Rethinking health spending

Núria more.Iese Business School

The current crisis and the demographic structure of our population are putting a strong pressure on the welfare state and, very particular, on health expenditure.If things do not change, our population pyramid indicates that in 2050 there will be 1.5 people of working age (of which by the way, in the last 10 years they have only effectively working 52 percent) for each person old65 years, with the consequent tension that this is for spending on pensions and health

Madrid (23-2-11) .- Spain today spends 9 percent of its GDP in health, level that has not stopped increasing in recent decades.In this article we are going to talk about some facts about health spending, the implications they have for the future of our health systems and some experiences in Spain and interesting international aimed not only to contain health spending but also to use it in a formadequate, also improving the health quality of the population.

Some empirical facts about health spending

1. International statistics indicate that as a country enriches the proportion of its income (public and private) aimed at health.

This trend is repeated by all types of countries (rich and poor) and health systems (public and private).Thus, in the future it is more than probable that we allocate an even greater proportion of our GDP to health spending (some estimates speak of 15 percent in 2050).

This increase in the weight of health spending will most likely accompanied by a higher level of demand of citizens who will want to know more insistence if this additional expense is worth it.Even more if we consider that the resources destined for health will be competing with those that we can allocate to pensions, for example.

Therefore, the relevant question is no longer how much we spend but what we are spending.Are we getting the best health we could get with the resources we are dedicating to you?

2. There is space to improve.

The first example of the existence of possibilities for improvement is the Dartmouth Atlas of Health Care, which reveals that more than 70 percent of the differences in the use of many procedures in the different health areas of the United States cannot be explained byNo age difference, income, etc.of its populations or for variations in the prevalence of diseases.Spain is carrying out similar experiments with the atlas of variations in medical practice, which confirm the existence of relevant differences in the treatment of certain diseases.Also for the Spanish case Peiró et al find significant variations in the emergency frequency between the different autonomous communities.

The second example is some data from the United States that Cutler collects such as the following: around a third of American health spending does not translate into better health or that 20 percent of patients hospitalized by acute episodes are readmitted in less than 30days.In addition, a study by the RAND highlights that even in cases where there are agreements on the recommended protocol, in the United States only 55 percent of patients end up receiving care endorsed by scientifically proven general standards.

3. Managing chronic patients is essential for the solvency of health systems.

The health expenditure of chronic patients is between 70 and 80 percent of health expenditure.Therefore the correct management of chronic diseases has become a key strategic variable for our health systems.

In addition, the National Health Survey shows that the prevalence ofChronic diseases increase substantially from 65 years, so that with our population pyramid its relevance for system sustainability will most likely increase.

For this reason, on October 5 a day was held on the management of chronic diseases organized by IESE and Health Dialog Spain in which I participated with Guillem López, Ana Miquel, Alberto de Rosa and Gabriel Beláustegui.

Implications for the future of health systems

The evidence indicates that the mechanism we have currently not working too well.For example, a survey conducted by Commonwealth Fund finds that only 43 percent of diabetics in the United States receive recommended preventive care.This number is not much higher for European countries, which move around 46 percent, with the exception of the United Kingdom where more than 60 percent of diabetes patients follow the recommended protocol.

This fact together with the three previous realities leads me to think that in the not too distant future we will have a health system quite different from what we have today and the difference will not come due to any radical change in covered services, or in patientsthat are insured, but by a different way of providing health.Here the new chronic management models with a greater integration into assistance and a greater role of new technologies will play a fundamental role.

Some international and own experiences can help us find the way to follow.

National and international experiences for chronic disease management

1. Integrated care.On the day of the IESE and Health Dialog Spain, Ana Miquel presented some results of a study for the Community of Madrid where it showed that many of the chronic patients are hyperphrequent of the system and most present pluripatologies.This fact confirms that the need to consider the chronic patient in an integrated way in the system is essential to guarantee the continuous care that the patient requires.

In the United States, Health Partners is a good example of integration: first, it is organized into clinical groups (composed of family doctors, specialists, dentists, clinics and hospitals).Second, when a patient is diagnosed with a chronic disease, it is immediately assigned to one of the clinical groups of their choice.Since 2004, Health Partners publishes evaluation indicators and results of their clinical equipment, to facilitate the choice of patients.Third, the doctors of the clinical group jointly prepare patient treatment patterns (protocols) based on medical evidence and their own experience.Fourth, there are nurses or educators specialized in diabetes that act as managers of the case.They are the patient's constant contact point with the clinical group and are involved every time the patient has a problem.Finally, there is also a 24 -hour telephone line that serves both patient consultations and to remind them of their visits and check if preventive measures (weight control, exercise, diets, etc.) follow agreed with their doctors.

2. The importance of the patient's environment.

For the correct chronic management, prevention and lifestyle are fundamental.That is why it is of great importance that the patient is involved not only to their environment (family, friends, school, etc).Alberto de Rosa commented that in Ribera Health they have also contacted the residences of the elderly to have greater access and coordination for the treatment of these patients with very positive results.

In Scotland, for example, the Chronic MedicationService (CMS) uses electronic recipe and medical-pharmaceutical partnership to improve the treatment of diabetes and asthma patients.The pharmacist acts as a point of contact with the system and contributes to the development and application of a personalized plan for each patient.

3. The new technologies.

Technology will play an increasingly important and key role in the health model the future.To detect where to improve information technologies are fundamental since it is difficult to improve what we cannot measure and compare.

The examples of new technologies applied to health that go far beyond traditional medical technologies are multiple and very varied.In Africa, mobile phones have already become a key element for the control of chronic patients (tuberculosis and HIV) in pilot programs used by SMS both to involve the patient or their relatives and to communicate with community workers specialized in these ailments.In Europe there are devices capable of measuring the level of hemoglobin in the blood of a diabetic and sending the result with a special notice to the corresponding doctor if the patient is about to suffer a crisis.The electronic recipe is extending rapidly through many countries, etc.

4. The incentives.

Once we know what works, the next step is to do well and this is more difficult than it may seem -we know, for example that a good practice can take between 10 and 20 years to be implemented -but in this process the incentives are fundamental.

It is difficult, for example, to achieve greater coordination in our health system if the different doctors are paid separately instead of paying them by capita.Following the previous example, Health Partners doctors receive compensation for results that also contributes to the continuous improvement of the equipment.

I am convinced that we can find a system that makes a better quality compatible with lower costs, but for this we need four fundamental elements: first more research to know what works and why.Second, information technologies to measure and compare the results.Third, an emphasis on the prevention and integration of health care and fourth, an incentive system that facilitates the implementation of the objectives pursued.

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