differences in health care structure and incentives – do ... · (here: in england and wales)...

Differences in health care structure and incentives –do they worsen or reduce health inequalities?q

Reinhard Busse, Prof. Dr. med. MPHDepartment of Health Care ManagementBerlin University of Technology/(WHO Collaborating Centre for Health Systems Research and Management)European Observatory on Health Systems and Policies

1Differences in health care structures and incentives20 November 2013

Life expectancy at birth, in yearsWhat we usually look at: life expectance by country

80

AustriaBulgariaEstonia

75

EstoniaFranceGermanyGreeceItalyLatviaat aLithuaniaPolandPortugalRomaniaSpain

70

SwedenUnited Kingdom

651970 1980 1990 2000 2010

20 November 2013 Differences in health care structures and incentives 2

What we forget (or don’t have good data for): MALE life expectancy at birth by socio‐economic classMA life expectancy at birth by socio economic class(here: in England and Wales)

SwedenSweden

Portugal

Office for National Statistics (2011) Trends in life expectancy by the National Statistics Socio-economic Classification 1982–2006. Newport


What we forget (or don’t have good data for): FEMALE life expectancy at birth by socio‐economic classF MA life expectancy at birth by socio economic class(here: in England and Wales)

France

Poland

Office for National Statistics (2011) Trends in life expectancy by the National Statistics Socio-economic Classification 1982–2006. Newport


What we usually look at:chronic disorders/ multimobidity by age (here: in Scotland)chronic disorders/ multimobidity by age (here: in Scotland)

Source: Barnett K et al. (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380: 37-43. 5

What we forget (or don‘t have good data for):multimobidity by socio‐economic status (here: in Scotland)y y ( )

+ >10 years withoutmultimorbidity

Factor 2

Source: Barnett K et al. (2012) Lancet 380: 37-43.20 November 2013 Differences in health care structures and incentives 6

The inverse care law (early 1970s) –The inverse care law (early 1970s) –still true today!?

• [Doctors] tend to gather where the climate is healthy... and where the patients can pay for their services.

(I Illi h)(Ivan Illich)

[ ]h l b l f d d l d• [T]he availability of good medical care tends to vary inversely with the need for it in the population servedserved.

(Julian Tudor Hart)


Let‘s take Germany as an example:Areas with higher/lower incomemore/fewer physiciansAreas with higher/lower income more/fewer physicians

Median household income2009

Physician supply (PCP) 2010

Source: www.versorgungsatlas.de


My framework to understand what we are talking about …

N d (b i i t t th i it / i ti t t t )Need (by socio‐economic status, ethnicity/ migration status etc.)

UUnmetneed

Unmetneed

Realisedaccess

x Quality = Outcomes20 November 2013 Differences in health care structures and incentives 9

Insurance coverage: the importance is known todayusually by U.S. data; here: access problems in 2012 for U.S. adultsusually by U.S. data; here: access problems in 2012 for U.S. adults

63Experienced cost‐

27

63Experienced costrelated access

problem

42Serious problems/ unable to pay

Uninsured

Insured all year15

p ymedical bills

Insured all year

42

39Spent $1,000 or more out‐of‐pocket

0 20 40 60 80 100

%%

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.


%

The benefit basket also matters: e.g. gaps in dental care

75 Did not visit dentist/hygenist/dental clinic in past two yearsSkipped dental care because of cost in past year

%

4145

60

19 22 23 26 27 27 282519 21 20

3329 32

30

10 10 11812 11

6

0

15

0GER SWE NOR NETH SWIZ CAN UK FR US AUS NZ

Covered in basicpackage

Complementarycoverage high Not covered

Own elaboration based on data from 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.


Cost‐sharing: size and protection mechanisms are important

%

Experienced cost-related access problem*

Spent US$1,000 or more out-of-pocket

50

60 Cap for cost‐sharingCost‐sharinguncapped

3740

5041

13 13 15 16 18 21 2220

30

14 1724 25

4 610 13 13 15

102 3

7 7 9 11 14

0

Source: modified from 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

* Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.


But “no cost‐sharing” is not enough; here: screening

• Socioeconomic deprivation isa strong predictor ofparticipation in screening forcolorectal cancer in Glasgowcolorectal cancer in Glasgow, although screening is offeredwithout charge

• The introduction of(effective) screeningprogrammes may result in increasing inequality inincreasing inequality in cancer outcomes Adjusted for age, sex, GP etc.,

the most disadvantaged wereSource: McCaffery K et al. (2002) Socioeconomic variation in participation in colorectal cancer screening. J Med Screen 9: 104-8


gmore than 2x as likely to decline!

