HEALTH CARE SYSTEM: NEW CHALLENGES

SMART INVESTMENTS FOR A SUSTAINABLE

HEALTH CARE SYSTEM

Maria M. Hofmarcher-Holzhacker

“Current Status Austria: New Challenges for the Heal th Care System”14th Summit Talk on the SchafalmAlpbach, August 25, 2015

http://www.healthsystemintelligence.euhttp://healtheconomics.meduniwien.ac.at

KEY MESSAGES

� Health outcomes could be better with the money invested

� Health reform 2013 � is ambitious in trying to re-shape the delivery chain and to

further optimize care processes� does not explicitly address the issue of waste � is path-dependent in aiming at making “hostile” actors working

together

� Social Justice is still high but slightly down

� Clever policies are required focusing those most in need while improving policy coordination in particular across policy areas 2

GRADUAL EXPANSION OF PUBLIC COVERAGE OF HEALTH CARE

SERVICES HAS BEEN ACCOMPANIED BY EFFORTS TO IMPROVE

EFFICIENCY AND GOVERNANCE

3

Source: Statistik Austria 2015, own compilation

Health care Expenditure in Austria, % GDP

6,2

2,1

0,0

2,0

4,0

6,0

8,0

10,0

12,0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

In %

GD

P

Public

Private

Imp

lem

enta

tion

DR

G F

inan

cing

, par

tial b

ud

get

cap

Fed

eral

Hea

lth A

gen

cy,

„ref

orm

po

ol“,

ÖS

G,

e-ca

rd

“Bes

t p

oin

t of s

ervi

ce”,

pri

mar

y ca

re c

apac

ity, g

lob

al

bu

dg

et, e

nh

ance

d m

on

itori

ng a

nd

mid

-ter

m fo

reca

sts

YET, HIGHER LIFE EXPECTANCY COULD BE

ACHIEVED WITH THE MONEY INVESTED

4

HEALTH REFORM 2013 AIMS TO OVERCOME THE GOVERNING

DIVIDE AND TO ENHANCE PERFORMANCE THROUGH

- BETTER FORMALISED COOPERATION AND COORDINATION – “ZIELSTEUERUNG” - A GLOBAL BUDGET CAP WHICH IS EXPECTED TO LEVERAGE STRUCTURAL CHANGE IN CARE DELIVERY

5

Source: Hofmarcher 2014

MEASURES PROPOSED BY HEALTH REFORM 2013 WHICH ARE SUBJECT TO IMPACT ASSESSMENT IN 2017

6

Likelihood of

achievement

in 2017

Remarks

Measure 1 Ensure best point of service

• Increase day care 4.2 pp. to 25 per cent of all hospital

admission **** Average length of

stay targets

expected to be

failed

• Reduce bed-days

****

Measure 2 Build capacity for innovative, multidisciplinary care models

• Increase the number of such models

• Make existing ambulatory care more responsive to

patient needs, e.g. opening hours

** Target is

conservative: 1% of

the population

should be cared in

such models

Measure 3 Enhance targeted health promotion and prevention

• Definition of unified principals for newly established funds

on the regional level

• 150 Mio. Euros between 2013-2022

** Funds will operate in

parallel with other

funding and

governance sources

Measure 4 Enhance quality with focus on outcome quality

• Establish outcome measurement comparable across

sectors by 2014

-- Largely devolved to

the regional level

Measure 5 Establish a monitoring system to enable evaluation of

objectives and to promote transparency

• Establish a monitoring framework in 2013

• Provide annual monitoring reports per „Land“, first 2014

for the year 2013

**** 1. Monitoring report:

June 2014; 2. Report:

February 2015

Measure 6 Warrant effective and efficient use of drugs

• Establish a commission in 2013 which recommends the

use of high price drugs used across sectors and

recommend which reimbursement mode is to apply

-- Established

Note , *low likelihood, *****very high likelihood.Source: Gesundheitsreformgesetz 2013, Gesundheit Österreich GmbH 2014/2015, own compilation and assessment

THE AUSTRIAN GROWTH PERFORMANCE DIFFERS

FROM OECD AND IS RECENTLY PRETTY VOLATILE!?

