Transcript Document

European Health Care Policy and
Health Care Reform
Panos Kanavos
London School of Economics
Athens, 21 June 2011
Outline
• Key problems in European health systems
• Main responses
• Incentives and quality
• Example: P4P and incentives in outpatient care
• Improving efficiency in multi-stakeholder
settings
• Example: pharmaceutical policy
• Conclusions
European Healthcare Problems
1.
2.
3.
4.
5.
6.
Demographic pressures
Lifestyle issues
Inappropriate variation in clinical practice
Technical innovations
Public expectations
Resource constraints and sustainability
Health spending and national income, 2008
5000
Denmark
Total health expenditure
per capita (Euro)
4000
France
Germany
3000
Spain
Luxembourg
Ireland
Netherlands
Austria
Sweden
Finland
United Kingdom
Italy
Greece
Slovenia
2000
Portugal
Slovak Republic
Czech Republic
Hungary
Estonia
Poland
1000
0
0
10000
20000
30000
40000
50000
GDP per capita (Euro)
60000
70000
80000
90000
Pharma spending and national income, 2009
Total pharmaceutical expenditure
per capita (Euro)
800
Greece
Ireland
600
France
Germany
Spain
Austria
Italy
Finland
400
Portugal
Slovenia
Slovak Republic
Hungary
200
Sweden
Denmark
Netherlands
United Kingdom
Luxembourg
Czech Republic
Estonia
Poland
0
0
10000
20000
30000
40000
50000
GDP per capita (Euro)
60000
70000
80000
90000
Already prior to the economic crisis, governments were facing severe
difficulties to manage budget deficits and debt burdens ...
2007
2010
Budget deficit (% of GDP)
Budget deficit (% of GDP)
15
15
UK
12
Ireland
12
Greece
US
9
9
6
6
US
Brazil
3
Ireland
Mexico
0
India
UK
Russia
-6
0
20
China
3
Brazil
S. Korea
Italy
0
Germany
Higher GDP generally implies higher
stability if all other parameters
similar
Mexico
Netherlands
China
-3
France
Netherlands Portugal
India
Germany Italy
Russia
Greece
Portugal
France
Spain
Spain
-3
S. Korea
Maastricht
criteria
40
Maastricht
criteria
-6
60
80
100
120
140
0
Public debt (% of GDP)
20
40
60
80
100
; 5-10% =
; 10-14% =
; >14% =
1. Carmen M. Reinhart and Kenneth S. Rogoff, "Growth in a Time of Debt", NBER Working Paper No. 15639, Jan 2010
Source: Bank for international settlements; Economy Watch 2010
140
Public debt (% of GDP)
Bubble size corresponds to GDP (current prices $)
Unemployment rate: <5% =
120
Debt levels with negative impact on growth1
Responses
1. Service re-engineering and improving
efficiency
2. Use of clinical guidelines
3. Disinvestment
4. Public health
5. Health Technology Assessment and
Value for money
6. Performance measurement
7. Quality
The debate on Efficiency
• … Strong focus to improve efficiency, through:

















Separation of purchases from providers ( e.g. UK)
Competition between providers (e.g. UK, Germany, The Netherlands, etc)
Competition between insurers (e.g. Germany, The Netherlands)
Decentralisation and budget devolution (e.g. UK, Italy, Spain, Scandinavia)
DRG payments (will influence the possible hospital investments in new
technologies) and performance related payments (US, EU)
Increasing patient choice
Hospital restructuring, alternatives to hospital care
Attempt to improve efficiency through performance indicators (many)
National service frameworks
Quality of health care
Incentives
Service re-engineering
Extensive private provision
Demand-side cost containment
The changing nature of health professions
Tendering for outpatient drugs
Private provision
Source: European Observatory, CMS.
Incentives and Quality
Payment for Performance (P4P)
• International trend
– Adopted in many high income countries: US, UK, Australia, NZ,
Italy, Netherlands, Sweden, Norway, Germany, France
– Also in middle and low income countries: Cambodia, Rwanda,
Haiti, Philippines, Uganda
• Main idea: Linking payment to performance measures
• Foundations: Existing payment mechanisms do not reward
providers for higher quality
• Increased and better performance measurement
Percent of primary care doctors reporting any
financial incentives* targeted on quality of care
* Financial incentives are defined as the receipt or the potential to receive payment
for: clinical care targets, high patient ratings, managing chronic disease/complex
needs, preventative care or QI activities.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
Doctors Can Receive Any Financial Incentives
Percent who can receive any financial incentives for targeted care or meeting goals*
100
89
81
80
70
75
65
62
58
50
50
36
35
25
10
0
UK
NET
NZ
ITA**
AUS
CAN
GER
FRA
US
NOR
* Can receive financial incentives for any of six: high patient satisfaction ratings, achieve clinical care targets, managing patients
with chronic disease/complex needs, enhanced preventive care (includes counseling or group visits), adding nonphysician clinicians
to practice and non-face-to-face interactions with patients. Italy not asked non-face-to-face.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
SWE
Incentives for quality:
some examples
Pay for Performance & Performance Management System
Quality and Outcomes Framework
http://www.qof.ic.nhs.uk/
http://www.leapfroggroup.org/
Doctors Office Quality (DOQ) Project
http://cms.hhs.gov/quality/doq/
http://www.bridgestoexcellence.org/bte/
P4P: Outcomes - Evidence from the UK QOFs in diabetes – London SHA
DM12: The percentage of patients with
diabetes in whom the last blood pressure is
145/85 or less;
DM17: The percentage of patients with
diabetes whose last measured total
cholesterol within the previous 15 months is
5mmol/l or less;
DM23: The percentage of patients with
diabetes in whom the last HbA1c is 7 or less
(or equivalent test/reference range depending
on local laboratory) in the previous 15
months;
DM25: The percentage of patients with
diabetes in whom the last HbA1c is 9 or less
(or equivalent test/reference range depending
on local laboratory) in the previous 15
months.
