Mossialos pdf

Health systems’ responses to crises

Elias Mossialos

LSE HealthLondon School of Economics & Political Science

Objective

– Provide overview of recent health policy responses to fiscal pressures in Denmark, England, the Netherlands, France, Italy, Portugal and Spain, with a focus on health systems’ responses to crises and cost containment

– Analyze policies in terms of efficiency, equity and protection of vulnerable populations

Health Policy Responses

Source: authors

Policy objectives and reality

• First define objectives and then the means to achieve them

• Often about how much rather than whether

• Cost containment = efficiency - wrong

• Cost

– If U (health) > U (elsewhere)then health

Choice and cost

Source: authors based on Maresso et al. 2015; Thomson et al. 2015, 2014

Health Policy Responses: Impact on Efficiency

Source: Authors based on Maresso et al. 2015; Thomson et al. 2015, 2014

Health Policy Responses: Impact on Equity

Total Health ExpenditureReductions in 5 Countries and Slower Growth in 2 Countries (FR,NL)

1.500

2.500

3.500

4.500

USD

PP

P /

cap

ita

Denmark

Actual

Projected*

1.500

2.500

3.500

4.500

France Italy Netherlands

1.500

2.500

3.500

4.500

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

Portugal

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

Spain

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

United Kingdom

* Projection of total expenditure from 2009 to 2013 if average annual growth rate between 2000 and 2009 had remained unchanged

Source:authors based on OECD 2015

Service Availability• Accelerating reduction in hospital beds per 1,000 population in Denmark and the

UK; slight increase in Portugal due to shift from public to private sector; similar declines as pre-crisis in other countries

• Changes in human resources (no. of active physicians and nurses per population) not clearly visible

Source: authors based on OECD 2015

Measure CountryAnnual Avg pre-2009 Annual Avg post-2009

% Change % Change

Hospital Beds, per 1,000

population

Denmark -1,9% -3,0%

France -1,6% -1,1%

Italy -2,2% -1,8%

Netherlands -0,4% nd

Portugal -0,9% 0,2%

Spain -1,4% -1,3%

UK -2,0% -3,1%

No. of active doctors, per

1,000 population

Denmark 1,9% 0,9%

France 0,0% 0,4%

Italy 0,0% 0,1%

Netherlands 2,0% 2,5%

Portugal nd nd

Spain 1,3% 1,3%

UK nd nd

Utilization• Reversal of growth in doctor consultations in France and Denmark; accelerating

growth in the Netherlands (could be related to increases in primary care funding post-2010) and slower growth in Portugal

• Reversal of growth in hospital discharges in Portugal and the UK; accelerating decrease in Denmark and Italy; changing trend in Spain not visible

• Potential substitution effects between primary and secondary care not clear


% Change % Change

Doctors consultations (in all

settings), per 1,000 population

Denmark 1,0% 0,0%

France 0,7% -0,9%

Italy 0,0% nd


Portugal 1,6% 0,6%

Spain nd nd

UK 0,0% nd

Inpatient care discharges (all

hospitals), per 1,000 population

Denmark 0,0% -1,1%

France -1,7% 0,0%

Italy -1,7% -2,7%

Netherlands 2,3% nd

Portugal 0,3% -0,6%

Spain -0,5% -0,6%

UK 0,2% -0,5%


Access: Waiting TimesIncreasing waiting times for common elective surgery in Portugal and Spain (could be related to cuts) and the UK; decreases in Denmark and the Netherlands


