Health system reform
in Europe: access, efficiency
and economic crisis
Sarah Thomson
Senior Health Financing Specialist, W...
Reforms:
 Health coverage
 Public funding
 Purchasing
Themes:
 Challenges
 Trends: 2000-2008
 Crisis and beyond
Options for addressing the
challenge of financial
sustainability
 spend more
 spend less
 spend better
 in line with g...
The move to universal
coverage was the key
achievement of EU health
systems in the early 21st
Century: why and how did
thi...
Recent coverage
expansions in EU countries
2000: France (residents)
2001: Ireland (older people)
2006: Netherlands (reside...
WHY expand coverage?
 People should not face financial hardship
when accessing effective care
 Financial protection make...
Population Total health spending
1%
5%
10%
55%
69%
27%
Source:Monheit2003andBerkandMonheit2001
Health spending is not even...
"Unless you're a Warren Buffett
or Bill Gates, you're one
illness away from financial
ruin in this country"
Himmelstein et...
Coverage has three
dimensions:
Source:WorldHealthReport2010
HOW did countries achieve
universal coverage?
 By cutting other dimensions of
coverage? Spending less publicly,
expanding...
Trends in private spending
 A more systematic approach to defining
benefits based on value (efficiency)
 More use of HTA
 Reductions often at the ...
UK HTA decisions usually
recommend coverage
0
20
40
60
80
100
Recommended Recommended
only in research
Not
recommended
Ava...
 Widely applied in EU health systems
 Mixed trends over time
 Increase in protection: poor, chronic
conditions, ambulat...
User
charges
GP visits
Specialist
visits
Outpatient
drugs
Dental care
Inpatient
care
AUT     
BEL    
DEN  
FIN...
Protection from user charges in
selected countries, 2012
Primary care
annual cap
OP prescription annual
cap
Inpatient annu...
Value-based user charges
for outpatient drugs
Source: Thomson, Schang and Chernew, Health Affairs 2013
The value-based app...
 User charges are a blunt policy tool and
may undermine efficiency
 Evidence of financial barriers to access
 Strong po...
% reporting health care to be
unaffordable, EU27, 2007
Out of
pocket %
of total
Hospitals Specialists GPs
Highest
CY 47 MT...
Source: WHO 2009
0
10
20
30
40
50
60
Cyprus
Latvia
Greece
Bulgaria
Switzerland
Lithuania
Slovakia
Hungary
Poland
Portugal
...
Source: Cylus and Pearson 2013 in press
0
1
2
3
4
5
6
7
8
9
10
Ireland
Greece
Latvia
Iceland
Slovakia
Hungary
Portugal
Fin...
Countries in which VHI = >10%
of total health spending (2009)
Very few large VHI markets
globally
Source: WHO data
0
10
20
30
40
50
60
70
80
90
100
France
Slovenia
Germany
Ireland
Cyprus
Neths
Spain
Austria
Belgium
Portugal
Lux
Malta
Hun...
0 10 20 30 40 50 60
France
Slovenia
Netherlands
Germany
Ireland
Austria
Luxembourg
Spain
Belgium
Portugal
Denmark
Malta
Tu...
Coverage: policy responses
during the crisis
Coverage Population
Benefits
package
User
charges
No change
BG DE DK EE FI
HR...
Trends in public spending
Public spending on health as a
% of GDP has risen, EU27
Source: WHO
0
1
2
3
4
5
6
7
8
9
10
Cyprus
Latvia
Estonia
Bulgaria
...
Total government spending as a
% of GDP has declined, EU27
Source: WHO
0
10
20
30
40
50
60
70
Slovakia
Estonia
Latvia
Lith...
Health spending has grown as a % of
total government spending, EU27
Source: WHO
0
2
4
6
8
10
12
14
16
18
20
Cyprus
Latvia
...
The economic challenge: sustained
decline in public spending on health
2009 2010 2011
Bulgaria Croatia Germany
Croatia Cze...
Source: Cylus and Pearson 2013 in press
The crisis has lowered the public share of health
spending in just over half of EU...
