WAITING TIMES POLICIES in the HEALTH SECTOR What Works? SECTION 1

WAITING TIMES POLICIES IN THE HEALTH SECTOR What works? SECTION 1

WAITING TIMES FOR HEALTH CARE: A CONCEPTUAL FRAMEWORK Long waiting times for health services are a prominent health policy issue in many OECD countries.

Emergency Currently a national Elective Primary health Outpatient Long-term Country departments/ Cancer care strategy to reduce surgery care (GPs) speciality care care surgery w aiting times

Australia X X X X X X Yes Austria X Yes Canada X X X X X X Yes Czech Republic X X X No Denmark X X X X Yes England X X X X X X Yes Finland X X X X X Yes Germany X X X No Iceland X X X X No Ireland X X X X X Yes Israel X X X X X No Netherlands X X X No Norw ay X X X X X No New Zealand X X X X Yes Poland X X X X No Portugal X X X X X X Yes Scotland X X X X X Yes Slovak Rep X Yes Slovenia X X X X Yes Spain X Yes Sw eden X X X X X Yes Turkey X X X X X X Yes Source: OECD (2013). Annexe 1A1. Waiting Times Policies in the Health Sector. What Works? Paris, OECD Publishing Why do some OECD countries experience waiting times and others don’t?

Strong negative association between waiting times and the availability of curative care beds.

Curative care beds per 1 000 population and percentage waiting four months or more for elective surgery, 2010

Linear (With Germany) Linear (Without Germany) 30

CAN 25 SWE NOR 20 UK AUS 15 Corr=-0.55, p-value=0.10 10 NZL SWITZ Corr=-0.67, p-value=0.02 elective surgery

5 USA FRA NLD GER 0 Percentage four waited months or more for 0 1 2 3 4 5 6 Curative care beds, per 1 000 population

Source: OECD (2012), OECD Health Data 2012, OECD Publishing, Paris, DOI: 10.1787/health-data-en; and C. Schoen, R. Osborne et al. (2010), “How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries”, Health Affairs, Vol. 29, No. 12, pp. 2322-2337. Large variation in surgical volumes

Hip and knee replacement per 100 000 population, 2010 (or nearest year)

Hip replacement surgery Knee replacement surgery Germany 295 United States 226 Switzerland 265.5 Germany 213.1 Austria 249.1 Belgium 245 Switzerland 211.9 Norway 242.4 Austria 200.6 Denmark 225.4 Finland 187 France 224.7 Belgium 177.6 Netherlands 213.3 Denmark 174.7 Sweden 210.4 Australia 168.6 Luxembourg 207.6 Luxembourg 155.4 United States 203.7 Canada 144.1 Finland 199.1 United Kingdom 141.5 United Kingdom 181.2 Iceland 131.6 Iceland 172.6 Netherlands 127.6 Czech Republic 162.7 Sweden 125.3 Australia 161.1 Slovenia 159.3 France 124 OECD 153.5 OECD 121.6 Italy 146.9 Czech Republic 111.5 New Zealand 143.4 Korea 107.9 Canada 123.5 Spain 104.4 Ireland 121.5 Italy 97.7 Hungary 99.4 New Zealand 94.7 Spain 97 Slovenia 85.5 Portugal 87.8 Norway 84.1 Estonia 84.5 Portugal 61.7 Slovak… 74.4 Israel 48.4 Poland 63.2 Hungary 45.2 Israel 51.9 Chile 22.1 Ireland 44.2 Korea 17.9 Chile 6.2 Mexico 7.5 Mexico 3.3 0 100 200 300 0 50 100 150 200 250 Per 100 000 population Per 100 000 population

Source: OECD (2012), OECD Health Data 2012, OECD Publishing, Paris Waiting times are not necessarily bad!