% Change % Change

Mean waiting time from

specialist assessment to cataract

surgery, days

Denmark 15,5% -5,4%

France nd nd

Italy nd nd

Netherlands 0,0% -2,3%

Portugal -15,0% 2,4%

Spain -2,1% 2,5%

UK -6,4% 2,0%


specialist assessment to hip

replacement, days

Denmark -2,6% -4,7%

France nd nd

Italy nd nd


Portugal -8,5% 1,6%

Spain -1,1% 2,4%

UK -6,4% 0,4%


specialist assessment to knee

replacement, days

Denmark -1,7% -5,5%

France nd nd

Italy nd nd


Portugal -11,5% 2,0%

Spain nd 0,0%

UK -6,8% 0,6%


Pharmaceuticals• Decreased pharmaceutical expenditure in all countries except Italy and the UK

(slower growth) but generally no decrease in consumption (except in hypertensive and diabetic drugs in Portugal) mainly price effect

• Increase in share of generics

Measure CountryAnnual Avg % Change

pre-2009

Annual Avg % Change

post-2009

Total Pharmaceutical Sales,

per capita, USD at PPP

Denmark 8,5% -0,2%

France 6,1% -0,5%

Italy 7,3% 0,2%


Portugal 5,3% -4,2%

Spain 5,2% -3,1%

UK 3,6% 0,9%

Volume share of generics in

reimbursed pharmaceutical

market

Country % Share, 2009 % Share, 2013

Denmark 42,4% 54,0%

France 23,6% 30,2%

Italy 11,6% 20,3%


Portugal 20,1% 39,0%

Spain 23,8% 46,5%

UK 72,5% 83,4%


Access: Self-Reported Unmet Need• Reversed trend of decreasing unmet need due to cost in Spain, trends of increases continued

in France and Italy

• Some increase in Portugal post-2012

• Eurostat SILC data not always consistent with local sources: E.g. 20% unmet need due to cost in the Netherlands based on Commonwealth Fund survey (Schoen et al. 2013), declining unmet need due to cost through 2012 based on Spanish health survey (Garcia-Subirats et al. 2014)

0

2

4

6

8

10

12

14

Denmark UnitedKingdom

Netherlands Spain France Italy Portugal

Per

cen

tage

rep

ort

ing

un

met

nee

d

Self-reported unmet need due to cost

Poorest Quintile 2005



Total 2005

Total 2009

Total 2013

Source: authors based on Eurostat 2015

Conclusions

• Expenditure decline in most countries, most significant reductions in southern European countries subject to external pressures; slowed growth in France and the Netherlands

• Focus on cost cutting through price reductions or cuts to capacity and activity; some policies have uncertain output effects

• Pharmaceuticals a common target for apparently successful cost containment (price cuts, generic substitution); provider price reductions and controls of health worker incomes also common

• Despite nominal increases to user charges, out-of-pocket payments remain a limited source of financing (some increases in OOP share in Spain and Portugal).

Conclusions

• Most policies are technically simple to implement and aim at short-term savings

• Expansion of HTA, evidence-based disinvestment or value-based user charges are technically more demanding and less common; this may represent a missed opportunity

• Effect on service availability and utilization not clearly visible although some increase in self-reported unmet need and waiting times; data limitations and delayed effect of crisis on health system behavior and health outcomes may not yet allow for full assessment

• Too early to conclude whether short-term cuts will have sustainable effect or lead to longer-term cost increases (“squeezed balloon”)

• Relative to consumption, the total OOP expenditures have been in an upward trend since 2010 (mostly driven by the fact that the drop in consumption has been larger than drop in OOP health expenditures).

• Relative to consumption, the disaggregated health expenditure follows similar patterns to the disaggregated OOP expenditures in absolute terms.

0,00

1,00

2,00

3,00

4,00

5,00

6,00

7,00

2008 2009 2010 2011 2012 2013 2014

Greece: out-of-pocket health expenditure per household member (total and disaggregated), in% of consumption

Health

Medical products

Pharmaceutical products

Other medical

Therapeutic appliances

Outpatient services

Medical services

Dental services

Paramedical services

Hospital services

Health insurance

• Overall, prior to the crisis, the OOP per household member in the capital have been slightly higher compared to the rest of the country.

