Health Reform Issues

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Health Reform Issues

• TH Tulchinsky
• Braun SPH
• Jan 2004

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Health 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

3
Financing

• Financing within national means for social
  benefits
• Adequate overall financing (gt6GNP)
• 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 lt3.0/1,000
• District health authorities with capitation
  funding 

4
Defining 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

5
Management 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

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Participants (Stakeholders) in National Health
Systems

• 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

• 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
•  

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Participants (Stakeholders) in National 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

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Health System Problems World Bank

• 1. 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

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Typology of Financing and Administration of
National Health Systems

• Type
• Financing Source
• Administration

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Categories of Services

• 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

• Institutional Care
• Pharmaceuticals and Vaccines
• Ambulatory Care
• Home Care
• Elderly Support
• Categorical Programs
• Immunization, MCH
• Family planning, Mental health, TB, STDs,
  HIV, Screening

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Classical Market Factors

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

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Regulatory Factors

• Regulate supply
• Regulate demand gatekeeper, user fees
• Regulate price
• Regulate benefits
• Regulate method of payment
• Health promotion issues

13
Health 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)

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System 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

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Semashko National Health Systems

• 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

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Bismarckian 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

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Beveridge 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

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Douglas 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

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Mixed 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

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Laws

• Suttons law
• Capones law
• Roemers law
• Bunkers law
• Murphys law

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Basic issues

• Universality
• Equity
• Comprehensiveness
• Accessibility
• Portability
• Tax (social security) based
• Quality

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A Comprehensive Health Services Continuum
Manitoba, Canada
Promotion
Healthy Public Policy Prevention Promotion
Protection
Hospitals
Palliation
Support Services To Seniors
Community Health Centres
Outpatient Ambulatory Care
Urban Community
Rural Community
Palliation
Tertiary
Community Oriented Services
Home Care
Extended Treatment Long Term Care
Rehabilitation
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Decentralization

• Transfer of responsibility to lower level of
  govt
• Transfer of funds to provide care
• Monitoring of stndards

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Devolution

• Transfer of govtal responsibility to non-govt
  organization
• Universities
• Colleges of physicians etc
• Accreditation by consortium of organizations e.g.
  medical, nursing etc.

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Regionalization

• Decentralization
• Integration of related services
• Vertical integration of acute care with long term
  care
• Organizational and financial linkages

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Prospective Payments Systems

• Payment before service
• Predictable
• Limits liability
• Defines responsibility
• Risk sharing
• Capitation
• DRGs

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Balance of Services

• Health promotion to terminal care
• Spectrum of services
• Care depends on person or patient needs

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Cost Restraint

• Gate keeper function
• Downsize-Upgrade
• Basket of services
• Limit liability
• Patient participation user fees
• Private insurance

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Models of Care

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

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Health for All

• Basic primary care for all govt based
• Immunization
• MCH
• Environmental health
• Nutrition
• Secondary and tertiary care via health insurance
• Contradictions and imperfect models

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Trends

• Down-size hospital sector
• Develop PHC
• Linkage between insurance and service
• Define basket of services
• Generic drugs
• Clinical guidelines
• Technology assessment

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Health Reforms

• Continuous or periodic process
• Economic and political factors
• Epidemiologic factors
• Public consciousness and knowledge

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PH Professional Roles

• Provide evidence
• Regional variations
• Inequities socioeconomic, ethnic, regional,
  urban-rural
• Identify new interactions, risk factors, diseases

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Motivation/Advocacy

• Whistle blowing
• Advocacy
• Investigation
• Media
• Professional bodies
• Publication

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Famous 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

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Intellectual Challenges

• Think global, act local
• Think outside of the box
• Think

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Motivation

• Commitment
• Responsibility moral, professional
• Professionalism
• Stay the course
• Self esteem
• Recognition
• Isolation

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Thank You