• From the standpoint of hospital efficiency, there is a role for some patient waiting time – expensive hospital services, like surgical suites, can be used at full capacity – The existence of a waiting list decreases the probability that supply exceeds demand, leaving capacity under-utilised • However, as the waiting lists increases, hospital costs also increase SECTION 2 MEASURING WAITING TIMES ACROSS OECD COUNTRIES Interested in waiting times not waiting lists

• Waiting list provides the stock of patients to be treated at a point in time • Waiting time is determined by the time necessary to treat all the patients on the current waiting list through current and future supply of treatments • From the patients’ perspective what matters is the ‘time’ waited, not the length of the list • International consensus now around ‘time’ When does the patient’s waiting time start and finish? Primary care Specialised care

Referral to treatment i) General iii) Outpatient Practice ii) iv) Inpatient ii) Doctor Diagnostic Diagnostic Treatment Appointment Appointment started

Referral Referral Referral Decision to Contact written Patient Examinations, received evaluated treat Examinations listed , laboratory laboratory,

measurements measurements Portugal Finland Ireland New Zealand Finland Canada Denmark Netherlands England (HES Sweden* Australia Portugal Denmark inpatient) England Finland Sweden Norway The Netherlands Scotland Spain (referral England (RTT) Finland to a specialist) Scotland England (HES outpatient) Portugal

Finland New Zealand

Scotland (RTT) Sweden

Scotland Spain (elective (outpatient) surgical procedure)

Finland

Source: Adapted from SALAR (2011), “Swedish Waiting Times for Health Care in an International Perspective”, SALAR, Stockholm, updated by the OECD Secretariat. Mean vs Median

• Distribution of waiting times positively skewed with a tail of patients waiting very long times. • Mean influenced by small number of patients with long waits. Mean and median inpatient waiting time of patients admitted for treatment (England, 2008-09) Episodes Mean Median (days) (days) Primary Hip Replacement Cemented (HRG H80) 37,207 82 74 Primary Hip Replacement Uncemented (HRG H81) 21,769 87 77 Primary Knee Replacement (HRG H04) 70,813 89 78

Phakoemulsification Cataract Extraction and Insertion of Lens (B13) 313,640 61 56 Source: HES on line; www.hesonline.nhs.uk

Other percentiles of the distribution

Inpatient waiting times for patients admitted from the waiting list, public hospitals (Australia, 2008- 09) Admissions Days waited at Days waited at % waiting more 50th percentile 90th percentile than 365 days (median) Total Hip 7939 100 364 9.6 Replacement Total Knee 11493 147 393 14.9 Replacement Cataract extraction 51436 84 320 3.6 Hysterectomy 9879 48 171 1.2 Source: National Elective Surgery Waiting Times Data Collection, table 10.7, Australian Institute of Health and Welfare 2010. Australian hospital statistics 2008–09. Health services series no. 17. Cat. no. HSE 84. Canberra: AIHW

Is there a role for survey data?

Waiting time of four months or more for elective surgery

% 2001-02 2005 2007 2010 50

41 40 ,38

33 30 30 ,27 27 ,26 25 ,23 22 21 21 20 19 20 1818

8 8 8 10 7 7 7 7 6 ,5 5 5

0 0

Source: OECD (2011), Health at a Glance 2011 – OECD Indicators, OECD Publishing, Paris, based on the Commonwealth Fund Survey (Schoen et al., 2010). Is there a role for survey data? OECD Waiting times pilot data collection

• OECD pilot data collection – Waiting times data collected as part of 2013 OECD data collection  OECD Health at a Glance 2013 – Seven elective surgical procedures e.g. Hip replacement, knee replacement, cataract surgery... – Canada has submitted this data (thanks…)

Section 3 POLICIES TO TACKLE WAITING TIMES: LESSONS FROM OECD COUNTRIES Policies to address waiting times can target the supply side, the demand side, or both Potential effect on Policies Commonly used waiting times 1. Increased production in the public sector 6/13 countries Weak by funding extra activity 2. Contracting with private sector 6/13 countries Weak 3. Sending patients abroad 3/13 countries Weak Supply-side policies 4. Increased productivity by introducing 3/13 countries Medium activity-based financing (DRGs) 5. Increased choice of providers 5/13 countries Medium 6. Improved management of waiting lists Medium

1. Explicit guidelines to prioritise patients 7/13 countries Medium Demand-side policies 2. Subsidise private insurance 5/13 countries Weak 1. Waiting-time guarantees 13/13 countries Weak Combined policies 2. With sanctions 3/13 countries Strong 3. With choice and competition 6/13 countries Strong

