What can we learn from European healthcare? Yanick Labrie, M.Sc. Economist, Montreal Economic Institute First Thinkers Conference University of Winnipeg, Manitoba February 22, 2013
Plan of the presentation How does Canada compare? Health spending Medical resources Quality of care Patient safety Accessibility Hospital efficiency Brief overview of three European healthcare systems France, Germany and UK What lessons should Canada learn from these countries? 4 key elements of success
Health indicators HOW DOES CANADA COMPARE?
Comparative figures for the Canadian and selected European healthcare systems Indicators Canada France Germany UK Healthcare spending as a % of GDP (2010) 11.4% 11.6% 11.6% 9.6% Healthcare spending per capita, US$ PPP (2010) Public spending on health as % of total (2010) Population 65 years old and over (2011) Source: OECD Health Statistics 2012 US$ 4,445 US$ 3,974 US$ 4,338 US$ 3,433 71.1% 77.0% 76.8% 83.2% 14.4% 17.3% 20.7% 16.2%
Health spending growth Average annual growth rate of total health expenditures, 2000-2009, real terms 6% 5% 4.9% 4.5% 4.3% 4% 3% 2% 2.6% 2.0% 1% 0% UK Canada OECD France Germany Source: OECD Health data 2012
Resources: Health professionals Physicians per 1000 population, 2010 Nurses per 1000 population, 2010 Germany 3.6 Germany 11 France 3.3 France 8.2 OECD 3.1 OECD 8.7 UK 2.7 UK 9.7 Canada 2.4 Canada 9.4 0 1 2 3 4 0 2 4 6 8 10 12 Source: OECD Health Data 2012
General health indicators Life expectancy at birth, 2010 Infant mortality rate, 2010 Germany 80.5 Germany 3.4 France 81.4 France 3.6 UK 80.6 UK 4.2 OECD 79.1 OECD 4.8 Canada 80.8 Canada 5.7 77 78 79 80 81 82 0 1 2 3 4 5 6 Source: Results from the International Surveys of the Commonwealth Fund, 2010
Quality: Amenable mortality rate 120 Rate of avoidable mortality caused by deficient health care (per 100 000 discharges), 2007 103.5 101.5 100 88.3 87 80 63.6 60 40 20 0 OECD UK Germany Canada France Source: J. Gay (2011), OECD.
Cancer care 87% 86% 85% 84% 86.6% Breast cancer, five-year survival rate 83.5% 83.3% 83% 82% 82.2% 81.3% 81% 80% 79% 78% Canada (2002-07) OECD (16 countries) Germany (2003-08) France (1997-2002) UK (2004-09) Source: OECD Health at a glance 2011
Cancer care 66% 64% 63,4% Colorectal cancer, five-year survival rate 62% 60% 60,4% 59,9% 58% 57,0% 56% 54% 53,3% 52% 50% 48% Canada (2002-07) Germany (2003-08) OECD (16 countries) France (1997-02) UK (2004-09) Source: OECD Health at a glance 2011
Patient safety Foreign body left in during procedure, (per 100 000 discharges), 2009 Accidental puncture or laceration, (per 100 000 discharges), 2009 Canada 9.5 Canada 517 OECD 5.7 OECD 219 UK 5.1 UK 144 Germany 4.5 Germany 160 France 4.8 France 98 0 2 4 6 8 10 0 100 200 300 400 500 600 Source: OECD Health Data 2011
Accessibility and wait times Patients who must wait 2 hours or more in emergency room (%), 2010 80% 70% 67% 60% 50% 52% 50% 40% 37% 35% 30% 20% 20% 10% 0% Québec Canada Ontario France UK Germany Source: Results from the International Surveys of the Commonwealth Fund, 2010
Accessibility and wait times Patients who saw doctor the last time they needed, the same or next day, 2011 100% 90% 87% 80% 70% 60% 50% 58% 55% 40% 30% 20% 10% 7% 33% 20% 23% 0% Quebec Ontario Man./Sask. Canada France Germany UK Source: Results from the International Surveys of the Commonwealth Fund, 2012
Accessibility and wait times 90 80 70 60 Average number of days before seeing a specialist, 2010 83 68 57 50 40 30 44 34 20 10 0 Quebec Canada Ontario France UK Germany 14 Source: Results from the International Surveys of the Commonwealth Fund, 2010
Accessibility and wait times Patients who must wait 4 months or more for elective surgery (%), 2010 30% 25% 20% 25% 21% 15% 10% 7% 5% 0% Canada UK France Germany 0% Source: Results from the International surveys of the Commonwealth Fund, 2010
Hospital system effectiveness Hospital discharges (per 1000 pop.) Average length of stay, acute care (days) Canada 84 Canada 7.7 UK 138 Uk 6.8 OECD 160 OECD 5.9 Germany 237 Germany 7.5 France 263 France 5.2 0 50 100 150 200 250 300 0 2 4 6 8 10 Source: David Squires, Commonwealth Fund, 2012
