Transcript Health reform Issues

Health Reform Issues
TH Tulchinsky
Braun SPH
Jan 2004
Health for All
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National political commitment
Health as a government responsibility
Universal access
Adopt international standards
Regional and social equity in access
Free choice by consumers and providers
Healthy life-style as national policy
Health promotion as policy
Law/regulations
Regulate consumers rights in health
Public information on health
Advocacy groups - public, professional
Financing
• Financing within national means for social
benefits
• Adequate overall financing (>6%GNP)
• Shift from supply side planning to cost per capita
per output
• Categorical grants to promote national objectives
• Increase financing at national, state and local
government levels (7-9% GNP)
• Health insurance as supplement
• Define "basket of services" and consumer rights
• Reduce acute care beds to <3.0/1,000
• District health authorities with capitation funding
Defining National Health Targets
• Define leading causes of morbidity, mortality
and YPLL, hospitalization with regional
analysis
• Health promotion vs treatment philosophy
• Prioritization for use of available resources
• Use relevant international standards
• Social factor analysis in health
• Improve health KABP
• Community attitudes to health promotion
• Promote public health, nutrition,
environment,
• Immunization policies
Management for Cost-Effectiveness
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Cost containment
Cost-effective health initiatives
Decentralized management
National policy, monitoring and standards
Information systems/monitoring
District health profiles
Increase primary care
Increase home care, long-term beds
Increase non-admission surgery, long-term
care
• Health information systems
• Managed care and DRGs
Participants (Stakeholders) in
National Health Systems
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• Risk groups - persons
Government - national,
with special risk factors
state and local health
for disease e.g age,
authorities;
poverty;
Employers - through
• Providers - hospitals,
negotiated heath
managed care plans,
benefits for
medical, dental, nursing,
employees;
laboratories, others;
Insurers - public, not- • Providers - not-for-profit
for-profit and private
provider institutions;
for-profit;
• For-profit institutions,
individuals and groups;
Patients, clients or
consumers - as
• Teaching and research
individuals or groups;
institutions;
Participants (Stakeholders) in
National Health Systems
• Professional
• Economies - national,
associations;
regional and local;
• Social security
• International health
systems;
organizations and
• The public;
movements;
• Political parties;
• Pharmaceutical and
• Advocacy groups - age,
medical technology
disease, poverty or
industries
public interest groups;
• The media;
Health System Problems: World Bank
1. Misallocation of Resources: Public money is
spent on interventions of dubious costeffectiveness, e.g. bone marrow transplants for
breast cancer, while highly cost-effective
interventions (TB and STD management) are
neglected;
2. Inequity: Poor and rural populations receive
less health care, while public monies go to
urban and affluent groups who have better
access to tertiary care services;
3. Inefficiency: Much waste in health care, in use
of brand name drugs, inefficient use of health
personnel and inappropriate utilization of
hospital beds;
Typology of Financing and
Administration of National Health
Systems
• Type
• Financing Source
• Administration
Categories of Services
Institutional Care
Pharmaceuticals and
Vaccines
Ambulatory Care
Home Care
Elderly Support
Categorical Programs
Immunization, MCH
Family planning,
Mental health, TB,
STDs, HIV,
Screening
Community Health
Activities
Healthy communities
Health promotion, risk
groups, environment and
occupational health,
nutrition and food safety,
safe water supplies,
special groups
Research
Professional education
and training
Classical Market Factors
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Supply
Demand
Competition in cost, quality
System macro-efficiency
Vertical integration
Lateral integration
System micro-efficiency
Incentives
Disincentives
Reputation
Regulatory Factors
• Regulate supply
• Regulate demand – gatekeeper,
user fees
• Regulate price
• Regulate benefits
• Regulate method of payment
• Health promotion issues
Health and Societal Factors
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Differing population needs
Social inequities
Improve infrastructure to reduce needs
Socioeconomic improvements
Public social policies
Health as a national and local priority
Health promotion
Improve KABP (knowledge, attitudes,
beliefs and practices)
System Determinants
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Shift in resource allocation
Technological innovations
Substitution e.g. generic drugs
Total Quality Management
institutional and community care
New vaccines, drugs, diagnostic equipment,
ORS, community health workers
• Home care, generic drugs, nurse
practitioners
• External accreditation, internal review
systems, patient choice, continuous quality
improvement
Semashko National Health
Systems
• Former USSR and Soviet countries
• Government financing
• Strong central government planning and
control
• Financing by fixed norms per population
• High ratio of hospital beds and medical
staff;
• Post 1990 reforms emphasize
decentralization with capitation and
compulsory health insurance i.e. payroll
taxation
Bismarckian Health Insurance
• Funded through social security e.g.
