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What can we learn from European healthcare?
First Thinkers Conference University of Winnipeg, Manitoba
February 22, 2013
Yanick Labrie, M.Sc. Economist, Montreal Economic Institute
Plan of the presentation
How does Canada compare? Health spending Medical resources Quality of care Patient safety Accessibility Hospital efficiency
Brief overview of three European healthcare systems
France, Germany and UK
What lessons should Canada learn from these countries? 4 key elements of success
HOW DOES CANADA COMPARE? Health indicators
Comparative figures for the Canadian and selected European healthcare systems
Indicators Canada France Germany UK
Healthcare spending as a % of GDP (2010)
11.4% 11.6% 11.6% 9.6%
Healthcare spending per capita, US$ PPP (2010)
US$ 4,445 US$ 3,974 US$ 4,338 US$ 3,433
Public spending on health as % of total (2010)
71.1% 77.0% 76.8% 83.2%
Population 65 years old and over (2011)
14.4% 17.3% 20.7% 16.2%
Source: OECD Health Statistics 2012
Health spending growth
Source: OECD Health data 2012
Average annual growth rate of total health expenditures, 2000-2009, real terms
4.9% 4.5% 4.3%
2.6%
2.0%
0%
1%
2%
3%
4%
5%
6%
UK Canada OECD France Germany
Resources: Health professionals
Source: OECD Health Data 2012
Physicians per 1000 population, 2010 Nurses per 1000 population, 2010
2.4
2.7
3.1
3.3
3.6
0 1 2 3 4
Canada
UK
OECD
France
Germany
9.4
9.7
8.7
8.2
11
0 2 4 6 8 10 12
Canada
UK
OECD
France
Germany
General health indicators
Source: Results from the International Surveys of the Commonwealth Fund, 2010
80.8
79.1
80.6
81.4
80.5
77 78 79 80 81 82
Canada
OECD
UK
France
Germany
5.7
4.8
4.2
3.6
3.4
0 1 2 3 4 5 6
Canada
OECD
UK
France
Germany
Life expectancy at birth, 2010 Infant mortality rate, 2010
Quality: Amenable mortality rate
Source: J. Gay (2011), OECD.
Rate of avoidable mortality caused by deficient health care (per 100 000 discharges), 2007
103.5 101.5
88.3 87
63.6
0
20
40
60
80
100
120
OECD UK Germany Canada France
Source: OECD Health at a glance 2011
Cancer care
86.6%
83.5% 83.3%
82.2% 81.3%
78%
79%
80%
81%
82%
83%
84%
85%
86%
87%
Canada (2002-07)
OECD (16 countries)
Germany (2003-08)
France (1997-2002)
UK (2004-09)
Breast cancer, five-year survival rate
Source: OECD Health at a glance 2011
Cancer care
Colorectal cancer, five-year survival rate
63,4%
60,4% 59,9%
57,0%
53,3%
48%
50%
52%
54%
56%
58%
60%
62%
64%
66%
Canada (2002-07)
Germany (2003-08)
OECD (16 countries)
France (1997-02)
UK (2004-09)
Patient safety
Source: OECD Health Data 2011
Foreign body left in during procedure, (per 100 000 discharges), 2009
Accidental puncture or laceration, (per 100 000 discharges), 2009
4.8
4.5
5.1
5.7
9.5
0 2 4 6 8 10
France
Germany
UK
OECD
Canada
98
160
144
219
517
0 100 200 300 400 500 600
France
Germany
UK
OECD
Canada
Accessibility and wait times
Source: Results from the International Surveys of the Commonwealth Fund, 2010
Patients who must wait 2 hours or more in emergency room (%), 2010
67%
52% 50%
37% 35%
20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Québec Canada Ontario France UK Germany
Accessibility and wait times
Source: Results from the International Surveys of the Commonwealth Fund, 2012
Patients who saw doctor the last time they needed, the same or next day, 2011
7%
33%
20% 23%
87%
58% 55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Quebec Ontario Man./Sask. Canada France Germany UK
Accessibility and wait times
Source: Results from the International Surveys of the Commonwealth Fund, 2010
Average number of days before seeing a specialist, 2010 83
68
57
44
34
14
0
10
20
30
40
50
60
70
80
90
Quebec Canada Ontario France UK Germany
Accessibility and wait times
Source: Results from the International surveys of the Commonwealth Fund, 2010
Patients who must wait 4 months or more for elective surgery (%), 2010
25%
21%
7%
0% 0%
5%
10%
15%
20%
25%
30%
Canada UK France Germany
Source: David Squires, Commonwealth Fund, 2012
Hospital system effectiveness
Hospital discharges (per 1000 pop.)
263
237
160
138
84
0 50 100 150 200 250 300
France
Germany
OECD
UK
Canada
Average length of stay, acute care (days)
5.2
7.5
5.9
6.8
7.7
0 2 4 6 8 10
France
Germany
OECD
Uk
Canada
Hospital Spending per Discharge, 2009 (US$, Adjusted for Differences in Cost of Living)
Source: David Squires. Explaining high health care spending in the United States: An international comparision of supply, utilization, prices and quality. Commonwealth Fund, May 2012.