Source: David Squires. Explaining high health care spending in the United States: An international comparision of supply, utilization, prices and quality. Commonwealth Fund, May 2012. Cost efficiency in hospital spending Hospital Spending per Discharge, 2009 (US$, Adjusted for Differences in Cost of Living) 16000 14000 13 483 $ 12000 10000 8000 6000 4000 6 222 $ 5 204 $ 5 072 $ 2000 0 Canada OECD France Germany
Health reforms BRIEF OVERVIEW OF EUROPEAN HEALTHCARE SYSTEMS
The French Healthcare system Main characteristics Universal system Health insurance, financed by payroll taxes, covers the entire population All French citizens with incomes below 8 644 euros a year are covered by the public insurance with no contribution required from them All have freedom of choice between a diversity of providers 93% of the population have complementary insurance Dual practice for physicians is allowed, with restrictions Recent reforms: Activity-based funding of hospitals (T2A) in 2004 GPs as gatekeepers (2004)
The French Healthcare system Main highlights Ranked first among 191 countries by World Health Organization in 2000 Ranked first in the world for amenable mortality, 1997-2007 Among the countries with the slowest growth rate of health spending (real terms) in the last decade Waiting times are not an issue Largest market for private hospitalization in Europe
Sources: French Ministry of Health, US Department of Health and Human Services, German Federal Statistical Office, OECD Health Data 2012 A large role for private providers in France Private for-profit hospitals, as a share of total, 2009 45% 40% 35% 30% 38.6% 32.5% 25% 20% 17.2% 15% 10% 5% 0% 0.7% France Germany USA Canada
The three largest hospital chains in France Sources: Annual reports of Hospital chains; Fédération de l hospitalisation privée; Ministère français de la santé, Le panorama des établissements de santé, édition 2011 Générale de santé Vitalia Capio Total for-profit hospitals Hospitals 110 48 26 1,051 Beds 16,200 5,700 3,830 96,460 Average hospital size 147 beds 119 beds 147 beds 92 beds Employees 23,800 7,200 5,100 150,000 Revenus 2.0 B 650 M 490 M 12.1 B
A large role for private providers in France 56% of all surgeries and nearly 70% of ambulatory surgery in France Nearly 50% of people with cancer and 27% of births 2 million patients treated each year in 130 emergency services 50% of patients receiving social security under the CMU (least welloffs) choose to be treated in for-profit hospitals
Surgeries performed in the private for-profit sector in France, as a share of total, 2011 Cardiac 36.9% Nervous system 27.6% Ophtalmology ORL 69.1% 67.5% Orthopedic Digestive system 46.2% 52.4% Others 24.0% All 55.6% 0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% 80,0% Source: French Ministry of Health, Les etablissements de sante en France, edition 2012
The French Healthcare system What researchers have to say about it: [private clinics] have developed in underserved areas, where public hospitals failed to meet the needs of the population. (V. Mennessier, 2008) The results show that an admission to a for-profit hospital is associated with a lower conditional probability of death discharge from the hospital (C.Milcent, 2005) [Activity-based] reimbursement is associated with greater hospital efficiency than reimbursement by global budget. (C. Milcent, 2005)
The German healthcare system Main characteristics: Universal system Health insurance, financed through income-based contributions, covers 90% of the population; others are insured by private insurance Competition between a diversity of providers is encouraged Dual practice for physicians is allowed, with restrictions Widespread freedom of choice for patients Recent important reforms: Activity-based funding for hospitals (2003) Nationwide benchmarking exercise for hospitals Hospitals are now required to publish quality reports annually
The German healthcare system Main highlights: Lowest growth rate of health spending per capita (real terms) since 2000 Emergency overcrowding and waiting times for elective surgeries are uncommon, if not inexistent Largest database monitoring hospital quality in the world No other country has privatized more public hospitals in the last two decades (the number of for-profit hospitals increased by 90% since 1991)
