Health Care in – An Overview

Reinhard Busse, Prof. Dr. med. MPH FFPH Dept. Health Care , University of Technology (WHO Collaborating Centre for Health Systems Research and Management), Charité – University Berlin & European Observatory on Health Systems and Policies

1. Actors and organisation: are Bismarck´s and Beveridge´s grandchildren look-alikes? 2. Financing 3. Ensuring access and quality http://mig.tu-berlin.de4. Services, costs and reimbursement 5. Contribution to wealth/ productivity

Prof. Dr. Reinhard Busse -2- Potsdam, 15.1.2007

1 Third-party Payer

Population Providers

Prof. Dr. Reinhard Busse -3- Potsdam, 15.1.2007

Collector of Third-party payer resources

http://mig.tu-berlin.dePopulation Providers

Prof. Dr. Reinhard Busse -4- Potsdam, 15.1.2007

2 Classical integrated NHS-type systems Central government

NHS = General payer & taxation provider

PopulationLimited Public providers choice

Prof. Dr. Reinhard Busse -5- Potsdam, 15.1.2007

“NHS” Central government

Purchaser – General provider taxation split http://mig.tu-berlin.dePopulationLimited Public providers choice

Prof. Dr. Reinhard Busse -6- Potsdam, 15.1.2007

3 “NHS” Central government

Purchaser – General provider taxation split

PopulationLimited Public choice “autonomous” providers

Prof. Dr. Reinhard Busse -7- Potsdam, 15.1.2007

“NHS” Central government

Purchaser – General provider taxation split Public http://mig.tu-berlin.deLimited Population “autonomous” more choice providers (money follows patient)

Prof. Dr. Reinhard Busse -8- Potsdam, 15.1.2007

4 “NHS” Central Regional governments

Purchaser – General provider taxation split Public Limited Population “autonomous” more choice providers

Prof. Dr. Reinhard Busse -9- Potsdam, 15.1.2007

“NHS” Regional governments

Purchaser – General provider taxation split http://mig.tu-berlin.dePopulation Limited Public “autonomous” more choice and private providers

Prof. Dr. Reinhard Busse -10- Potsdam, 15.1.2007

5 Social Health Insurance (SHI) systems Sickness funds

SHI Purchaser – contributions provider split

Population Choice Public “autonomous” and private providers

Prof. Dr. Reinhard Busse -11- Potsdam, 15.1.2007

Social Health Insurance (SHI) systems Sickness funds

Observation 1: BasicSHI configuration Purchaser of– actors contributionsis now similarprovider across EU member states.split http://mig.tu-berlin.dePopulation Choice Public “autonomous” and private providers

Prof. Dr. Reinhard Busse -12- Potsdam, 15.1.2007

6 Third-party Payer

Taxes prepaid Social Health Insurance contributions Voluntary insurance Population Providers Out-of-pocket

Prof. Dr. Reinhard Busse -13- Potsdam, 15.1.2007

Third-party Payer

75% Taxes public Social Health 71% Insurance contributions Voluntary insurance 5% 2% http://mig.tu-berlin.dePopulation Providers Out-of-pocket 18% 26% EU-15 12 new EU members

7 Third-party Payer

75% 45% Taxes public Social Health 71% Insurance contributions Voluntary insurance 5% 2% 37% Population Providers Out-of-pocket 18% 26% USA 14%

Third-party Payer

75% 45% Taxes public 46% Social Health 71% Insurance contributions 1% Voluntary insurance 5% 2% 37% http://mig.tu-berlin.dePopulation Providers Out-of-pocket 18% 26% 50% CIS (ex-Soviet Union) 14%

8 Third-party Payer 53% 75% 45% Taxes public 46% Social Health 71% Insurance contributions 1% Voluntary insurance 5% 2% 1% 37% Population Providers Out-of-pocket 18% 26% 50% South-East Asia 14% 40%

Third-party Payer 53% 75% 45% 56% Taxes public 46% Social Health 71% Insurance contributions 9% 1% Voluntary insurance 5% 2% 1% 37% http://mig.tu-berlin.dePopulation Providers Out-of-pocket 18% 26% 50% 35% America (without USA) 14% 40%

9 Total health expenditure as % of gross domestic product (GDP), WHO estimates 16 ot-atAsia South-East East. Mediteranean

15 USA Aus tri a 14 Belgium Bulgaria 13 EU-15 Cyprus Czech Republic 12 Denmark Estonia 11 Finland France 10 Africa Greece 9 Hungary Ireland 8 Italy Latvia 7 Lithuania Luxembourg 6 Ma l ta Netherlands 2nwEU 12 new Poland 5 Portugal Romania 4 CIS Slovakia Slovenia 3 West. Pacific West.

