cambridge march 15, 2006 international health leadership programme health system reform – lessons...

CambridgeMarch 15, 2006

INTERNATIONAL HEALTH LEADERSHIP PROGRAMME

HEALTH SYSTEM REFORM – HEALTH SYSTEM REFORM – LESSONS AND EXAMPLESLESSONS AND EXAMPLES

Dr. Nicolaus HenkeDr. Nicolaus Henke

HEALTH SYSTEM REFORM – HEALTH SYSTEM REFORM – LESSONS AND EXAMPLESLESSONS AND EXAMPLES

Dr. Nicolaus HenkeDr. Nicolaus Henke

050913 GCC conference Systems reform breakout

2

OUR 2005/2006 EXPOSURE TO HEALTH REFORM

Americas

•Canada

•U.S.•Mexico

Europe

•Germany•U.K.•Norway•Portugal

• Ireland•Spain•Belgium•Sweden

Middle Eastand Africa

•Mauritania•Bahrain•Egypt•Abu Dhabi

•KSA•Libya

Asia/Australasia

•Singapore• India

•South Korea

•China•Japan

System level and payer/ provider

Payer/ provider


3

Need to be specific about…

-which policy / mechanisms that can unleash change

- what good looks like in 5 years

Large quality variations in spite of growing amount of money inflows

2

Patients starting to act as consumers and demanding better services – but are unwilling to accept resulting tax burden

3

Main elements of reform agreed at policy level – challenges in execution and engagement

4

CHALLENGES

Government led systems generally unresponsive

1

011706 Team Update V7

4

MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS

Improve public health status1


5



Ensure financing access to care2


6




Foster quality3


7




Foster quality3

Adjust capacity4


8




Foster quality3

Adjust capacity4

Involve consumer5


9




Foster quality3

Adjust capacity4

Involve consumer5

Introduce competition6


10




Foster quality3

Adjust capacity4

Involve consumer5


Adjust regulation and institutions / MOH7


11


Improve public health status

1

Ensure financingaccess to care

2

Foster quality3

Adjust capacity4

Involve consumer5

Introduce competition

6

Adjust regulation and ministry

7


12

… AND THREE WAYS TO DRIVE THROUGH EACH

BUILDAWARENESS


1


2

Foster quality3

Adjust capacity4

Involve consumer5


6


7


13


BUILDAWARENESS

SETINCENTIVES


1


2

Foster quality3

Adjust capacity4

Involve consumer5


6


7


14


BUILDAWARENESS

SETINCENTIVES

MANDATEDACTIONS


1


2

Foster quality3

Adjust capacity4

Involve consumer5


6


7


15

Improve public health status - Examples1

Awareness:

Incentives:

Mandates:

- Educate public on diet, exercise, smoking, safe sex- Measure “Early Health”

Differential insurance premiums based on successful lifestyle changes

- Smoking ban- Vaccination campaigns- Require the use of automotive seat restraints and motorcycle helmets


16

WHAT THE EARLY HEALTH INDEX COULD LOOK LIKE

Single index

Traffic light system

• ‘Nominal’– Index– Financial

Description

• Major indicators are scored red, yellow or green

Education

Vaccination

Diet

In vivo Dx

…

US China

Japan …

Example

Spend by disease stage (Diabetes example)

Prev-ention

DiagnosisTreat-ment

Comp-lication

~1%

35%

64%

~0%

• ‘Actual’– DALY– Expectation of life lost– Healthy life expectancy at birth

US

China

Japan

UK

…

Life lost due to low investment in ‘Early Health’

15 years

20 years

5 years

15 years


17

‘STRAW MAN’- A SMALL NUMBER OF INTERVENTIONS DRIVE ‘EARLY HEALTH’ PERFORMANCE FOR MAJOR DISEASES

* Trachea/Bronchus/Lung Cancer

1 HIV/AIDS

Critical ‘Early Health’ interventions

Prevention Screening Diagnosis

• Education • In vitro diagnostics • In vitro diagnostics

2 Resp. cancer*• Education (e.g., reduction in

smoking)• Genotyping (?)• In vivo diagnostics

• In vivo diagnostics• In vitro diagnostics (e.g.,

pathology)3 COPD

4 Measles • Vaccination • Physician consultation • Physician consultation

5 Road traffic accident

• Education • – • –

6 Stomach cancer • Education (e.g., reduction in smoking ?)

• Diet

• Endoscopy• Genotyping (?)

