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Euractiv has reported on Commissioner Dalli’s comments that the Euro-zone crisis should not turn into a public health crisis. He added: “difficult times can indeed

Johnny C Fiddle

Policy options may look good, but do they actually play decent music? (Photo credit: Cindy Funk)

provide an incentive to think creatively and push forward in-depth reforms and contain costs, while building modern, responsive, and sustainable health systems fit for the future.”

I agree, yet despair.

Countries have healthcare systems for good reasons and allocate resources because they believe the system in place is the best solution. What we are now seeing is that these systems are very costly, perhaps with weak GDP, almost unaffordable in terms of medical inflation and the impact of demographic factors on services, which outstrip society’s ability to afford more, given other competing demands.  The ability to affect needed healthcare reform is further complicated by governments with limited policy instruments or imaginations. Some may have been literally captured from a policy perspective by powerful vested interests.

My hope is that the current austerity will be a spur to reform; however, in this case, my thinking is that governments need to see themselves as encouraging innovation, and not protecting the status quo.  We can no longer afford to continue to put taxpayers’ money into unreformed governmental and healthcare systems.

As I have written elsewhere, governments fear the creative destruction of public institutions, yet these are frequently the ones most likely to be the barriers to system reform.

The Euractiv article gave some illustrations of the responses by government, none of which involved in-depth reforms. Let’s take a look at some of the examples in the Euractiv article and deconstruct them a bit: (the Euractiv’s text is italicised, my deconstruction follows).  The following comments are not intended to be comprehensive, and I have not addressed in detail whether in some cases there was fundamental logic in the actions. I am looking at these actions in the context of IF you’re thinking like this, THEN you are NOT thinking of more sustainable strategies. You are only, as they say, kicking the can down the road for others to deal with in a few years.

