaCBA‐ratio

5. NationalInstituteforPriority

Setting,NIPS,Methodsfor(explicit)prioritysetting

Fiscalchallengeandlegitimacyof

thepublichealthcaresystem

CBA‐ratio:atleast1:1andmost

likely1:>1

6. Expensivemedicine Institutionforprioritysetting CBA‐ratio:atleast1:1andmostlikely1:>1

Fiscalchallengeandqualityofcare CBA‐ratio:atleast1:17

8. Co‐payment Fiscalchallenge CBA‐ratio:1:13

9. Improvedpsychiatrictreatment/care

Weakness,psychiatryhasfallenbehind

FordepressionthecostsperQALYrangefrom$15‐35,000‐whichis

‘goodvalue’.Nocost‐benefitratiohasbeenestimated.

10. Diagnosticcenters/fasttrack

diagnosing

Accessandcoherentpatient

pathways

GuesstimateCBA‐ratio:1:1and

likely1:>1

Becarefulwiththeinterpretationofthecost‐benefitratios.Theycannotbeequatedto‘savings’inthehealthcaresystem.Consider,forexample,Solution2inthetableabove.Thecost‐benefitratiois1:26.Thismeansthatindividualwillingnesstopayforanadditionallifeyearleadstothisresult(inaccordancewith

thethinkingbehindcost‐benefitanalysis).However,viewedfromthehealthcaresystem’sperspective,thesolutionis‘costneutral’.Forpracticalpurposesitisthisresultthatisofinterest.However,ifonewantstoputamonetaryvalueontheaddedlifetime,thiscanbedonebyapplyinganestimateoftheindividual’s

willingnesstopayfor(afractionof)anextralifeyear.Itshouldbeobviousthatthiscannotbeinterpretedas‘savings’,butratheristhemonetaryvalueofadditionallifetime.Itshouldbenotedthattheindividualwillingnesstopaymaydifferfromthepoliticalwillingnesstopayforanaddedlifeyear–andresource

allocationinhealthcareessentiallyispolitical.

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