• Endoscopy

Causes of death

7 Hypertensive heart disease

• Education• Diet

• Physician consultation• Genotyping (?)

• Physician consultation

8 Tuberculosis • Vaccination • In vitro diagnostics (e.g., microbiology)

• In vivo diagnostic

• In vitro diagnostics (e.g., microbiology)

• In vivo diagnostic

9 Self inflicted • Education • Physician consultation • Physician consultation

10 Ischemic Heart disease

• Education (e.g., reduce BP, reduce obesity, reduce cholesterol)

• Physician consultation• In vitro diagnostics

• Physician consultation• In vivo diagnostics (e.g.,

angiography)


18


- Educate about need to save

- Tax incentives and employer contribution to insurance schemes

- Mandated insurance or tax funded provision for all

Pages Hencke AI v0.1

MAURITANIA TESTS A MICRO-INSURANCE SCHEME FOR FULL PREGNANCY COVERAGE FOR $ 9 PER PREGNANCY

Payment of all costs included in the services pack

Respect of the standardised therapeutic procedures

Regular and secured purchase of medicines and consumables

Presence of qualified personnel at all instances of care

Availability of all technical means necessary to administer the care needed and covered

1

2

3

4

5

Pages Hencke AI v0.1

20

PRELIMINARY RESULTS IN NUMBERS: ENCOURAGING PARTICIPATION IN PREVENTIVE ACTIVITIES; STRONG REDUCTION OF MORTALITY

Access to care

*CME: Consultation prénatale**Consultations Pré-et Post-Natale)

Number consultations / woman 2,6 1,7

Laboratory visits attendance 98% 31%

Echography 81% 21%

Childbirth's file made and maintained 100% 40%

Attendance of standard pre- and postnatal consultations 83% 50%

Maternal mortality 103 747(par 100k/par naissance ou par femme)

With F-F obst. care

Without F-F obst. care


21

Ensurequality in a devolved system

1. Setstandards

3. Monitor and provide information

4. Assess, audit and enforce

5. Enable choice and competition through stronger payer function

Levers

• Strengthen national registration process, credentialing and accreditation mechanisms

• Strengthen peer review and ongoing validation• Introduce rigorous privileging at the provider level

• Use multiple levers to increase information available to patients• Prioritise key indicators to measure outcomes and adherence to best practice • Provide real-time standardised information through clear data protocols • Make information freely available to commissioners, public and providers • Build GP capabilities to monitor provider performance and analyse data

• Make investigation and enforcement for quality failures faster and more effective

• Strengthen consequence management for poor performers

• Extend choice and patient ownership of care decisions (e.g., treatments)• Strengthen payer skills, resources and systems to improve quality • Leverage payer purchasing power through joint commissioning (e.g., consortia)• Standardise care pathways and adherence to high quality care through commissioning • Strengthen existing quality incentives in contracts• Create competitive commissioning market

2. Provide incentives

• Provide financial incentives for high quality care to primary and secondary care providers

• Build quality indicators into Payment by Results

Foster quality3


22

DETAILED STANDARDS FOR CARE – FOR EXAMPLE JCAHO AND CMS

*JCAHO implementation with July 2004 discharges**CMS and JCAHO changing to 120 minutes with July 2004 dischargesSource:JACHO; CMS; interviews; team analysis