The crisis has slowed but not reversed per capita
public spending growth in most EU28 countries
Source: Cylus and Pearson ...
Public funding reforms
 Centralising and enforcing collection
 Broadening the revenue base
 Addressing stability issues...
Trends in purchasing
How the US health system
wastes $750 billion a year
Source: Institute of Medicine 2012
Purchasing: competition
 Purchasers: countries with multiple
insurers
 Hospitals: waiting times
 Mixed effects
Purchasing: paying providers
 DRGs to pay hospitals
 P4P mainly in primary care
 Mixed effects
 Useful as governance t...
Health care expenditure growth
slowed in the 2000s
Source: Thomson et al 2009 using OECD data in national currency units a...
THE
COMMONWEALTH
FUND
76
88 89
81
88
99 97
109
116
106
97
134
115 113
127
120
55 57 60 61 61 64 66 67
74 76 77 78 79 80 83...
P4PHTA
Skill
mixCoordinated
care
Adapted from Repullo 2013
Public
Health
Rationalise
hospitals
E health
User
charges
Staff...
Purchasing: lessons from
the crisis
 Countries can do more with less but
complex reform is difficult
 Strong pressure fo...
What does the
direction of change
tell us?
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Trends in Healthcare Reform in Europe

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THL Vaikuttajaseminaari 3.-4.10.2013 Sarah Thomson

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Trends in Healthcare Reform in Europe

  1. 1. Health system reform in Europe: access, efficiency and economic crisis Sarah Thomson Senior Health Financing Specialist, WHO Europe Head of the LSE Hub, European Observatory Associate Professor, Department of Social Policy, LSE Helsinki, 3 October 2013
  2. 2. Reforms:  Health coverage  Public funding  Purchasing Themes:  Challenges  Trends: 2000-2008  Crisis and beyond
  3. 3. Options for addressing the challenge of financial sustainability  spend more  spend less  spend better  in line with goals
  4. 4. The move to universal coverage was the key achievement of EU health systems in the early 21st Century: why and how did this happen?
  5. 5. Recent coverage expansions in EU countries 2000: France (residents) 2001: Ireland (older people) 2006: Netherlands (residents) 2008: Belgium (self-employed people) 2009: Germany (residents) 2009: Estonia (long-term unemployed) 2011: Spain (residents)
  6. 6. WHY expand coverage?  People should not face financial hardship when accessing effective care  Financial protection makes a huge contribution: individuals, society, economy  Financial protection is about efficiency and access  Lack of universality created access and efficiency problems in these countries
  7. 7. Population Total health spending 1% 5% 10% 55% 69% 27% Source:Monheit2003andBerkandMonheit2001 Health spending is not evenly distributed across the population 50% 97%
  8. 8. "Unless you're a Warren Buffett or Bill Gates, you're one illness away from financial ruin in this country" Himmelstein et al (2009), Medical bankruptcy in the United States, 2007: results of a national study, JAMA 122(8): 741-746. The quote is by S Woolhandler from Harvard (interviewed for CNN).
  9. 9. Coverage has three dimensions: Source:WorldHealthReport2010
  10. 10. HOW did countries achieve universal coverage?  By cutting other dimensions of coverage? Spending less publicly, expanding OOPs or VHI  By increasing public funding? Spending more  By enhancing value? Spending better
  11. 11. Trends in private spending
  12. 12.  A more systematic approach to defining benefits based on value (efficiency)  More use of HTA  Reductions often at the margin, not always evidence based  Technical, financial, political obstacles Coverage: benefits package
  13. 13. UK HTA decisions usually recommend coverage 0 20 40 60 80 100 Recommended Recommended only in research Not recommended Available from: http://www.nice.org.uk/newsroom/nicestatistics/TADecisionsRecommendationSummary.jsp
  14. 14.  Widely applied in EU health systems  Mixed trends over time  Increase in protection: poor, chronic conditions, ambulatory care  Increase in value-based approaches Coverage: user charges
  15. 15. User charges GP visits Specialist visits Outpatient drugs Dental care Inpatient care AUT      BEL     DEN   FIN      FRA      GER      GRE     IRE (I)  IRE (II)   ITA    NETH    POR    SPA  SWE      UK   Source:ThomsonandReedforthcoming User charges in EU14, 2012
  16. 16. Protection from user charges in selected countries, 2012 Primary care annual cap OP prescription annual cap Inpatient annual cap (daily charge) AUT €10 (poor free) 2% 28 days (10%) BEL €450-1,800 depending on income DEN FREE €480 (chronic only) FREE GER 2% (1% for chronically ill) FIN €630 (minors free) x 7 days (minors only) (€32) FRA x (chronic free, minors free primary care) 31 days (€18 + 20%) IRE x (poor free) €120-€1,440 (chronic free, low for poor) €750 (poor free) (€75) NETH FREE €220 NOR €250 SE €105 €205 x (€10) UK FREE €130 FREE Source: Thomson and Reed forthcoming
  17. 17. Value-based user charges for outpatient drugs Source: Thomson, Schang and Chernew, Health Affairs 2013 The value-based approach is not a panacea!
