Globalization and Health Care Systems Reform

Bernardo Ramirez MD, MBA

UCF Health Management and Informatics

April 2013

Global Health Care Management Experience

Globalization and Health Care Systems

•Global Health Care Management Experience•Study tour 2005 (US, Canada, Mexico,UK and Australia)•All countries in the Americas•Partnerships Europe, CEE and NIS(Hospitals, Managed Care, Health Systems, Health Reform, Education and training on health services management [human resources development, institutional strengthening])

•Managerial and Health Services Research Perspectives•Globalization impact in health and health care services and management•Health systems reform strategies with issues like competitiveness, state regulations, insurance companies, public private partnerships and patient empowerment•Quality, safety and performance improvement•Value and impact of heath care. Chronic Care

3

Percent

Physician Views of the Health System, 2009 and 2012:“System Works Well, Only Minor Changes Needed”

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

4

Percent

Physician Satisfaction with Practicing Medicine

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Examples of global issues in healthcare include:

Outsourcing of medical services (e.g. medical transcribing, radiology, billing support – similar to other businesses)

Acquisitions and consolidations in the pharmaceutical industry

Movement of health professional labor across national borders

Medical tourism; competition for international patients Immigration and global workforce Global health – pandemics (e.g. HIV/AIDS, Avian flu,

SARS) Comparative Health Systems and Health Reforms

HEALTH AS A SYSTEMHEALTH AS A SYSTEM

RESOURCESRESOURCES

POPULAT IONPOPULAT ION

HEALTH SERVICES HEALTH STATUS

PRODUCTIVITY EFFICIENCY

UTILIZAT IONEFFECTIVENESS

STRUCTUREPROCESS

OUTPUTSOUTCOMES

Adapted from Donabedian A. (2005) Evaluating the Quality of Medical Care. Milbank Quarterly Vol 83-No4, Reprinted from Vol44No3, 1966. AndFrom Bradbury R. (1992) Health Systems Analysis and Hospital Quality Improvement. ISQUA,9th International Conference Mexico.

Health Services Elements

Population Access/utilization (Education, Health

Promotion, Options for Care, Legal Aspects, Geographical and Cultural Barriers)

Epidemiology (Transition, Mortality, Morbidity, Population, Life Expectancy)

Life Styles and behaviors (Prevention and chronic health, Patient & Family Centered)

Health Services Elements

Resources Physical Resources, (hospitals, clinics, private-

public, Ambulatory services) Equipment/Technology, Medicines Human resources (Education, health

manpower, Incentives, training, continuing education, Physicians, nurses, technicians and emerging professions)

Financial Resources (Resource allocation, budgets, financial schemes, reimbursement, insurance mechanisms)

Health Services Elements

Health Services Primary/Secondary health care. Systems. Management Information Systems Clinical Standards and Protocols. Safety Issues. Quality Assurance and Quality Improvement Legal aspects (malpractice) Incentives, Performance management. Cost or services Efficiency, clinical & Management efficiency Effectiveness, Health Impact and outcomes

Types of Health Care Services

Traditional, spiritual, empirical Charitable and altruistic organizations Entrepreneurial Private practice Welfare-oriented, social insurance Government and centrally planned Prepaid voluntary insurance Owned by industry for their workers

Origins of Health Care Systems

England. Chadwick report on laboring conditions. Boards of Public Health (1850). Mandatory Insurance for workers (1911) Welfare State Beveridge Report (1942), NHS (1948)

Germany. Bismarck, Mandatory insurance for injury and illness (1883)

Central Planning Concept: Semashko. (1923) Mixed Systems from tax-free health care in

Saudi Arabia to combination of public-private

Ward in a London Hospital 2003

Infant Mortality and Total Heath Spending (% GDP)

Total Health Spending (% GDP) & Body Mas Index

THE HEALTH TRIANGLETHE HEALTH TRIANGLE

ACCESSEQUITY

QUALITY &PERFORMANCEMANAGEMENT

COST

Adapted from Cost, access, quality triangle. Harvard Medical International, 2002Retrieved from the Internet December 20, 2006 http://www.hmiworld.org/hmi/issues/Sept_Oct_2002/features_health_systems.html

Source: OECD Health Data 2012.