CMS JCAHO

Acute MI

• Aspirin at arrival• Aspirin prescribed at discharge• ACE inhibitor for left ventricular systolic dysfunction• Adult smoking cessation advice/counseling• Beta blocker prescribed at discharge• Beta blocker at arrival• Mean time to thrombolysis• Thrombolytic agent received with 30 minutes of hospital arrival • Mean time to PCI• PCI received within 120 minutes of hospital arrival• Inpatient mortality

****,**

Heart failure

• Discharge instructions• Left ventricular function assessment• ACE inhibitor for left ventricular systolic dysfunction• Adult smoking cessation advice/counseling

Pneumonia

• Initial antibiotic received within 4 hours of hospital arrival• Initial antibiotic received within 8 hours of arrival• Antibiotic timing (Mean)• Initial antibiotic selection for community acquired pneumonia (CAP) in

immunocompetent patients• Blood cultures performed with 24 hours prior to or after hospital arrival• Blood culture performed before first antibiotic received in hospital• Influenza vaccination• Pneumococcal screening and/or vaccination • Adult smoking cessation advice/counseling• Oxygenation assessment

***

*

Surgical infection prevention

• Prophylactic antibiotic received with 1 hour prior to surgical incision• Prophylactic antibiotic selection for surgical patients• Prophylactic antibiotics discontinued within 24 hours after surgery end time

***

“I foresee JCAHO and CMS merging toward a common standard. We need leadership from a federal entity to ensure we don’t have disparate standard.”

– JCAHO Associate Director of Oryx

“JCAHO and CMS have plans to work together to expand standards into areas like pain management, children’s asthma, and ICV care. We have no qualms about taking on metrics other organizations like Leapfrog have developed.”

– JCAHO Associate Director of Oryx


23

METRICS USED BY CMS/Premier Demonstration Project *

Heart Attack (Acute Myocardial Infarction or AMI) • Aspirin at arrival • Aspirin at discharge • ACE Inhibitor for Left Ventricular Systolic Dysfunction• Beta Blocker at arrival • Beta Blocker at discharge • Thrombolytic received within 30 minutes of hospital arrival• PCI received within 120 minutes of hospital arrival • Smoking cessation advice/counselling • Inpatient mortality rate

Coronary Artery Bypass Graft (CABG)• Aspirin at discharge• CABG using internal mammary artery• Prophylactic antibiotic 1 h prior to surgical incision• Prophylactic antibiotic selection for surgical patients• Prophylactic antibiotics discontinued within 24 hours after surgery• Inpatient mortality rate• Post operative haemorrhage or haematoma• Post operative physiologic and metabolic derangement

Heart Failure (HF) • Assessment of Left Ventricular Function • ACE Inhibitor for Left Ventricular Systolic Dysfunction• Detailed discharge instructions• Adult smoking cessation advice/counselling

*3 year pilot at consortium of nonprofit health systems including 270 hospitals and treating 400,000 patients in the 5 conditions Source: CMS/Premier Demonstration Project; WSJ, 4 May 2005; CMS Press Release 3 May 2005

Hip and Knee replacement• Prophylactic antibiotic 1 h prior to surgical incision• Prophylactic antibiotic selection for surgical patients• Prophylactic antibiotics discontinued within 24 hours after surgery• Post operative haemorrhage or haematoma• Post operative physiologic and metabolic derangement • Readmissions 30 days post discharge

Community Acquired Pneumonia (CAP)• Oxygenation Assessment• Initial Antibiotic• Antibiotic timing • Pneumococcal screening / vaccination• Blood culture performed first antibiotic received in hospital • Smoking cessation advice/counselling • Influenza screening / vaccination

