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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
2
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
3
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
4
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
5
Diagnosticcenters/fasttrackdiagnosingandevaluation .....................................................................80
Summaryforsolutions ..........................................................................................................................82
Endnotes ...........................................................................................................................................84
References ........................................................................................................................................94
6
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
7
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
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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’.
9
• 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
10
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.
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Table1:CombinedSWOTanalysisandproposedsolutions(1…Nmeansitems/topics)
Internalcharacteristics
Strengths(S)
1...N
Weaknesses(W)
1...NOpportunities(O)
1...N
(SO)Solutions
1...N
(WO)Solutions
1...N
External
characteristics
Threats(T)
1...N
(ST)Solutions
1...N
(WT)Solutions
1...N
Ofcourseitisonlyaframework.Insomecaseswewilldeviatefromit,forinstancebecausesomesolutionsbothfurtherdeveloppositionsofstrengthandalleviateweaknessesorthatsomethreatsoropportunitiesmaybeinternalandnotexternal.
TheSWOTanalysistakesplacewithinthe(figurative)frameworkofthefigurebelow:
InthespaceallocatedforthepresentanalysisonlysomeoftheareasshowninFigure1willbetouched
upon.
12
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
13
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
14
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
15
• 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
7. Reducingthenumberofinfectionsandadverseevents’
Fiscalchallengeandqualityofcare
8. Co‐payment Fiscalchallenge
9. Improvedpsychiatrictreatment/care Weakness,psychiatryhasfallenbehind
10. Diagnosticcenters/fasttrackdiagnosing Accessandcoherentpatientpathways
16
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)
17
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
18
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.
19
• 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.
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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
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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
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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
23
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
24
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
25
thatintermsofpolicychangesmuchchangeneedtotakeplaceoutsidethehealthcaresystemtraditionallydefined,e.g.workenvironmentorstructuralchanges,e.g.taxationoftobaccooralcohol.
Figure10:Aconceptualmodelofthemaindeterminantsofhealth17
Morbidityvaries–notonlyaccordingtoageandgender,whichisnatural–butalsoaccordingtoschoolingandeducationwhichgivesrisetoequityconcerns.Thelattervariationistermed‘socialgradient.Thisisillustratedinfigure11for(selfreported)diabetesandlongtermillnesswithseverefunctionalrestrictions.
Ageandgenderdifferenceshaveeliminatedsothateducationaldifferenceareclearlyseen.
Figure11:Illustrationofsocialgradientfordiabetesandlongstandingillness
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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
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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.
28
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
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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:
30
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.
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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
32
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
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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.
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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
off.
Inarecentarticle37itwasnotedthattherearethreemainobstaclestotheadvancementofpersonalizedmedicine:scientificchallenges(apoorunderstandingofmolecularmechanismsoralackofmolecular
markersassociatedwithsomediseases,forexample),economicchallenges(poorlyalignedincentives),andoperationalissues.Althoughscientificdifficultiesremain,theeconomicchallengesandoperationalquestionsnowseemtobethebiggesthurdle.
Davisetal37notesthatinvestorsandanalystshavesuggestedthatpersonalizedmedicinecandramatically
reducehealthcarecosts.Yetmostpayershavebeenslowtoinvestinpersonalizedmedicine.Leadersinpayerorganizationssaythatseveralfactorscouldexplainthisreluctance.First,itishardtoidentifywhich
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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
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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
time.
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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
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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.
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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.
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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;
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• 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.
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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
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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
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• 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,
DDKM.
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
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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.
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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
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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
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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
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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
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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.
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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
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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
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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.
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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.
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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
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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
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
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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.
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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
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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
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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
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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
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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.
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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.
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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
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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
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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.
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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
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• 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).
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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
QALY.
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.
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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
80
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
81
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.
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SummaryforsolutionsTable4showsasummaryofthesolutions,theissuestheyaddressandtheroughcost‐benefitratiosand/orcostsperQALY.
Table4:Summaryofthe10solutions
Solution ThesolutionaddressesthefollowingSWOT‐elementsand
objectives
Cost‐benefitratioand/orcostsperqualityadjustedlifeyears,
QALY
1. Increaseduseoftelemedicine:
Projectwithbrief‐casefortele‐monitoring/advisingthe
chronicallyill
Demographicchallenge(the
chronicallyill),thefiscalchallengeandpopulationexpectations
CBAratio1:1‐2
2. Cost‐effectivepreventive
activities/healthpromotion:Healthtestsandhealth
consultationsadmodumEbeltoft
Demographicchallenge(the
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
7. Reducingthenumberofinfectionsandadverseevents’
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
83
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.
84
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