I G E S I n s t i t u t G m b H · w w w . i g e s . d eFriedrichstraße 180 · 10117 Berlin · Germany +49 30 230 80 90 · +49 30 230 80 911

Reducing Health InequalitiesWhat Do We Really Know About Successful Strategies?

BerlinMay 9, 2009

IGES Institut

Bertram Häussler

Early inequality in access can heighten efficiency in health care supply mid-term

Reducing Health Inequalities | Seite 2 Berlin | May 9, 2009

Constant increase of life expectancy (at birth in Germany from 1960-2006)

Source: OECD 2008

Reducing Health Inequalities | Seite 3 Berlin | May 9, 2009

Life expectancy in Germany by gender and east/west

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

1950

1951

1952

1953

1954

1955

1956

1957

1958

1959

1960

1961

1962

1963

1964

1965

1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

male / eastmale / westfemale / eastfemale / west

1975

1960

1990

female

male

west

east

west

east

Reducing Health Inequalities | Seite 4 Berlin | May 9, 2009

Impact of health care on increase of health status / life expectancy?

Thomas McKeown 1976: The role of medicine: Dream, mirage oder nemesis?

"Health results from a combination of social, economic, and psychological as well as purely biological phenomena. Most doctors now understand this and so increasingly do politicians; this enhances their reluctance to invest heavily in health services when they have only a small effect on health." (Morrison und Smith 1994)

Contrary to what has been suggested by some authors, there appears to be a significantly positive relation between health expenditure and health, particularly for women. (Or, Z, 2000)

Reducing Health Inequalities | Seite 5 Berlin | May 9, 2009

Health care is not a static factor

Evidence-based Medicine:

„Burn your textbooks because knowledge renews every few years.“

Straus SE, Richardson WS, Glasziou P, Haynes RB (2005)

Reducing Health Inequalities | Seite 6 Berlin | May 9, 2009

Progress in pharmaceutical care (Germany, 1975: West Germany)

1975 20081 Acetyldigoxin Ibuprofen

2 Methyldigoxin Omeprazol

3 Chlordiazepoxid Diclofenac

4 Rachentherapeutikum Levothyroxin-Natrium

5 Phenacetin oder Paracetamol, ASS u.a. Metoprolol

6 Calcium u. Vit. D Simvastatin

7 Oxazepam Metamizol-Natrium

8 Metoclopramid Bisoprolol

9 Diazepam Ramipril

10 Reserpin und Butizid Metformin

11 Laxanz, Kombination Amlodipin

12 Schilddrüsenhormon (Kombi T3 u. T4) Enalapril

13 Indometacin Metoclopramid

14 Reserpin u. Clopamid Torasemid

15 Naftidrofudryl Allopurinol

16 Vermutlich Kombi mit Vitamin B-Komplex Xylometazolin

17 Dipyramidol und Oxazepam Amoxicillin

18 Codeinphosphat und Phenyltoloxamin Acetylsalicylsäure

19 Cinnarizin Paracetamol

20 Phenylephrin und Dimetinden (Nasentropfen) Salbutamol

21 Heute: Birkenblätter und Goldrutenkraut Ramipril und Hydrochlorothiazid

22 Retinol (Augentropfen) Furosemid

23 NSAR-Salbe Tramadol

24 Propyphenazon und Drofenin Prednisolon

proven efficacy, life saving

proven efficacy, not life saving

efficacy not proven,

efficacy not proven,

benzodiazepines

Reducing Health Inequalities | Seite 7 Berlin | May 9, 2009

2008 market shares of TOP25 drugs prescribed in 1975

0,00%

0,20%

0,40%

0,60%

0,80%

1,00%

1,20%

1,40%

1,60%

Anteil an allen VO in % (historisch)

Anteil VO Präparat 2008

market share in 1975

market share in 2008

Reducing Health Inequalities | Seite 8 Berlin | May 9, 2009

729

593

300

1.119

771

596

00

200

400

600

800

1.000

1.200

19

68

19

69

19

70

19

71

19

72

19

73

19

74

19

75

19

76

19

77

19

78

19

79

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

Tod

esf

älle

(st

and

.) j

e 1

00

.00

0 E

inw

oh

ne

r

„War against heart disease“: Cardiovascular causes of death decline much faster since mid 80s (West Germany)

Herz-Kreislauf-Erkrankungen

Andere Todesursachen - 49%

- 23%

All other COD

Cardiovascular COD

771

593 596

300

DM

DR

(dea

ths

per 1

00,0

00

1985

1970

2000

2006

- 19%

- 31%

Reducing Health Inequalities | Seite 9 Berlin | May 9, 2009

0

2.000

4.000

6.000

8.000

10.000

12.000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Noch unbekannte Sonst AMD Asthma Knochenfusion

Autoimmun Krebs etc. Krebs Virusinfektionen Osteoporose

Wachstum ART Epo etc. Gerinnung Lyse etc.

Orphan Diabetes

Health care costs strongly influenced by expen-ditures for innovative services (here: biologicals)

4.014

6.022

9.690

Noch unbekannte AM

Autoimmun-krankheiten

Krebs

OrphanDiabetes

WachstumEpo

1,5

2,4

2,3

0,40,30,4

1,9

expe

nd. i

n 1,

000,

000

Euro

s

Reducing Health Inequalities | Seite 10 Berlin | May 9, 2009

Cost containment strategies frequently based on assessment and apraisal of new services (drugs)

price regulationafter utility

assessment

no noyes yes yes yes yes

„high equity countries“

Reducing Health Inequalities | Seite 11 Berlin | May 9, 2009

Countries with strong regulations („high equity countries“) show late penetration of new drugs

0%

20%

40%

60%

80%

100%

120%

140%

< 2 years 2 - 5 years 5 - 10 years > 10 years

USA

Canada

Great Britain

France

Danzon and Furukawa, 2003

mar

ket p

enet

ratio

n of

new

mol

ecul

es re

lativ

e to

USA

Reducing Health Inequalities | Seite 12 Berlin | May 9, 2009

13 4198

145 122 134180

225

314

469

582

689

872

994

1.203

1.362

1.485

1.775

0

200

400

600

800

1.000

1.200

1.400

1.600

1.800

2.000

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Mil

lio

ne

n D

DD

Verbrauch Statine (Millionen DDD, GKV, ambulant)

Late penetration deprives patients of (proven) health benefits (e.g. statins)

proof of efficacy

Reducing Health Inequalities | Seite 13 Berlin | May 9, 2009

equity

little choice

health for all

early penetration (for

few)

stimu-lus for innova-

tion

limited choice

late penetration (for

all)

finan-cial

limits

Reducing Health Inequalities | Seite 14 Berlin | May 9, 2009

From a different world:How the airbag penetrated the car market

1981Airbag verfügbar

1.800 DM (nur Fahrer-Airbag)5 % von 39.000 DM

Airbag NICHT verfügbar(1.800 DM entsprächen

15 % von 12.000 DM)

1991Airbag seit 10 Jahren

verfügbar

Airbag ERSTMALIG verfügbar1.120 DM (Fahrer + Beifahrer)6% bzw. 3% von 18.000 DM

2001 Airbag = Serienausstattung Airbag = Serienausstattung

Reducing Health Inequalities | Seite 15 Berlin | May 9, 2009

How „high equity countries“ can stimulate the innovation process

Allow early use of services only for out-of-pocket-payers

Establish innovation insurance scheme as add on

Allow choice within public health care systems

www.iges.de