Dr Paul GARASSUS President UEHP

Transcription

1 Sustainable Healthcare EU-HCWM Final Meeting Birmingham November, Dr Paul GARASSUS President UEHP President Scientific Council, BAQIMEHP 106 rue d Amsterdam, Paris, France General secretary, French Health Economics Society SFES

2 The Eco" Twins in Sustainability Ecology and Economics, and the missing link Ecology Economics Environmental question Benchmark Competition Respect of resources : Energy, Air, Purchasing with Budgets Water Healthcare modernization A selective implication on hospital Waste More care, less hospitals management News technologies: who pays for? Personal implication by professionals on common goal Actual and irreversible trends on ecology policy Life-cycle conception Provider organisation According to public healthcare policy in European Social Model including budget constraints The common link : long term investment a whole life-cycle cost model

3 Sustainable design for health by Rosemary Glanville, Phil Nedin in Investing in hospitals of the future. Bernd Rechel, Stephen Wright, Nigel Edwards, Barrie Dowdeswell, Martin McKee. Ch.12, pp World Health Organization 2009, on behalf of the European Observatory on Health Systems and Policies HEALTH AND EUROPEAN INTEGRATION: PART OF THE PROBLEM OR PART OF THE SOLUTION? Helmut Brand and Willy Palm - Eurohealth 2014; 20(3). A sustainable approach requires that selections be based on a whole life-cycle cost model. There appears to be little doubt that there will be an increase in the initial capital cost of a project when developing it as a sustainable model. However, these additional costs can be offset over the life of the facility. Achieving a sustainable design can typically add 6 12% to overall capital costs The goal must be to create a sustainable facility that is capable of being adapted to changing circumstances and which provides a healing or therapeutic environment, with decisions based on an understanding of costs over the whole life of the facility and not just the construction phase. This is inevitably challenging, as the future is intrinsically unpredictable. Health protection is also considered to be intrinsically part of the so-called European social model Angela Merkel, reminded us that in the EU, with 7% of the world s population, we generate 25% of the world s economy but also spend nearly 50% of all social benefits in the world. The main question was the effects of the crisis for health, the focus turned to how health systems can be made resilient and innovative

4 Umwelt und Nachhaltigkeit Rhön-Klinikum Geschäftbericht 2013, Seite 56 Unsere Erfahrung zeigt : ökonomische und ökologische Ziele lassen sich oft mit denselben Mitteln erreichen. Neurologische Klinik Bad Neustadt (Rhoen Klinikum)

5 Gruppo San Donato (Italia) e comportamenti ecologicamente responsabili

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7 Elements of sustainable, highquality and fair models for European healthcare systems Thought provoking experts : A Top-down reform. Is there a best structure for healthcare systems? Can different stakeholders agree on common goals? What needs to change now to move towards an improved system? Pascal Garel, Chief Executive, European Hospital and Healthcare Foundation (HOPE) Jaak Peeters, Chairman, EMEA, Janssen Joanna Groves, Chief Executive Officer, International Alliance of Patients Organizations. Birgit Beger, Secretary General, Standing Committee of European Doctors Financing: who pays? Should the private sector bear more of the cost of healthcare and be more involved with the modernisation of the public sector? Should the individual be prepared to shoulder a higher cost of healthcare? Guillem López Casanovas, President, International Health Economics Association; Member of the Board, Central Bank of Spain and Professor of Applied Economics and Dean, Universidad Pompeu Fabra. Paul Garassus, Vice-president, French Health Economic Society and Member of the Board, European Union of Private Hospitals (UEHP). Josep Figueras, Director, European Observatory on Health Systems and Policies and Head, WHO European Centre on Health Policy

8 About the Expert Panel on effective ways of investing in Health (EXPH) Sound and timely scientific advice is an essential requirement for the Commission to pursue modern, responsive and sustainable health systems. To this end, the Commission has set up a multidisciplinary and independent Expert Panel which provides advice on effective ways of investing in health (Commission Decision 2012/C 198/06). The core element of the Expert Panel s mission is to provide the Commission with sound and independent advice in the form of opinions in response to questions (mandates) submitted by the Commission on matters related to health care modernisation, responsiveness, and sustainability. The advice does not bind the Commission. The areas of competence of the Expert Panel include, and are not limited to, primary care, hospital care, pharmaceuticals, research and development, prevention and promotion, links with the social protection sector, cross-border issues, system financing, information systems and patient registers, health inequalities, etc. Expert Panel members Pedro Barros, Margaret Barry, Helmut Brand, Werner Brouwer, Jan De Maeseneer (Chair), Bengt Jönsson (Vice-Chair), Fernando Lamata, Lasse Lehtonen, Dorjan Marušič, Martin McKee, Walter Ricciardi, Sarah Thomson