  18. 18.  User charges are a blunt policy tool and may undermine efficiency  Evidence of financial barriers to access  Strong policy design important  Policy focus should be on purchasing and delivery Coverage: user charges
  19. 19. % reporting health care to be unaffordable, EU27, 2007 Out of pocket % of total Hospitals Specialists GPs Highest CY 47 MT 57 PT 78 EL 43 LV 38 BG 52 EL 71 CY 39 Finland 18 22 59 17 EU27 16 21 35 11 Lowest FR 7 SE 7 DK 7 UK 4 DK 6 DK 1 SE 7 DK 1 Source: EC 2007, WHO 2012
  20. 20. Source: WHO 2009 0 10 20 30 40 50 60 Cyprus Latvia Greece Bulgaria Switzerland Lithuania Slovakia Hungary Poland Portugal Estonia Spain Malta Belgium Italy Romania Finland Sweden Austria Norway Slovenia CzechRepublic Denmark Germany Iceland UnitedKingdom Ireland France Netherlands Luxembourg 1998 2008 Out-of-pocket payment as a % of total health spending Countries in which OOPs have increased as % of TEH since 1998 Source: WHO GHO 2011
  21. 21. Source: Cylus and Pearson 2013 in press 0 1 2 3 4 5 6 7 8 9 10 Ireland Greece Latvia Iceland Slovakia Hungary Portugal Finland Spain Belgium Sweden Slovenia Switzerland Italy UK CzechRep Austria Cyprus Germany Most countries did not seen much increase in OOPs during the crisis % change 2009-2010
  22. 22. Countries in which VHI = >10% of total health spending (2009) Very few large VHI markets globally Source: WHO data
  23. 23. 0 10 20 30 40 50 60 70 80 90 100 France Slovenia Germany Ireland Cyprus Neths Spain Austria Belgium Portugal Lux Malta Hungary Greece Finland Denmark UK Italy Latvia Lithuania Bulgaria Estonia Sweden Czech Poland Romania Slovakia                             Large variation in market size: spending & coverage Source:Thomson2012forthcoming VHI as % of total health spending, EU 2009 % of population covered by VHI, EU 2009
  24. 24. 0 10 20 30 40 50 60 France Slovenia Netherlands Germany Ireland Austria Luxembourg Spain Belgium Portugal Denmark Malta Turkey Cyprus Finland UK Hungary Greece Italy Latvia Lithuania Sweden Estonia Bulgaria Czech Rep Poland Romania Slovakia PHI as % TEH OOP as % TEH VHI ranked by % of private spending on health (from low to high) in 2009 … Source:WHOdata … shows VHI does not do well in filling gaps in coverage
  25. 25. Coverage: policy responses during the crisis Coverage Population Benefits package User charges No change BG DE DK EE FI HR HU IT LV MT NL PL PT RO SK UK DE DK FI LV SE SI SK MT Increased protection AT BE EL FR LT SE AT BE BG HR FR IT LV MT NL UK AT BE BG DE DK EE EL ES FI FR HU IT LV NL PT RO SK UK Decreased protection CY CZ ES IE SI BE BG CZ EE HU IE LT NL RO AT BG CY CZ DK EL ES FI FR HR IE IT LV NL PT RO SE SI Mixed BE CY CZ DK EL ES HU PL RO EE EL ES FI FR IT LV NL PT UK Source: Thomson et al forthcoming 2013
  26. 26. Trends in public spending
  27. 27. Public spending on health as a % of GDP has risen, EU27 Source: WHO 0 1 2 3 4 5 6 7 8 9 10 Cyprus Latvia Estonia Bulgaria Poland Romania Lithuania Slovakia Greece Malta Hungary Slovenia Spain CzechRepublic Finland Ireland Luxembourg Italy Belgium Portugal UnitedKingdom Sweden Netherlands Austria Germany France Denmark 1997 2007