Germany, Japan, France, Austria, Belgium,
Switzerland, Israel
• Compulsory employer-employee tax
payment to Sick Funds or through Social
Security
• Germany - governments regulate Sick
Funds which pay private services; strong
Sick Fund and doctor's syndicates;
• Israel's Sick Funds compete as HMOs with
per capita payments for mandatory basket
of services
Beveridge National Health Service
• United Kingdom, Norway, Sweden,
Denmark, Italy, Spain, Portugal, Greece
• Government - taxes and revenues; UK
national financing; Nordic countries
combine national, regional and local
taxation
• Central planning, decentralized
management of hospitals, GP service and
public health; integrated district health
systems
• Capitation financing in UK with SMR
modifier
Douglas national health insurance
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Financed through government
Canada, Australia
Taxation based
Cost-sharing between provincial and federal
governments e.g. Saskatchewan, Manitoba
Provincial government administration
Federal government regulation;
Medical services paid by fee-for-service
Hospitals on block budgets;
Reforms to regionalize and integrate services
Mixed Private/Public System
• United States, Latin America (e.g Colombia),
Asia (e.g Philippines) and African countries
(e.g. Nigeria)
• Private insurance through employment
• Public insurance through Social Security for
specific population groups (Medicare, Medicaid)
• High percentage of uninsured
• Strong government regulation (US);
• Mixed private medical services, public and
private hospitals, state/county preventive
services;
• DRG payment to hospitals, managed care;
extension of Medicaid coverage
“Laws”
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Sutton’s law
Capone’s law
Roemer’s law
Bunker’s law
Murphy’s law
Basic issues
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Universality
Equity
Comprehensiveness
Accessibility
Portability
Tax (social security) based
Quality
A Comprehensive Health Services
Continuum: Manitoba, Canada
Promotion
Healthy Public
Policy Support
Prevention Services
Promotion
To
Protection Seniors
Hospitals
Community
Health
Centres
Palliation
Outpatient
Urban
Ambulatory
Community
Care Rural
Tertiary
Community
Community Home Care
Extended
Oriented
Treatment &
Services
Long Term Care
Palliation
Rehabilitation
Decentralization
• Transfer of responsibility to lower
level of gov’t
• Transfer of funds to provide care
• Monitoring of stndards
Devolution
• Transfer of gov’tal responsibility to
non-gov’t organization
• Universities
• Colleges of physicians etc
• Accreditation by consortium of
organizations e.g. medical, nursing
etc.
Regionalization
• Decentralization
• Integration of related services
• Vertical integration of acute care with
long term care
• Organizational and financial linkages
Prospective Payments
Systems
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Payment before service
Predictable
Limits liability
Defines responsibility
Risk sharing
Capitation
DRGs
Balance of Services
• Health promotion to terminal care
• Spectrum of services
• Care depends on person or patient
needs
Cost Restraint
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Gate keeper function
Downsize-Upgrade
Basket of services
Limit liability
Patient participation – user fees
Private insurance
Models of Care
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Private practice
Charity services
Guilds and friendly societies
NHS
Soviet model
Sick Funds
Prepaid group practice
Health maintenance organizations
Health for All
• Basic primary care for all – gov’t
based
– Immunization
– MCH
– Environmental health
– Nutrition
• Secondary and tertiary care via
health insurance
• Contradictions and imperfect models
Trends
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Down-size hospital sector
Develop PHC
Linkage between insurance and service
Define basket of services
Generic drugs
Clinical guidelines
Technology assessment
Health Reforms
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Continuous or periodic process
Economic and political factors
Epidemiologic factors
Public consciousness and knowledge
PH Professional Roles
• Provide evidence
• Regional variations
• Inequities – socioeconomic, ethnic,
regional, urban-rural
• Identify new interactions, risk
factors, diseases
Motivation/Advocacy
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Whistle blowing
Advocacy
Investigation
Media
Professional bodies
Publication
Famous last words
• IBM boss - will only need 5
computers world wide
• Music teacher – Beethoven is
hopeless as a composer
• Decca records – The Beatles will
never make it
• Tom Lehrer – when Mozart was my
age he had been dead for 10 years
Intellectual Challenges
• “Think global, act local”
• “Think outside of the box”
• Think
Motivation
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Commitment
Responsibility – moral, professional
Professionalism
Stay the course
Self esteem
Recognition
Isolation