Health Policy Developments 12: Focus on Value for Money, Funding and Governance, Access and Equity

topics

Preface

Dear readers,

Well into its sixth year of existence, the International Network Health Policy & Reform is alive and thriving. With no signs of age or wearing out, we continue to develop ourselves further and venture for new partnerships and cooperations.

For this most recent issue number 12 of our biannual series Health Policy Developments, we-the long-time editors-take great pride in introducing our new author, Ray Moynihan, from Byron Bay, New South Wales, Australia. Though thousands of miles apart, we discovered that we are following the same key themes of health policy, particularly around issues such as access, affordability, and equity, as well as determinants of health and governance issues. Following Ray’s suggestion, we also produced a companion video and a short promo film to disseminate the book’s key messages the virtual way (watch at www.hpm.org in the download section).

New author Ray Moynihan

We are equally delighted to announce our new partner institute and liaison person from Spain, Joan Gené Badia. Based at the University of Barcelona, Joan is an experienced expert on primary care advancements and international developments. With him on board we are somewhat shifting focus from a health economics perspective, so well presented by our former partners from Universidad Pompeu Fabra, to a health services research focus, so active a community these days in Spain.

New partner in Spain

So what is number 12 all about? Departing from the primary care and care coordination focus of the previous volume, this current issue focuses more on economic aspects. Quite interestingly, we see this as a re-emerging pattern across the 20 countries that we observe. While care coordination remains high on the agenda everywhere, countries again turn to funding and efficiency questions. In chapter 1, we examine how health systems are trying to maximize value for money, going beyond traditional avenues. In the United Kingdom, for instance, the National Institute for Health and Clinical Excellence no longer just assesses drugs and procedures but now asks how well public health interventions work-and which ones offer value for money.

What should we spend the money on...

However, preceding the value question there is a much simpler question: Where does the money come from in the first place? As rising cost is one of the most consistent pressures on health systems everywhere, cost containment has long been one of the more salient themes in health policy discussions. Chapter 2 therefore looks at debates around who should pay for what? How much of total expenditure on health care should originate from general taxation, (social) health insurance, or out-of-pocket? And what should be the share of voluntary or private health insurance? Even in Canada, where this has long been a taboo, some see growing privatization as a way of reducing the costs to the public purse. France, on the other hand, has decided to increase taxes for private health insurers to help fund rising national health expenditure.

... and who should pay for what?

With blurring roles between the private and public sphere and more and more cross-system learnings between classic Bismarckian and Beveridge type healthcare systems taking place, the former continue to suffer from their somewhat inbuilt paradox: Bismarckian systems, while tightly controlled by the state, are based on privately owned and operated funds. The paradox remains, as we will see in chapter 3 on governance. For example, in Switzerland, the unresolved question is whether the introduction of more competition will result in a reduction in solidarity if the sick ultimately have to pay a lot more for their premiums than the healthy. And in France, the debate turns the other way: Will decentralized control of purchasing hospital care result in more privatization in provision?

Governance in Bismarckian systems

In Asia, nations as diverse as Japan, South Korea and Singapore are responding to the needs of aging populations and the ethical challenges of demographic change. As will be illustrated in chapter 4, a common theme is enabling people to die with dignity at home or in hospice care, rather than in big hospitals. Countries need to balance how much care is being provided in institutions and how much at home, or in intermediary settings. At the same time, countries have to be cautious: If structures in patients’ living environments are not well prepared, sending people home to die might be a simple way to get rid of costly and needy patients (also see our video on www.hpm.org in the download section).

Responding to patients’ needs

Last but not least, questions of how to ensure access and equity, and how to guarantee patient safety and quality of care, and how to organize healthcare services do remain high on the policy implementation agenda in the countries we observe. We present the latest measures addressing these questions in chapters 5, 6 and 7.

Organizing healthcare services

The sources of information for this book were the expert reports of the International Network for Health Policy & Reform and other materials cited at the end of each chapters. The current volume presents the results of the twelfth half-yearly survey which covers the period from May 2008 to September 2008. From the 82 reports received, we have selected 33 for inclusion in this report.

Reporting period spring to autumn 2008

Our thanks go to all experts from the partner institutions and their external co-authors: Ain Ain Aaviksoo, Gerard Anderson, Toni Ashton, Chantal Cases, Elena Conis, Fiona Cram, Luca Crivelli, Asher Elhayany, Patricia Fernandez-Vandellos, Gisselle Gallego, Joan Gené Badia, Peter P. Groenewegen, Revital Gross, Maria M. Hofmarcher, Jessica Holzer, Soonman Kwon, Margaret MacAdam, Stephanie MacKenzie, Jan Mainz, Ryozo Matsuda, Lim Meng Kin, Julien Mousques, Michel Naidich, Adam Oliver, Zeynep Or, Gerli Paat, Hannele Palosuo Tanaz Petigara, Rade Pribakovic Brinovec, Marita Sihto, Taro Tomizuka, Lauri Vuorenkoski.

We hope you enjoy the read and as always look forward to receiving your feedback and suggestions.

Kerstin Blum, Reinhard Busse, Sophia Schlette

Value for money?