7

-1,0

0,0

1,0

2,0

3,0

4,0

5,0

6,0

7,0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

AT THE

AT GG HE

OECD THE

OECD GG HE

Per capita growth rates for health care financing agents yoy, current spending in real terms, 2000-2013, Austria (AT) and OECD

Source: OECD August 2015, own calculations

THE: Total Health Expenditure; GG HE: General Government Health Expenditure

DOES THIS HERALD BADLY WANTED STRUCTURAL

CHANGE IN CARE DELIVERY?

8

2,0

0,5

1,7

1,3

4,7,

GG

: +2,

8

1,0,

GG

: +1,

2

0,7,

GG

:1,2

0,0,

GG

: -0,

3

0,1,

GG

: 0,5

1,5,

GG

:0,8

1,5,

GG

: 0,2

2,0,

GG

: 0,5

-3,0

-2,0

-1,0

0,0

1,0

2,0

3,0

4,0

5,0

6,0

05-09 09-13 05-09 09-13 05-09 09-13 05-09 09-13 05-09 09-13 05-09 09-13

INPATIENT OUTPATIENT LTC PHARMACEUTICALS PREVENTION ADMIN

AT

EURO L

Average annual per capita growth rates for health care spending components, in real terms, 2005-2013, Austria (AT) and Euro Countries (Euro L)*(GG: General Government)

*Excluding in INPAT/OUTP: GRE, IRE, ITA, POR, in LTC: GRE, IRE, ITA, in PHARMAC: GRE, in PREVENTION/ADMIN: GRE, IRE

Source: OECD August 2015, own calculations

WEAK ECONOMIC CONDITIONS CHALLENGE FISCAL

SUSTAINABILITY AS DEFINED IN 2013

9

638

-455

985

-124

1.077

-219

1.321

-84

1.904

383

1.054

145

1.460

1.211

1.980

1.543

2.255

2.086

2.199

2.199

-600

-100

400

900

1.400

1.900

2.400

2.900

3.400

3.900

4.400

2014 2015 2016 2017 2018

Gap to GDP growth when performance is better than expected

Likely: cost containment when performance is better than expected

Gap to GDP growth when cost containment according to the 2013 legislation

Expected: cost containment according to the 2013 legislation

The spending gap is increasing but likely less strong than expected, in 1000 Euros

Source: Gesundheitsreformgesetz 2013; 2017-2018: own estimates, Hauptverband der Sozialversicherungsträger: 2014: final; 2015-2016: forecasts; 2017-2018: own estimates, 2013-2015: Bundesfinanzrahmen 2013; 2016-2018: Bundesfinanzrahmen 2014: Gesundheit, Mittelfristige Prognose WIFO -Monatsberichte, 1/2015: 2014-2019

FISCAL PRESSURE FROM AGEING IS EVERYWHERE

10

Main areas of social spending 2013 and 2040, Austria (AT) and Euro Area (EA), %GDP

Source: European Commission, Aging Report 2015, baseline scenario: Pension, Education, Unemployment; Health Care and Long-Term Care: AWG risk scenario, own compilation.

0,80,8

1,0

0,80,6

0,7

-0,1

-0,3-0,2

-0,5

2,2

1.6

-1,0

-0,5

0,0

0,5

1,0

1,5

2,0

2,5

0

5

10

15

20

25

30

35

AT EA AT EA AT EA AT EA AT EA AT EA

Pensions Health Care Long-Term Care Education Unemployment Total

perc

enta

ge p

oint

s ch

ange

in %

of G

DP

dark=2013|light=2040 difference 2040-2013 (right scale)

SOCIAL JUSTICE NEEDS TO

BE ADDRESSED AND MORE

ATTENTION

11

AUTBELCZE R

DK

EST

FIN

GER

GREHUN

ISL

ITA

LUX

NL

NOR

POL

PORESP

SWE

CHE

TUR

UK

LIT

BUL

y = 1,3643ln(x) - 4,1264R² = 0,5024

0,0

1,0

2,0

3,0

4,0

5,0

6,0

7,0

8,0

9,0

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Social Sustainability Index

Log. (Social Sustainability Index )

Source: Bertelsmann Stiftung: Sustainable Governance Indicatorshttp://www.sgi-network.org/2014/, OECD Health at a GlanceEurope 2014, own compilation

Social Sustainability Index and health expenditure per capita, 2012 (or nearest year), EUR PPP

MORE INCLUSIVE PREVENTIVE CARE AND BETTER INTEGRATION

POLICY IS NEEDED

12

Source: Bertelsmann Stiftung: Sustainable Governance Indicators http://www.sgi-network.org/2014/Austria/Social_Policies

-0.3 points between 2011-2014 in Eurrozone.

