Health Reforms in the OECD

Nuffield TrustHealth Strategy Summit, March 2009

Sherry GliedMailman School of Public

HealthColumbia University

Thanks to the Commonwealth Fund and especially Robin Osborn.

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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

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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 2,760

2007. Per capita GDP and Health spending – PPP adjusted US$.

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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

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Variations: Organization

Automatic enrollment

General/earmark tax financed

Public purchasers Waiting times

Enroll with fund Community rated

premiums Private purchasers No waiting times

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Push toward greater equity

Mandates for coverage Growing public share of spending Risk adjustment across purchasers Nationally pooled financing Low income subsidies

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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

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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

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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

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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

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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

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Commonality: Financing

Provider pays (except UK)• Some direct subsidies• Some enhanced fees

Costly national efforts• Evidence for cost-saving is meager

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Commonality: Privacy

Issue everywhere EU rules and national rules Access to own records, discretion as

to what is included

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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

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Pharmaceuticals

Health technology assessment• Effectiveness and cost-effectiveness

Reference pricing within a therapeutic class• Very broad

Marketing restrictions• No DTCA• Limits on provider promotion

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Common Challenges

Speeding up drug approval process• EU rules• High priority drugs

Involving stakeholders Delisting existing drugs

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Innovations

Sweden• Value-based pricing for drugs• Compared to therapeutic class

UK• Velcade risk sharing agreement

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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