America Sweden 2

1

0 1998 1999 2000 2001 2002 2003 2004 2005 2006

Total health expenditure as % of gross domestic product (GDP), WHO estimates 16 ot-atAsia South-East East. Mediteranean

15 USA Aus tri a 14 Belgium Bulgaria 13 EU-15 Cyprus Czech Republic 12 Observation 2: Denmark Estonia 11 Finland France

There is a distinct EuropeanAfrica way 10 Germany Greece 9 Hungary of financing health care. Ireland 8 Italy Latvia 7 Lithuania Luxembourg 6 Ma l ta Netherlands 2nwEU 12 new Poland 5 Portugal Romania 4 http://mig.tu-berlin.deCIS Slovakia Slovenia 3 West. Pacific West. Spain

America Sweden 2 United Kingdom

1

0 1998 1999 2000 2001 2002 2003 2004 2005 2006

10 Personnel well qualified? Needs-based High-quality Institutions of high standards? access? results? Technologies effective?

Environment Nutrition/ agriculture Other sectors Population health status (need) Patients: demand, Health care access outcome: Health Human Process satisfaction, gain/ complica- resources Structures tions etc. Outcome and organisation Techno- logies Health care system

Financial resources Patients receiving How much? Prof. Dr. Reinhard Busse -21- Fair andPotsdam, sustainable 15.1.2007 funding? appropriate services? Is it worth it?

Professional (re-)certification Universal “Do the thing right“: coverage; Provider (re-)accredition Health Technology Assessment Benchmarking/ cost-sharing league tables; registers limits Concentration of services

Environment Nutrition/ agriculture Other sectors Population health status (need) Patients: demand, Health care access outcome: Health Human Process satisfaction, gain/ complica- resources Structures tions etc. Outcome and http://mig.tu-berlin.deorganisation Techno- logies Health care system

Financial resources “Do the right thing“: ex ante Guidelines/ disease management programmes/ reminders; ex post Review

11 Professional (re-)certification Universal “Do the thing right“: coverage; Provider (re-)accredition Health Technology Assessment Benchmarking/ cost-sharing league tables; registers limits Concentration of services

Environment ObservationNutrition/ agriculture 3: EU healthOther care sectors systems Population health status face the same challenges (need) Patients: demand,and are choosingHealth care access outcome: Health Human Process satisfaction, gain/ very similar answers.complica- resources Structures tions etc. Outcome and organisation Techno- logies Health care system

Financial resources “Do the right thing“: ex ante Guidelines/ disease management programmes/ reminders; ex post Review

Costs and reimbursement of European hospitals: hip replacement

12000

10000

8000 Data embargoed until February 22

6000

Denmark England 4000 Reimbursement (Euros) Reimbursement France Germany Hungary http://mig.tu-berlin.deItaly 2000 Netherlands Poland Spain 0 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 Total cost (Euros) Unpublished data from HealthBASKET project (presentation: conference Berlin, 22.2.07)

12 Costs and reimbursement of European hospitals: stroke 8000

7000

6000

5000

4000 Data embargoed until February 22 Denmark England 3000 France

Reimbursement (Euros) Reimbursement Germany Hungary 2000 Italy Netherlands

1000 Poland Spain

0 0 2000 4000 6000 8000 10000 12000 14000 16000 Total cost (Euros) Unpublished data from HealthBASKET project (presentation: conference Berlin, 22.2.07)

Costs and reimbursement of European hospitals: stroke 8000

7000 Observation 4: 6000 Actual treatment and costs differ 5000 in the EU - but mainly within, 4000 Denmark not systematically between countries.England 3000 France Reimbursement (Euros) Reimbursement Why do countries pretendGermany Hungary 2000 Italy http://mig.tu-berlin.dethey need their ownNetherlands 1000 Poland specific reimbursement systems?Spain

0 0 2000 4000 6000 8000 10000 12000 14000 16000 Total cost (Euros) Prof. Dr. Reinhard Busse -26- UnpublishedPotsdam, data 15.1.2007 from HealthBASKET project (presentation: conference Berlin, 22.2.07)

13 Life expectancy at birth, in years 85

Life expectancy is visibly rising … Aus tri a Belgium Bulgaria Cyprus Czech Republic 80 Denmark Estonia Finland France Germany Greece Hungary Ireland 75 Italy Latvia Lithuania Luxembourg Ma l ta Netherlands Poland Portugal Romania 70 Slovakia Slovenia Spain Sweden United Kingdom

65 1976 1986 1996 2006 2016

Today we know that health care does improve health …

England USA France Japan Italy Sweden Nether- Spain & Wales lands Time analysed 1956-1978 1969-84 1975-90 Age groups included 5-64 y. 0-74 y. 5-64 y.

