Health care models in the world: facing a discussion on the health system efficiency
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(2) 279. Studies & Proceedings of Polish Association for Knowledge Management No. 39, 2011. 2. Health system’s performance A system is defined as a group or combination of interrelated, interdependent or interacting elements forming a collective entity. A health system is therefore an integrity composed of the subsystems, organizations and institutions. The objective of the national health systems’ performance assessment (1) is to provide governments, health authorities and populations with appropriate information about the state of their health care. The question is the extent to which the performance of individual elements contributes to the general performance of the system. Differences in the design, content and management of health systems translate into differences in a range of socially valued outcomes such as health, responsiveness or fairness. Decision-makers at all levels need to quantify the variation in health system performance, identify factors that influence it and ultimately articulate policies that will achieve better results in a variety of settings. Without a systematic method of summarizing performance along all the dimensions it is not possible to assess whether unusually bad performance of one indicator is due to poor decision making or whether it is explained by the organization having an unusually good performance on some other dimension. Assessing how well a health system functions requires dealing with two large questions. The first is how to measure the outcomes of interest – that is, to determine what is achieved with respect to the three objectives of good health, responsiveness and fair financial contribution (attainment). The second is how to compare those attainments with what the system should be able to accomplish – that is, the best that could be achieved with the same resources (performance) (2). The assessment of relative performance should include how well a country is doing on controlling the level of non-health system determinants to the scope that a good health system can influence the level of these determinants through effective intersectoral action (1). To improve performance, decision-makers need to be able to measure the extent to which the systems contribute to the desired outcomes, identify factors that influence attainment, and develop policies that will achieve better results. Meaningful, comparable information on health system performance and the key factors that explain observed variations can strengthen the scientific foundations of health policy, but this requires a consistent framework, which defines what systems should seek to achieve, and how to measure attainment (3). 3. Health system’s efficiency in light of the performance construct The rising demand for health care together with the scarcity of resources, have led the policy and decision makers into the question of system performance and its efficiency. This issue is currently highly debated worldwide. The WHO (4) overall system performance rating is an efficiency measure, which compares how short each country’s actual overall health system performance fell of the ideal maximum level it ought to have attained if the system operated efficiently, given its health spending and educational attainment. Efficiency is defined as a ratio of the observed level of attainment of a goal to the maximum that could have been achieved with the observed resources. In order to measure the contribution of the health system we have to determine what it achieves in excess of what would be achieved in its absence (the minimum) (5)..
(3) 280 Nina Szczygiel, Malgorzata Rutkowska-Podolowska Health care models in the world: facing a discussion on the health system efficiency. Table 1: Diversity of health care efficiency definitions Entity IOM Palmers&Torgerson 1999 Economic theory Economic theory Economic theory AQA. GAO. MedPAC. Definition Avoiding waste, including waste of equipment, supplies, ideas and energy Health care resources are being used to get the best value for money Technical efficiency means that the same level of the output cannot be produced with fewer of the inputs Productive efficiency refers to the maximization of output for a given cost, or minimization of cost for a given output Social (or Pareto) efficiency exists when no one can be made better off without making someone else worse off A measure of the relationship of the cost of care associated with a specific level of performance measured with respect to the other five IOM aims of quality Providing or ordering a level of services that is sufficient to meet patients’ health care needs, but not excessive, given a patient’s health status Using fewer inputs to get the same or better outcomes. Efficiency combines concepts of resource use and quality. Source: McGlynn, EA. Identifying, Categorizing, and Evaluating Health Care Efficiency Measures. Final Report (prepared by the Southern California Evidence-based Practice CenterRAND Corporation, under Contract No. 282-00-0005-21). AHRQ Publication No. 080030. Rockville, MD: Agency for Healthcare Research and Quality. April 2008. Definitions of efficiency vary greatly depending on perspective. The perception will depend on a position of various stakeholders in the demand/offer relation: health services providers and receivers. Efficiency is thus perceived differently by health providers, consumers and payers as they have different view on what comprises quality and what is a fair cost. In health, measuring efficiency is complicated due to multidimensional nature of health and complexity of health services. Table 1 presents the multiplicity of perspectives of efficiency. A proper definition of efficiency brings the attention to the outputs which are here understood as outcomes: outcomes in health and outcomes as services. Health care efficiency is then assessed in terms of outcomes achieved instead of outputs produced. A number of measures incorporating various aspects of health outcomes have been developed and is applied to evaluate the impact of health policies among time. Efficiency evaluation is an important component of the system’s performance. Efficiency is just one of the dimensions of the compound concept of the performance together with health improvement, fair access, effective delivery of appropriate health care, patient/caregiver experience, health outcomes (6). Both terms are, nonetheless, frequently used as synonyms (5). The WHO (2) equates the performance of national health sectors to how well the countries pursue the service goals of achieving efficiency, responding to health needs, and averting severe personal financial losses due to ill health. Handler et al. (7) developed a conceptual framework to measure the public health system performance in which efficiency is put together with effectiveness and equity and determine the overall system’s performance. Little is known about the range of methods.
