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Health Policy Success Stories
The Australian Government provides financial incentives to both parents and immunisation providers to support child immunisation outcomes. Since the introduction of the General Practice Immunisation Incentives Scheme in 1998, the average practice immunisation coverage has increased from around 76 per cent to around 92 per cent.
The Health Insurance Review and Assessment service (HIRA) of Korea developed the so-called HIRA-Value Incentive Program (VIP) in 2007. This pay-for-performance scheme covers 43 tertiary hospitals for improvements in acute myocardial infarction treatment (based on seven indicators including timeliness of reperfusion therapy, case fatality and the administration of aspirin) and reductions in unnecessary caesarean deliveries. High performers and those with improving performance were paid financial incentives from the second year of implementation of the scheme, while penalties for bad performers will begin to apply from the third year. To date, the programme has resulted in a 1.68% improvement in the quality measure for myocardial infarction measure and a 0.6% point drop in C-section delivery, as well as savings of 1.8 billion won.
Higher than average in-hospital heart attack mortality rates in Ontario prompted action by the Ottawa Heart Institute and its partners. The Institute brought together key representatives from the hospitals, paramedic and Health Ministry organisations to redesign the heart attack care protocol. Critical success factors in reducing the time to treatment (a key prerequisite to reducing the heart attack mortality rate) include direct access for qualifying patients to a catheterisation laboratory rather than to the emergency department and training paramedics to recognise a heart attack wave form on an echocardiogram.
ActNowBC is a pioneering all-of-government approach to health promotion that sets long-term (2005-15) targets for key risk factors. The initiative’s goals are to develop and promote programs across society that make healthy choices easier, build community capacity to create healthier, more sustainable and economically viable communities, and, reduce the demand on the health care system. The ActNowBC initiative is built on four pillars: promoting physical activity; healthy eating; living free from tobacco; and responsible alcohol consumption, especially during pregnancy.
All government ministries in British Columbia are required to view their mandate through a health promotion lens and reflect initiatives in their service plans that create health-supporting environments aligned to the four pillars of ActNowBC. Ministries are working in partnership with communities, non-government and private sector organisations to broaden responsibility for population health beyond the health sector.
The Ottawa Ankle Rules (OAR, Canada) offer simple guidelines to help emergency physicians decide when to use radiology for patients with ankle injuries. Prior to the introduction of the rules, patients with ankle injuries were routinely X-rayed, even if only 15% of such X-rays were actually needed. Studies have shown that the Ottawa Ankle Rules could reduce the number of unnecessary X-rays by 30-40%. Some clinical studies have also shown the application of the OAR to children could result in a 25% reduction in x-ray usage in children. Clinical testing of the rules has revealed that the guidelines have been effective at reducing the use of ankle x-rays, waiting for treatment and costs, without under-diagnoses of fractures and without patients’ dissatisfaction. In the US, cost savings have been estimated between US$614, 226 and US$3,145, 910 per 100, 000 patients depending on the charge for x-rays. In Canada, total savings estimated are CAN$730,145 per 100,000 patients. The Rules were developed for ankle and foot injuries only, however, similar guidelines have now been developed for other injuries, such as the Ottawa Knee Rules.
The Specific Health Check-up and Specific Health Guidance System in Japan has mandated health insurers to implement screening and guidance with the aim of preventing lifestyle related diseases. The focus of the programme is on the metabolic syndrome, and the target is individuals over 40 years old. Those who are diagnosed with the metabolic syndrome, or as being at risk of developing it, in the health check-up are provided with health guidance to encourage behavioural changes and improve lifestyle. An improved lifestyle is expected to contribute to better quality of life and to an adjustment in health expenditure growth in the mid- to long-term. An early evaluation suggests that the programme was effective in reducing the numbers of individuals with, or at high risk for, the metabolic syndrome after a 6-month follow-up.
Pharmaceutical spending accounts for 24% of total health spending in Mexico. Measures aimed at restraining spending and improving efficiency have recently been introduced in the sector, with evidence of some initial success. Since 2008, an intergovernmental commission has coordinated the purchase and negotiates maximum prices paid on patented pharmaceuticals and other health inputs registered in the National List of Essential Medicines. The commission also offers recommendations on prescription practices. These measures resulted in savings of USD 310 million in 2009. A further USD 265 million saving was realised in 2009 by requiring States to follow certain criteria governing the provision, distribution, and the rational use of pharmaceuticals covered under the Popular Health Insurance (Seguro Popular) programme, a programme targeting the uninsured population.
Integrated health systems relying on budget financing and government-sector providers, such as hospitals, are often contrasted with systems that rely on income from insurance premia. One of the advantages of the integrated system is that it can be easier to control costs – for example, by applying top-down budget caps on spending, without having to renegotiate agreements with different providers or requiring coordination among different insurance bodies. But while it is true that some insurance-based systems are among the highest spenders in the OECD, others spend less than the OECD average. The experience of the Netherlands suggests that it is the incentives faced by insurers and providers – such as the way individual providers are paid and the way contractual arrangements with providers are set – that play a far greater role in whether expenditure growth is easy to contain or not, than where the money comes from. The Netherlands had a very effective system of cost-containment during the 1980’s and 1990’s while having a social security-type health system. In contrast, during the past decade, the Netherlands started paying individual providers fee-for-service (in an attempt to reduce waiting lists), and expenditure increased rapidly. In the United States, integrated delivery systems such as those of Kaiser or that of the Veterans Affairs have provided incentives for coordinated and efficient care among teams of health professionals. Rather than looking for an ideal ‘system’, it is more important to look at how the money is spent and the incentives facing providers and users if we want to understand what will deliver value for money.
Improved care coordination between hospitals and community health services helped to deliver better and cheaper services inTrondheim. To enable a quick transition of patients out of hospital, the Søbstad Helsehus unit has employed a larger number of medical staff than is usual in a nursing home. Patients enjoy better outcomes than others with similar care needs receiving treatment in a more conventional structure– as measured for example by lower re-admissions (19% versus 36%) and lower mortality rates after one year (8% versus 31%). After six months of stay at Søbstad unit, a quarter of patients were able to live independent lives, against only 10 percent of those who were treated in the hospital setting. In addition, the cost of stay at Søbstad was significantly lower. This and similar findings suggest the potential efficiency gains that could stem from better care coordination, for example at the interface between hospital and community health-services. The 2010 White Paper “The Coordination Reform” outlines proposals to “provide proper treatment, at the right place and right time”. The reform will address three main challenges in the Norwegian health system: patients’ need for better coordinated health services; the inadequacy of disease-prevention initiatives; and the need to address changes in epidemiological patterns due to the demographic evolution.