90 9386 90

64 76

85 9170 80

AMI CABG HF Hip &Knee

CAP

Median quality scores improvements – year 1


24

DIFFERENCES IN QUALITY BETWEEN PUBLICLY REPORTING AND NON-PUBLICLY REPORTING PLANS

Measure * Public reporters, %

94.6

81.2

75.2

66.0

80.9

49.9

84.9

61.0

88.7

90.2

60.4

Non-public reporters, %

90.1

71.5

67.8

52.4

73.3

39.4

81.4

55.5

85.6

81.2

40.6

Difference, %

19.8

9.0

4.5

9.7

7.4

13.6

7.6

10.5

3.5

5.5

3.1

• Adolescent immunisation status (combo 1)

• Beta-blocker treatment after heart attack

• Check-ups after delivery

• Childhood immunisation status (combo 1)

• Cholesterol management – Control (LDL <130)

• Cholesterol management – Screening

• Comprehensive diabetes care – Eye exams

• Comprehensive diabetes care – HbA1c testing

• Comprehensive diabetes care – Lipid control (LDL <130)

• Comprehensive diabetes care – Lipid profile

• Timeliness of prenatal care

*Selected averages for commercial (non-Medicare/Medicaid) providers

Source:NCQA – The State of Health Care Quality, 2004


25

USE OF INFORMATION TO DRIVE QUALITY

0

5

10

15

20

25

30

35

1991-1995 1996-1999 1999-2002

Reduction in mortality rates since data began to be published by a private company

Mortality rate for open heart procedures in children under 1 %

Individual hospital trusts

A

BCD

EF

Source: Aylin et al. British Medical Journal, October 2004

U.K. EXAMPLE


26

QUALITY MANAGEMENT IN PRIMARY CARE – NETHERLANDS

• Physicians take part in 6–12 peer reviews per yearPeer

reviews

Treatment guidelines

• About 70 guidelines have been developed

Quality monitoring

• Statistical analysis of treatment processes and outcomes

• Video recordings of physician-patient interaction

Practice visits

• Goal is mainly to evaluate management processes

• About 40% of all general practitioners take part

Key factsMeasures to ensure qualityHistory of quality initiatives

Initiatives to introduce peer reviews and treatment guidelines

Dekker reforms introduce competition and focus on quality

Law passed to enforce annual quality reviews

1970s

1980s/90s

1996

IMPROVE QUALITY


27

CHRONIC DISEASE MANAGEMENT SHOWS POTENTIAL EXAMPLE

Source: PCT interviews; North Bradford PCT Performance Report, Sept. 2004; CDM Compendium, DH, 2004

Example: North Bradford PCT

DiabetesGPs

RespiratoryGPs

FrequentflyersGPs

Primary care center

Nurse support

Emergency admissions

25% 38%-73% 15%-70%

45% 90% 40%-50%

Average length of stay

Results

Approach

• Region’s patients stratified by risk group, creating 4-5 pools, e.g.,– Diabetes– Respiratory– Frequent hospital use

• GPs merged into primary care groups of up to 10, with 2 each trained on 1 disease (e.g., diabetes), networked with local specialist (to handle escalated cases), and given 24/7 nurse support

• Each patient assigned exclusively to GP/nurse, located at the primary care center

• System designed to reduce complications and time spent in the hospital


28

CHRONIC DISEASE MANAGEMENT AND PRO-ACTIVE CASE MANAGEMENT

• Constant weight checks • More healthy nutrition • Best practice medication

Disease

Congestiveheart failure (CHF)

1

Disease management interventions GPs Nurse O/P

Effects on existing treatment structures

• Daily blood sugar checks• Expert patient programme• Best practice medication

Diabetes2

• Best practice medication• Expert patient programme• Peak flow monitoring

Asthma3

COPD4

CHD/ Hypertension

5 • Monitoring risk profile• Behaviour modification• Best practice medication

High risk / older people / Frequent flyers

6

A&EEmergency Admissions LOS

• Best practice medication• Expert patient programme• Peak flow monitoring

• Identification of patients• Allocation of case manager• Regular monitoring and

review• Pro-active assessment and

treatment• Best practice medication

25% 45%

40-90% 30%

38-73% 90%

20% 70%

??% ??%

15-70% 40-50%

Source: McKinsey analysis; Chronic disease management compendium, DH, 2004


29

Adjust capacity - examples4

•Specialised players in US and UK

•Home monitoring to support chronic disease management

•Intermediate care in U.S.