9 Symbiosis Reciprocal Rewards Stabilize Cooperation in the Mycorrhizal. E. Toby Kiers et al. Science, 333, 880 (2011) Plants and their arbuscular mycorrhizal fungal symbionts interact in complex underground networks involving multiple partners. This increases the potential for exploitation and defection by individuals, raising the question of how partners maintain a fair, two-way transfer of resources. We manipulated cooperation in plants and fungal partners to show that plants can detect, discriminate, and reward the best fungal partners with more carbohydrates. In turn, their fungal partners enforce cooperation by increasing nutrient transfer only to those roots providing more carbohydrates. control is bidirectional, and partners offering the best rate of exchange are rewarded. An alternative explanation for the stability of the plant-mycorrhizal mutualism is that both plants and fungi are able to detect variation in the resources supplied by their partners, allowing them to adjust their own resource allocation accordingly. On the basis of these observations we conclude that, unlike many other mutualisms, the symbiont cannot be enslaved. Rather, the mutualism is evolutionarily stable because

10 What kind of performance measurements are needed to make an impact on policy-making? By Liisa-Maria Voipio-Pulkki, Director health Care Group, Minister of Health Finland (Gastein Forum 2014) The WHO Health System Framework System Building Blocks Overall Goals / Outcomes Service delivery Health Workforce Access Coverage Improved Health (level and equity) Responsiveness Medical Products, Vaccines & Technologies Social & Financial Risk Protection Financing Leadership Governance Quality Safety Improved Efficiency

11 Recent Publication in Parliament Magazine Smart Hospitals by UEHP

12 Key words for a smart hospital* Three major causes for changes : public health program, healthcare systems sustainability, and more over technology innovation (* Pr. François Langevin, EHESP Rennes France) Complexity of healthcare imposes cooperation for action and payment Hospital downsizing, development of ambulatory care (and units) Coordination of actors, the role of competition for an efficient development, changes in prospective payment reforms including quality indicators and incentives, e-health New generation of informed patient, empowered and / but ageing Free access in an open Europe : inequalities to be reduced west to east, north to south Big data, predictive medicine, NCD and chronic disease = link to diagnostics experts New generation of physicians (and care givers) Innovation is expensive (pharmaceuticals, treatments, diagnostics), and states budgets are limited : more value for money in a sustainable system Economic constraints for policy makers : a new social contract to rationalize the system of an historic European social model. Regulatory policy and behavioural economics can help (Pete Lunn, OECD library 2014) The private sector combines a positive attitude towards innovation with a strong managerial efficiency

13 Healthcare Expenditures per capita in USD A 20 years survey (data World Bank) $10, Healthcare Expenditures per capita in USD $9, $8, $7, $6, $5, $4, $3, $2, $1, $ European Union United States World

14 Growth rate in per person healthcare expenditure at zero in OECD EU countries in 2013

15 Growth rates of health spending for selected functions per capita, OECD average, More value for money : is the money following the patient or the structure payment? How to link prevention, treatment and follow-up in a coordinated providers action? In the next future, challenge is the share of activity and expenditure between outpatient and inpatient Average annual growth rates in real terms % 6% 5.9% 5.6% 5% 4% 3.9% 3.8% 3% 2% 2.4% 1.7% 2.7% 1.9% 1% 0.7% 0.8% 0% -1% -0.3% -2% -1.8% -3% Inpatient care Outpatient care Long-term care Pharmaceuticals Prevention Administration

16 Health expenditure per capita USD PPP, 2013 (or nearest year) OECD , ,325 5,862 5,131 4,904 4,819 4,553 4,553 4,371 4,351 4,256 4,124 3,866 3,713 Total Private Residual Public 3,677 3,663 3,453 3,442 3,328 3,235 3,077 2,898 2,514 2,511 2,428 2,366 2,275 2,040 2,010 1,719 1,653 1,606 1,573 1,542 1,530 1,471 1,380 1,216 1,121 1,

