Quality and CostQuality and CostInternational PerspectivesInternational Perspectives

Derek FeeleyDerek FeeleyDirector of Healthcare Policy and StrategyDirector of Healthcare Policy and Strategy

NHS ScotlandNHS Scotland

Health Care Spending per Capita in 2003Health Care Spending per Capita in 2003Adjusted for Differences in Cost of LivingAdjusted for Differences in Cost of Living

$1,886

$2,231$2,280$2,903$2,996$3,003

$5,635

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

United States Canada Germany Australia OECD Median United

K ingdom

New Zealanda

a

Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.

a2002

Percentage of Gross Domestic Product Spent Percentage of Gross Domestic Product Spent on Health Care in 2003on Health Care in 2003

7.7%

8.1%8.4%9.7%9.9%

11.1%

15.0%

0%

2%

4%

6%

8%

10%

12%

14%

16%

United States Germany Canada Australia OECD Median New Zealand United K ingdom

a

a

a2002 Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.

Health Care Expenditure per CapitaHealth Care Expenditure per Capitaby Source of Funding in 2003by Source of Funding in 2003

Adjusted for Differences in Cost of LivingAdjusted for Differences in Cost of Living

25032100 2343

1973 1768 18601484

2339

455341

341

94371

793

448 312590

793

296106

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

United States Canada Germany Australia OECD Median United

K ingdom

New Zealand

Out-of-Pocket Spending

Private Spending

Public Spending

a

a

a2002 Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.

Healthy life expectancyHealthy life expectancyWHO World Health Report 2006WHO World Health Report 2006

69.3

72

72.6

70.670.8

67

68

69

70

71

72

73

1

USA

Canada

Aus

UK

NZ

% of total life expectancy lost to % of total life expectancy lost to poor health (male and female)poor health (male and female)

WHO Report 2006WHO Report 2006

9.9

10.7

9.2

10.7

9

10.4

8.8

10.4

9.3

11.1

0

2

4

6

8

10

12

1 2

USA

Canada

Aus

UK

NZ

Infant Mortality Rates 2000Infant Mortality Rates 2000Source NCHSSource NCHS

6.9

5.3 5.2

5.7

6.3

0

1

2

3

4

5

6

7

8

1

USA

Canada

Aus

UK

NZ

Quality IndicatorsQuality IndicatorsSource OECD, Hussey et al 2004Source OECD, Hussey et al 2004

USAUSA CanadaCanada AusAus UKUK NZNZ

Survival Survival RatesRatesBreast Breast CancerCancer

11 44 22 55 33

Kidney Kidney TransplantTransplant

55 11 22 33 33

ProcessProcess

Cancer Cancer ScreeningScreening

33 22 11 44 55

Flu vaccineFlu vaccine 44 33 11 22 55WaitingWaiting

Elective Elective surgerysurgery

11 44 22 55 33

SafetySafety: : Medical Mistake, Medication Error, Medical Mistake, Medication Error, or Test Error in Past Two Yearsor Test Error in Past Two Years

Percent

2005 Commonwealth Fund International Health Policy Survey

2730

23 2522

34

0

25

50

AUS CAN GER NZ UK US

EffectivenessEffectiveness; ; Preventive CarePreventive Care

Percent received:Percent received: AUSAUS CANCAN NZNZ UKUK USUS

Pap in past 3 years, Pap in past 3 years, age 25-64age 25-64 7878 7777 8181 7777 8989

Mammogram in past Mammogram in past 3 years, age 50-643 years, age 50-64 8080 7979 8181 7777 8686

Flu shot in past year, Flu shot in past year, age 65+age 65+ 7777 6666 6767 7474 7272

2004 Commonwealth Fund International Health Policy Survey

TimelinessTimeliness; ; Access to Doctor When Access to Doctor When Sick or Need Medical AttentionSick or Need Medical Attention

54

7

27 25

60

2

41

13

33

19

0

25

50

75

Same day appointment Wait of 6 days or more

Percent

AUS CAN NZ UK US AUS CAN NZ UK US

2004 Commonwealth Fund International Health Policy Survey

Patient CenteredPatient Centered; ; Missed Missed Opportunities to Engage PatientOpportunities to Engage Patient

Percent saying doctor:*Percent saying doctor:* AUSAUS CANCAN NZNZ UKUK USUS

Does NOT give you clear Does NOT give you clear instructionsinstructions 1010 1212 88 1313 1313

Does NOT make goals and Does NOT make goals and plans clearplans clear 1414 1515 1313 1919 2020

Does NOT tell you about Does NOT tell you about treatment choices or ask treatment choices or ask your opinionsyour opinions

3535 3535 3030 5050 4444

*Doctor only sometimes, rarely or never

2004 Commonwealth Fund International Health Policy Survey

EfficiencyEfficiency; Coordination Problems by ; Coordination Problems by Number of DoctorsNumber of DoctorsPercent

2005 Commonwealth Fund International Health Policy Survey

15 1623

711

2227

31 30 3026

43

0

25

50

75

AUS CAN GER NZ UK US

1 doctor 4 or more doctors

* Either records/results did not reach doctors office in timefor appointment OR doctors ordered a duplicate medical test

* Inequity counted when significant difference between income groupswhere p .05 and gap of >5%; for U.S. p<.05 and gap>5%, or gap>5%.