•Regional emergency care planning in England


30

Increasing case loadNumber of heart surgeries

Lower costsUS$000

43

27

THIU.S. average

- 37%

Higher quality – better survival rate, %

8292

THI5 year

U.S.average 1 year

SPECIALISATION IN HEART SURGERY – USA

Source: Texas Heart Institute

137

THIU.S. average

10,500

IMPROVE QUALITY


31

SYSTEM PATIENT FLOW (REGION WITH 3 MILLION PEOPLE)

Blue light ambulance

Emergency care

Community care (incl

GPs)

Paramedic

Social care

Acute Care•“A&E”•ITU•CCU

•Inpatient care

Diagnostics

Outpatients

Intermediate care

Elective care

24x7 service

Telephone service

Patient

Source: Team analysis

Key thrusts• Triage early• Avoid inappropriate hospitalisation• Provide scheduled care where possible


32

UTILIZATION CHANGES

* Based on 5-year projections** Based on national targets for diagnostics


-20-30%

Activity redistribution to other Services (e.g. ECS)

Activity redistribution to self care

Underlying Activity Growth

ALOS reduction(partially due to transfer to Intermediate care; likely to be less than full 30% identified in initiatives, as simpler cases will have been transferred out)

16%

-84%

0%

A+E 16%

-36%

-8%

Inpatient spells

16%

-60%

-10%

OutpatientEpisodes

117%**

-44%

0%

DiagnosticEpisodes

Activity

Productivity


33

IMPACT ON SITES

Acute care

Emergency care

Community care

Diagnostics

Intermediate care

Elective care

*22 community hospitals, 12 of which are non-Trust sites. Many of these currently provide (sub)-residential care**Highly preliminary


SustainableSystem (5yrs+)

5-7

3-4

20

Co-located with Acute care/Emergency care

17-22

100-200

Current

3

Co-located with acute

22*

390

9

6

InterimSystem (2-3yrs)**

6-18

22

300-350

7-8

5-6


34

*Stroke: 4 days acute, then rehab, Joint replacement 2 days acute then rehab, fractured neck of femur 2 days acute then rehabilitation in intermediate care

Source:Hospital bed utilisation in the NHS, Kaiser Permanente and the US Medicare programme. Ham et al. BMJ 2003;327:1257-60, Bedfordshire and Hertfordshire SHA

• NHS OBDs per 100’000 population >65 yrs, 000s

StrokeJoint

Replace-ment

Fractured neck of femur

Total

• ALOS in NHS, days

• ALOS in Kaiser, days

• OBDs with Kaiser ALOS, 000s

• OBDs saved per 100’000 population >65yrs,000s

• Total OBDs, 000s

• Current ALOS, days

• Best practice ALOS, days

• OBDs if applied best practice, 000s

• OBDs save, 000s

Comparison Kaiser—NHS

Benchmarking Beds and Herts SHA (1.5m population)

22.3

27

4.26

3.5

18.8

55.5

17.7

~4*

12.5

33.0

8.2

12

4.3

2.9

5.3

38.3

13.5

~4

11.3

27.0

8.4

27

4.9

1.5

6.9

34.0

20

~2

3.4

31.6

30.7

12.5

91.6

38.9

34.0

• Current LOS range, days 0–393 0–225 0–515

• Kaiser comparison suggests there is much scope to reduce LOS in hospitals38.9

INCREASE CAPACITY

STEPDOWN SERVICES CAN SUBSTANTIALLY REDUCE LENGTH OF STAY IN ACUTE CENTRES

• Top 3 conditions account for 40% of potential shift from acute sector to intermediate

