Transcript Cost-effective introduction of new drugs

Great expectations:
What can we learn from Sweden?
Anders Anell, PhD, director
The Swedish Institute for Health
Economics (IHE), Lund
Swedish Health Care
• Cornerstone of the Swedish welfare state
– Quality health care for all, distributive justice
• Decentralised decision-making
– 21 county councils responsible for hospitals and
primary care services
– 289 municipalities responsible for care of the elderly
and mentally handicapped (home care, nursing homes)
• Public ownership and political control
– With local exceptions
• Weak primary care services
New policies introduced at different
government levels
• National government
– Responsibility of local governments
– Specific issues (focus on access, quality and equity)
– Legislation or agreements + budget infusion
• Local government
– Experimentation with choice of providers, purchaserprovider split, contracting, privatisation, hospitals
mergers and closure, new primary care models,
integrated care and more
Impact of new policies
• Impact of local-government reforms and national
agreements limited compared to new legislation
• The formation of reforms can often be explained
by a political logic (i.e. maintaining legitimacy)
– Politicians produce rhetoric, plans and actual changes
– Coherence not necessary for survival
• Changes in welfare and advances in medical
technology more important than both local and
national government reform
Development of GDP and total expenditure on health in
Sweden, 1970-2004
(Index 1970=100, 2000 GDP price level)
Index
280
260
240
220
200
180
160
140
Total
expenditure on
health
GDP
120
19
70
19
72
19
74
19
76
19
78
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
100
Source: OECD Health Data 2005
Year
Acute care bed days per capita and age
group in Sweden, 1993 and 2004
9
1993
Bed days per capita
8
7
6
2004
5
4
3
2
1
0
0-14
15-24
25-44
Source: Sjukvårdsdata i Fokus, SKL, 2006
45-64
65-74
75-84
85+
Age
Expenditures for county council health care and municipal care
of the elderly and the handicapped. Constant 1999 prices.
Billion SEK
140
120
100
80
60
40
20
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
County council exp.
Municipality exp.
County council exp. (rev.)
Pharmaceuticals
Source: Nationell handlingsplan för äldrepolitiken. Lägesrapport
2001. Statistisk Årsbok för Landsting. Apoteket AB.
Development of total health care expenditure in Sweden
1993-2004 (constant 2004 prices)
Public share Pharmaceutical
Total health Total health Health care
of total
expenditures as
Year expenditure expenditure expenditure
health
% of total health
billion SEK per capita (SEK) as % of GDP expenditure
expenditure
1993
142.0
16 242
7.9%
82.5%
11.5%
1994
140.6
15 950
7.5%
82.0%
12.7%
1995
146.0
16 520
7.5%
81.2%
13.3%
1996
152.5
17 242
7.6%
81.6%
14.8%
1997
154.8
17 500
7.5%
80.3%
13.5%
1998
164.1
18 534
7.6%
80.4%
14.8%
1999
174.1
19 644
7.7%
79.7%
15.1%
2000
182.2
20 516
7.7%
79.8%
15.0%
2001
191.7
21 520
8.0%
80.0%
14.4%
2002
203.8
22 792
8.4%
80.2%
14.2%
2003
209.5
23 336
8.5%
80.4%
13.8%
2004
214.3
23 779
8.3%
80.3%
13.4%
Source: Swedish National Accounts, SCB 2006 and own calculations
Health care expenditure and GDP per capita
in the EU (15) + US and Norway, 1975
Health care exp./capita, US$ PPP
700
DK
600
US
DE
SE
500
NL
A
400
FR
FI
NO
300
IE
BE
L
G
ES
200
PT
100
0
2 000
3 000
4 000
5 000
GDP/capita, US$ PPP
Source: OECD Health Data 2005
6 000
7 000
8 000
Health care expenditure and GDP per capita
in the EU (15) + US and Norway, 2003
6000
US
5500
TEH/capita, US$ PPP
5000
4500
4000
NO
LU
3500
NL
BE
DE
3000
FR
2500
DK
SE
GR
IT
2000
ES
AT
FI
IE
GB
PT
1500
1000
15 000
20 000
25 000
Source: OECD Health Data 2005
30 000
35 000
40 000
GDP/capita, US$ PPP
45 000
50 000
55 000
60 000
”How would you assess health care services
today compared to 10 years ago?”
