This presentation was made by Tim Muir, OECD Secretariat, at the 6th Meeting of the Joint OECD DELSA-GOV Network on Fiscal Sustainability of Health Systems, held at the OECD Conference Centre, Paris, on 18-19 September 2017

1. COORDINATING
HEALTH AND LONG-
TERM CARE
Care coordination problems in OECD countries and how
health system financing can make things better or worse

2. This presentation covers three things
2
3
1
How health system financing can cause or
solve coordination problems
A proposal for work this group can take
forward in this area
Quantifying poor coordination of care in
OECD health systems

3. QUANTIFYING POOR
COORDINATION IN OECD
HEALTH AND LONG-TERM
CARE SYSTEMS

4. Problems arise at the interfaces
between different parts of the system
Long-term
care
Hospitals
Primary
care
Public
health
Community
health care
Mental
health care
At the interfaces between
care services we see:
Failure to share information
Duplication of effort
Errors
Delays
Poor quality care
Some countries
can quantify
problems here

5. Some health systems can measure
delays in hospital discharge
England Norway
Denmark
Delays in transferring patients from hospitals
Total number of days per year per 1000 population
Why has the
problem got worse?

6. The UK (England) can isolate problems
relating to long-term care
Delays in transferring patients from hospitals in England, by responsible organisation
Total number of days, three-month rolling average, index September 2010=100
Source: NHS England

7. THE ROLE OF FINANCING
IN CREATING PROBLEMS
AND FINDING SOLUTIONS

8. The way health and LTC systems are
financed can cause coordination issues
Different health and long-term care services…
…are provided by different organisations, each with its own budget
…which are funded by different ministries or levels of government.
There is a risk of cost-
shifting between budgets

9. Copayments for long-term care can be
much higher than for health
0%
20%
40%
60%
80%
100%
Netherlands
Iceland
Sweden
Canada:Ontario
Belgium
Canada:NovaScotia
Japan
Slovenia
England
Korea
France
Israel
CzechRepublic
UnitedStates:California
Croatia
UnitedStates:Illinois
Copayment rate for people with median income receiving LTC at home for moderate needs
Out-of-pocket payments as a percentage of total cost of long-term care
Source: Muir (2016) “Measuring social protection for long-term care”, OECD Health Working Papers

10. Financial mechanisms may encourage
providers to cooperate more effectively
Financial incentives can target specific interfaces of care…
…or they can try to align incentives across the system as a whole
• Municipal co-financing in Denmark and Norway – municipalities (who
fund community care) share the cost of delayed hospital discharges.
• The Better Care Fund in England is a £5.9bn pooled budget (around
5% of total health spending) jointly administered by the NHS and
Local Authorities to fund health and social care.
…they can target specific care pathways…
• German insurance funds can contract for “integrated care”. Multiple
providers must cooperate to deliver a care pathway and share a single
payment from the insurer.

11. Or multiple providers can be merged
into a single organisation
United States
• Accountable care organisations (ACOs) bring
together multiple providers to take collective
responsibility for delivering care to a population.
• Based on existing integrated care systems such
as Kaiser Permanente.
• Range from fully integrated systems, where all
services are provided by one organisation, to
looser networks of providers.
• Similar approaches are being considered in
England.

12. National care coordination initiatives
have sometimes failed to deliver
A number of care coordination initiatives in England have had limited success
An evaluation of 16 “integrated care pilots” found very mixed
results.
• More patients had a care plan… but patients actually felt
less involved in decisions.
• Elective admissions reduced… but emergency admissions
increased by 9%.
A recent evaluation of the Better Care Fund by the National
Audit Office found that is had:
“not achieved the expected value for money, in terms of
savings, outcomes for patients or hospital activity”

13. But there are some apparent success
stories
Norway’s Coordination Reform
Wide-ranging reforms introduced in 2012 to promote early
intervention and better management of complex needs.
Financial incentives: municipalities pay part of the cost for certain
types of hospital admission or delayed discharge.
New care settings: national roll-out of intermediate care.
Case management: for long-term care users with complex needs.
Delays in transferring
patients from hospitals
Total number of days per year
per 1000 population
Coordination Reform introduced

14. A PROPOSAL TO DEVELOP
OUR UNDERSTANDING OF
THIS ISSUE

15. We propose that this group lead
research on this topic
Share experiences of coordination problems between
different organisations and budgets
Identify financial mechanisms that are designed to
improve coordination and whether they work
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3
Map out the organisations that hold the budget for
each type of service / provider in each country1
The Secretariat proposes carrying out a simple survey to: