Globalization and Health Care Systems Reform

1
Globalization and Health Care Systems Reform

• Bernardo Ramirez MD, MBA
• UCF Health Management and Informatics
• April 2013

2
Global Health Care Management Experience

• Globalization and Health Care Systems
• Global Health Care Management Experience
• Study tour 2005 (US, Canada, Mexico,UK and
  Australia)
• All countries in the Americas
• Partnerships Europe, CEE and NIS
• (Hospitals, Managed Care, Health Systems, Health
  Reform, Education and training on health services
  management human resources development,
  institutional strengthening)
• Managerial and Health Services Research
  Perspectives
• Globalization impact in health and health care
  services and management
• Health systems reform strategies with issues like
  competitiveness, state regulations, insurance
  companies, public private partnerships and
  patient empowerment
• Quality, safety and performance improvement
• Value and impact of heath care. Chronic Care

3
Physician Views of the Health System, 2009 and
2012System Works Well, Only Minor Changes
Needed
Percent
Source 2012 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
4
Physician Satisfaction with Practicing Medicine
Percent
Source 2012 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
5
Examples of global issues in healthcare include

• Outsourcing of medical services (e.g. medical
  transcribing, radiology, billing support
  similar to other businesses)
• Acquisitions and consolidations in the
  pharmaceutical industry
• Movement of health professional labor across
  national borders
• Medical tourism competition for international
  patients
• Immigration and global workforce
• Global health pandemics (e.g. HIV/AIDS, Avian
  flu, SARS)
• Comparative Health Systems and Health Reforms

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HEALTH AS A SYSTEM
STRUCTURE
EFFECTIVENESS
Adapted from Donabedian A. (2005) Evaluating the
Quality of Medical Care. Milbank Quarterly Vol
83-No4, Reprinted from Vol44No3, 1966. And From
Bradbury R. (1992) Health Systems Analysis and
Hospital Quality Improvement. ISQUA,9th
International Conference Mexico.
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Health Services Elements

• Population
• Access/utilization (Education, Health Promotion,
  Options for Care, Legal Aspects, Geographical
  and Cultural Barriers)
• Epidemiology (Transition, Mortality, Morbidity,
  Population, Life Expectancy)
• Life Styles and behaviors (Prevention and chronic
  health, Patient Family Centered)

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Health Services Elements

• Resources
• Physical Resources, (hospitals, clinics,
  private-public, Ambulatory services)
• Equipment/Technology, Medicines
• Human resources (Education, health manpower,
  Incentives, training, continuing education,
  Physicians, nurses, technicians and emerging
  professions)
• Financial Resources (Resource allocation,
  budgets, financial schemes, reimbursement,
  insurance mechanisms)

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Health Services Elements

• Health Services
• Primary/Secondary health care. Systems.
• Management Information Systems
• Clinical Standards and Protocols. Safety Issues.
• Quality Assurance and Quality Improvement
• Legal aspects (malpractice)
• Incentives, Performance management.
• Cost or services
• Efficiency, clinical Management efficiency
• Effectiveness, Health Impact and outcomes

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Types of Health Care Services

• Traditional, spiritual, empirical
• Charitable and altruistic organizations
• Entrepreneurial Private practice
• Welfare-oriented, social insurance
• Government and centrally planned
• Prepaid voluntary insurance
• Owned by industry for their workers

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Origins of Health Care Systems

• England. Chadwick report on laboring conditions.
  Boards of Public Health (1850). Mandatory
  Insurance for workers (1911) Welfare State
  Beveridge Report (1942), NHS (1948)
• Germany. Bismarck, Mandatory insurance for injury
  and illness (1883)
• Central Planning Concept Semashko. (1923)
• Mixed Systems from tax-free health care in Saudi
  Arabia to combination of public-private

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Ward in a London Hospital 2003
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Infant Mortality and Total Heath Spending ( GDP)
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Total Health Spending ( GDP) Body Mas Index
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THE HEALTH TRIANGLE
ACCESS EQUITY
QUALITY PERFORMANCEMANAGEMENT
COST
Adapted from Cost, access, quality triangle.
Harvard Medical International, 2002 Retrieved
from the Internet December 20, 2006
http//www.hmiworld.org/hmi/issues/Sept_Oct_2002/f
eatures_health_systems.html
16
Average Health Care Spending per Capita,
19802010Adjusted for Differences in Cost of
Living
Dollars (US)
2009
Source OECD Health Data 2012.
17
Health Care Spending as a Percentage of GDP,
19802010
Percent
2009
GDP refers to gross domestic product. Source
OECD Health Data 2012.
18
Health Care Spending per Capita by Source of
Funding, 2010Adjusted for Differences in Cost of
Living
Dollars (US)
8,233
5,269
4,463
4,445
4,338
3,974
3,758
3,670
3,433
3,035
3,022
2009.
Source OECD Health Data 2012.
19
Pharmaceutical Spending per Capita, 2010Adjusted
for Differences in Cost of Living
Dollars (US)
2009. 2008.
Source OECD Health Data 2012.
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Relation of Health with Physicians

• Will problems be solved in developing countries
  if there were more physicians?
• More and other health professionals?
• Different Health Personnel Ratios?
• How about training, incentives, etc?
• More hospitals and health centers?
• More technology?

21
Number of Practicing Physicians per 1,000
Population, 2010
2009.
Source OECD Health Data 2012.
22
Average Annual Number of Physician Visits per
Capita, 2010
2009. 2008.
Source OECD Health Data 2012.
23
Doctors Perception of Patient Access Barriers
Percent reporting their patients OFTEN have AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Difficulty paying out-of-pocket costs 25 26 29 21 42 26 4 6 16 13 59
Difficulty getting diagnostic tests 16 38 41 27 7 59 10 15 3 14 23
Long waits to see a specialist 60 73 59 68 21 75 60 49 10 28 28
Source 2012 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
24
Practice Has Arrangement for Patients
After-Hours Care to See Doctor or Nurse
Percent
In Norway, respondents were asked whether there
practice has arrangements or if there are
regional arrangements.
Source 2012 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
25
Practice Uses Nurse Case Managers or Navigators
for Patients with Serious Chronic Conditions
Percent
Note Question asked differently in France.
Source 2012 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
26
Primary Care Doctors Receipt of Information from
Specialists
Percent said after their patient visits a specialist they always receive AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Report with all relevant health information 32 26 51 13 13 41 26 12 59 36 19
Information about changes to patients drugs or care plan 30 24 47 12 5 44 22 13 44 41 16
Information that is timely and available when needed 13 11 26 4 1 15 4 8 27 18 11
Source 2012 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
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Health Sector Reforms Around The World

• Balance the Iron Triangle (Access-Quality-Cost)
• Reorient MOH (make them smaller or more
  functional, performance, accountability,
  modernization, separate provision from financing,
  competition, Chronic-Acute Care)
• Institute user charges-Accountability-
• Institute or expand health insurance schemes
• Decentralize-Empowerment
• Third party Contracts with private/public
  providers

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Sustainability

• The capacity of health services to function with
  efficiency, including the financial, environment
  and social interaction that guaranties an
  effective service now and in the future, with a
  minimum of external intervention and without
  limiting the capacity of future generations to
  fulfill their needs.

Adapted from Gallopin Gilberto. A systems
approach to sustainability and sustainable
development. Sustainable Development and Human
settlements Division. ECLAC/Government of the
Netherlands. Project Sustainable Assessment in
Latin America and the Caribbean Santiago de
Chile, March 2003
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Areas and Dimensions

• Sustainability of Processes
• Sustainability of Organizations
• The dimensions of sustainability are grouped in
  five areas
• The environment
• Socio-Cultural
• Institutional Capacity Development
• The Financial Dimension
• The Political Dimension