• Extrapolates to 3m bed days in England


35

Involve consumer5

•Urban sickness funds in China

•Differentiate offering to consumer segments

•Consumer information in Norway


36

Increasing rights and expectations• Growing demand for efficient, convenient, and

personalized services (from and beyond health care)• Greater clarity of treatment outcomes• More power to challenge health-care professionals• Larger influence of advocacy groups

Increasing and changing health-care needs• Aging population• Increased prevalence and burden of disease• Greater focus on wellness and prevention• Broader definition of disease

Increasing responsibilities• Rolling back of health-

care systems (increased rationing and co-payment)

• Requirement for active decision making

• Product innovation from insurers/providers

Advanced technology and more information• Better access to health

information• More treatment options• Advancing medical and

information technology• Growing innovation in

private sector

FOUR MAIN DRIVERS OF CONSUMERISM


37

GOVERNMENT RESPONDING TO SOCIAL PRESSURE

*Police definition

Source:Ministry of Public Security statistics; People’s Daily

• Government launched “Harmonious Society” campaign, November 2004– Intended to “enable all people to share the social wealth created in reform

and development”– Includes increased investments in healthcare and other social infrastructure

• In healthcare, is seeking to increase “Basic Urban” insurance cover from 130 to ~450 MM

• Is also piloting rural insurance scheme, though at very low coverage levels

10

50

96

9

40

95

2532

01 02

58

2003

45

11

98

12

94 00

15

1993 97 99

“Mass incidents”* in ChinaThousands

Government needs to improve healthcare to address foreign investors’:• Concerns about lost productivity• Concerns about having to pick up the slack

Government increasingly concerned by violent protests


38

Lives 2003

Basis of industry growth projections

Most insurance products have high deductibles and co-pays, leading to continued suppressed demand

Insurance coverage

ILLUSTRATIVE

• Rural scheme or out of pocket

• Without private insurance• Low, very cost-sensitive

demand

Other

• Rural scheme with U.S.$75 deductible, 80% co-pays

• Private cover to reduce out-of-pocket expense

Coastal rural

• Urban scheme deductible 10% average salary (U.S.$700/yr in Shanghai);

• Co-pay ~40% (outpatient), 10-20% (inpatient), depending on region and service

Mass market

~25MM• Private insurance • Urban SchemePremium

MULTI-TIER CONSUMER MARKET IS EMERGING

*Projection assumes premium and coastal urban segments grow at private insurance premium CAGR (13% 2003-2010); all Premium have Urban Basic insurance; Government achieves goal of insuring 450 MM urban population; Chinese population grows to ~1,380 MM

Source: MOH 2003 National Health Services Survey; Asian Demographics; literature survey; team analysis

Lives 2015

~100MM

~105MM ~350MM

~15MM ~50MM

~1,150MM ~900MM


39

386.4

600.0

236.01,319.0

Cost of treatment 80% Co-payExcluded services

96.6

Deductible Reimbursement

MEDICAL EXPENSE EXAMPLE: BROKEN FINGERRMB (US$1 = 8.3 RMB)


40Sources: 1,500 telephone interviews evenly distributed in Germany, U.K., Italy in March 2001; McKinsey analysis

Desire for health-care proactivity

“Anxious Seeker”

14%

“Receiver”17%

“Proactive”21%P

sych

olo

gic

al b

urd

en

of

hea

lth

co

nce

rns High

Low High

Low

“Depender”14%

“Avoider”18%

“Stoic”16%

While distinct segments exist, patient behavior varies widely within each segment

