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