Average Health Care Spending per Capita, 1980–2010Adjusted for Differences in Cost of Living

16

Dollars ($US)

THECOMMONWEALTH

FUND* 2009

GDP refers to gross domestic product.Source: OECD Health Data 2012.

Health Care Spending as a Percentage of GDP, 1980–2010 17

Percent

THECOMMONWEALTH

FUND

* 2009

18Health Care Spending per Capita by Source of Funding, 2010Adjusted for Differences in Cost of Living

* 2009.

Dollars ($US)

8,233

4,463 4,445 4,3383,974

3,758 3,6703,035

3,433

5,269

Source: OECD Health Data 2012.

THECOMMONWEALTH

FUND

3,022

19Pharmaceutical Spending per Capita, 2010Adjusted for Differences in Cost of Living

* 2009.** 2008.Source: OECD Health Data 2012.

THECOMMONWEALTH

FUND

Dollars ($US)

Relation of Health with Physicians

Will problems be solved in developing countries if there were more physicians?

More and other health professionals?

Different Health Personnel Ratios?

How about training, incentives, etc?

More hospitals and health centers?

More technology?

Number of Practicing Physicians per 1,000 Population, 2010

* 2009.Source: OECD Health Data 2012.

21

THECOMMONWEALTH

FUND

22Average Annual Number of Physician Visits per Capita, 2010

* 2009.** 2008.Source: OECD Health Data 2012.

THECOMMONWEALTH

FUND

23

Doctors’ Perception of Patient Access Barriers

Percent reporting their patients OFTEN have:

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Difficulty paying out-of-pocket costs

25 26 29 21 42 26 4 6 16 13 59

Difficulty getting diagnostic tests

16 38 41 27 7 59 10 15 3 14 23

Long waits to see a specialist

60 73 59 68 21 75 60 49 10 28 28

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

24

Percent

Practice Has Arrangement for Patients’ After-Hours Care to See Doctor or Nurse

* In Norway, respondents were asked whether there practice has arrangements or if there are regional arrangements.Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

25

Percent

Practice Uses Nurse Case Managers or Navigators for Patients with Serious Chronic Conditions

Note: Question asked differently in France.Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

26

Primary Care Doctors’ Receipt of Information from Specialists

Percent said after their patient visits a specialist they always receive:

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Report with all relevant health information

32 26 51 13 13 41 26 12 59 36 19

Information about changes to patient’s drugs or care plan

30 24 47 12 5 44 22 13 44 41 16

Information that is timely and available when needed

13 11 26 4 1 15 4 8 27 18 11

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Health Sector Reforms Around The World

Balance the Iron Triangle (Access-Quality-Cost) Reorient MOH (make them smaller or more

functional, performance, accountability, modernization, separate provision from financing, competition, Chronic-Acute Care)

Institute user charges-Accountability- Institute or expand health insurance schemes Decentralize-Empowerment Third party Contracts with private/public providers

Sustainability:The capacity of health services to

function with efficiency, including the financial, environment and social interaction that guaranties an effective service now and in the future, with a minimum of external intervention and without limiting the capacity of future generations to fulfill their needs.

Adapted from Gallopin Gilberto. A systems approach to sustainability and sustainable development. Sustainable Development and Human settlements Division. ECLAC/Government of the Netherlands. Project “Sustainable Assessment in Latin America and the Caribbean” Santiago de Chile, March 2003

Areas and Dimensions

Sustainability of Processes Sustainability of OrganizationsThe dimensions of sustainability are

grouped in five areas: The environment Socio-Cultural Institutional Capacity Development The Financial Dimension The Political Dimension