  28. 28. Total government spending as a % of GDP has declined, EU27 Source: WHO 0 10 20 30 40 50 60 70 Slovakia Estonia Latvia Lithuania Ireland Romania Luxembourg Spain Cyprus Bulgaria Poland Malta Slovenia UnitedKingdom Germany CzechRepublic Netherlands Portugal Finland Italy Austria Belgium Hungary Denmark France Sweden Greece 1997 2007 Size of government
  29. 29. Health spending has grown as a % of total government spending, EU27 Source: WHO 0 2 4 6 8 10 12 14 16 18 20 Cyprus Latvia Poland Bulgaria Greece Romania Hungary Estonia Lithuania Finland CzechRepublic Slovenia Malta Italy Sweden Belgium Slovakia Portugal Spain Austria UnitedKingdom France Netherlands Luxembourg Ireland Germany Denmark 1997 2007 ‘Priority’ in allocating resources to health care
  30. 30. The economic challenge: sustained decline in public spending on health 2009 2010 2011 Bulgaria Croatia Germany Croatia Czech Rep Greece Ireland Estonia Portugal Latvia Finland UK Lithuania Greece Romania Ireland Italy Slovakia Slovenia Spain Source: Cylus and Pearson 2013 in press using WHO NHA per capita public spending on health Other constraints: uncertainty? time? info? capacity? opposition?
  31. 31. Source: Cylus and Pearson 2013 in press The crisis has lowered the public share of health spending in just over half of EU28 countries
  32. 32. The crisis has slowed but not reversed per capita public spending growth in most EU28 countries Source: Cylus and Pearson 2013 in press
  33. 33. Public funding reforms  Centralising and enforcing collection  Broadening the revenue base  Addressing stability issues  Better targeting
  34. 34. Trends in purchasing
  35. 35. How the US health system wastes $750 billion a year Source: Institute of Medicine 2012
  36. 36. Purchasing: competition  Purchasers: countries with multiple insurers  Hospitals: waiting times  Mixed effects
  37. 37. Purchasing: paying providers  DRGs to pay hospitals  P4P mainly in primary care  Mixed effects  Useful as governance tools
  38. 38. Health care expenditure growth slowed in the 2000s Source: Thomson et al 2009 using OECD data in national currency units at 2000 GDP price level
  39. 39. THE COMMONWEALTH FUND 76 88 89 81 88 99 97 109 116 106 97 134 115 113 127 120 55 57 60 61 61 64 66 67 74 76 77 78 79 80 83 96 0 50 100 150 France Australia Italy Japan Sweden NorwayNetherlands Austria Finland Germ any Greece IrelandNew Zealand Denm ark United KingdomUnited States 1997–98 2006–07 Deaths per 100,000 population* * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S. Health systems have improved avoidable mortality Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011.
  40. 40. P4PHTA Skill mixCoordinated care Adapted from Repullo 2013 Public Health Rationalise hospitals E health User charges Staff cuts Salary cutsPopulation exclusions Delayed investment Cutting benefits Training, research cuts Price controls HTA Guidelines Crisis: policy responses P4P Co-ordinated care Skill mix Public health
  41. 41. Purchasing: lessons from the crisis  Countries can do more with less but complex reform is difficult  Strong pressure for short-term savings but savings ≠ efficiency  Importance of being selective and context-specific  Governance and leadership
  42. 42. What does the direction of change tell us?
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