(4) 281. Studies & Proceedings of Polish Association for Knowledge Management No. 39, 2011. that exist to measure efficiency and how well available efficiency metrics capture the constructs of interest. It is, however, crucial to distinguish conceptual and methodological issues behind the constructs in use as they may require different techniques. Precision in a way the term is being used is helpful in advancing the dialogue among stakeholders. On the other hand, some degree of allocative inefficiency is inevitable in any health care system, since by shielding consumers from the full cost of medical care, it leads them to consume care whose cost is less than their benefit (8). The concept of productivity and efficiency as a complement to pure economic measures of performance is widely accepted in practice. Productivity, commonly expressed as a mere ratio between outputs produced and inputs consumed, is perceived as an easily interpretable measure of operational performance. Efficiency denotes the relative productivity measurement resulting from a comparison with some reference, other comparable units and/or historical values (9). Efficiency is a term relative to productivity but not identical. Efficiency is productivity adjusted for the impact of environmental factors on performance. 4. Types of efficiency In economics, people usually distinguish different concepts of efficiency: technical efficiency – when the production is organized to minimize the inputs required for a given output; costeffectiveness efficiency – when a cost of producing a given output is minimized; and allocative efficiency – obtained when resources are allocated so as to produce the optimal level of each output according to the values that society places on them (10). The achievement of technical efficiency is beneficial to objectives such as a control of health expenditures, which has been one of the main worries in many developed countries. Any gain in technical efficiency allows for treating an increasing number of patients giving effectiveness to the principle of universality of service, which can be regarded as a founding principle of many National Health Systems (11). Good management maximizes the efficiency of human and other assets necessary to reach organizational goals (12). In comparisons of health programs or care procedures, technical efficiency is referred to as cost-effectiveness. This typology is not the only one (compare scheme 1)..
(5) 282 Nina Szczygiel, Malgorzata Rutkowska-Podolowska Health care models in the world: facing a discussion on the health system efficiency. Scheme 1. A typology of efficiency in health care Source: Academy Health Efficiency in Health Care. What Does it Mean? How is it Measured? How Can it be Used for Value-Based Purchasing? Highlights from a National Conference. 23–24 May 2006. Madison, Wisconsin. Different approaches used in different systems often make comparisons of the health sector efficiency impossible. The measurement depends on the methodological approach adopted and availability of data. Recently, discussions on the scientific value and robustness of existing features have been raised. There is surely a door to create uniform, standardized and adjusted measures which would allow for health systems’ comparisons. Little is also known on the impact of published measures for the further policy and consumer choices. 5. Efficiency, efficacy or effectiveness? The terms “efficiency” is sometimes used, incorrectly, as a synonym to efficacy and effectiveness. Efficacy is the ability to achieve a given goal. Contrary to efficiency, the focus of efficacy is to reach a pre-defined target as such, not the resources spent in achieving that effect. Thus, what is effective is not necessarily efficacious, and what is efficacious may not be, necessarily, efficient. Effectiveness (25) is the relationship between the level of resources invested and the level of.