Cost efficiency in hospital spending
13 483 $
6 222 $ 5 204 $ 5 072 $
0
2000
4000
6000
8000
10000
12000
14000
16000
Canada OECD France Germany
BRIEF OVERVIEW OF EUROPEAN HEALTHCARE SYSTEMS
Health reforms
The French Healthcare system
Main characteristics Universal system Health insurance, financed by payroll taxes, covers the entire population All French citizens with incomes below 8 644 euros a year are covered
by the public insurance with no contribution required from them All have freedom of choice between a diversity of providers 93% of the population have complementary insurance Dual practice for physicians is allowed, with restrictions
Recent reforms: Activity-based funding of hospitals (T2A) in 2004 GPs as gatekeepers (2004)
The French Healthcare system
Main highlights Ranked first among 191 countries by World Health Organization in
2000
Ranked first in the world for amenable mortality, 1997-2007
Among the countries with the slowest growth rate of health spending (real terms) in the last decade
Waiting times are not an issue
Largest market for private hospitalization in Europe
A large role for private providers in France
38.6%
32.5%
17.2%
0.7% 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
France Germany USA Canada
Private for-profit hospitals, as a share of total, 2009
Sources: French Ministry of Health, US Department of Health and Human Services, German Federal Statistical Office, OECD Health Data 2012
The three largest hospital chains in France
Générale de santé Vitalia Capio
Total for-profit hospitals
Hospitals 110 48 26 1,051
Beds 16,200 5,700 3,830 96,460
Average hospital size 147 beds 119 beds 147 beds 92 beds
Employees 23,800 7,200 5,100 150,000
Revenus € 2.0 B € 650 M € 490 M € 12.1 B
Sources: Annual reports of Hospital chains; Fédération de l’hospitalisation privée; Ministère français de la santé, Le panorama des établissements de santé, édition 2011
A large role for private providers in France
56% of all surgeries and nearly 70% of ambulatory surgery in France
Nearly 50% of people with cancer and 27% of births
2 million patients treated each year in 130 emergency services
50% of patients receiving social security under the CMU (least well-offs) choose to be treated in for-profit hospitals
Surgeries performed in the private for-profit sector in France, as a share of total, 2011
55.6%
24.0%
46.2%
52.4%
67.5%
69.1%
27.6%
36.9%
0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% 80,0%
All
Others
Digestive system
Orthopedic
ORL
Ophtalmology
Nervous system
Cardiac
Source: French Ministry of Health, Les etablissements de sante en France, edition 2012
The French Healthcare system
What researchers have to say about it: “[private clinics] have developed in underserved areas, where public
hospitals failed to meet the needs of the population.” (V. Mennessier, 2008)
“The results show that an admission to a for-profit hospital is associated with a lower conditional probability of death discharge from the hospital” (C.Milcent, 2005)
“[Activity-based] reimbursement is associated with greater hospital efficiency than reimbursement by global budget.” (C. Milcent, 2005)
The German healthcare system
Main characteristics: Universal system Health insurance, financed through income-based contributions, covers
90% of the population; others are insured by private insurance Competition between a diversity of providers is encouraged Dual practice for physicians is allowed, with restrictions Widespread freedom of choice for patients
Recent important reforms: Activity-based funding for hospitals (2003) Nationwide benchmarking exercise for hospitals Hospitals are now required to publish quality reports annually
The German healthcare system
Main highlights: Lowest growth rate of health spending per capita (real terms)
since 2000
Emergency overcrowding and waiting times for elective surgeries are uncommon, if not inexistent
Largest database monitoring hospital quality in the world
No other country has privatized more public hospitals in the last two decades (the number of for-profit hospitals increased by 90% since 1991)
The three largest private hospital chains in Germany
Helios Kliniken
(Fresenius) Asklepios Rhön
Klinikum
Total for-profit hospitals
Hospitals 75 66 42 679
Beds 23,000 18,000 16,000 74,735
Average hospital size 308 beds 273 beds 380 beds 110 beds
Employees 43,000 33,500 38,000 n.a.
Revenus € 2.7 B € 2.3 B € 2.6 B n.a.
Source: Annual reports of Hospital chains; German Statistical Office
The German healthcare system
What researchers have to say about it:
“Our findings show that conversions from public to private for-profit
status were associated with an increase in efficiency of between 2.9 and 4.9%.” (O. Tiemann et al., 2012)
“The study suggests that private for-profit hospitals provide higher quality of care, measured as risk-adjusted in-hospital mortality rates, compared to other types of ownership.” (O.Tiemann et al., 2011)
The English healthcare system
Main characteristics: Universal Tax-financed (Beveridgian model) like in Canada Competition between a diversity of providers encouraged (mostly public
and not-for-profit) Patients can visit various websites to compare hospitals’ performance
and make an informed choice Dual practice allowed for physicians, though restricted
Recent reforms: Activity-based hospital funding (Payment by results) in 2003 Targets for wait times Since 2006, GPs must offer patients a choice of at least 4 providers
The English healthcare system
Main Highlights: Average length of stay fell rapidly after the activity-based funding
reform
97% of patients who show up in an emergency room receive a diagnosis from a physician within 4 hours
The median wait time for elective surgery decreased by more than 60% between 2002-2010
Reduction in wait times for cataract surgeries and hip and knee replacements has been greater for patients from less well-off areas.
