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.