health care in europe – an overview...2007/01/15 · health care system universal coverage;...

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Reinhard Busse, Prof. Dr. med. MPH FFPHDept. Health Care Management, Berlin University of Technology

(WHO Collaborating Centre for Health Systems Research and Management),Charité – University Medicine Berlin &

European Observatory on Health Systems and Policies

Health Care in Europe –An Overview

- 2 -Prof. Dr. Reinhard BussePotsdam, 15.1.2007

1. Actors and organisation: areBismarck´s and Beveridge´sgrandchildren look-alikes?

2. Financing3. Ensuring access and quality4. Services, costs and reimbursement5. Contribution to wealth/ productivity

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Third-party Payer

Population Providers


Third-party payer


Collector of resources

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Central government

Population Public providers

General taxation

Limited choice

Classical integrated NHS-type systems

NHS =payer &provider


Central government

Population Public providers

General taxation

Limited choice

Purchaser –provider

split

“NHS”

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Central government

Population Public “autonomous”

providers

General taxation

Limited choice


split

“NHS”


Central government

Population Limitedmore choice

(money follows patient)


splitGeneral

taxation

Public “autonomous”providers

“NHS”

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Central Regional governments

Population


splitGeneral

taxation

Limitedmore choice

Public “autonomous”providers

“NHS”


Regional governments

Population Limitedmore choice


splitGeneral

taxation

Public “autonomous”and privateproviders

“NHS”

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Sickness funds

Population Choice


split

SHI contributions


Social Health Insurance (SHI) systems


Sickness funds

Population Choice


split

SHI contributions


Social Health Insurance (SHI) systems

Observation 1:Basic configuration of actors

is now similaracross EU member states.htt

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Third-party Payer


Taxes

Social HealthInsurance

contributions

Voluntary insurance

Out-of-pocket

prepaid

Third-party Payer


Taxes


contributions

Voluntary insurance

Out-of-pocket

EU-15

18%

public

12 new EU members

26%

5% 2%

75%

71%

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Third-party Payer


Taxes


contributions

Voluntary insurance

Out-of-pocket

USA

18%

public

26%

5% 2%

75%

71%

45%

37%

14%

Third-party Payer


Taxes


contributions

Voluntary insurance

Out-of-pocket

CIS (ex-Soviet Union)

18%

public

26%

5% 2%

75%

71%

45%

37%

14%

46%

1%

50%

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Third-party Payer


Taxes


contributions

Voluntary insurance

Out-of-pocket

South-East Asia

18%

public

26%

5% 2%

75%

71%

45%

37%

14%

46%

1%

50%

53%

1%

40%

Third-party Payer


Taxes


contributions

Voluntary insurance

Out-of-pocket

America (without USA)

18%

public

26%

5% 2%

75%

71%

45%

37%

14%

46%

1%

50%

53%

1%

40%

56%

9%

35%

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0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

1998 1999 2000 2001 2002 2003 2004 2005 2006

AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited Kingdom

Total health expenditure as % of gross domestic product (GDP), WHO estimates

South-EastAsia

Africa

CISW

est. PacificA

merica

USA

East. Mediteranean

EU-15

12 newEU

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

1998 1999 2000 2001 2002 2003 2004 2005 2006


Total health expenditure as % of gross domestic product (GDP), WHO estimates

South-EastAsia

Africa

CISW

est. PacificA

merica

USA

East. Mediteranean

EU-15

12 newEU

Observation 2:There is a distinct European way

of financing health care.

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Health careoutcome:

satisfaction, complica-tions etc.Structures

and organisation

Patients: demand, access

Process

Population healthstatus(need)

Health gain/

Outcome

Other sectors

Nutrition/ agriculture

Environment

Health care system

Fair and sustainable funding?

Needs-basedaccess?

Personnel well qualified?Institutions of high standards?

Technologies effective?

High-qualityresults?

Patients receivingappropriate services?

How much?Is it worth it?

Human resources

Techno-logies

Financial resources

Health careoutcome:


and organisation


Process


Healthgain/

Outcome

Other sectors


Environment

Health care system

Universalcoverage;

cost-sharinglimits

Professional (re-)certificationProvider (re-)accredition

Health Technology AssessmentConcentration of services

“Do the thing right“:Benchmarking/

league tables; registers

“Do the right thing“: ex ante Guidelines/ diseasemanagement programmes/ reminders; ex post Review

Human resources

Techno-logies

Financial resources

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Health careoutcome:


and organisation


Process


Healthgain/

Outcome

Other sectors


Environment

Health care system

Universalcoverage;

cost-sharinglimits

Professional (re-)certificationProvider (re-)accredition

Health Technology AssessmentConcentration of services

“Do the thing right“:Benchmarking/

league tables; registers

“Do the right thing“: ex ante Guidelines/ diseasemanagement programmes/ reminders; ex post Review

Human resources

Techno-logies

Financial resources

Observation 3:EU health care systems

face the same challengesand are choosing

very similar answers.