Outcomes: Evidence from UK QOFs – individual SHAs, 5 indicators
Multiple stakeholders and efficiency:
the case of pharmaceuticals
National and regional wholesaler presence in select EU27
member states (2010) - I
A us tri a
B elgium
B ulgaria
Czech Republic
Denmark
E stonia
Finl and
France
Germany
Greec e*
Hungary
Ireland
It aly
Luxembourg
Netherlands
P ort ugal
Romania
S lovakia
S lovenia
S pain
S weden
UK
0
20
Nati onal Wholesalers
40
60
80
100
120
Regional Wholes alers
The absolute number of wholesalers in a country varies
significantly across the EU. Greece, Italy, Spain, Estonia,
Romania and the Czech republic have the largest number of
wholesalers, whether regional or national.
Source: Kanavos, Schurer and Vogler, 2011.
Number of community pharmacies across the EU27 region: total
number of pharmacies
Denmark
Sweden
Slov enia
Netherlands
Aus t ria
F inland
Lux embour
UK
Czec h
Portugal
Poland
Hungary
Germany
Slov ak ia
It aly
Ireland
F rance
Lat v ia
Est onia
Lithuania
Spain
Belgium
Malta
Cy prus
Bulgaria
Greece
0
0.2
0.4
0.6
0.8
Number of Pharmacies per Capit a (per 1,000 populat ion, 2005)
Greece, Bulgaria, Cyprus and Malta have the highest number of
pharmacies per 1000 population, while Denmark, Sweden and
Slovenia have the lowest
Source: Kanavos, Schurer and Vogler, 2011.
1
HP ex-factory price (EFP) (upper panel) and net pharmacy retail price (PRP) (lower panel)
(including dispensing fees but no VAT) ranking across the EU27 MS as of 15 June 2009.
Branded
MP ex-factory price (EFP) (upper panel) and net pharmacy retail price (PRP) (lower panel)
(including dispensing fees but no VAT) ranking across the EU27 MS as of 15 June 2009.
Branded
Source: Kanavos,
Schurer and Vogler,
2011.
Presentation of branded HP-A (expensive), MP-S (mid-priced) and LPHC (low priced) ex-factory price (EFP), wholesale (WS) margin/markup,
pharmacy (Ph) margin/markup
Branded
Source: Kanavos, Schurer and Vogler, 2011.
Generic LP-HC ex-factory price (EFP) (upper panel) and net pharmacy retail price (PRP) (lower
panel) (including dispensing fees but no VAT) ranking across the EU27 Member States, as of 15
June 2009
Generic
Source: Kanavos, Schurer
and Vogler, 2011.
LP-HC (generic): EFP, PPP, and net PRP across EU27 Member States, as
of 15 June 2009.
Generic
Source: Kanavos, Schurer and Vogler, 2011.
Drug spend per capita in comparative terms, 2000 – 2008/9
Greece
Ireland
France
Germany
Austria
Spain
Italy
Finland
Sweden
2008
Luxembourg
2000
Denmark
Portugal
Netherlands
Slovenia
Slovak Republic
United Kingdom
Hungary
Czech Republic
Estonia
Poland
0
100
200
For Greece data are for 2009.
Source: Kanavos et al, European Parliament, 2011.
300
400
Euro per capita
500
600
700
800
Impact of tendering for outpatient drugs - The Netherlands
Top – 10 preferred packs by market impact, May-June 2008
Preferred supplier
PPP1 (May
2008)
PPP1 (June
2008)
Change
1. Omeprazole
tablets/capsules, 20mg
Ratiopharm
€0.36
€0.05
-88%
2. Alendroninezuur tables,
70mg
Centrafarm
€4.99
€0.36
3. Omeprazole
tablets/capsules, 40mg
Centrafarm
€0.65
€0.09
4. Paroxetine tablets, 20mg
Ratiopharm
€0.37
€0.07
€0.27
€0.04
€0.54
€0.13
€0.17
€0.03
€0.34
€0.07
€0.19
€0.03
€0.34
€0.04
Product
5. Simvastatin tablets,
40mg
6. Pravastatin tablets, 40mg
7. Simvastatin tablets,
20mg
Actavis
Focus Farma
Ratiopharm/Actavis
8. Tamsulozine
tablets/capsules, 0.4mg
Centrafarm
9. Amlodipine tablets, 5mg
Ratiopharm
10. Citalopram tablets,
20mg
Ratiopharm
-93%
-86%
-82%
-84%
-76%
-85%
-80%
-85%
-88%
Value-based pricing in EU/Switzerland, 2010: use clinical and/or
economic evidence to assess extent of (clinical) benefits and value of
innovation
Current practice
•
•
•
•
•
•
•
•
•
Denmark
Switzerland
Sweden
Finland
The Netherlands
England & Wales [NICE]
Portugal
Norway
Baltic states (Estonia, Latvia,
Lithuania)
• Poland
• Hungary
Under preparation or
rising in influence
•
•
•
•
•
France
Spain
Slovenia
Czech Republic
Slovakia
Concluding remarks
• Resources remain scarce and will continue to
do so
• Extensive reforms focusing on quality and
incentives
• Efficiency remains a key target
• Service frameworks to target chronic disease
• Sustainability: guarantee with continuous
actions; all stakeholders bear part of the
burden to avoid imbalances