Median waiting times for elective surgery in England, 1992-2010
0
2
4
6
8
10
12
14
16
Mar
199
2 N
ov 1
992
Jul 1
993
Mar
199
4 N
ov 1
994
Jul 1
995
Mar
199
6 N
ov 1
996
Jul 1
997
Mar
199
8 N
ov 1
998
Jul 1
999
Mar
200
0 N
ov 2
000
Jul 2
001
Mar
200
2 N
ov 2
002
Jul 2
003
Mar
200
4 N
ov 2
004
Jul 2
005
Mar
200
6 N
ov 2
006
Jul 2
007
Mar
200
8 N
ov 2
008
Jul 2
009
Mar
201
0
wee
ks
Payments by results (ABF) reform implemented in 2003
Source: UK Department of Health, Inpatient and Outpatient Waiting Times Statistics
The English healthcare system
What researchers have to say about it: “We find that higher competition [between hospitals] is positively
correlated with increased management quality.” (Bloom et al., 2010)
“We find that the effect of competition [between hospitals] is to save lives without raising costs.”(Gaynor et al., 2012)
“Reductions in unit costs may have been achieved [following the ABF reform] without detrimental impact on the quality of care.” (Ferrar et al., 2009)
WHAT LESSONS SHOULD CANADA LEARN?
Conclusion
4 key elements of success in these European healthcare systems
1. Competition: Allowing a diversity of providers within the public healthcare system
(private for profit, not-for-profit, and public hospitals)
2. Activity-based funding: Making money follow hospital patients
3. Freedom of choice:
Giving patients freedom to choose between providers
4. Benchmarking:
Making performance comparisons and quality indicators publicly available
Conclusion: What lessons for Canada?
All these factors combined lead to:
Improved access to care and reduced wait times
Increased innovation: new and better ways of delivering care
Improved management practices and cost efficiency
Higher quality and more patient-centered care
And all this without compromising the principles of universality and equity in access to care!
Is the picture all dark for Canada?
Last March, the Ontario government announced that the province will begin reimbursing 91 hospitals according to services provided (ABF)
The B.C. government set up a program that applies the same approach to about 17% of hospital funding (with encouraging results so far)
Some provinces, including Manitoba and Quebec, now make hospital waiting times data available online
CIHI, an independent research organization, now publicize hospital performance indicators on its website
THANK YOU!
References Barrie Dowdeswell (2009), “Rhön Klinikum, Germany”, dans Bernd Rechel et al. (eds), Capital investment for health: case
studies from Europe, European Observatory on Health Systems and Policies, World Health Organization, pp.143-157. Carine Milcent, “Hospital ownership, reimbursement system and mortality rates”, Health Economics, Vol. 14, No. 11, 2005,
pp. 1151-1168 Cathy Schoen, Robin Osborn, David Squires, Michelle M. Doty, Roz Pierson, and Sandra Applebaum, “How Health
Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries,” Health Affairs, Vol. 29 (2010), No. 12, pp. 2323-2334;
Frederik Roeder and Yanick Labrie, The private sector within a public health care system: The German example, Montreal Economic Institute, February 2012.
Nicholas Bloom, Carol Propper, Stephan Seiler and John Van Reenen, The impact of competition on management quality: evidence from public hospitals, National Bureau of Economic Research, May 2010.
Oliver Tiemann and Jonas Schreyögg, Changes in Hospital Efficiency after Privatization, Hamburg Center for Health Economics, 2011.
Oliver Tiemann et al., “Which type of hospital ownership has the best performance? Evidence and implications from Germany”, EuroHealth vol.17 (2011), no 2-3, pp.31-33.
Reinhard Busse, Ulrike Nimptsch, and Thomas Mansky, “Measuring, Monitoring, And Managing Quality In Germany’s Hospitals,” Health Affairs, Vol. 28 (2009), No. 2, pp. w294-w304.
Richard Cookson, Mauro Laudicella, Paolo Li Donni and Mark Dusheiko, “Effects of the Blair/Brown NHS reforms on socioeconomic equity in health care,” Journal of Health Services Research & Policy, Vol. 17 (2012), suppl. 1, pp. 55-63.
Shelley Ferrar et al.,“Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis,” BMJ, Vol. 339 (2009), p. b3047.
Yanick Labrie and Marcel Boyer, The private sector within a public health care system: The French example, Montreal Economic Institute, April 2008.
Yanick Labrie, Activity-based hospital funding: We’ve waited long enough, Montreal Economic Institute, May 2012. Zach Cooper et al., “Does hospital competition save lives? Evidence from the English NHS patient choice reforms,” The
Economic Journal, Vol. 121 (2011), pp. F228-F260; Zachary N. Cooper, Alistair McGuire, S. Jones, J. Le Grand and Richard Titmuss, “Equity, waiting times, and NHS reforms:
retrospective study,” BMJ, Vol. 339 (2009), p. b3264.