17 Expenditure on health by type of financing, 2013 (or nearest year) - OECD 2015 % of current health expenditure Other Private insurance Private out-of-pocket Social security General government

18 Growth of health spending by financing, OECD average, OECD General government/ Social security Private out-ofpocket Private insurance Annual growth rates per capita in real terms (%)

19 Current health expenditure by function of health care, 2013 (or nearest year) OECD 2015 % Collective services Medical goods Long-term care Outpatient care** Inpatient care*

20 Hospital beds by function of health care, 2010 (or nearest year) Health at a Glance: Europe OECD 2012 EU acute care beds mean value = 69% 100% Other hospital beds Long-term care beds Psychiatric care beds Curative care beds 80% 60% 40% 20% % Germany Austria Hungary Czech Republic Lithuania Poland Bulgaria Belgium France Slovak Republic Romania Finland Luxembourg Estonia Latvia EU-27 Greece Netherlands Slovenia Malta Cyprus Italy Denmark Portugal Spain Ireland United Kingdom Sweden Croatia Switzerland FYR of Macedonia Norway Turkey

21 UEHP Private Hospitals in EU28 In contract with public insurance, stays according to authorized status by national government Certified in all Member States by Quality Agencies Access to all citizens, tariffs determined by national authorities and paid by Social Insurance according to DRG tariff 20% of total European beds, from 0 to 50% in Member States (2014)

22 Milano UEHP Congress, September 2015

23 Complexity and sustainability Pr. Gabriele Pelissero, University of Pavia and AIOP Italy The inherent complexity of healthcare is related with the difficulties all healthcare systems experience in being truly sustainable. Since the 60s-70s, healthcare has reached its industrial stage. Innovation has became pervasive: pharmaceuticals, treatments, diagnostics. Innovation is expensive, and states budgets are shrinking due to the high costs of the European social model. With state budgets shrinking and a shrinking demography, public debt is no longer an option to sustain the welfare systems. The private sector combines a positive attitude towards innovation with a strong managerial efficiency. Its role can be in helping to rationalize the system: well-advised approach to innovative cures, best management capabilities.

24 Evolution of French Private Acute Care Hospitals No direct influence of financial crisis Acute For Inpatient Day care Dialysis center Total Discharges Public % Private % ,30% ,70% ,24% ,76% ,76% ,24% ,71% ,29%

25 Surgery Stays in France, Data Baqimehp 2015 France Surgery Stays ALOS Complete Hospitalisation Day Care Year PUB PRIV % PUB % PRIV PUB PRIV % PUB % PRIV Alos PUB Alos PRIV % PUB % PRIV % 55% 6,2 3,9 48% 52% 7,5 5,3 34% 66% % 58% 5,9 3,7 45% 55% 7,3 5,2 32% 68% % 56% 5,9 3,9 47% 53% 7,1 5,3 33% 67% % 59% 5,8 3,6 44% 56% 7,2 5,1 31% 69% % 60% 6,1 3,5 44% 56% 7,7 5,1 29% 71% % 61% 6,0 3,4 44% 56% 7,6 5,1 28% 72% % 61% 5,9 3,2 44% 56% 7,5 5,0 28% 72% % 60% 5,5 3,0 46% 54% 8,2 5,8 33% 67% % 61% 5,9 3,0 47% 53% 8,2 5,6 29% 71% % 60% 5,8 2,8 48% 52% 8,1 5,5 29% 71% % 59% 5,7 2,9 49% 51% 8,1 5,5 31% 69% % 58% 5,5 2,8 50% 50% 8,1 5,5 32% 68% % 57% 5,3 2,7 50% 50% 7,1 4,7 29% 71% % 57% 5,2 2,6 51% 49% 7,0 4,7 30% 70% % 57% 5,0 2,4 51% 49% 6,9 4,6 30% 70% % 56% 4,9 2,3 52% 48% 6,9 4,5 31% 69% % 56% 4,8 2,1 52% 48% 6,9 4,5 32% 68%