Are we getting value for money in health care? As perplexing as it is important, this monster of a question casts its shadow over almost every debate in health policy, whether we have the temerity to ask it or not. But perhaps an even more frightening question is its lesser-known cousin: How do we know that we are getting value for money in health care? In this opening chapter we look at how some health systems are facing up to these questions and in some cases starting to look for answers.

One of the first countries to build this question of cost-effectiveness into the very infrastructure of its healthcare system was Australia. Following changes to the national laws in the early 1990s, all new prescription medicines would be assessed for their benefits, harms and cost-effectiveness before they were added to the national list of subsidized drugs, the Pharmaceutical Benefits Scheme (Harris 2008; see also Health Policy Developments 5, p. 71). The approach involves independent committees of experts- notably the Pharmaceutical Benefits Advisory Committee- assessing at what price (if any) a new drug might offer value for money, and making a recommendation to the federal health minister to add the drug to the schedule of the Pharmaceutical Benefits Scheme. Initially unhappy with many aspects of the new approach, the pharmaceutical industry has slowly accepted the reality of this method. Moreover, in recent years improvements in transparency have meant that extracts from the cost-effectiveness deliberations are routinely made public.

Leading the way down under

Now, 15 years later, the importance of analyzing whether a new pill, procedure, or process is cost-effective is widely acknowledged everywhere-at least in theory. In a report on technology assessment and value for money, published by the World Health Organization on behalf of the European Observatory on Health Systems in 2008, authors wrote that products that provide the most value for investment must be identified and supported (Sorenson et al. 2008). The report also recommended more attention giving to transparency in decision-making, and broadening the focus of analysis from technology and treatment to preventive strategies.

Calls for value assessments

In the United Kingdom, policy makers have for some time been asking whether new clinical interventions give value for money, but now as we will read in this chapter, there is a fascinating push to examine whether public health strategies are also giving a good bang for the buck-or better: punch for the pound. For almost a decade, the influential National Institute for Health and Clinical Excellence (NICE) in the United Kingdom has been analyzing the cost-effectiveness of clinical interventions-largely but not exclusively looking at pharmaceuticals (see Health Policy Developments 2, p. 54). Following criticism that NICE was focused too heavily on clinical interventions, in 2005 its remit was broadened to start examining the effectiveness and cost-effectiveness of public health approaches like programs to increase physical activity in the workplace. Given the large numbers of stakeholders, including non-health players, involved in public health strategies, new systems have been created to analyze whether public health strategies are offering value for money (see report on the United Kingdom, p. 16). The new approach is raising intriguing questions about whether new methods of cost-effectiveness analysis will be needed to assess whether public health strategies offer value for money.

Public health: a good punch for the pound?

One such public health strategy in the United Kingdom may well be analyzed to see if it offers value for money: It is the new plan to offer direct personal financial incentives to people to change their behavior in order to prevent illness and improve health (see report on the United Kingdom, p. 20). Proposals at various stages of planning or piloting include incentives for people to exercise more; incentives for pregnant mothers to seek healthy eating advice; and incentives for adherence to certain anti-psychotic medications. The emerging debate around these plans is raising more questions about whether governments should use taxation to pay people to do things many consider they ought to be doing anyway, and whether such payments will perversely reduce healthy activities already being performed voluntarily.

Are personal financial incentives worthwhile?

In Australia a different sort of incentive is being introduced: a financial disincentive to drinking alcohol, in the form of a massive increase in taxation on sweet alcopops favored by many young people (see report on Australia, p. 23). In early 2008, the then relatively new federal government announced a 70 percent increase in the tax on ready-to-drink products, which combine alcohol and non-alcoholic beverages such as soft drinks or milk. The tax increase is part of a new national strategy on binge drinking, and the hopes are that the expected increase in tax revenue will be re-invested into prevention activities. Elements within the spirits and hotels industry are opposed to the plan, and concerns have been raised that the move will not reduce binge drinking because alcopops may be simply be replaced by other drinks. Experience from Germany, which increased taxes for alcopops by around € 1 per bottle as far back as 2004, shows that such replacement partly happens to a small degree. Alcopop consumption declined sharply and certain producers even completely withdrew their products from the market.

How about a disincentive?: binge drinking tax

While these examples from Australia and the U.K. show how financial incentives are used to try and influence behavioral patterns in the population, two reports from Estonia and the United States describe current efforts to pay incentives for physicians to improve performance. While both schemes unsurprisingly have had strong support from health professionals, after preliminary evaluations questions remain as to whether such incentives are the best way to spend health resources.

Paying physicians for performance

The Estonian Health Insurance Fund is offering family physicians financial incentives to improve the way they prevent disease and monitor chronic illness in their patients, as well as lift their general competence (see report on Estonia, p. 26, and earlier reports on P4P in Health Policy Developments 6, 9, and 10). From the beginning the reform was supported by family physicians, as it was designed in part to enhance the credibility and income of this sector of health professionals. An analysis of data from the Estonian Health Insurance Fund suggests the participation by doctors in the scheme has greatly increased, and more than half have received bonus payments. However, despite no published data on effects on health outcomes, and no formal published cost-effectiveness evaluation at this time, it appears the scheme