WE SEE SIX DISTINCT ATTITUDINAL SEGMENTS WHICH ARE GOOD PREDICTORS AND PROXIES FOR BEHAVIOUR


41

T H E 6 S E G M E N T S U S E C L I N I C A L S E R V I C E S V E R Y D I F F E R E N T L Y

P r o a c t i v e a b o u t h e a l t h a n d l i f e s t y l e

A v e r a g eU K d a t a

6 7 %

U n d e r t a k i n g i n d e p e n d e n t r e s e a r c h

2 9 %

C h a l l e n g i n g d o c t o r o n d i a g n o s i s o r t r e a t m e n t

1 9 %

1 38 8

- 5

- 1 3- 9

1 71 4

- 2

- 1 0- 1 4

- 5

96

- 3- 6

4

- 1 0

U s e o f d o c t o r p e r a n n u m

N o r m a l i s e d t o 1 0 0 % ( a p p r o x

4 . 7 v i s i t s / y e a r )

1 0

6 0 8 0

- 3 0- 5 0 - 6 0

S o u r c e : M c K i n s e y

E x h i b i t 2 0

P r o a c t i v e A n x i o u s S e e k e r D e p e n d e r R e c e i v e r A v o i d e r S t o i c


42

INVOLVE CONSUMER TO DRIVE HOSPITAL QUALITY

How it works

• Free choice of hospital (since January 2001)

• Patients free to call toll free number or visit website to find shortest waiting times and book treatment (since May 2003)

• Hospital outcome ratings and rankings of service level by hospital on internet (since September 2003)

• Patient is guaranteed treatment within a certain time period by law

Source:www.sykehusvalg.net; McKinsey


43


• Leads to new ideas and new dynamics (better services, more efficient medical cost management)

• Example: Germany, U.S.• May impede chronic disease management and add overhead cost

• Drives through improvements in efficiency and quality of care as well as responsiveness to patient needs

• Examples: Foundation Trusts in England, regional budgets and contracting (e.g., Norway, Italy, Germany)

• Need to make the choosing process meaningful and data transparent to avoid competition on meaningless parameters – in reality choice does not mean patients choosing hospitals, but doctors choosing doctors with very limited factual information

Hypotheses based on experiences so far

Competition between payors

Contestabilty for hospitals and doctors

Building blocks

• Regulatory framework critical for overall success, two key roles– Consumer protection / quality watchdog– Financial, governance and market rules and behaviours of players

Independent regulation


44

NHS IN ENGLAND IS BUYING IN DIAGNOSTIC AND SURGERY CAPACITY FROM THE PRIVATE SECTOR INCREASE CAPACITY


45

SETTING UP OF FOUNDATION TRUSTS IN ENGLAND

New freedoms bestowed on hospitals

Potential ways of improving services

• Able to borrow money on capital markets

• No more directives from DH (previously over one per day)

• Full profit and loss accountability

• Able to develop strategic partnerships

• Able to develop new services

• Companies with P&L, in charge of revenues and costs

• Investment in new facilities

• Innovating to develop patient services

• Focus on efficiency and cost effectiveness – keeping the savings


46

Policy

Regulation

Role

Payors

Although hospitals can be public sector, increasing trend to operational independence

of hospitals

Public and private insurers

Public and private insurers

Singapore GermanyUnitedKingdom Norway

Country

Private & public hospitals; private physicians

Ministry of Health

Professional organisations

Public hospitals

Dept. of Health

Primary Care Trusts

Healthcare Commission;SHAs

Public hospitals

Ministry of Health

Ministry of Health

National Board of Health

Private & public hospitals; private physicians

Ministry of Health

Qatar and Abu Dhabi

have already moved

functions from ministries to authorities;

the UAE federal

government is following

Service provision

Adjust regulation and institutions / MOH7


47

2 ROLES: ECONOMIC REGULATION AND CONSUMER PROTECTION TO REGULATE EX-STATE RUN INDUSTRIES (UK EXAMPLE)

*Reflects network/distribution segment of market vs. other market segments (e.g., broadcasting, gas metering) Source:Interviews with regulators

Economic regulation

Consumer protection

Healthcare

HousingGas & electricity*

Commu-nication* MailFTs Non-FTs IS

• Set conditions for market entry and exit

• Monitor and disclose financial performance

n/a

• Manage financial in-stability

n/an/a

• Achieve sustainable profits for providers

n/a n/a

• Manage competition

• Ensure affordable end-user pricing

n/a

• Set quality standards

• Monitor quality

n/an/a

n/a

• Encourage choice and innovation

• Promote safety of public

• Manage externalities (e.g., environmental impact)

n/an/a n/an/an/an/a

Water Rail Government

Economic regulator

Quality and safety regulator(s)


48

SHOULD MINISTRY AND HEALTH SERVICE BE SEPARATE?


