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Sherry Glied: Health reforms in the OECD

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  • 1. Health Reforms in the OECD Nuffield Trust Health Strategy Summit, March 2009 Sherry Glied Mailman School of Public Health Columbia UniversityThanks to the Commonwealth Fund and especially Robin Osborn.
  • 2. Non-US OECD Health Care Systems Misconception • Uniform • Stable and unchanging Reality • Variable (except with respect to coverage) • Intermittent significant reforms and frequent incremental modifications • Struggling with value for money 2
  • 3. Pop’n GDP Health Denmark 5,435 $35,000 $3,349 France 61,353 31,000 3,449 Germany 82,368 32,000 3,371 Netherlands 16,346 37,000 3,391 Sweden 9,081 35,000 3,202 Switzerland 7,484 38,000 4,311 UK 60,587 33,000 2,7602007. Per capita GDP and Health spending – PPP adjusted US$. 3
  • 4. Commonalities: Organization Universal or near universal coverage Defined, comprehensive benefit package Spending between 8-11% of GDP Free choice of primary care provider Low cost sharing, with exempt populations Limited private insurance to complement/supplement defined benefits 4
  • 5. Variations: Organization Automatic  Enroll with fund enrollment  Community rated General/earmark premiums tax financed  Private purchasers Public purchasers  No waiting times Waiting times 5
  • 6. Push toward greater equity Mandates for coverage Growing public share of spending Risk adjustment across purchasers Nationally pooled financing Low income subsidies 6
  • 7. Financing and Purchasing Risk adjusted capitated financing to insurance funds or regional purchasers • Defined benefits • Regulated provider fees • Regulated, community rated premiums • Very little selective contracting 7
  • 8. Physicians UK, Denmark, Netherlands, (Sweden) • Primary/specialty care  Direct service provision  Care coordination and navigation  Gatekeeping  Mainly capitated or salaried payment France, Germany, Switzerland, (Sweden) • Outpatient/inpatient  Some gatekeeping incentives  Fee-for-service practice 8
  • 9. Increased use of non-MDs Particularly in gatekeeping countries • Not all nurse-practitioners – chronic care nurses, pharmacists, etc. • Rx, immunizations, care coordination, outpatient clinics, chronic care clinics 9
  • 10. Quality and satisfaction Routine patient feedback Integration Recertification of providers Performance reporting P4P in UK • Quality, organization, experience Extra pay for • After hours, home visits, prevention • Capitated pay for disease management 10
  • 11. Information technology National IT strategy Main element is EHRs • Centralized  UK • Local development, central coordination  Denmark, Netherlands, Sweden Standards, portals, cards, etc. to facilitate interoperability 11
  • 12. Commonality: Financing Provider pays (except UK) • Some direct subsidies • Some enhanced fees Costly national efforts • Evidence for cost-saving is meager 12
  • 13. Commonality: Privacy Issue everywhere EU rules and national rules Access to own records, discretion as to what is included 13
  • 14. Variability: Extent of e-use EHRs Decision support, drug alerts • E-prescribing  E-labs, E-radiology • E-mail with patients  E-referrals ∗ E-discharge notes 14
  • 15. Pharmaceuticals Health technology assessment • Effectiveness and cost-effectiveness Reference pricing within a therapeutic class • Very broad Marketing restrictions • No DTCA • Limits on provider promotion 15
  • 16. Common Challenges Speeding up drug approval process • EU rules • High priority drugs Involving stakeholders Delisting existing drugs 16
  • 17. Innovations Sweden • Value-based pricing for drugs • Compared to therapeutic class UK • Velcade risk sharing agreement 17
  • 18. Watch this space IT expansions Further primary care innovations • Physician- and nurse-led disease management Purchasing and financing Costs are growing faster than incomes • Rising share of health care in GDP 18