(6) 283. Studies & Proceedings of Polish Association for Knowledge Management No. 39, 2011. results, or improvements in health. Assessing effectiveness consists of measuring the effects of medical practices and techniques (therapeutic, diagnostic, surgical and pharmacological) on individuals' health and wellbeing. This must take into consideration not only observed improvements in health but also negative impacts, such as side effects and iatrogenic effects. The economic dimension of effectiveness introduces the concept of cost, and thus refers to costeffectiveness and cost reduction. The purpose of efficiency is to maximize results effectively, or services delivered, given a particular budget. According to this concept, each service must be delivered at the lowest possible cost, have benefits of value equal to or greater than its cost, and make optimum use of the resources invested. Efficiency is distinct from effectiveness in that it considers costs’ reflection on benefits. 6. Health care models Above its ethical dimension, health is a substantial component of a country economic activity. Public health organizations are nowadays being challenged to increase the quality of care services while guaranteeing the sustainability of the system. This question inevitably leads to a discussion on how to organize the provision of health care at a country level and which health care model may be a premise to a success in the future. In light of an ongoing discussion of health systems efficiency, the attention is driven to the health care concepts on which health models are based. In Europe the health and social care systems are connected with the history, tradition and cultural aspects of a country, however, all of them have common features. Amongst them one can distinguish: • universalism – a concern about protection of all citizens against social dangers, or various incidents connected with every man’s life (illness, unemployment, physical inefficiency, oldness), • income redistribution degree – in the European Union countries 30% of income is spent on social protection, • diverseness from private insurances’ philosophies – the amount of compensation does not depend on the amount of a paid fee. Solidarity occurs here, which helps in facing the economic changes, occurring throughout last twenty years (instability in the area of employment, economic and social consequences of unemployment, life expectancy extension) (13). At present, four basic models are used in the health care: Bismarck’s model; Beveridge’s model and residual, called also the X, model. The Netherlands – Bismarck`s model The Dutch and German systems are based on the Bismarck`s model. Every region in Holland has its own system of medical services which create a so-called care net (clinics, care homes, psychiatry, paediatrics, etc). It is patients and their needs that decide how many doctors are needed on a given area (in a given region). The most important (central figure) in this system is the family doctor. A patient is referred to a specialist only with a written instruct from the family doctor. The information about issuing such an order is placed in the patient’s record (14). In the Netherlands, the health service must not be left ‘in the hands’ of the market, because it may cause a huge rise of the costs. However, at present, Holland cannot afford the support for.
(7) 284 Nina Szczygiel, Malgorzata Rutkowska-Podolowska Health care models in the world: facing a discussion on the health system efficiency. social care centres. The reorganization of the health service structure is also planned. Their aim is, among others, to keep senior citizens in their family homes as long as possible, supported by a nurse who would spend 20 hours per week with them. A group of the elderly who are in relatively good medical condition but unable to take care of themselves, would be directed to an intermediate sector of health care, and obliged to cover a part of the costs. Forcing the patients to bear some costs aims at making them realize how expensive the care actually is (15). Great Britain – Beveridge`s (NHS)-model The National Health Service (NHS), in Great Britain, is undergoing a crisis. There is a growing demand for the services of emergency ambulances, a rapid growth of administrative expenses, which in turn lead limiting the range of services provided by hospitals, postponing planned surgeries and purchases of equipment. The lack of resources may lead to the hospitals suspending the reception of patients, except for emergency situations. In 1993 the government launched the ‘private financing initiative’ of the health care. Doctors generally do not refer patients over 75 years of age or those who are seriously ill to hospital for expensive surgeries, e.g. artificial hip joint implants or dialysis and, therefore, about 14% of households in Britain have purchased health insurances in private companies becoming independent of the NHS services. In this situation, the government must increase the NHS budget considerably or introduce substantial economy cuts (16) (17) (18) (26). U.S. – the residual model, called Model X The United States has both the best and the worst health care. This paradox lies in the fact that the most scientific discoveries, the most Nobel Prize winners from the U.S., the most modern clinics and hospitals require considerably more financial resources than in other countries. On the other hand, on the free market health care does not work. In the United States the spending on health is of 4500 USD per capita per year. Most of it comes from voluntary private health insurance financed by employers. About 2/3 of Americans are in fact insured by employers. Nevertheless, employers are not obliged to insure their employees and there is no regulation regarding the scope of this insurance. Hence, many people are deprived of any health insurance (19). The U.S. spends more on health care than other wealthy nations – in 2006, health care expenditures were 15 percent of GDP in the U.S., compared to 11 percent in France and Germany, 10 percent in Canada, and 8 percent in the United Kingdom and Japan. Yet health outcomes in the U.S. are generally not better than those in other countries (8). The lack of full accessibility to health services and elevated costs have resulted in numerous discussions about reforming the health care system. Even Bill Clinton's government tried to introduce a universal healthcare program (federal health care system) (20). Finally, Barack Obama led to the introduction of compulsory health insurance. On 21 March 2010, the House of Representatives passed a bill the U.S. Congress to reform health care. President Obama signed the Act of 23 March 2010 (21). The new law brings an equal access to treatment for all citizens, and public insurance system to compete with private insurance companies (22). One of the compromises is to cover by insurance half of the current number of uninsured citizens until 2019. International experts have concluded that health systems using public funds to finance public service provision are more efficient than those which use public funds to subsidize private servic-.