Minister of Health

Standards and quality (CMO)

Primary Care

Strategy and Policy co-ord

DH Finance

DH IT policy and standards

DH HR policy and standardds

DH communications

Secondary Care

Social Care & Public Health

Other Care (Drugs, Mental health, Dental)

Cancer

Diabetes

…Investigations & Inquiries

NHS communications

Health Service Executive

SHAs

Provider developmentNHS Finance, Strategy & PlanningNHS IT implementation

NHS workforce

Planning and capability development

DRAFT


49

DRAWING IT TOGETHER – EXAMPLE OF A DIAGNOSTIC

Issue Action

• System appears to be accumulating debt

• System unable to make most effective use of resources

• Fix Patient Treatment at the Expense of the State

• Fix Health Insurance Organisation• Rationalise services

2. Fix financing

• Poor exposed to health shocks as a result of high level of out of pocket spend

• Launch package• Shift OOP spending into pools• Subsidise poor/ fund for non-risk

events (i.e., primary care, ?old age?)

1. Increase pooling

• Poor responsiveness of system, notably hospitals, to patient needs– Centrally driven – hospitals have little

flexibility on staff & budget

• Fix clinic/ hospital management through increased autonomy and building capabilities– Devolve (some) resource flexibility

(staff, budget)• Focus on defined basic package

3. Improve service delivery

• While physical access is not an issue, service, drug & quality staff availability is

• Increase incentives to work in rural areas (clinicians & management)

• Reform takleef (existing allocation mechanism)

4. Improve access for the poor/ rural

• 94% of nurses have only secondary level of education

• Medical schools are expanding imperilling standards

• Weakest doctors are allocated to positions with least oversight/ training

• Step up post-high school nurse training• Increase oversight/ training for rural

doctors

5. Increase levels of education

• MoHP currently sprawls across all roles• Suboptimal performance

• Institute independent quality assessment/ accreditation

• Simplify organisational structure

6. Refocus organisations


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EXAMPLE OF A PROGRAM – ENGLAND 1999-2008

Steps

1) Create capacity 1999-2004•Set targets•Abandon 4 regional HQ and health authorities, create 28 SHAs and 300 PCTs under

•Triple nominal spend over 10 years to meet targets

2) Create plural market 2004-2008•Aggressive new access targets•Choice•Plurality of supply (FT, ISTC)• Incentives – PBR, Consultant contract, GP contract


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0

50,000

100,000

150,000

200,000

250,000

300,000

Mar-00Sep-00

Mar-01Sep-01

Mar-02Sep-02

Mar-03Sep-03

Mar-04Sep-04

Sep-05Mar-05

WAITING TIMESInpatient waiting times in England (March 00 – September 05)Number of patients waiting for admission

> 6 months

> 9 months

> 12 months

> 15 months


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KEY OBSERVATIONS AND TAKEAWAYS

•Seven ideas underlying most system reforms

• Incentives matter, including how payers pay and how provider contestability is enabled

• Information matters

•Balance of mandates vs incentives vs information is important

• Involving the consumer will be critical

•Sequencing and capability building is one of the biggest challenges

•Success may be driven by

–A very clear view of what system success looks like in 3-5 years (results)

–Focus on executing on 2-3 key policies to get there, and evolving them over time

cambridge march 15, 2006 international health leadership programme health system reform – lessons...

Documents

team update v7

reform programs

financing access

foster quality

early health index

health reform americas

underlying ideas

nicolaus henke slide