26 Hospital Evolution in Germany Öffentliche Freigemein-nützige Private Sonstige

27 Privately Owned Hospitals 2015 (Germany, by BDPK) RWI, Boris Augursky, Adam Pilny, Ansgar Wübker Balance sheet Private Non Profit Municipal Equity ratio 33,1 30,7 22,7 EBITDA including KHG Funds 11,2 6,7 5,3 EBITDA exlcuding KHG Funds 10,0 4,0 2,1 Return on revenue (after Tax) 4,2 1,2-0,8 Return on total capital % 5,2 1,9 0,0 Taxes / Incomes % 0,9 0,1 0,1 Taxes, m 137,0 31,0 44,0 Investments in general hospitals Private Non Profit Municipal Investments / total revenues % 6,3 5,3 6,1 fixed assets currently versus cost of acquisition and production % 68,6 49,4 50,0 Investments per bed, in

28 Of course, big ideas are fine but implementation is the true challenge! Dr Antonio Duran. Technical Advisor, European Observatory on Health Systems and Policies Engage with stakeholders (especially with doctors) Strengthen governance (make the necessary new arrangements) Manage change (change organizational culture/ build institutional capacity) Papanicolas I, Smith PC and Mossialos E (2008) Principles of performance measurement. Euro Observer, Spring 2008, Volume 10, Number 1, pp. 1 4 Agent Information needs Data requirements Monitoring of regulatory & financing Information on performance at national & international Government procedures; information collection; reg. levels; access & equity; service utilization, waiting times. effectiveness and efficiency. Regulators Purchaser organizations Provider organizations Protecting patients safety and welfare; ensuring that market is functioning efficiently. Timely, reliable & continuous info on patient safety and welfare. Ensuring contracts they offer their patients Info on patient experiences and patient satisfaction; provider are in line with objectives their patients and performance; cost-effectiveness of treatments. payers expect. Monitoring & improving existing services; assessing local needs. Aggregate clinical performance data;information on patient experiences & satisfaction; access & equity of care Doctors Patients To stay up to date with current practice; to be able to improve performance Ability to choose provider when in need; assurance of good emergency care. Information on current practice &best practice; comparative performance. Information on location and quality of nearby emergency health services; quality of options for elective care.

29 Competition among providers EXPERT PANEL ON EFFECTIVE WAYS OF INVESTING IN HEALTH (EXPH) European Commission The European Union of Private Hospitals (UEHP) welcomes with satisfaction the preliminary opinion on competition among health care providers, through a comparative study of the reforms implemented in a few health systems. From this investigation about policy options undertaken by the EC Panel of expert follows that EU countries efforts to introduce competition have not always achieved the expected results. Nevertheless, we would like to draw the experts attention on the issue concerning the results of the regulatory reforms introduced to increase competition, often through the creation of quasi markets or welfare markets in the healthcare field, underlining that the attempts at active competition in healthcare markets have often been weakened, if not reversing the policy trends at theoretical level, at least not adequately implementing them. Same question in the EUROFOUND working group

30 Two main topics Payment reform to achieve better health care Health Affairs, September 2012, vol.31, N 9 Getting control of Big Data Harvard Business Review, October 2012

31 Lecture Data Science for Business What you need to know about data mining and data-analytic thinking Foster Provost & Tom Fawcett. O Reilly 2013 The signal and the noise The art and science of prediction Nate Silver Penguin Books 2013 Superforcasting The art of science and prediction Philipp E. Tetlock and Dan Gardner - Crown Publisher NY 2015 Misbehaving The making of behavioral economics Richard H. Thaler Norton & Company 2015 The black swan The impact of highly improbable Nassim Nicholas Taleb 2007 Valuing life Humanizing the regulatory state Cass R. Sunstein. The University of Chicago Press 2014

32 Valuing life Humanizing the regulatory state Cass R. Sunstein. The University of Chicago Press 2014 When regulators fail, it is often because they fall prey to one of two problems: hysteria or neglect. Moral judgements that are most sensible can steer us in bad directions when we are investigating regulatory issues. (page 8) Valuing life 1 & 2. Are there easy cases? Consider the idea of prioritarism, insisting that public officials should give special priority to those who rare least well-off. The points bear on significant debates about how to value life debates that are likely to become increasingly important in the next decades.