(8) 285. Studies & Proceedings of Polish Association for Knowledge Management No. 39, 2011. es. There is a lot of data collected through a daily functioning of the health system. The question arises on how adequate and correct decisions can be taken by health organizations in light of a very limited feedback from the system reaching the proper decision making process. Few health systems work on the integration and collaboration basis and much is still to be done in terms of information and communication systems integration and information sharing between particular health care providers. Public health and social services organizations have found that cost-effective healthcare IT depends on using familiar tools that do not require a large amount of user training. This fact is especially true as organizations extend these tools to members of the general public, who increasingly demand more control over their health information but do not always have the digital skills to properly use that control (12). Countries today are at an early stage of implementation, integrating the different systems that clinicians use at the point of care to document clinical patient data. Consequently, policy makers, developers and managers have thus far been primarily concerned with addressing the many challenges associated with programme implementation (23). 7. Conclusions While significant achievements have been made in quality measurement over the last decades, scientific evidence on performance and efficiency measurement is still lagging behind. Current concerns of the health care are driving the attention into these aspects constituting a constant pressure to elaborate a framework of health systems and services efficiency assessment. Incorrectly constructed or applied measures can lead to involuntary negative consequences for health providers and patients (24). The following suggestions can be driven from our analysis: • The whole Europe and USA have problems with the constantly growing costs of health care. • Health services need an infusion of cash to cover the expenses. • Health systems’ problems with a lack of financial sustainability have to do with an increasing public expenditure on health. Inappropriate drugs prescribing and over-use of pharmaceuticals is a major source of inefficiency. • Nearly every country considers plans of the system reorganization or putting limits on the expenses on medical care, limiting expensive treatments as well as closing down some of institutions. However, real changes cannot happen unless they result from the developing of private competition on the market. • Incentives created to foster the quality of care aim at minimizing the cost per admission rather than minimizing the cost for the health system in treating the population over time. • As the number of elderly people increases over time, health spending naturally will grow what makes the need for reforms even more urgent. 8. Literature 1. Murray C.J.L., Frenk J. A framework for assessing the performance of health systems. Bulletin of the World Health Organization. 2000;78(6). 2. WHO. The World Health Report 2000. Health Systems: Improving Performance 2000. 3. Evans D.B., Tan-Torres Edejer T., Laurer J., Frenk J., Murray Ch.J.L. Measuring quality:.
(9) 286 Nina Szczygiel, Malgorzata Rutkowska-Podolowska Health care models in the world: facing a discussion on the health system efficiency. from the system to the provider. Int J Qual Health C. 2001;13(6):436–46. 4. Blendon B.J., Kim M., Benson J.M. The Public Versus The World Health Organization On Health System Performance. Health Affairs. 2001;20(3). 5. Evans D.B., Tandon A., Murray Ch.J.L., Lauer J.A. Comparative efficiency of national health systems: cross national econometric analysis. BMJ. 2001;323:307–10. 6. National Health Service. NHS performance indicators. National figures: February 2002: NHS; 2003. 7. Handler A., Issel M., Turnock B. A Conceptual Framework to Measure Performance of the Public Health System. American Journal of Public Health. 2001;91(8). 8. The National Bureau of Economic Research. The Relative (In)Efficiency of the U.S. Health Care System. 