The three largest private hospital chains in Germany Helios Kliniken (Fresenius) Asklepios Rhön Klinikum Total for-profit hospitals Hospitals 75 66 42 679 Beds 23,000 18,000 16,000 74,735 Average hospital size 308 beds 273 beds 380 beds 110 beds Employees 43,000 33,500 38,000 n.a. Revenus 2.7 B 2.3 B 2.6 B n.a. Source: Annual reports of Hospital chains; German Statistical Office
The German healthcare system What researchers have to say about it: Our findings show that conversions from public to private for-profit status were associated with an increase in efficiency of between 2.9 and 4.9%. (O. Tiemann et al., 2012) The study suggests that private for-profit hospitals provide higher quality of care, measured as risk-adjusted in-hospital mortality rates, compared to other types of ownership. (O.Tiemann et al., 2011)
The English healthcare system Main characteristics: Universal Tax-financed (Beveridgian model) like in Canada Competition between a diversity of providers encouraged (mostly public and not-for-profit) Patients can visit various websites to compare hospitals performance and make an informed choice Dual practice allowed for physicians, though restricted Recent reforms: Activity-based hospital funding (Payment by results) in 2003 Targets for wait times Since 2006, GPs must offer patients a choice of at least 4 providers
The English healthcare system Main Highlights: Average length of stay fell rapidly after the activity-based funding reform 97% of patients who show up in an emergency room receive a diagnosis from a physician within 4 hours The median wait time for elective surgery decreased by more than 60% between 2002-2010 Reduction in wait times for cataract surgeries and hip and knee replacements has been greater for patients from less well-off areas.
Median waiting times for elective surgery in England, 1992-2010 16 14 Payments by results (ABF) reform implemented in 2003 weeks 12 10 8 6 4 2 0 Mar 1992 Nov 1992 Jul 1993 Mar 1994 Nov 1994 Jul 1995 Mar 1996 Nov 1996 Jul 1997 Mar 1998 Nov 1998 Jul 1999 Mar 2000 Nov 2000 Jul 2001 Mar 2002 Nov 2002 Jul 2003 Mar 2004 Nov 2004 Jul 2005 Mar 2006 Nov 2006 Jul 2007 Mar 2008 Nov 2008 Jul 2009 Mar 2010 Source: UK Department of Health, Inpatient and Outpatient Waiting Times Statistics
The English healthcare system What researchers have to say about it: We find that higher competition [between hospitals] is positively correlated with increased management quality. (Bloom et al., 2010) We find that the effect of competition [between hospitals] is to save lives without raising costs. (Gaynor et al., 2012) Reductions in unit costs may have been achieved [following the ABF reform] without detrimental impact on the quality of care. (Ferrar et al., 2009)
Conclusion WHAT LESSONS SHOULD CANADA LEARN?
4 key elements of success in these European healthcare systems 1. Competition: Allowing a diversity of providers within the public healthcare system (private for profit, not-for-profit, and public hospitals) 2. Activity-based funding: Making money follow hospital patients 3. Freedom of choice: Giving patients freedom to choose between providers 4. Benchmarking: Making performance comparisons and quality indicators publicly available
Conclusion: What lessons for Canada? All these factors combined lead to: Improved access to care and reduced wait times Increased innovation: new and better ways of delivering care Improved management practices and cost efficiency Higher quality and more patient-centered care And all this without compromising the principles of universality and equity in access to care!
Is the picture all dark for Canada? Last March, the Ontario government announced that the province will begin reimbursing 91 hospitals according to services provided (ABF) The B.C. government set up a program that applies the same approach to about 17% of hospital funding (with encouraging results so far) Some provinces, including Manitoba and Quebec, now make hospital waiting times data available online CIHI, an independent research organization, now publicize hospital performance indicators on its website
THANK YOU!
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