Better than 10 years ago
15,6%
About the same as 10 years ago
17,6%
Worse than 10 years ago
42,3%
Don´t know/uncertain
24,5%
Total
100%
Source: Rosén P. Population survey in county council of Östergötland
(Sample = 4 000 with 58% response rate, n = 2284, ages 18+).
Why?
• Cost-containment policies in mid 90s and
increased pressure for explicit priority setting
• Political rhetoric
– Election every fourth year; shift of local government
common. Opposition (and media) has an interest to
highlight problems.
• Increased transparency related to access and
quality (absolute level and differences)
• Demand for patient influence and less reliance on
experts
Waiting times and government policies
• Important problem for politicians since late 1980s
– Used as an argument for overall reform (privatisation)
– Waiting time ’guarantees’, budget infusion from
national level
• Several explanations behind existing waiting times
– Wider indications for treatment most important
– Waiting list for cataract surgery doubled 1990-2000; the
volume produced increased by 140%
Number of procedures per 100 000
Number of hip replacements in Sweden
per 100 000 population and age group
1994, 1999 and 2004
1200
1000
800
1994
600
1999
400
2004
200
0
45-64
65-74
Source: Sjukvårdsdata i Fokus, SKL, 2006
75-84
85+
Age
Number of procedures per 100 000
Number of coronary bypass and PCI
in Sweden per 100 000 population and age
1994, 1999 and 2004
700
600
500
1994
400
1999
300
2004
200
100
0
45-64
65-74
75-84
Coronary bypass
Source: Sjukvårdsdata i Fokus, SKL, 2006
85+
45-64
65-74
75-84
PCI
85+
Age
Regional expenditure per capita in Sweden for
five new oncology drugs1, 2005-01 – 2005-06
Stockholm region
21.44 SEK
Uppsala/Örebro
20.16 SEK
Northern region
19.31 SEK
Southern region
16.99 SEK
Southeastern region
16.34 SEK
Western region
16.08 SEK
Source: Dagens Medicin, 21 September 2005, p. 4-7.
1 Herceptin/trastuzumab, Erbitux/cetuximab, Avastin/bevacizumab,
Mabthera/rituximab and Glivec/imatinib.
Variation in access to cancer therapy
• Local priorities not transparent and limited by
budget criteria
• Less acceptance by national government (and the
population) of variation in access to treatment
(’post-code rationing’)
• Towards a national cancer-plan (= agreement +
budget infusion)?
– increased use of national guidelines, less discretion for
decision-making at local level and additional funding?
Expenditures for cancer drugs per capita
in selected countries in 2002/2003
France
16 Euro
Italy
13 Euro
Sweden
12 Euro
Germany
12 Euro
Switzerland
11 Euro
Spain
11 Euro
Austria
10 Euro
UK
10 Euro
Norway
9 Euro
Netherlands
9 Euro
Finland
9 Euro
Denmark
7 Euro
Sweden identified as ’average’
in terms of uptake of new cancer
drugs in pan-European study.
(Austria, Spain and Switzerland
= top three countries; Czech Republic,
Hungary, Norway,Poland and UK
below-average.)
Source: Wilking, Jönsson (2005)A pan-European
comparison regarding patient access to cancer drugs.
Karolinska Institutet, Stockholm.
Some challenges for the future
• Balance between national and local decisionmaking
– Ongoing parliamentary committee expected to suggest
larger regions to replace county councils
• Long-run financing of services (from 2015)
– Alternatives to tax funding?
• Recruitment of human resources
– Both municipalities and county councils
• Development of primary care and integration of
services
Inequity in distribution of physician visits in Sweden due
to weak primary care services
Fig. 5: Horizontal inequity (HI) indices for the annual mean number of visits
to a doctor in 19 OECD countries
van Doorslaer, E. et al. CMAJ 2006;174:177-183