Sherry Glied: Health reforms in the OECD
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Transcript of Sherry Glied: Health reforms in the OECD
Health Reforms in the OECD
Nuffield TrustHealth Strategy Summit, March 2009
Sherry GliedMailman School of Public
HealthColumbia University
Thanks to the Commonwealth Fund and especially Robin Osborn.
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Non-US OECD Health Care Systems
Misconception • Uniform• Stable and unchanging
Reality• Variable (except with respect to
coverage)• Intermittent significant reforms and
frequent incremental modifications• Struggling with value for money
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Pop’n GDP Health
Denmark 5,435 $35,000 $3,349
France 61,353 31,000 3,449
Germany 82,368 32,000 3,371
Netherlands 16,346 37,000 3,391
Sweden 9,081 35,000 3,202
Switzerland 7,484 38,000 4,311
UK 60,587 33,000 2,760
2007. Per capita GDP and Health spending – PPP adjusted US$.
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Commonalities: Organization
Universal or near universal coverage Defined, comprehensive benefit
package Spending between 8-11% of GDP Free choice of primary care provider Low cost sharing, with exempt
populations Limited private insurance to
complement/supplement defined benefits
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Variations: Organization
Automatic enrollment
General/earmark tax financed
Public purchasers Waiting times
Enroll with fund Community rated
premiums Private purchasers No waiting times
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Push toward greater equity
Mandates for coverage Growing public share of spending Risk adjustment across purchasers Nationally pooled financing Low income subsidies
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Financing and Purchasing
Risk adjusted capitated financing to insurance funds or regional purchasers• Defined benefits• Regulated provider fees• Regulated, community rated premiums• Very little selective contracting
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Physicians
UK, Denmark, Netherlands, (Sweden)• Primary/specialty care
Direct service provision Care coordination and navigation Gatekeeping Mainly capitated or salaried payment
France, Germany, Switzerland, (Sweden)• Outpatient/inpatient
Some gatekeeping incentives Fee-for-service practice
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Increased use of non-MDs
Particularly in gatekeeping countries• Not all nurse-practitioners – chronic
care nurses, pharmacists, etc.• Rx, immunizations, care coordination,
outpatient clinics, chronic care clinics
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Quality and satisfaction
Routine patient feedback Integration Recertification of providers Performance reporting P4P in UK
• Quality, organization, experience Extra pay for
• After hours, home visits, prevention• Capitated pay for disease management
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Information technology
National IT strategy Main element is EHRs
• Centralized UK
• Local development, central coordination Denmark, Netherlands, Sweden
Standards, portals, cards, etc. to facilitate interoperability
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Commonality: Financing
Provider pays (except UK)• Some direct subsidies• Some enhanced fees
Costly national efforts• Evidence for cost-saving is meager
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Commonality: Privacy
Issue everywhere EU rules and national rules Access to own records, discretion as
to what is included
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Variability: Extent of e-use
EHRs Decision support, drug alerts
• E-prescribing E-labs, E-radiology
• E-mail with patients E-referrals
∗ E-discharge notes
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Pharmaceuticals
Health technology assessment• Effectiveness and cost-effectiveness
Reference pricing within a therapeutic class• Very broad
Marketing restrictions• No DTCA• Limits on provider promotion
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Common Challenges
Speeding up drug approval process• EU rules• High priority drugs
Involving stakeholders Delisting existing drugs
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Innovations
Sweden• Value-based pricing for drugs• Compared to therapeutic class
UK• Velcade risk sharing agreement
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Watch this space
IT expansions Further primary care innovations
• Physician- and nurse-led disease management
Purchasing and financing Costs are growing faster than
incomes• Rising share of health care in GDP