Transcript Governance and health care system performanc

Public reporting
and
accountability
The Dutch case
Gert Westert
Professor of Health Services Research,
Radboud University Nijmegen Medical
Centre;
Head DHCPR, National Institute of Public
Health (2006 – 2011)
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Dutch health care: brief
history
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Untill 1940: no government regulation with respect to
health insurance: private initiatives
1941: mandatory public health insurance for low- and
middle income groups
1970-1985: Pressure on central goal: universal access,
government plays important role
1980s focus on control of costs
2000: awareness of side effects of supply-side
regulation, focus on quality. New paradigm:
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From supply-oriented to demand-oriented (patient-centered
care)
More important role for health insurers
More room for providers
Efficiency through managed competition
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Context: regulated competition
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Dekker – report (CEO Philips); 1984
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“The Dutch government believes the
performance potential of the health care
system can be substantialle boosted if
centralised state control makes room for a
decentralised system of regulated
competition” (Ministry of Health, 2004)
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2006 New Health Insurance Act
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“More market elements”
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Consumers (18+) have to take out private insurance and
receive a government defined health insurance package
(broad and deep)
Insurers are obliged to accept all applicants
Health insurers compete, and critically purchase services
from providers
Providers will provide “more for less”, in terms of access,
quality, costs
Government takes backseat;
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Less “controlitis” and central planning, increasing competition
Speed up technical and organizational innovations
Increase responsiveness
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Regulated competition
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Dutch Health Care Authority (Nza) controls the right
functioning of the three markets
Health Care Inspectorate (IGZ) sets quality and
safety standards
Health Care Insurance Board (CVZ) advises on the
cost-effectiveness of the insurance package (too
broad, too deep?)
MoH responsible for access, quality, costs, but
operates at distance
Website to support citizens (Kies Beter/ Choose
Better)
Indenpendent researchers monitor (un)intended
effects and change: DHCPR
Public Reporting Performance
assessment
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Public Health Status and
Forecasts report
 State of Public Health
 Since 1993, fifth edition
2010, next 2014
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Health Care Performance
report
 State of Health Care
 Since 2006, third edition
2010 (May), next 2014
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DHCPR
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Commisioned by MoH; independence?
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Target group: Dutch citizens, represented by members of Parliament
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Describe access, quality and costs of healthcare system (prevention –
cure and long term care)
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Use limited number of macro indicators (150)
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Time series comparisons
International comparisons
Regional variations/ benchmarking
Patiënt perspective
Focus on outcomes
Pay attention to: efficiency, effect of reforms
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From assessment to action
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DHCPR: used?
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Bridging the gap between science and policy
is …”it isn’t love at first sight”
MoH prefers more than one source (partner)
Send to Parliament by MoH
Use all sources available and summarize
Provide key messages and an executive
summary
Provide a research agenda (Chapter 6:
Towards the next …
Stick to your role: evidence and science
Keep in mind: healthcare is about value for
patients
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Issues to discuss
 What
makes this urgent in the Australian
context? Accountability issues.
 What
needs to happen in Australia to get
PR established? Barriers and enablers.
 Role
of Independence and engagement
all stakeholders.
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lunchbreak
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Does it work, the Dutch
model?
Most important issues 2013:
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Access is good, quality varies
Insurers tend to contract on (total) price and less
on quality, but license to operate is at stake …
System is focussed on volume of healthcare; shift
towards value for patients needed
Expenditure growth not sustainable … 14% GDP
Transparancy and quality information: opaque,
but improving, focus on outcomes
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Expenditure growth not sustainable
14% GDP
Healthcare reforms 2006
Health expenditures percentage GDP
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Does this work (in a period of
economic downturn)?
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Dutch GP’s: 59 percent state that
patients receive too much care
IHP 2012, Commonwealth Fund
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“For a few dollars more”: well
spent?
 Waiting
lists (2001): ∨
 Hospital productivity: ∧
 Life expectancy ∧
Pay for volume
Elderly use more services, lower mortality
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Is this too much or value for
money?
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No waiting lists: overtreatment?
Expenditures up: price and volume issues (cataract
surgery)
Practice variation huge, but invisible (IQ healthcare,
2012)
GPs and hospital physicians: “live in separate worlds”
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Separate budgets and income schemes induce
overdiagnosis and - treatment
GP per enrolee/ service (60/40);
Hospital (physician) paid fee for service/ volume
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What’s next
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Government: expenditure / hospital volume
growth restricted (2.5%)
Out-of-pocket 50 EURO for visit ER (bypassing the
GP)
350 EURO deductible for hospital care
Tracking unnecessary or unwarranted care (20 –
35%)
TRANSPARANCY: how much we spend; what we
spend our money on (activities) and what the
outcome for patients is, but … disruptive
Nobody really wants to know: payer, provider,
politicians caught in a trap >>> patients can help
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Geographic perspective
Utilisation
(VOLUME)?
Expenditures?
Outcomes (VALUE)?
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Back hernia,
CTS
Prostate
Gallbladder
Varicose veins
Tonsillectomies
Cataract
Knee replacements
Dutch Atlas of Health Care Variation:
Elective surgery
1. Huge variation in activities (pilot)
2. What is the price of activities at local level?
3. What is the value for patients?
We don’t know? Need to measure outcomes
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http://praktijkvariatie.depraktijkindex.n
The Federation of Patients and
Consumer Organisations in the
Netherlands (NPCF).
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http://praktijkvariatie.depraktijkindex.n
“We have a problem”
 Neurosurgeon
presented to colleagues
(Wilco Peul): back hernia surgery
 Factor
3 to 4 between catchment areas
Response “brothers in arms”
 Data
isn’t right
 Data maybe right, not my problem
 My patients are different
 Let’s
take a look
Uitspraak
“50% van de zorg die wij bieden is onzin, we
weten alleen niet welke 50%” (oncologe)
Why?
 Medical
uncertainty is huge
 50% is effective
 We see more, but far less important things
 Professional autonomy (in isolation)
 Cookbook medicine
 Art and improvisation versus scientific
approach
What is definitely wrong
 We
pay for “income”, not for outcome
 Quantity dominates quality
 Doing dominates“watchfull waiting”
 More is better >>> Less is more
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Categorize care in 3 categories
 Effective
care: 25%
 Preference-sensitive
 Supply-sensitive
care: 25%
care: 50%
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 Signal
practice variation on map
(utilisation, costs, outcomes)
 Use
these signals to get stakeholders in a
room (lock the door)
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 Shared
decision making: the silent
misdiagnosis
T
= f(Md, Pd)
 Doctor
and doctor
Thesis
 Most
of the time we do things good, but
are we doing the right thing?
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Further reading
www.healthcareperformance.nl
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Questions?
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Thanks
Gert Westert
[email protected]
Let’s collaborate; we need
more fingers for our dykes!
Le$$