  1. Many countries in Europe have cut public health budgets drastically since the beginning of the global financial crisis in 2008. Regretfully, this is usually the simplest and easiest thing for governments to do. I accept that healthcare system reform is not easy, particularly because of the perceived influence and power of healthcare professionals, and the public’s deep lack of knowledge of how healthcare funding can be mis-spent. That expenditure might be too high for the delivered value of the expenditure actually buys is of course the real issue, not whether budgets can be cut per se.
  2. In France, the government expects to reduce spending by €2.4 billion on the health insurance side. Some 40% of these reductions will be made through a shift to generic medications and savings on medical devices, while measures in favour of greater efficacy in hospitals are expected to lower cost by €1.5 billion. France has failed to balance its public accounts since the 1970s — why should now be any different? The centrality of government in France makes it hard to use local or regional drivers of change as there is the bureaucratic overhang of the centre — what is surprising in France is that despite this overhang, and the central ministry of health employing over 15,000 people (what do all these do all day??) regional outcome differences exist.  Despite some regional level reforms (the ARS), hospital cost structures and payment to doctors (in France doctors can extra-bill!) are the real cost drivers. Shifting to generic medicines is a typical knee-jerk approach. But medicines spending often suffers from poor, even irrational, prescribing practices, weak medicines use management, and weak patient adherence programmes — perhaps 30% is misused, unused or disposed of so much of this expenditure may be suspect.  France has a weak record in biotechnology (despite what they say) and its research has worried the Ministry of Health as it lacks global visibility across a broad spectrum. But investment in life sciences R&D is, for most countries now, seen as a critical driver of economic growth (despite the fact that few countries actually have the research, development, university or commercial infrastructure to do just that). So as generics replace branded medicines, so investment in life sciences research will leave to more congenial countries (other macroeconomic policies may encourage this). The same can be said of trying to save money on medical devices; though devices are not priced like medicines and do not behave like medicines — there are no generic devices in that sense. So it is hard to image what might be meant by savings here. As for hospitals, the great sink hole of healthcare expenditure in any country, what tools are available to drive ‘greater efficiency’?  Country after country is grappling with this. However, €1.5 billion is not a lot of money in the French system which accounts for 11.8% of French GDP (3rd highest in the OECD), which translates into €3872 per person, of which €1639 per person is spent on hospitals. I would be looking for significant analysis of hospital cost structures, skill and service mix, utilisation, etc. to know how efficiency gains will be realised through resource releasing strategies.
  3. In Estonia since July 2009, the sickness benefit rate has been reduced from 80% to 70% of the insured person’s income. The sickness benefit rate in the case of caring for a child under 12 was reduced from 100% to 80%. Cost-shifting to the patient is a regretfully increasing tendency; it also affects lower incomes more than higher incomes. The likely ability to alter patient behaviour and use of healthcare is not completely clear, though the research does show that increasing or even the existence of co-payments reduces the likelihood individuals will seek healthcare and hence lead to increased burden of ill-health, particularly amongst those most price-sensitive. Better to have targetted the underlying costs, first; however, with a shift to a larger co-payment, there is the potential to increase public awareness of healthcare costs and use consumer behaviour to drive faster and more thorough-going reform than simply through government diktat.
  4. The Greek government this year decreased its mental health services by 50%, and the budget was further reduced to cover only 45% of the psychosocial rehabilitation services. In the end, I suspect that this will have a longer term negative impact on mental health status, the problems from which Greece will not be able to export to other EU member states, under the cross-border health rules. Reductions in budgets alone, though, do not tell the whole story as embedded in these services may be higher overheads and administrative burden, inefficient work patterns, and poor use of available expertise (perhaps low case loads); these comments do not say Greek therapists may not be up to the challenge, but the system they work in may constrain their ability to deliver better care through infrastructural and systemic inefficiences. This is where I would look. My view is that as these are broadly predictable costs within known demographic factors, decoupling this debt component from the total would be sensible as it can in the end by better managed than through short-term quick fixes.
  5. In Latvia, nurses’ salaries have fallen 20-40% since 2009. Between 2006 and 2010, the number of hospitals in Latvia have decreased to 39 from 106 and the number of hospital beds decreased to 493 from 761. Reducing the number of hospitals, in and of itself, is not a problem, nor is the reduction in numbers of beds. Bed utilisation is what matters and the intensity with which beds are used, such as length of stay and whether people are hospitalised inappropriately, or held in hospital because of poor discharge facilities (e.g. step-down units, community care) all of which can be provided at substantially lower costs (owing partly to different skill mix, and partly to lower capital costs). Cutting nurses’ salaries (and presumably doctors, physiotherapists, pharmacists, etc., too, though I doubt it) may be counterproductive as it will simply create a reason for people to leave; there is a global shortage of nurses. Better, is to focus on work processes. We know that up to 30% or more of a nurse’s time can be unproductive in terms of patient care. By simply reducing this waste of time through systematic reform of work practices, staffing can increase the equivalent of 15% or so; equally, nursing is a highly stressful job, and nurses tend to have very high absenteeism rates; perhaps 10% of the nurse complement exists simply to respond to absenteeism.
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The financial markets have broadly spoken and find the leaders of the Euro-zone patently unable to implement the solutions to the crisis.  Knowing what the problem

Confused Man Reading a Bill or Bank Statement

Where did it all go wrong? I thought there was enough money…. (Photo credit: s_falkow)

 

really is is very important and it now appears that the core structural reforms necessary seem too hard for doctrinaire European thinking. If you keep trying to implement the same solutions and keep getting the same results — namely a sovereign bailout — that is a rational clue that you are doing the wrong thing.

Medical indebtedness is a big part of the problem, as much of the debt arises from state controlled or funded health systems, and therefore the payment from public funds to pharmacists, doctors, hospitals, etc. adds to the debt load. Indeed, going forward, the debt rating of Euro-zone countries may be in part determined by their ability to handle these types of debts. So far, though, the prognosis is not good.