-+1 point between 2011-2014 in Austria

Performance in Social Policy areas, Austria compared t o Eurozone countries

MAIN CHALLENGES REMAIN: GOVERNANCE AND ACCOUNTABILITY

13

Sources of financing in % of current health expenditure, 2013 and growth since 2010 (pp-change over each bar)

Sources: Statistik Austria, own calculation

Social health insurance StateCost sharing/direct

paymentsPrivate health insurance

Non-profit organisationsand companies

Health=100 52,5 22,8 17,2 5,8 1,6Long-term care=100 0,6 80,6 18,2 0,0 0,6

+0.1

-1.1

+0.5

+0.3+0,20.0

-0.6

+1.0

-0.50

10

20

30

40

50

60

70

80

90

TARGETING “WASTE” IS IMPORTANT AS THE COST

DRIVER “AGING” IS ONLY PART OF THE FUTURE

CHALLENGE

14

0

1

2

3

4

5

6

Perc

ent o

f GD

P

Projected Increases in Public Health Spending, 2011 -2030Aging

Excess cost growth

Weighted average=3.0

Unweighted average=2.2

Quelle: IMF, FAD June 2011

SMART INVESTMENTS IN HEALTH EMPLOYMENT IS

CRUCIAL TO BETTER ACCOMMODATE FUTURE HEALTH

NEEDS AND TECHNOLOGICAL CHANGE

153%

4%

5%

6%

7%

8%

9%

10%

2000 2002 2004 2006 2008 2010 2012

AT

BE

DK

DE

FR

NL

SE

CH

EU15

Employment in health and social care per capita (2000-2013)

Sources: EUROSTAT, NACE rev. 1.1 and 2, own calculation 2014

TO JOINTLY ADDRESS CHALLENGES CLEVER POLICIES ARE REQUIRED FOCUSING

THOSE MOST IN NEED WHILE IMPROVING POLICY COORDINATION WITHIN HEALTH

AND ACROSS POLICY AREAS

Source: Daniel Kahnemann: Don’t Blink! The Hazards of Confidence, NYT Magazine, October 19, 2011

17

THANK YOU FOR YOUR ATTENTIONSelected Readings

� OECD (2014): Health at a Glance Europe , OECD Publishing.

http://ec.europa.eu/health/reports/docs/health_glance_2014_en.pdf

� OECD (2014): Social Expenditure Up-date, November 2 014: http://www.oecd.org/social/expenditure.htm

� Schraad-Tischler, D., Ch.Kroll (2014) Social Justice in the EU – A Cross-national Comparison Social Incl usion

Monitor Europe (SIM) – Index Report : http://www.sgi-

network.org/docs/2014/basics/Social_Justice_in_the_EU_2014.pdf

� GÖG (2015): Migration und Gesundheit:

http://www.goeg.at/cxdata/media/download/berichte/m igration_und_gesundheit_2015.pdf

� EC (2015): The 2015 Ageing Report Economic and budg etary projections for the 27 EU Member States (2010 -

2060): http://ec.europa.eu/economy_finance/publications/eu ropean_economy/2012/pdf/ee-2012-2_en.pdf

� Hofmarcher M.M. (2014) The Austrian health reform 2 013 is promising but requires continuous political

ambition, Health Policy, October 2014, Volume 118, Issue 1, Pages 8–13:

http://dx.doi.org/10.1016/j.healthpol.2014.09.001

� Hofmarcher M M, (2013) Austria: Health system revi ew. Health Systems in Transition, 2013; 15(7): 1–29 1,

http://www.euro.who.int/__data/assets/pdf_file/0017 /233414/HiT-Austria.pdf

� Gönenç, R., M. M. Hofmarcher and A. Wörgötter (2011), “Reforming Austria's Highly Regarded but Costly Hea lth

System”, OECD Economics Department Working Papers, N o. 895, OECD Publishing.

http://dx.doi.org/10.1787/5kg51mbntk7j-en

� OECD (2010), Health Care Systems: Efficiency and Po licy Settings, OECD Publishing.

http://dx.doi.org/10.1787/9789264094901-en