DELSA/GOV 3rd Health meeting - Mads Bager HOFFMANN

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This presentation by Mads Bager HOFFMANN was made at the 3rd Joint DELSA/GOV Health Meeting, Paris 24-25 April 2014. Find out more at …

This presentation by Mads Bager HOFFMANN was made at the 3rd Joint DELSA/GOV Health Meeting, Paris 24-25 April 2014. Find out more at www.oecd.org/gov/budgeting/3rdmeetingdelsagovnetworkfiscalsustainabilityofhealthsystems2014.htm

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  • 1. Decentralized governance of the Danish health care system Mads Bager Hoffmann
  • 2. • A public health care system • Equal and free access for all citizens • 85 pct. is financed through general taxes o 15 pct. is out of pocket payments • Decentralized organization THE DANISH HEALTH CARE SYSTEM
  • 3. Expenditure on health and life expectancy 68 70 72 74 76 78 80 82 84 Switzerland Italy Iceland Australia Israel Netherlands Austria UnitedKingdom Greece Portugal Finland OECD Denmark Chile Poland SlovakRepublic Turkey Life expectancy, 2011 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 UnitedStates Switzerland Canada Danmark Austria Portugal Spain Iceland Norway Finland Slovenia Israel CzechRepublic Korea Luxemburg Total expenditure on health as a share of GDP, 2011
  • 4. POLITICAL & ADMINISTRATIVE LEVELS • National level: One parliament and government / minister • Regional level (executive): 5 regions / regional councils • Local level (executive): 98 municipalities / municipal councils Reform of the structure of local govenment in 2007: • From 13 councils to 5 regions • From 271 small municipalities and 13
  • 5. NATIONAL RESPONSIBILITIES Regulating, coordinating and advising functions of the decentralized providers of health care services • Determining national health policies • Adopting legislation • Setting overall framework of the economy • General planning within the health sector • Defining guidelines • Performing control
  • 6. REGIONAL RESPONSIBILITIES • Hospital and psychiatric treatment • Primary health care / public health care scheme • General Practitioners (family doctors) • Private practicing specialists • Adults dental services • Physiotherapy
  • 7. MUNICIPAL RESPONSIBILITIES • Preventive care and health promotion • Rehabilitation outside hospital • Treatment of alcohol and drug abuse • Child nursing • Child dental services and special dental care • School health care • Home nursing
  • 8. SOMATIC HOSPITALS 1998 2011 Public somatic hospitals 79 53 Beds 19,700 18,303 Discharges 996,000 1,316,000 Average stay 5.8 4.8 (2009) Out patient visits 4,900,000 7,036,000
  • 9. FINANCING OF HEALTH CARE STATE MUNICIPALITIES REGIONS BLOCK GRANT BLOCK GRANT (75 percent) Activity related contribution (5 percent) Co-financing (20 percent) Collect direct taxes Collects direct taxes
  • 10. Municipalities State Hospitals GP excl. medicine Medicine grants Regions Municipalities (4,4 bill euro) State (0.2 bill euro) Hospitals (9.9 bill euro) GP excl. Medicine (2.0 bill euro) Medicine grants (0.9 bill euro) FINANCING OF HEALTH CARE PUBLIC EXPENDITURE ON HEALTH
  • 11. • Principle since 1970, municipalities and regions (decentralised public services) • ‘Equal partners’ • Combining budgetcontrol with local flexibility • Avoid detailed regulations: risk of neglect of responsibility and displacement of focus BUDGET COORPORATION
  • 12. Planned Realised • Figure shows annual real growth in public health expenditure, 1993-2010 • Difficult to control public health expenditure across governments PUBLIC HEALTH EXPENDITURE ACROSS GOVERNMENTS
  • 13. Goals • To support the credibility of the fiscal policies • To strengthen the governance of public expenditures • To make sure that overall costs do not exceed the passed budget Content • The overall expense ceilings are passed by parliament for a period of 4 years • 3 separate expense ceilings for state, regions and municipalities Sanctions • Implemented if budget/actual costs exceeds agreed target NEW BUDGET-LAW
  • 14. STRENGTHS IN CONTROLLING HEALTH CARE COSTS • General practitioners as gate keepers • Municipal co-financing of regional health care • Yearly budget-agreement between government and regions • Visitation guidelines
  • 15. • Negotiations every year with regions and municipalities • Fixed total level of spending, separate budgetceilings for service and investments • Policy targets to be met including a 2 pct. productivity target • New analyses - e.g. on activity trends • Output monitoring based on last years activity target as negotiated • Key: delivering on ceilings and targets! BUDGET AGREEMENTS
  • 16. • Rewarding quantity, not quality • Lack of priority • Lack of exchange of knowledge and best practices between regions • The right to get diagnosed within a month CHALLENGES IN CONTROLLING HEALTH CARE COSTS
  • 17. Incentive structure in the health care sector • More and better health at the same ressource level • Right now the incentives are too focussed on quantity • Stimulate coordination and continuity in treatment within and between sectors in the health care system • Map and spread best pratice
  • 18. PRODUCTIVITY IN THE REGIONS 1.4 -3.2 4.2 5.6 5.3 1.4 -4.0 -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 2007 2008 2009 2010 2011 2012 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Hovedstaden Sjælland Syddanmark Midtjylland Nordjylland Denmarkintotal Annual growth in productivity in public hospitals, pct., 2007-2012 Productivity by region, 2012
  • 19. • Transparency reform: o Better care and quality, more value for money o Transparency and better use of data o Development of quality indicators o Development of a patient related cost database o Better use of indicators and data at local level TRANSPARANCY REFORM – BETTER USE OF DATA
  • 20. Improving the health of the population Improving quality per patient Fewer costs per patient Why? Better practice and knowledge sharing – what works? Relevant and better documentation Data should be shared and used – also across sectors TRIPPLE AIM
  • 21. Thank you for your attention!