Source: Based on OECD Secretariat assessment of 13 case studies and review of the literature. Increased funding to reduce waiting times

• Almost every country has tried increasing funding … with little effect – UK, Australia, Sweden, Portugal, etc • Initial decrease in waiting times, but then they raise again • Often perverse incentives with added funding • Supply increase is usually limited and not sustained Learning from the experience of other OECD countries

–Targets and Terror –Waiting Times Guarantee –Introducing Competition –Demand-side Management Targets and Terror in the UK

• UK model had very concrete target regime that was ratcheted to 18 weeks; inpatient waiting time reduced in England

Source: OECD (2013). Chapter 16: United Kingdom. Waiting Times Policies in the Health Sector. What Works? Paris, OECD Publishing Finnish Waiting-time Guarantee

Number of patients waiting longer than 180 days for specialist care per 10 000 inhabitants, Finland, October 2002 to April 2011

140 140

120 120

100 100 Intervention

80 80

60 60

40 40

20 20

Meannumber of patients per 10 000 inhabitants 0 0

Mean value for health districts Intervention threshold

Source: National Institute for Health and Welfare in Finland (2012). Introducing supply-side competititon - lifting the cap The Netherlands

Mean waiting time (weeks) of patients admitted by surgical procedure in Dutch hospitals, 2000 2011 Surgical procedure2 2000 2006 2007 2008 2009 2010 2011 Cataract surgery 16 7 7 6 5 5 5 Varicose veins 15 7 6 5 5 5 4 Hip replacement 14 8 8 8 8 7 6 Knee replacement 12 10 8 8 8 8 6 Inguinal and femoral hernia 11 5 4 4 5 5 5 Cholecystectomy 10 4 4 4 5 5 5 Hysterectomy 9 5 5 5 5 5 5 Prostatectomy 9 5 5 5 5 5 5 PTCA 3 2 2 3 3 3 2 CABG n.a. 4 5 5 4 3 4

Source: Siciliani, L. and J. Hurst (2003), “Explaining Waiting Times Variations for Elective Surgery across OECD Countries”, OECD Health Working Papers, No. 7, OECD Publishing, Paris, NZa (2012), Marktscan medisch specialistische zorg: weergave van de markt 2006-2011, Dutch Healthcare Authority, Utrecht.

Introducing supply-side competititon - European Union directive on patients’ rights in cross-border health care

Patients willing to travel to another EU country because of long waiting times For which of the following reasons would you travel to another EU country to receive medical treatment? To receive treatment more quickly than at home

Yes No Don't know/Not applicable

1 0 1 5 3 2 5 3 4 2 3 3 7 4 3 2 4 7 5 4 1 3 2 6 4 7 6 6 6 9 11 13 8 10 16 19 17 22 27 32 33 33 29 35 37 41 42 40 42 48 48 48 39 45 47 50 48 57 62 63

90 88 86 85 81 79 79 76 70 66 65 64 64 61 61 57 54 54 54 53 51 50 50 50 47 46 46 37 33 32 IRL ITA FIN EST BEL ESP CZE SVK PRT LTU LVA FRA LUX SVN POL NLD GRC AUT GBR BGR DEU MLT DNK SWE HUN CYP* ROM EU15 EU27 NMS12

* Note on Cyprus: 1) Footnote by Turkey: The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of United Nations, Turkey shall preserve its position concerning the “Cyprus issue”. 2) Footnote by all the European Union Member States of the OECD and the European Commission: The Republic of Cyprus is recognised by all members of the United Nations with the exception of Turkey. The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus. Source: European Commission (2007) ““Eurobarometer: Cross-border Health Services in the EU Analytical report”, Reaxys Database Information. Portugal: IT solution, with competition New Zealand: Demand management • 20 year history of introducing clinical prioritization tools (CPAC) • Categorises patients into 3 classes: booked; guarantee; sent back to GP – Very difficult to operationalise – Multiple criteria • Severity, benefit, multi-dimensions of quality • Includes both clinical and economic threshold – Clinical ownership of tools—initially led by MoH • Currently, 30 National Tools covering 67% of cases and 57 nationally recognised local tools cover 31%

