Health Reform IssuesHealth Reform Issues

TH Tulchinsky

Braun SPH

Jan 2004

HealthHealth for All for All• National political commitment• Health as a government responsibility• Universal access• Adopt international standards• Regional and social equity in access• Free choice by consumers and providers• Healthy life-style as national policy• Health promotion as policy• Law/regulations• Regulate consumers rights in health• Public information on health• Advocacy groups - public, professional

FinancingFinancing• Financing within national means for social benefits • Adequate overall financing (>6%GNP)• Shift from supply side planning to cost per capita

per output• Categorical grants to promote national objectives• Increase financing at national, state and local

government levels (7-9% GNP)• Health insurance as supplement• Define "basket of services" and consumer rights • Reduce acute care beds to <3.0/1,000• District health authorities with capitation funding 

Defining National Health TargetsDefining National Health Targets• Define leading causes of morbidity, mortality and

YPLL, hospitalization with regional analysis• Health promotion vs treatment philosophy• Prioritization for use of available resources• Use relevant international standards• Social factor analysis in health• Improve health KABP• Community attitudes to health promotion• Promote public health, nutrition, environment, • Immunization policies

Management for Cost-EffectivenessManagement for Cost-Effectiveness• Cost containment• Cost-effective health initiatives• Decentralized management• National policy, monitoring and standards • Information systems/monitoring• District health profiles• Increase primary care• Increase home care, long-term beds• Increase non-admission surgery, long-term

care• Health information systems• Managed care and DRGs

Participants (Stakeholders) in Participants (Stakeholders) in National Health SystemsNational Health Systems

• Government - national, state and local health authorities;

• Employers - through negotiated heath benefits for employees;

• Insurers - public, not-for-profit and private for-profit;

• Patients, clients or consumers - as individuals or groups;

•  

• Risk groups - persons with special risk factors for disease e.g age, poverty;

• Providers - hospitals, managed care plans, medical, dental, nursing, laboratories, others;

• Providers - not-for-profit provider institutions;

• For-profit institutions, individuals and groups;

• Teaching and research institutions;

Participants (Stakeholders) in Participants (Stakeholders) in National Health SystemsNational Health Systems

• Professional associations;

• Social security systems;• The public; • Political parties;• Advocacy groups - age,

disease, poverty or public interest groups;

• The media;

• Economies - national, regional and local;

• International health organizations and movements;

• Pharmaceutical and medical technology industries

Health System Problems: World BankHealth System Problems: World Bank1. Misallocation of Resources: Public money is

spent on interventions of dubious cost-effectiveness, e.g. bone marrow transplants for breast cancer, while highly cost-effective interventions (TB and STD management) are neglected;

2. Inequity: Poor and rural populations receive less health care, while public monies go to urban and affluent groups who have better access to tertiary care services;

3. Inefficiency: Much waste in health care, in use of brand name drugs, inefficient use of health personnel and inappropriate utilization of hospital beds;

Typology of Financing and Typology of Financing and Administration of National Health Administration of National Health

SystemsSystems

• Type

• Financing Source

• Administration

Categories of ServicesCategories of ServicesInstitutional CarePharmaceuticals and

VaccinesAmbulatory CareHome CareElderly SupportCategorical Programs

Immunization, MCHFamily planning, Mental health, TB, STDs, HIV, Screening

Community Health Activities

Healthy communities

Health promotion, risk groups, environment and occupational health, nutrition and food safety, safe water supplies, special groups

Research

Professional education and training

Classical Market FactorsClassical Market Factors• Supply • Demand• Competition in cost, quality • System macro-efficiency • Vertical integration • Lateral integration • System micro-efficiency • Incentives• Disincentives• Reputation

Regulatory FactorsRegulatory Factors

• Regulate supply

• Regulate demand – gatekeeper, user fees

• Regulate price

• Regulate benefits

• Regulate method of payment

• Health promotion issues

Health and Societal FactorsHealth and Societal Factors• Differing population needs

• Social inequities

• Improve infrastructure to reduce needs

• Socioeconomic improvements

• Public social policies

• Health as a national and local priority

• Health promotion

• Improve KABP (knowledge, attitudes, beliefs and practices)

System DeterminantsSystem Determinants• Shift in resource allocation • Technological innovations• Substitution e.g. generic drugs• Total Quality Management• institutional and community care• New vaccines, drugs, diagnostic equipment,

ORS, community health workers• Home care, generic drugs, nurse practitioners• External accreditation, internal review systems,

patient choice, continuous quality improvement

Semashko National Health Semashko National Health SystemsSystems

• Former USSR and Soviet countries

• Government financing

• Strong central government planning and control

• Financing by fixed norms per population

• High ratio of hospital beds and medical staff;

• Post 1990 reforms emphasize decentralization with capitation and compulsory health insurance i.e. payroll taxation