A summary: figures arising in the period February 2012 to date [Sources: Financial Times, Reuters]

  1. overall, pharmaceutical companies are owed €12 billion in unpaid bills for medicines (debts more than 30 days unpaid).
  2. about €6 billion of that is apparently in Spain; overdue bills in Spain are approaching 800 days unpaid; recently, though, the Spanish central government found €17 billion euros to pay suppliers of the autonomous communities — 73% of this amount was for unpaid medical bills
  3. medical device makers are owed about €4 billion
  4. one device company recently took back about €4 million in unpaid inventory
  5. an insulin supplier shifted to cash on delivery for Greece and has threatened to withhold new drugs from the market
  6. many pharmaceutical companies are reprofiling their product portfolio in high risk payment countries, with a focus on medicines where there is no alternative source of supply or where there is higher clinical need
  7. there is in some cases a broad strategic shift away from customers who don’t pay their bills (e.g. hospitals) to the patients, thereby avoiding high risk local or regional government payers
  8. many health industry intermediaries are diversifying their business away from this sector
  9. some companies have written down their debt selling sovereign bonds; amounts in the tens of millions of Euros are involved.
  10. some of Greek national debt arose from hospital capital expenditure and the failure to properly account for these in national accounts, despite the fact that their hospitals are in poor physical condition; there is a comparable risk associated with capital expenditures across the Euro-zone as it generally involves public bodies and public debt
  11. and so on….

What does this mean?

Consequences to health systems are unlikely to be short term. The suppliers are bearing the costs of granting credit to governments with increasingly fragile credit ratings. They are going to be more cautious in future, no doubt. But a few consequences can be anticipated based on current actions:

  1. There is an evident shift from state payers to patients, forcing patients to pay full costs and then recover these costs from payers. This can be serious hardship for some patients. To some extent, increasing copayment/full payment increases price awareness amongst patients, and increases their awareness of true costs and medicines or device availability. Where national policies may act to suppress introduction of innovative products, public salience of this will rise. Increased public salience will have the effect of limiting the ability of governments to act to constrain costs and availability. This alone could lead to calls for radical reform of state controls in health systems.
  2. Innovative medicines and devices are unlikely to be supplied to at-risk countries until there are assurances of payment. Indeed, medicine reimbursement policies which seek to drive down medicines prices or encourage generic substitutions are likely to have a perverse consequence as industry has the option of restricting to supply to manifest demand, or delaying the introduction of innovative medicines for fear not only that they won’t get paid, but the price paid may be punitive.
  3. Infrastructure renewal in the healthcare system will come under considerable scrutiny. Do we need to renovate hospitals; should new ones be built or should we be looking at newer ways to deliver healthcare at lower costs (e.g. e-health), and how will the vested interest groups (health professionals) react to far reaching system reform to reduce the capital costs of hospitals?
  4. Reduction in availability of supplies has a variety of consequences: shortages of medical/surgical supplies delay operations; shortages of gloves can increase the risk of spread of hospital infections (which can cost upwards of €100,000 per incident to clean up, a lot more than gloves cost); general cost containment can compromise linen supply and sterilisation, increase the risky use of reusable surgical instruments and encourage staff to take risks with reusing equipment in general; given the scale of infrastructure, staff shortages (not hiring replacements) can lead to increased patient loads for health professionals and thereby shorten time available for patient care. This list can go on and on.

The point is that healthcare is a system, and shocks to that system, whether unpaid medicine bills, staff shortages, hospital infections, whatever, have consequences throughout and many of these consequences are likely to be far more costly than the savings and could lead to widespread risks to public health.

Solutions? In my view, the time is ripe for the at-risk countries, in particular, to reflect on the cost-drivers in their systems and focus on substantial reform of the delivery system, as well as the financing itself. Long-term sustainability is needed, so short-term or ill-thought through reforms will only make things worse. We’ve already seen the consequences of that with current Euro-zone leadership.

Email me your suggestions and let’s start building a list of possible solutions that protects the integrity of the public’s health without bankrupting the country.

/p

Map of countries by public debt from CIA 2009 ...