New Zealand: demand side management

Numbers of people waiting more than six months for treatment and first specialist assessment, New Zealand, 2000 to 2011

45 000 41 903 39 694 40 000 37 152 36 251

35 000 32 197

30 000 28 05628 040

25 62225 130 24 129 25 000 24 062

20 000

15 523 15 000

10 000

5 504 8 134 7 532 4 484 4 622 6 868 7 428 7 059 7 055 7 079 4 067 4 083 4 050 3 829 3 766 3 775 5 000 6 474 6 683 3 335 2 821 5 152 3 899 3 650 3 204 2 969 3 322 3 395 3 022 3 234 2 989 3 425 2 310 2 483 2 447 0 1 349 June Dec June Dec June Dec June Dec June Dec June Dec June Dec June Dec June Dec June Dec June Dec June Dec 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 > 6 months > 6 months Section 4 POLICIES TO TACKLE WAITING TIMES: CANADA’S EXPERIENCE Policies to address waiting times can target the supply side, the demand side, or both Potential effect on Policies Commonly used waiting times 1. Increased production in the public sector 6/13 countries Weak by funding extra activity 2. Contracting with private sector 6/13 countries Weak 3. Sending patients abroad 3/13 countries Weak Supply-side policies 4. Increased productivity by introducing 3/13 countries Medium activity-based financing (DRGs) 5. Increased choice of providers 5/13 countries Medium 6. Improved management of waiting lists Medium

Source: Based on OECD Secretariat assessment of 13 case studies and review of the literature. Waiting times in Canada

• Pre-2004: long waiting times in Medicare; many Canadian provinces had started exploring their own solutions • 2004: 10-Year Plan to Strengthen Health Care • 2007: $1 billion Patient Wait Time Guarantees – Standardisation of outcome indicators – Annual wait times report from 2007

28 Waiting times in Canada

• 10-Year Plan to Strengthen Health Care (2004) – Plan made between federal, provincial and territorial governments – Focused on priority area: cancer, heart, diagnostic imaging, joint replacement, sight restoration – Promise by the provinces to deliver evidence-based waiting time benchmarks and measurable waiting times reductions in five priority areas – All provinces have developed public websites with waiting times data. – New federal funding. Benchmarks for waiting times were reduced; BUT no financial penalty if waiting time is not met. Waiting times in Canada

• Each province and territory pursued its own path towards improved performance – British Columbia provincial strategy: governance, organisational structure, patient management, accountability. • In 2007 Ministry established operational waiting times targets requiring an average of 90% of patients treated within national benchmarks • Improving practice in management • Patient registry with assessments for urgency with real-time data • Annual performance agreements between ministry and health authorities – Ontario province: • Ontario Cardiac Care Network (CCN) established in 1990 as a province- wide cardiac surgical patient registry • An urgency rating system and waiting time guidelines to inform patient prioritisation

Health Council of Canada, Progress Report 2011

• ‘Despite the fact that the 2003 accord created a separate Diagnostic and Medical Equipment Fund of $1.5 billion to shorten wait times, long waits for diagnostic imaging (particularly MRI scans) persist in many jurisdictions, and there is reason to believe that some people waiting in the queues don’t medically need to be there’. • ‘This lack of progress shows that it takes more than money to reduce wait times. A comprehensive strategy, which would include the use of computerized order-entry systems linked to best practice guidelines, should also help physicians order the appropriate tests’. Conclusions

• Standardisation of benchmarks is a considerable achievement • Reporting could be expanded – Second review of the 10-Year Plan (2012) by the Senate Committee recommended the development of benchmarks on waiting times for all specialty medical care, hospital emergency departments, and long-term care • Reporting on public websites could be improved • Definition of waiting time to be expanded? Conclusions

• Learning from other OECD countries – A waiting time guarantee? – Clinical prioritisation for certain procedures – For longer term sustainability in intervention: consider competition Thanks for listening!

Mark Pearson

[email protected]

http://www.oecd.org/els/health-systems/waitingtimepolicies.htm