Bismarckian Health InsuranceBismarckian Health Insurance

• Funded through social security e.g. Germany, Japan, France, Austria, Belgium, Switzerland, Israel

• Compulsory employer-employee tax payment to Sick Funds or through Social Security

• Germany - governments regulate Sick Funds which pay private services; strong Sick Fund and doctor's syndicates;

• Israel's Sick Funds compete as HMOs with per capita payments for mandatory basket of services

Beveridge National Health ServiceBeveridge National Health Service

• United Kingdom, Norway, Sweden, Denmark, Italy, Spain, Portugal, Greece

• Government - taxes and revenues; UK national financing; Nordic countries combine national, regional and local taxation

• Central planning, decentralized management of hospitals, GP service and public health; integrated district health systems

• Capitation financing in UK with SMR modifier

Douglas national health insuranceDouglas national health insurance

• Financed through government • Canada, Australia• Taxation based• Cost-sharing between provincial and federal

governments e.g. Saskatchewan, Manitoba• Provincial government administration • Federal government regulation; • Medical services paid by fee-for-service• Hospitals on block budgets; • Reforms to regionalize and integrate services

Mixed Private/Public SystemMixed Private/Public System• United States, Latin America (e.g Colombia), Asia

(e.g Philippines) and African countries (e.g. Nigeria)

• Private insurance through employment• Public insurance through Social Security for

specific population groups (Medicare, Medicaid)• High percentage of uninsured• Strong government regulation (US); • Mixed private medical services, public and private

hospitals, state/county preventive services; • DRG payment to hospitals, managed care;

extension of Medicaid coverage

““Laws”Laws”

• Sutton’s law

• Capone’s law

• Roemer’s law

• Bunker’s law

• Murphy’s law

Basic issuesBasic issues

• Universality

• Equity

• Comprehensiveness

• Accessibility

• Portability

• Tax (social security) based

• Quality

A Comprehensive Health Services A Comprehensive Health Services Continuum: Manitoba, CanadaContinuum: Manitoba, Canada

Healthy Public PolicyPreventionPromotionProtection

CommunityOrientedServices

SupportServices

ToSeniors

Home Care

CommunityHealth Centres

ExtendedTreatment &

Long Term Care

OutpatientAmbulatory

Care RuralCommunity

UrbanCommunity

Tertiary

Rehabilitation

Palliation

HospitalsHospitalsPromotionPromotion

PalliationPalliation

DecentralizationDecentralization

• Transfer of responsibility to lower level of gov’t

• Transfer of funds to provide care

• Monitoring of stndards

DevolutionDevolution

• Transfer of gov’tal responsibility to non-gov’t organization

• Universities

• Colleges of physicians etc

• Accreditation by consortium of organizations e.g. medical, nursing etc.

RegionalizationRegionalization

• Decentralization

• Integration of related services

• Vertical integration of acute care with long term care

• Organizational and financial linkages

Prospective Payments Prospective Payments SystemsSystems

• Payment before service

• Predictable

• Limits liability

• Defines responsibility

• Risk sharing

• Capitation

• DRGs

Balance of ServicesBalance of Services

• Health promotion to terminal care

• Spectrum of services

• Care depends on person or patient needs

Cost RestraintCost Restraint

• Gate keeper function

• Downsize-Upgrade

• Basket of services

• Limit liability

• Patient participation – user fees

• Private insurance

Models of CareModels of Care

• Private practice• Charity services• Guilds and friendly societies • NHS• Soviet model• Sick Funds• Prepaid group practice• Health maintenance organizations

Health for AllHealth for All

• Basic primary care for all – gov’t based– Immunization– MCH– Environmental health– Nutrition

• Secondary and tertiary care via health insurance

• Contradictions and imperfect models

TrendsTrends

• Down-size hospital sector

• Develop PHC

• Linkage between insurance and service

• Define basket of services

• Generic drugs

• Clinical guidelines

• Technology assessment

Health ReformsHealth Reforms

• Continuous or periodic process

• Economic and political factors

• Epidemiologic factors

• Public consciousness and knowledge

PH Professional RolesPH Professional Roles

• Provide evidence

• Regional variations

• Inequities – socioeconomic, ethnic, regional, urban-rural

• Identify new interactions, risk factors, diseases

Motivation/AdvocacyMotivation/Advocacy

• Whistle blowing

• Advocacy

• Investigation

• Media

• Professional bodies

• Publication

Famous last wordsFamous last words

• IBM boss - will only need 5 computers world wide

• Music teacher – Beethoven is hopeless as a composer

• Decca records – The Beatles will never make it

• Tom Lehrer – when Mozart was my age he had been dead for 10 years

Intellectual ChallengesIntellectual Challenges

• “Think global, act local”

• “Think outside of the box”

• Think

MotivationMotivation

• Commitment

• Responsibility – moral, professional

• Professionalism

• Stay the course

• Self esteem

• Recognition

• Isolation