• However, the crisis has resulted with a sharper drop in OOP health expenditures in the capital region compared to the rest ofthe country.

• In particular, in the capital region, sharp decline has been registered in the outpatient services and dental services. The decrease in OOP expenditures in these two categories of healthcare expenditure has been less severe in the rest of the country.

0,00

100,00

200,00

300,00

400,00

500,00

600,00

700,00

800,00

900,00

1.000,00

2008 2009 2010 2011 2012 2013 2014

Attica: out-of-pocket health expenditure per household member (total and disaggregated), in Euros (real)

Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services 0,00

100,00

200,00

300,00

400,00

500,00

600,00

700,00

800,00

900,00

1.000,00

2008 2009 2010 2011 2012 2013 2014

Rest of Greece: out-of-pocket health expenditure per household member (total and disaggregated), in Euros

(real)Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services

Greece: out-of-pocket heatlh expenditure per household member (total and disaggregated), in % of consumption

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2008 2009 2010 2011 2012 2013 2014

1st consumption quintile

Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services

Health insurance0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2008 2009 2010 2011 2012 2013 2014

2nd consumption quintile

Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services

Health insurance

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2008 2009 2010 2011 2012 2013 2014

3rd consumption quintile

Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services

Health insurance0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2008 2009 2010 2011 2012 2013 2014

4th consumption quintile

Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services

Health insurance

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2008 2009 2010 2011 2012 2013 2014

5th consumption quintile

Total Health

Medical products


Other medical


Outpatient services

Medical services

Dental services


Hospital services

Health insurance

Policy options

22Health Care Costs Concentrated in Sick Few—

Sickest 10 Percent Account for 65 Percent of Expenses

Source: Agency for Healthcare Research and Quality analysis of

2009 Medical Expenditure Panel Survey.

Distribution of health expenditures for the U.S. population,

by magnitude of expenditure, 2009

1%5%

10%

50%

65%

22%

50%

97%

Population Share of Health Spending

A focus on whole population health models

From…

Single contracts• Payer-to-provider contracts remain the norm,

structured service by service

Money that follows organisations• Which makes collaboration hard

Payment tied to activity• About half of hospital reimbursement is via a tariff

system that reflects

• But even block contracts are usually based on

historic and projected activity

Understanding costs at the provider level• Usually procedure based, so do not capture total

costs across the pathway

Accountability for organisational performance• CEOs and boards held to account for the

performance of their individual organisations

Towards…

Collaborations between providers• Integrated provision will require increasingly

sophisticated provider-to-provider contracting

Money that follows people/patients• For which collaboration is usually required

Payment tied to patients • Payment linked to quality and cost for a specified

population

• Or payment linked to quality and cost for a

specified patient group (e.g. cancer patients)

Understanding costs at person level• An understanding of the total costs across

sectors and providers at the patient level

Accountability for patient and population

outcomes• Health leaders held to account for the healthy of

their populations and systems

Five observations about where the health systems are going

1

2

3

4

Systems and populations not just organisations• Organisations to be held “jointly” accountable

• Underpinned by place-based budgets

Triply integrated provision• Between hospital and general practice/family doctors and pharmacies; between mental and

physical health; between health social care/older people care

The first role of a payer/insurer: allocate resources wisely• Technical or operational efficiencies won’t close the funding gap

• We must invest seriously in prevention, bending the future curve of demand

• We must also ensure that we get maximum return on investment

The second role: catalysing new models of provision• To work alongside local areas to redesign how healthcare is delivered, deploying new technology

and workforce models, and using dedicated transformation resources

• Higher value models: better patient and population outcomes and the same or lower cost

Leading to a new way of doing making and implementing national policy• Traditional way: develop an intellectual framework at the Ministry of Health and then ask the

NHS/providers to implement it

• New way: work together from the beginning with local areas and providers helping them to design

and implement change – and learn lessons that can be spread elsewhere

5

Documents

Mossialos pdf