How and why has health system spending grown and how does ... · infectious), life -threatening...
Transcript of How and why has health system spending grown and how does ... · infectious), life -threatening...
How and why has health system spending grown and how does the system need to
adapt to remain sustainable in the face of long term health conditions?
Nicholas Mays
London School of Hygiene and Tropical Medicine
Affording Our Future Conference Wellington, 10-11 December, 2012
Outline
• Track and explanations for health and long term care spending increases
• Emerging international consensus on elements in sustainable response to rise of long term conditions – focus on LTCs and assuming what matters is
how spending is allocated and on what • How NZ is placed • Main elements in a sustainable response
Definition of ‘sustainability’
• Continuing to provide the range and type of services (outcomes) currently available (or better without incurring excessive levels of taxes and/or debt
How does NZ public & private health and long term care spending compare?
Total health expenditure % GDP, 2010
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GDP per capita, USD, 2010
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NZ
AUS
UK
OECD Average
LUX
6.9% public
Long term care spending as % GDP, OECD, 2008
0.00.51.01.52.02.53.03.54.0
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% of GDP public LTC expenditure private LTC expenditure
1.4% 1.5%
Growth in core Crown health spending has outstripped national income...
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Health: 412%
GDP: 144%
% change since 1950
Core Crown health expenditure per capita and GDP per capita (indexed real growth)
...but NZ is not alone in increasing health care spending
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Real annual growth rate in total health spending (%)
Growth in total per capita health expenditure in OECD countries (1993-2008)
Why is health care spending increasing? • Myths abound in this field • Demographic change (population ageing)
– not the main contributor to health care costs, though more impact on long term care costs
– proximity to death is more important than ageing • Non-demographic reasons are more important
– income growth – technology widening scope to treat – lower productivity growth than the rest of the
economy (health care is labour-intensive, long term care even more so)
As with health care, population ageing is not the whole story for long term care spending
AUS
AUT
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ISLJPN
KOR
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SLOESP
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USA
R² = 0.2383
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0% 1% 2% 3% 4% 5% 6% 7%
Share of population aged 80+
LTC spending (% GDP)
Treasury’s current projections of health and long term care spending
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History and Budget 2012 forecast Projection
% GDPProjected core Crown health expenditure
11.1%
6.9 %
... of which long term care spending is projected to grow from 1.3% (2010) to 2.3%
(2060) of GDP
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1.0%
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2.5%
2007 2017 2027 2037 2047 2057
% of GDP
Older people & psycho-geriatric
Older people, psycho-geriatric, & disability support
Projected change in composition of govt expenditure (excl. financing)
Health
Superannuation
Education
Other
Non-NZS welfare
21%
31%
2010
2060
High level policy implications
• Focus on efficiency improvements in health care to offset necessary increase in labour costs in long term care where there is limited scope for efficiency gains
• Focus on maintaining active (fit) and healthy middle age and older people to minimise long term care needs
Challenge is also to adapt the system to a changing pattern of morbidity and constrained resources • Increasing prevalence of people with
LTCs, mostly non-communicable diseases – diabetes, COPD, CVD, dementia, many
cancers – in part, a ‘good news’ story (e.g. acute, life-
threatening conditions becoming chronic) • Most people living with LTCs have >1
This has major implications for organising health and long term care
• Systems evolved to manage acute (e.g. infectious), life-threatening conditions – care tended to be episodic, reactive, delivered by
individual professionals – emphasis on hospitals & doctor-led care organised
around medical specialties – patients were seen as passive rather than
contributors to their own care • Even systems with strong emphasis on LTCs
suffer from variations in quality, weaknesses in coordination, unplanned hospital admissions
What do we know about high performing systems for people with LTCs? (Ham, 2010)
1. Universal coverage 2. Cost not a deterrent at point of use 3. Prevention emphasised, not just
treatment 4. Emphasis on patient self-management 5. Priority to primary health care,
especially multi-disciplinary, nurse-led teamwork
What do we know about high performing systems for people with LTCs?
6. Support is commensurate with clinical risk 7. Primary care teams can access specialist
advice easily, day-to-day 8. ICT is used to enable diverse staff to work
together and to support people at home 9. Care is coordinated across health & care
for people with multiple conditions who are at greater risk of hospital admission
What do we know about high performing systems for people with LTCs?
10.Coherent strategy for 1-9 based on clinical leadership, measuring outcomes, aligned payment incentives and community support
– acting at all levels, not organisational integration
To what extent does NZ exhibit the features of a high performing system for people with LTCs?
• Some key prerequisites that NZ has – universal, largely publicly funded, co pays limited, Vote
Health covers health and long term care, almost everyone has a ‘usual’ source of primary medical care
• Long engagement with many of the issues since 1980s
• Considerable scope for improvement though the system performs reasonably well comparatively – wide variety of initiatives though questions of scale, scope,
ambition & duration, and little or no evaluation
• Government has only recently emphasised systemic change in how services are delivered
To what extent does NZ exhibit the features of a high performing system for people with LTCs?
• Significant NZ weaknesses such as: – GPs still depend on patient visit fees alongside
public capitation so must emphasise responsiveness
– public funder has limited scope to encourage GPs’ preventive activities
– sharp divide between specialists & primary care with specialists still largely hospital-based and ICT lacking to link them
– very limited attention to the inter-relationship between health care and long term care, and scope for efficient substitution
Individuals with the highest long term care use tend to have relatively low hospital costs
Georghiou et al (2012) Understanding patterns of health and social care at the end of life. London: Nuffield Trust
What (more) could be done at macro, meso & micro levels?
1. Long-term efforts to develop clinically integrated groups or networks
– some user choice between or within the groups/networks based on contractual & financial integration
2. Integrated health and long term (social) care teams
3. Innovative care coordination involving users themselves – e.g. personal health &/or care budgets
allowing choice and integration of services
Other necessary foci of continuing attention • Altering payment systems to align with
system goals, e.g. – dis-incentivise unplanned & inappropriate
hospital use – encourage health maintenance (e.g. ‘year of
care’ payments) – considering more use of P4P in 20 prevention
• Integrating health & long term care policy, funding and provision – e.g. towards end of life
Other foci of continuing attention
• Activating and supporting people with LTCs to manage their lives as ‘expert patients’
• Encouraging an active, engaged old age
Further awkward considerations
• No single, simple, cost saving solutions • Cost-effectiveness is plausible though
difficult to prove definitively – most initiatives studied for too short a time – most take at least a decade to mature – some attract commercial interest (e.g. tele-
health & tele-care) • The public may not be entirely comfortable
with whole system change – importance of showing the value of a more
integrated system
Conclusions
• This is continuous, unspectacular, long-term work
• The changes needed are complex, multi-faceted and need to act at all levels
• Requires persistent national leadership, absent until very recently
• Case for far more monitoring & external evaluation