Green is good = lower public debt

Vito Tanzi’s book on the modern state “Government versus Markets” is a mine of fresh perspectives. His subtle challenging of the ability of governments to intervene in market failure is thoughtful — when is market failure simply an excuse for hyperactive civil servants to do something, rather than clear evidence of a problem? And not to speak of motives as we are familiar with the ‘rent-seeking’ behaviour of public bodies/officials which can frustrate efforts to streamline and prioritise public services.

European governments are today the cause of considerable global anxiety with their bloated state bureaucracies, high levels of taxation and disincentivised, but pampered (subsidised) industries. It is instructive to reflect that a large component of state debt arises from their healthcare sectors; that much Greek debt lies in the capital funding of hospital construction, and that rising taxes in France are designed to protect social welfare and health benefits through the regressive social charges (contribution, in French).

Tanzi also challenges the scale of modern governments, as a percentage of the economy.  An article by Neil Reynolds, writing in Toronto’s Globe and Mail started the discussion. (lead article here) A subsequent article in The Globe and Mail listed the following countries as a short list of small state sector countries: (specific reference here):

Hong Kong: Population: 7.1 million. GDP: $302-billion (U.S.). Per-capita GDP: $42,748. Unemployment: 5.3 per cent. Inflation: 0.5 per cent. Five-year compound average growth rate: 3.1 per cent. Percentage of GDP spent by the state: 18.6 per cent.

Singapore: Population: 4.8 million. GDP: $240-billion. Per-capita GDP: $50,523. Unemployment: 3.0 per cent. Inflation: 0.2 per cent. Five-year compound annual growth rate: 4 per cent. Percentage of GDP spent by the state: 17.2 per cent. Singapore requires its citizens to buy their own health and employment insurance – a requirement that has produced an exceptionally high level of savings and one of the richest countries on Earth.

Chile: Population: 17 million. GDP: $243-billion. Per-capita GDP: $14,341. Unemployment: 10.8 per cent. Inflation: 1.7 per cent. Five-year compound annual growth rate: 2.8 per cent. Percentage of GDP spent by the state: 21.1 per cent.

Costa Rica: Population: 4.6 million. GDP: $35-billion. Per-capita GDP: $11,579 (the highest in the country’s Central American neighbourhood). Unemployment: 7.8 per cent. Inflation: 5.8 per cent. Five-year compound annual growth rate: 4.5 per cent. Percentage of GDP spent by the state: 20.9 per cent. (Costa Rica is running a deficit these days – keeping tax revenue as a percentage of GDP to 15 per cent.)

Taiwan: Population: 23.1 million. GDP: $736-billion. Per-capita GDP: $31,834. Unemployment: 5.9 per cent. Inflation: 0.9 per cent. Five-year compound annual growth rate: 2.5 per cent. Percentage of GDP spent by the state: 18.5 per cent.

Now, returning to healthcare, these countries also tend toward healthcare systems that are not social insurance or national taxation based, but are what some authors (see S-Y Lee and C-B Chun, The National Health Insurance system as one type of new typology: the case of South Korea and Taiwan. Health Policy  2008 Jan;85(1):105-13. Epub 2007 Aug 20. Abstract here) are called “national health insurance systems”, characterised by a large government interest through establishing rules and standards, but mainly private delivery, with high co-payments, consideration patient choice, and rising levels of investment. These emerging successful, small state sector economies may also be inventing an affordable and sustainable healthcare system, which could be explored in more detail in European countries as they grapple with public debt. The current financial crisis in Europe, entails the need for root and branch reform of the largest elements of public expenditure — health and social care, university funding, etc. — along with venting the gaseous expansion of the regulatory state.

It will be difficult for European-level policymakers to engage in sensible policies when key drivers of cost are driven at the member state level. An obvious example is Spain, where the debt resides at the regional level, but the policy tools for that debt are owned by the national government. To illustrate, Castille La-Mancha can’t pay the pharmacists for drugs, so pharmacists are asking patients to pay cash. (article here: scroll down to find the specific reference).