2010 [Accessed 30 October 2010]; Available from: http://www.nber.org/aginghealth/2008no3/w14257.html. 9. Agrell P.J., West B.M. A caveat on the measurement of productive efficiency. Int J Prod Econ. 2001;69(1):1–14. 10. Hurley J. An overview of the normative economics of the health sector. In: Culyer A.Y., J.P. N, editors. Handbook of health economics. Amsterdam: Elsevier Science B.V; 2000. 11. Cellini R., Pignataro G., Rizzo I. Competition and Efficiency in Health Care: An Analysis of the Italian Case. International Tax and Public Finance. 2000;7(4):503–19. 12. Crounse B., Greenstein B., Jordan N., Smolke P. Improving Efficiency in Health Microsoft Corporation 2010 13. Rutkowska M. Towarzystwa ubezpiecze wzajemnych. Społeczne aspekty funkcjonowania w ubezpieczeniach zdrowotnych. Warsaw: PWN; 2006. 14. Moens P. Communication at the Consulate of the Netherlands. 12 April 1997. 15. Rutkowska M., Zaleska-Tsitini M. Health policy in Poland and selected EU countries: attempts to reduce the fast growing medical costs. EMERGO. In print. 16. Aksman E. Narodowa Słuba Zdrowia w Wielkiej Brytanii. Antidotum. 1999;no. 4. 17. Flynn J., Lowry Miller K. Brytyjska słuba zdrowia wymaga intensywnej kuracji. Business Week Polska. 1997. 18. Rutkowska M. Ubezpieczenia zdrowotne. Wroclaw: Agencja promocyjna Monada s.c.; 1997. 19. Gould E. The erosion of employment-based insurance: more families left uninsured. International Journal of Health Services. 2008;38(2):213–51. 20. Deptula T. Bitwa o zdrowie. Newsweek. 30.08.2009;15. 21. Wieczorkowska A. Reforma systemu ochrony zdrowia w USA. Wolno czy solidarno. społeczna? 2010 [Accessed 3 June 2010]; Available from: www.telemedicus.pl. 22. Polski ekspert o amerykaskim systemie ubezpiecze zdrowotnych: on jest dobry. 2009 [Accessed 25 August 2009]; Available from: http://www.rynekzdrowia.pl/Ubezpieczeniazdrowotne/Polski-ekspert-o-amerykanskim-systemie-ubezpieczen-zdrowotnych-on-jestdobry,9985,4.html. 23. OECD Health Policy Studies. Improving Health Sector Efficiency. The Role of Information and Communication Technologies. 2010. 24. Academy Health. Efficiency in Health Care. What Does it Mean? How is it Measured? How Can it be Used for Value-Based Purchasing? Highlights from a National Conference. Madison, Wisconsin 23–24 May 2006. 25. http://dsp-psd.pwgsc.gc.ca/Collection-R/LoPBdP/BP/bp350-e.htm Accessed 3 November 2010.
(10) 287. Studies & Proceedings of Polish Association for Knowledge Management No. 39, 2011. 26. http://www.emedyk.pl Accessed 28 October 2008. MODELE OPIEKI ZDROWOTNEJ NA ĝWIECIE W OBLICZU DYSKUSJI NA TEMAT EFEKTYWNOĝCI SYSTEMU ZDROWIA Streszczenie Współczesne systemy ochrony zdrowia dowiadczaj wyzwa, które pomimo rónic politycznych, społecznych, kulturowych i geograficznych, znajduj wspólny mianownik. Biorc pod uwag coraz wiksze potrzeby pacjenów, jak zreformowa system zdrowia gwarantujc jednoczenie jego stabilno? Jak zwalczy nieefektywne podejcie do zarzdzania zasobami i podnie jako wiadczonych usług przy istniejcych ograniczeniach budetowych? Jako e niewystarczajca i nieodpowiednia opieka zdrowotna moe, w rednim i długim okresie, doprowadzi do pogorszenia si stanu zdrowia społeczstwa i w konsekwencji obniy jako ycia, denie do zrozumienia funkcjonowania systemu słuby zdrowia w jego specyficznym dla danego kraju kontekcie oraz stałe poszukiwanie lepszych rozwiza w zakresie zarzdzania jest wyranie uzasadnione. W zalenoci od modelu opieki zdrowotnej, wykorzystywane s róne podejcia do procesu podejmowania decyzji, organizacji i sposobu wiadczenia usług zdrowotnych oraz finansowania systemu. Ponadto, rone podmioty odgrywaj aktywn rol na rynku usług zrowotnych i inne organy s odpowiedzialne za realizacj strategii zdrowia. Słowa kluczowe: system opieki zdrowotnej, efektywno , wydajno systemu zdrowia Nina Szczygiel Department of Economic, Management and Industrial Engineering GOVCOPP – Research Unit on Governance, Competitiveness and Public Policies University of Aveiro Campus Universitário de Santiago, 3810-193 Aveiro, Portugal e-mail: nina.szczygiel@ua.pt Malgorzata Rutkowska-Podolowska Department of Economy and Economics Law Institute of Organization and Management Wroclaw University of Technology Wybrzee Wyspiaskiego 27, 50-370 Wrocław, Poland e-mail: malgorzata.rutkowska@pwr.wroc.pl.
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