GeneralGeneralaccessaccess

(4)(4)

AccessAccessbecausebecauseof costof cost

(4)(4)

CoordinationCoordination

(9)(9)

Doctor–Doctor–PatientPatient

(8)(8)

PreventionPrevention

(5)(5)

TotalTotal

(30)(30)

AUSAUS 00 33 11 00 00 44

CANCAN 00 44 11 00 00 55

NZNZ 00 44 11 33 00 88

UKUK 00 11 00 00 00 11

USUS 33 44 55 77 22 2121

Source: Commonwealth Fund 2004 International Health Policy Survey.

EquityEquity; ; Number of Measures Where Below Average Number of Measures Where Below Average Income Adults Have More Negative ExperiencesIncome Adults Have More Negative Experiences

Cost = Quality?Cost = Quality?

Limited to patient experience?Limited to patient experience?

Yes butYes but……..…….. Confirms earlier survey findings;Confirms earlier survey findings; In line with WHO and OECD indicators In line with WHO and OECD indicators

which show a similar mixed story;which show a similar mixed story; In line with findings at system and sub-In line with findings at system and sub-

system levels within countries.system levels within countries.

And so…..And so…..

No discernable relationship between No discernable relationship between quality and cost;quality and cost;

Comparable data hard to come by;Comparable data hard to come by; No one country has the answer – each No one country has the answer – each

has scope to learn;has scope to learn; Social as well as clinical factors at play;Social as well as clinical factors at play;

Questions and answersQuestions and answers

Is international comparison worth the Is international comparison worth the trouble?trouble?

• Useful in;Useful in;• Raising questionsRaising questions• Benchmarking best practiceBenchmarking best practice

Are we measuring the right things?Are we measuring the right things?• Current OECD 15 an important 1Current OECD 15 an important 1stst step - but step - but

• Measuring what can be measuredMeasuring what can be measured• Acute focussedAcute focussed• Fail to cover all dimensions of qualityFail to cover all dimensions of quality

Policy ImplicationsPolicy Implications

Many of the indicators to which patients Many of the indicators to which patients attach value require a different model of attach value require a different model of care;care;

New ways of delivering care will require a New ways of delivering care will require a new quality paradigmnew quality paradigm

We need to change what we measure We need to change what we measure We need a different mindset about the We need a different mindset about the

business case for quality (social as well as business case for quality (social as well as financial)financial)

Shifting the balance of careShifting the balance of care Current viewCurrent view Evolving model of careEvolving model of care

Emphasises acute careEmphasises acute care Emphasises long-term Emphasises long-term conditionsconditions

Hospital centredHospital centred Embedded in communitiesEmbedded in communities Doctor dependent Doctor dependent Team basedTeam based Episodic careEpisodic care Continuous careContinuous care Reactive careReactive care Preventative carePreventative care Patient as passive recipientPatient as passive recipient Patient as partnerPatient as partner Carers undervaluedCarers undervalued Carers supported as partnersCarers supported as partners Low techLow tech High techHigh tech

Implications for National health Implications for National health systems, quality and costssystems, quality and costs

Population health as well as healthcarePopulation health as well as healthcare Longitudinal measures rather than Longitudinal measures rather than

episodicepisodic Patient activationPatient activation Improved ICT requiredImproved ICT required Incentives required for;Incentives required for;

Whole system integrationWhole system integration Prevention Prevention

AcknowledgementAcknowledgement

Thanks to the Commonwealth Fund for access to Thanks to the Commonwealth Fund for access to the data from international surveys, including;the data from international surveys, including;

o Multinational Comparisons of Health Systems Data, 2005 (Frogner Multinational Comparisons of Health Systems Data, 2005 (Frogner and Anderson)and Anderson)

o The Commonwealth Fund 2005 International Health Policy Survey The Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults in Six Countries (Schoen, Osborn, Huynh, Doty, of Sicker Adults in Six Countries (Schoen, Osborn, Huynh, Doty, and Fenley)and Fenley)

o The Commonwealth Fund 2004 International Health Policy Survey The Commonwealth Fund 2004 International Health Policy Survey of Primary Care in Five Countries (Schoen and Osborn)of Primary Care in Five Countries (Schoen and Osborn)

The views expressed are my own and should not The views expressed are my own and should not be construed as representing CMWF. be construed as representing CMWF.

Coronary Bypass ProceduresCoronary Bypass Proceduresper 100,000 Population in 2003per 100,000 Population in 2003

181

98 9787 82

6556 53

41

0

25

50

75

100

125

150

175

200

United

States

Canada New

Zealand

Germany Australia OECD

Median

United

K ingdom

Netherlands Francea

b

a b

a2002b2001 Source: OECD Health Data 2005.

Spending on Physician Services per Capita in 2003Spending on Physician Services per Capita in 2003Adjusted for Differences in Cost of LivingAdjusted for Differences in Cost of Living

$287$304$363

$428$480

$553

$1,271

$0

$500

$1,000

$1,500

United

States

J apan Australia OECD

Median

France Germany Canadaa

a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.