Quality and Cost International Perspectives
Derek Feeley
Director of Healthcare Policy and Strategy NHS Scotland
Health Care Spending per Capita in 2003 Adjusted for Differences in Cost of Living
$6,000 $5,635
$5,000
$4,000 $3,003 $2,996 $2,903 $2,280 $2,231 $1,886 $2,000
$3,000
$1,000
$0
United States Canada Germany Australia OECD Median United Kingdom
a
New Zealand
a
a2002
Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health
Percentage of Gross Domestic Product Spent on Health Care in 2003
16% 14% 12% 10% 8% 6% 4% 2% 0%
United States Germany Canada Australia OECD Median New Zealand
a
15.0%
11.1% 9.9% 9.7% 8.4%
8.1% 7.7%
United Kingdom
a
a2002
Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health
Health Care Expenditure per Capita by Source of Funding in 2003 Adjusted for Differences in Cost of Living
$6,000 793
$5,000
Out-of-Pocket Spending Private Spending Public Spending
$4,000 2339 $3,000 312 341
448 455
590 341 793 94 371 296 106 1484
$2,000 2503 2343
$1,000
2100
1973
1768
1860
$0
United States Canada Germany Australia OECD Median United Kingdom
a
New Zealand
a
a2002
Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health
Healthy life expectancy
WHO World Health Report 2006
73 72.6 72 72
71 70.6
70.8
USA Canada 70 Aus UK 69.3 69 NZ
68
67 1
% of total life expectancy lost to poor health (male and female)
WHO Report 2006
12 11.1 10.7 9.9 9.2 9.3 9 8.8 10.7 10.4 10 10.4
8
USA Canada 6 Aus UK NZ
4
2
0 1 2
Infant Mortality Rates 2000
Source NCHS
8 6.9 6.3 6 5.3 5 USA Canada 4 Aus UK NZ 3 5.2 5.7
7
2
1
0 1
Quality Indicators
Source OECD, Hussey et al 2004
USA Survival Rates
Breast Cancer
Kidney Transplant
Canada Aus
UK
NZ
1
5
4
1
2
2
5
3
3
3
Process
Cancer Screening
3 4
1
2 3
4
1 1
2
4 2
5
5 5
3
Flu vaccine
Waiting
Elective surgery
Safety: Medical Mistake, Medication Error,
or Test Error in Past Two Years
Percent
50 34 23 25 22
27 25
30
0 AUS CAN GER NZ UK US
2005 Commonwealth Fund International Health Policy Survey
Effectiveness; Preventive Care
Percent received:
Pap in past 3 years, age 25-64
AUS
CAN
NZ
UK
US
78
77
81
77
89
Mammogram in past 3 years, age 50-64 Flu shot in past year, age 65+
80
79
81
77
86
77
66
67
74
72
2004 Commonwealth Fund International Health Policy Survey
Timeliness; Access to Doctor When
Percent 75
Sick or Need Medical Attention
54 60
50 27 25
41 33 25 7 13 2 19
0
AUS CAN NZ UK US Same day appointment
AUS CAN NZ UK US Wait of 6 days or more
2004 Commonwealth Fund International Health Policy Survey
Patient Centered; Missed
Opportunities to Engage Patient
Percent saying doctor:* Does NOT give you clear instructions Does NOT make goals and plans clear Does NOT tell you about treatment choices or ask your opinions
AUS CAN NZ UK
10 14 12 15 8 13 13 19
US
13 20
35
35
30
50
44
*Doctor only sometimes, rarely or never
2004 Commonwealth Fund International Health Policy Survey
Efficiency; Coordination Problems by
Percent
75
Number of Doctors
1 doctor 4 or more doctors
50 27 25 15 16 7 0 AUS CAN GER NZ UK 31 23 11 30 30 26
43
22
US
* Either records/results did not reach doctors office in time for appointment OR doctors ordered a duplicate medical test
2005 Commonwealth Fund International Health Policy Survey
Equity; Number of Measures Where Below Average
Income Adults Have More Negative Experiences
General access (4)
Access because of cost (4) 3
4 4 1
Coordination (9)
Doctor– Patient (8)
Prevention (5)
Total (30)
AUS
CAN NZ UK
0
0 0 0
1
1 1 0
0
0 3 0
0
0 0 0
4
5 8 1
US
3
4
5
7
2
21
* Inequity counted when significant difference between income groups where p .05 and gap of >5%; for U.S. p<.05 and gap>5%, or gap>5%. Source: Commonwealth Fund 2004 International Health Policy Survey.
Cost = Quality?
Limited to patient experience?
Yes but……..
Confirms
earlier survey findings; In line with WHO and OECD indicators which show a similar mixed story; In line with findings at system and subsystem levels within countries.
And so…..
No
discernable relationship between quality and cost; Comparable data hard to come by; No one country has the answer – each has scope to learn; Social as well as clinical factors at play;
Questions and answers
•
Is international comparison worth the trouble?
Useful in; • Raising questions • Benchmarking best practice
•
Are we measuring the right things?
Current OECD 15 an important 1st step - but • Measuring what can be measured • Acute focussed • Fail to cover all dimensions of quality
Policy Implications
Many
of the indicators to which patients attach value require a different model of care; New ways of delivering care will require a new quality paradigm We need to change what we measure We need a different mindset about the business case for quality (social as well as financial)
Shifting the balance of care
Current view
Evolving model of care
Emphasises acute care Hospital centred Doctor dependent Episodic care Reactive care Patient as passive recipient Carers undervalued Low tech
Emphasises long-term conditions Embedded in communities Team based Continuous care Preventative care Patient as partner Carers supported as partners High tech
Implications for National health systems, quality and costs
Population
health as well as healthcare Longitudinal measures rather than episodic Patient activation Improved ICT required Incentives required for;
Whole system integration Prevention
Acknowledgement
Thanks to the Commonwealth Fund for access to the data from international surveys, including;
Multinational Comparisons of Health Systems Data, 2005 (Frogner and Anderson) o The Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults in Six Countries (Schoen, Osborn, Huynh, Doty, and Fenley) o The Commonwealth Fund 2004 International Health Policy Survey of Primary Care in Five Countries (Schoen and Osborn)
o
The views expressed are my own and should not be construed as representing CMWF.
Coronary Bypass Procedures per 100,000 Population in 2003
200 175 150 125 100 75 50 25 0
United States
b
181
98
97
87
82 65 56 53 41
Canada
a
New Zealand
Germany Australia
a
OECD Median
United Netherlands France Kingdom
b
a2002 b2001
Source: OECD Health Data 2005.
Spending on Physician Services per Capita in 2003 Adjusted for Differences in Cost of Living
$1,500 $1,271
$1,000
$553 $500
$480
$428
$363
$304
$287
$0
United States Japan
a
Australia
OECD Median
France
Germany
Canada
a2002
Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.