Having 19th century sized governments, does not entail having 19th century healthcare.

«Deep Sea Delta», boreplattform, her i Nordsjøen

Tightly coupled systems usually fail catastrophically, and reveal our inability to respond effectively

The challenges facing the UK’s coalition government, and many other governments around the world, point to potentially catastrophic failure of the ways we have thought about problems in the past, with an obvious need to adopt new problem-solving methods going forward.

One cause of the financial crisis, for instance, can be seen as the too-tightly coupled nature of the financial system, so problems in one area were almost immediately exported to other areas; tightly coupled systems mean in effect that you have no redundancy capabilities, but also that no area can easily be insulated from the pernicious contagion from another area.  You want more loosely coupled financial systems.  Is that what we see going forward? To some extent, efforts to decouple high-street banking from riskier investment banking suggest some understanding here, but the continuing dominance of large highly integrated banks is not promising.  Corporate behaviour being what it is, banks will try to recouple in order to ensure that no money is left on the table, as some might say. In the end, it may come done to a combination of loose coupling of systems, real, not Chinese, walls, and different compensation and incentive systems. It also might help if the business schools taught business for the real world, not an idealised fantasy world of private jets and personal fortunes.

Other areas have become tightly wound together too, with one aspect of social benefits creating dependencies on others, so benefits from one area implicate benefits from another. Separating the two and not calibrated criteria might help.

It is the logic of linking together what really needs to be linked, and keeping apart that which should be separate that is important.

The analogy I draw is what I do when my computer malfunctions — I turn it off and then on again — I reboot it.  I also get rid of software than has the effect of making my system work less well.

What would it mean to reboot a whole economy? What would it mean to reboot Britain?

It would mean identifying areas where systems are too tightly coupled. An example has recently been addressed whereby people have difficulty moving to take up employment because of the problems with housing and often social welfare benefits which lock people in.

But we can obviously go further. Re-booting Britain also means ensuring economic capacity is not concentrated in one or two centres, indeed, in London and no where else. The US has highly regionalised economies, and a fairly mobile labour force, with strong regional universities, and labour markets, and excellent transportation infrastructure. This creates redundancy capabilities which can be exploited to avoid the ‘eggs in one basket’ approach to planning.  Developing high-speed rail would help regionalise the UK economically and ensure easy movement of goods and services. Ensuring a strong regional infrastructure breaks down the tightly coupling of systems, so that alternatives become economically viable. As one area falls into economic decline or slump, other areas can respond with capabilities, knowing that infrastructure can accommodate in terms of housing, transportation, schooling and universities. Contrast this with, say, France, where virtually all biomedical research is done in and around Paris, so that none of the regional hubs have any significant impact in this area and so lack the necessary infrastructure.  Lyon, Bordeaux are regional centres but of little research significance and cannot therefore cannot generate economic growth through entrepreneurial activity — Britain is avoiding this in the main on research, but it is useful to see the consequences of getting in wrong.

In the end, the trick is to avoid over-engineering solutions to create systems that are highly interconnected and locked together to form rigid, stable systems — this presents us with a paradox. From a policy perspective, a key goal will be to ensure that solutions are not “one size fits all”, that consumers have choices, even with public services, and that public services need to be more flexible and less formalised procedurally so that they can respond to changing conditions in the real-world.  It means differentiated local economies, incentives which enable clustering, and dissuade economic concentration which rigidifies the ability of systems to respond to shocks.

In the end, the route to social and economic stability may ultimately rest on counter-intuitive factors as flexibility, instability, responsiveness, change. The world after all may be just one giant complex adaptive system, and we as humans aren’t yet smart enough to understand this.

Want to know more?

Thomas Homer-Dixon’s The Upside of Down addresses the problems of tightly/loosely coupled systems. His work is in the same vein as Jared Diamond on the reasons why some societies succeed and some collapse (link to TED video presentation). Annalee Saxenian’s work on regional economic advantage is also worth considering.