Inequitable waiting times (and other factors) for angiography after acute myocardial infarction andangiography after acute myocardial infarction and subsequent mortality (here: in Canada)

Higher income

decreased waiting time for & increased usage offor & increased usage of coronary angiography

lower mortality rate

Source: Alter DA et al. (1999) Effects of socioeconomic status

30% GP 12%24% cardiologist 42%67% high-volume hospital 89%Source: Alter DA et al. (1999) Effects of socioeconomic status

on access to invasive cardiac procedures and on mortality after Acute Myocardial Infarction. NEJM 341: 1359-67

g p53% tertiary hospital >50km 10%


Realised access: Inequity of physician visits by income(and equal need); in many countries visible – and a real problem(and equal need); in many countries visible and a real problem in certain ones with poor seeing GPs and rich seeing specialists

Realisedaccessaccess

http://www.oecd.org/health/health-systems/31743034.pdf


Unmet U t


Unmetneed

Unmetneed

Inequalities in unmet need due to income> age > employment > education > gender age employment education gender

Unmet U t


Unmetneed

Unmetneed

What can we do?

• Tackle income inequalities (through taxation and redistribution)? h f h i i b h l h d i strength of the association between health and income stronger than the unequal income distribution reducing inequities primarily a matter of health policy reducing inequities primarily a matter of health policy

• Focus health policy on the disadvantaged(e.g. English “Health action zones” to reduce health problems(e.g. English Health action zones to reduce health problems in disadvantaged areas)? limited success (maybe we should try it anyway)

• Best solution: take inequities explicitly into account when designing the overall health system (i.e. health care for entire

l i ) i i h (fi i l ll i )population) – starting with money (financial allocation)


Back to Germany first:How do physician numbers relate to needsHow do physician numbers relate to needs(as used in the risk structure compensation mechanism)?

Median household income2009

Physician supply (PCP) 2010 Equity index of outpatient care

Source: www.versorgungsatlas.de Source: Ozegowski & Sundmacher (2013)


Is England more successful (with taking area indicators rather than only individual factors into account)?area indicators rather than only individual factors into account)?

Percentage gain (loss) from equalization grant, g g ( ) q g ,183 English health districts

183

131

157

183

Manchester:funding +33 1%

79

105

131 funding +33.1%<75 mortality +35.4%

West Surrey:funding -18.3%

27

53

79g<75 mortality -20.5%

30 20 10 0 10 20 30 40 501

27

-30 -20 -10 0 10 20 30 40 50


20 November 2013 Differences in health care structures and incentives 21http://www.phoutcomes.info/

20 November 2013 Differences in health care structures and incentives 22http://www.phoutcomes.info/

Outcomes – the bad news:Variation in amenable mortality by SES in Australia 1997‐2001Variation in amenable mortality by SES in Australia, 1997 2001

Source: Page et al. 2006

Health care is doing a worse job in disadvantaged areas!

Differences in health care structures and incentives 23

Outcomes – the good news:Inequitable differences in amenable mortality can be addressedInequitable differences in amenable mortality can be addressed

Source: McCarthy et al. 2009


But how? By emphasising “quality for all”Here: Quality improvements through “Quality and outcomes 72

: 728

-736

Here: Quality improvements through Quality and outcomes framework” by deprivation, England 2004/05‐2006/07

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“Better health” is associated with lower for disparities –an argument for putting quality first (here: association between life disparityan argument for putting quality first (here: association between life disparity in a specific year andlife expectancy inthat year for malesthat year for males in 40 countries and regions, 1840–2009)

Vaupel J W et al. (2011) Life expectancy and disparity: an international comparison of life table data BMJ Open 1:e000128 26

The take‐home message

• Inequity in health care should be at the centre of health policy (just as inefficiency, bad quality …)

• However, interventions to “help” only the disadvantaged, often by well‐meaning enthusiasts, always have the potential for unwanted side effects (increasing inequities!)for unwanted side‐effects (increasing inequities!)

• Therefore, the only viable solution is “better health care for everybody” with clear incentives to improve access (byeverybody with clear incentives to improve access (by looking at all 7 hurdles) and especially quality: better averages can only be reached if the worst results are improved!y p

• For monitoring success, data should be much more readily available (e.g. “unmet need” measures every 6 months) – and health service researchers should include socio‐economic status/ income … in their studies.


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