Health system reform in Europe: access, efficiency and economic crisis

Transcription

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 Reforms: Health coverage Public funding Purchasing Themes: Challenges Trends: Crisis and beyond

3 Options for addressing the challenge of financial sustainability spend more spend less spend better in line with goals

4 The move to universal coverage was the key achievement of EU health systems in the early 21 st Century: why and how did this happen?

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 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 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

8 Source: World Health Report 2010 Coverage has three dimensions:

9 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

10 Trends in private spending

11 Coverage: benefits package 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

12 UK HTA decisions usually recommend coverage Recommended Recommended only in research Not recommended Available from:

13 Coverage: benefits package 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

14 Coverage: user charges Widely applied in EU health systems Mixed trends over time Increase in protection: poor, chronic conditions, ambulatory care Increase in value-based approaches

15 Source: Thomson and Reed forthcoming User charges in EU14, 2012 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

16 Coverage: user charges 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

17 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 FIN 630 (minors free) 2% (1% for chronically ill) x 7 days (minors only) ( 32) FRA x (chronic free, minors free primary care) 31 days ( %) IRE x (poor free) 120-1,440 (chronic free, low for poor) NETH FREE 220 NOR (poor free) ( 75) SE x ( 10) UK FREE 130 FREE Source: Thomson and Reed forthcoming

18 Value-based user charges for outpatient drugs The value-based approach is not a panacea! Source: Thomson, Schang and Chernew, Health Affairs 2013

19 % reporting health care to be unaffordable, EU27, 2007 Highest Out of pocket % of total Hospitals Specialists GPs CY 47 MT 57 PT 78 EL 43 LV 38 BG 52 EL 71 CY 39 Finland EU Lowest FR 7 SE 7 DK 7 UK 4 DK 6 DK 1 SE 7 DK 1 Source: EC 2007, WHO 2012

20 Ireland Greece Latvia Iceland Slovakia Hungary Portugal Finland Spain Belgium Sweden Slovenia Switzerland Italy UK Czech Rep Austria Cyprus Germany Most countries did not seen much increase in OOPs during the crisis % change Source: Cylus and Pearson 2013 in press

21 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 Source: Thomson 2012 forthcoming Large variation in market size: spending & coverage VHI as % of total health spending, EU 2009 % of population covered by VHI, EU

22 Source: WHO data VHI ranked by % of private spending on health (from low to high) in 2009 Slovakia Romania Poland Czech Rep Bulgaria Estonia Sweden Lithuania Latvia Italy Greece Hungary UK Finland Cyprus Turkey Malta Denmark Portugal Belgium Spain Luxembourg Austria Ireland Germany Netherlands Slovenia France PHI as % TEH OOP as % TEH shows VHI does not do well in filling gaps in coverage

23 Coverage: policy responses during the crisis Coverage No change Increased protection Decreased protection Mixed Population BG DE DK EE FI HR HU IT LV MT NL PL PT RO SK UK AT BE EL FR LT SE CY CZ ES IE SI Benefits package DE DK FI LV SE SI SK AT BE BG HR FR IT LV MT NL UK BE BG CZ EE HU IE LT NL RO BE CY CZ DK EL ES HU PL RO User charges MT AT BE BG DE DK EE EL ES FI FR HU IT LV NL PT RO SK UK AT BG CY CZ DK EL ES FI FR HR IE IT LV NL PT RO SE SI EE EL ES FI FR IT LV NL PT UK Source: Thomson et al forthcoming 2013

24 Trends in public spending

25 Cyprus Latvia Estonia Bulgaria Poland Romania Lithuania Slovakia Greece Malta Hungary Slovenia Spain Czech Republic Finland Ireland Luxembourg Italy Belgium Portugal United Kingdom Sweden Netherlands Austria Germany France Denmark Public spending on health as a % of GDP has risen, EU Source: WHO

26 Slovakia Estonia Latvia Lithuania Ireland Romania Luxembourg Spain Cyprus Bulgaria Poland Malta Slovenia United Kingdom Germany Czech Republic Netherlands Portugal Finland Italy Austria Belgium Hungary Denmark France Sweden Greece Total government spending as a % of GDP has declined, EU27 70 Size of government Source: WHO

27 Cyprus Latvia Poland Bulgaria Greece Romania Hungary Estonia Lithuania Finland Czech Republic Slovenia Malta Italy Sweden Belgium Slovakia Portugal Spain Austria United Kingdom France Netherlands Luxembourg Ireland Germany Denmark Health spending has grown as a % of total government spending, EU27 Priority in allocating resources to health care Source: WHO

28 Public funding reforms Centralising and enforcing collection Broadening the revenue base Addressing stability issues Better targeting

29 The economic challenge: sustained decline in public spending on health Bulgaria Croatia Germany Croatia Czech Rep Greece Ireland Estonia Portugal Latvia Finland UK Lithuania Romania Greece Ireland Italy Slovakia Slovenia Spain Other constraints: uncertainty? time? info? capacity? opposition? Source: Cylus and Pearson 2013 in press using WHO NHA per capita public spending on health

30 The crisis has lowered the public share of health spending in just over half of EU28 countries Source: Cylus and Pearson 2013 in press

31 The crisis has slowed but not reversed per capita public spending growth in most EU28 countries Source: Cylus and Pearson 2013 in press

32 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

33 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

34 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

35 Health systems have improved avoidable mortality Deaths per 100,000 population* France Australia Italy Japan Sweden Norway Netherlands Austria Finland Germany Greece Ireland New Zealand Denmark United Kingdom United States * 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. Source: Adapted from E. Nolte and M. McKee, Variations in Amenable Mortality Trends in 16 High-Income Nations, Health Policy, published online Sept. 12, THE COMMONWEALTH FUND

36 Trends in purchasing

37 How the US health system wastes $750 billion a year Source: Institute of Medicine 2012

38 Purchasing: competition Purchasers: countries with multiple insurers Hospitals: waiting times Mixed effects

39 Purchasing: paying providers DRGs to pay hospitals P4P mainly in primary care Mixed effects Useful as governance tools

40 Guidelines E health P4P HTA Skill mix Co-ordinated Coordinated care care HTA Skill mix Rationalise hospitals Public health Public Health Crisis: policy responses Delayed investment Cutting benefits Price controls Population exclusions User charges Training, research cuts Staff cuts Salary cuts Adapted from Repullo 2013

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 What does the direction of change tell us?