0

2000

4000

6000

8000

10000

12000

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Total cost (Euros)

Rei

mbu

rsem

ent (

Euro

s)

DenmarkEnglandFranceGermanyHungaryItalyNetherlandsPolandSpain

Unpublished data from HealthBASKET project (presentation: conference Berlin, 22.2.07)

Costs and reimbursement ofEuropean hospitals: hip replacement

Data embargoed until February 22

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0

1000

2000

3000

4000

5000

6000

7000

8000

0 2000 4000 6000 8000 10000 12000 14000 16000

Total cost (Euros)

Rei

mbu

rsem

ent (

Euro

s)



Costs and reimbursement ofEuropean hospitals: stroke

Data embargoed until February 22


0

1000

2000

3000

4000

5000

6000

7000

8000

0 2000 4000 6000 8000 10000 12000 14000 16000

Total cost (Euros)

Rei

mbu

rsem

ent (

Euro

s)



Costs and reimbursement ofEuropean hospitals: stroke

Observation 4:Actual treatment and costs differ

in the EU - but mainly within,not systematically between countries.

Why do countries pretendthey need their own

specific reimbursement systems?htt

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65

70

75

80

85

1976 1986 1996 2006 2016


Life expectancy at birth, in years

Life expectancy is visibly rising …

England& Wales

USA France Japan Italy Sweden Nether-lands

Spain

Time analysed 1956-1978 1969-84 1975-90 Age groups included 5-64 y. 0-74 y. 5-64 y. Share “medically amenable/ avoidable“ mortality of total mortality (cross-sectional analysis) 1956 17.3% 15.8% 15.3% 33.3% 19.7% 15.8% 1969 18.4% 1975/ 78 9.6% 6.3% 7.4% 19.6% 11.3% 7.1% 15.5% 1984 11.7% 1990 7.5% Change in mortality per year (longitudinal analysis) „Medically amenable“ mortality

-3.2% -3.6% -4.5% -5.6% -3.8% -4.2% -4.5% -6.5%

Other mortality -0.2% -0.4% -1.0% -2.5% -0.8% -0.1% -1.1% -1.2% Total mortality -0.6% -0.9% -1.4% -3.4% -1.3% -0.6% -1.6% -1.8% Share of “medically amenable“ mortality of change in total mortality 71% 59% 38% 46% 45% 78% 43% 41%

Busse 1998

Today we know that health care does improve health …

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Treatable Mortality: Men

0 50 100 150 200 250

SwedenNetherlands

FranceSpain

ItalyUK

GermanyIreland

FinlandAustria

SloveniaLithuaniaPortugal

PolandCzech Republic

EstoniaLatvia

HungaryBulgaria

Romania

Deaths/ 100 000 population

1990/912000/01/02

Treatable Mortality: Women

0 50 100 150 200 250

FranceSweden

SpainNetherlands

ItalyFinland

GermanyAustria Ireland

UKSloveniaPortugal

LithuaniaPoland

Czech RepublicEstonia

LatviaHungaryBulgaria

Romania

Deaths/ 100 000

1990/012000/01/02

Age-standardised death rates of treatable mortalityin 20 EU member states, 1990/91 and 2000/02

Newey, Nolte, McKee & Mossialos 2004


Rethinking investment in health: A virtuous cycle?

Suhrcke M, McKee M, Sauto Arce R, Tsolva S, Mortensen J.The Contribution of Health to the Economy in the European Union. Brussels: European Commission, 2005.

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The return on investment

47%

$996

$676

$3,302

$5,200

France

274%

$1,478

$395

$4,732

$4,810

Sweden

229%

$1,325

$403

$4,992

$5,420

Italy

252%

$1,780

$506

$4,498

$5,180

Spain

148%Return on health expenditure

$1,561Increase in health income

attributable to health care

$630Increase in health

expenditure

$4,108Increase in total health

income

$6,000Increase in GDP per capita

UK

3 4 5 6 7 8 9 10 11 1265

70

75

80

85AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited Kingdom

Y = 1.79X+61.97Y

X

X - Total health expenditure as % of gross domestic product (GDP), WHO estimates, 2002Y - Life expectancy at birth, in years, Last available

SpainFranceItaly

UK

Swe-den

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200 300 400 500 600 700 800 900 100065

70

75

80


Y = -0.01577X+82.55Y

X

X - Acute care hospital beds per 100000, 2002Y - Life expectancy at birth, in years, Last available

Don`t say: “the more – the better“ is always true:acute hospital beds/ capita vs. life expectancy

3 4 5 6 7 8 9 10 11 1265

70

75

80


Y = 1.79X+61.97Y

X


SpainFranceItaly

UK

Swe-den

EstoniaSlovakia

Romania

Back to spending vs. life expectancy …

Observation 5: If health care increaseswealth, then it is in our common EUinterest that low-spending countries

increase their health expenditure.

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3 4 5 6 7 8 9 10 11 1265

70

75

80


Y = 1.79X+61.97Y

X


Hungary

Germany

Bulgaria

Latvia


This presentation and more material can befound on the following websites:

http://mig.tu-berlin.de

www.observatory.dkhttp:/

/mig.

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health care in europe – an overview...2007/01/15 · health care system universal coverage;...

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