Share “medically amenable/ avoidable“ mortality of total mortality (cross-sectional analysis) 1956 17.3% 15.8% 15.3% 33.3% 19.7% 15.8% 1969 18.4% 1975/ 78 9.6% 6.3% 7.4% 19.6% 11.3% 7.1% 15.5% 1984 11.7% 1990 7.5%

Change in mortality per year (longitudinal analysis) „Medically -3.2% -3.6% -4.5% -5.6% -3.8% -4.2% -4.5% -6.5% http://mig.tu-berlin.deamenable“ mortality Other mortality -0.2% -0.4% -1.0% -2.5% -0.8% -0.1% -1.1% -1.2% Total mortality -0.6% -0.9% -1.4% -3.4% -1.3% -0.6% -1.6% -1.8%

Share of “medically amenable“ mortality of change in total mortality 71% 59% 38% 46% 45% 78% 43% 41% Busse 1998

14 Age-standardised death rates of treatable mortality in 20 EU member states, 1990/91 and 2000/02

Treatable Mortality: Men Treatable Mortality: Women

Romania Romania Bulgaria Bulgaria Hungary Hungary Latvia Latvia Estonia Estonia Czech Republic Czech Republic Poland Poland Portugal Lithuania Li thuania Portugal 1990/01 Slovenia 1990/91 Slovenia 2000/01/02 Austria 2000/01/02 UK Finland Ireland Irela nd Austria Germany Germany UK Finland Italy Italy Spain Netherlands France Spain Netherlands Sweden Sweden France 0 50 100 150 200 250 0 50 100 150 200 250 Deaths/ 100 000 population Deaths/ 100 000

Newey, Nolte, McKee & Mossialos 2004

Rethinking investment in health: A virtuous cycle? http://mig.tu-berlin.de

Suhrcke M, McKee M, Sauto Arce R, Tsolva S, Mortensen J. The Contribution of Health to the Economy in the . Brussels: , 2005.

Prof. Dr. Reinhard Busse -30- Potsdam, 15.1.2007

15 The return on investment

France UK Italy Spain Sweden

Increase in GDP per capita $5,200 $6,000 $5,420 $5,180 $4,810 Increase in total health income $3,302 $4,108 $4,992 $4,498 $4,732 Increase in health expenditure $676 $630 $403 $506 $395

Increase in health income attributable to health care $996 $1,561 $1,325 $1,780 $1,478

Return on health expenditure 47% 148% 229% 252% 274%

Prof. Dr. Reinhard Busse -31- Potsdam, 15.1.2007

Y Y = 1.79X+61.97 85 Aus tri a Belgium Bulgaria Swe- Cyprus Spain Italy den Czech Republic France Denmark 80 Estonia Finland France UK Germany Greece Hungary Ireland Italy 75 Latvia Lithuania Luxembourg Ma l ta Netherlands Poland Portugal 70 Romania Slovakia Slovenia http://mig.tu-berlin.deSpain Sweden United Kingdom

65 X 3 4 5 6 7 8 9 10 11 12 X - Total health expenditure as % of gross domestic product (GDP), WHO estimates, 2002 Y - Life expectancy at birth, in years, Last available

16 Y Y = -0.01577X+82.55 85 Aus tri a Don`t say: “the more – the better“ is always true: Belgium Bulgaria acute hospital beds/ capita vs. life expectancy Cyprus Czech Republic Denmark 80 Estonia Finland France Germany Greece Hungary Ireland Italy 75 Latvia Lithuania Luxembourg Ma l ta Netherlands Poland Portugal 70 Romania Slovakia Slovenia Spain Sweden United Kingdom

65 X 200 300 400 500 600 700 800 900 1000 X - Acute care hospital beds per 100000, 2002 Y - Life expectancy at birth, in years, Last available

Y Y = 1.79X+61.97 85 Aus tri a Back to spending vs. life expectancy … Belgium Bulgaria Swe- Cyprus Spain Italy den Czech Republic France Denmark 80 Estonia Finland France UK Germany Greece Hungary Ireland Italy 75 Slovakia Latvia Lithuania Estonia Luxembourg Ma l ta Romania Netherlands Poland Portugal 70 Romania Slovakia Slovenia http://mig.tu-berlin.deObservation 5: If health care increasesSpain Sweden wealth, then it is in our commonUnited EU Kingdom 65 X 3 4 5 6 7 8 9 10 11 12 interestX - Total health expenditure that as % low-spending of gross domestic product (GDP), WHO estimates, countries 2002 increaseY - Life expectancy at birth, their in years, Last available health expenditure.

17 Y Y = 1.79X+61.97 85 Aus tri a Belgium Bulgaria Cyprus Czech Republic Denmark 80 Estonia Finland France Germany Germany Greece Hungary Ireland Italy 75 Latvia Lithuania Bulgaria Luxembourg Ma l ta Netherlands Hungary Poland Portugal 70 Latvia Romania Slovakia Slovenia Spain Sweden United Kingdom

65 X 3 4 5 6 7 8 9 10 11 12 X - Total health expenditure as % of gross domestic product (GDP), WHO estimates, 2002 Y - Life expectancy at birth, in years, Last available

This presentation and more material can be found on the following websites:

http://mig.tu-berlin.de http://mig.tu-berlin.dewww.observatory.dk

Prof. Dr. Reinhard Busse -36- Potsdam, 15.1.2007

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