1. Health Reforms in the
OECD
Nuffield Trust
Health Strategy Summit, March 2009
Sherry Glied
Mailman School of Public
Health
Columbia University
Thanks to the Commonwealth Fund and especially Robin Osborn.

2. Non-US OECD Health Care
Systems
 Misconception
• Uniform
• Stable and unchanging
 Reality
• Variable (except with respect to
coverage)
• Intermittent significant reforms and
frequent incremental modifications
• Struggling with value for money
2

3. Pop’n GDP Health
Denmark 5,435 $35,000 $3,349
France 61,353 31,000 3,449
Germany 82,368 32,000 3,371
Netherlands 16,346 37,000 3,391
Sweden 9,081 35,000 3,202
Switzerland 7,484 38,000 4,311
UK 60,587 33,000 2,760
2007. Per capita GDP and Health spending – PPP adjusted US$. 3

4. Commonalities: Organization
 Universal or near universal coverage
 Defined, comprehensive benefit
package
 Spending between 8-11% of GDP
 Free choice of primary care provider
 Low cost sharing, with exempt
populations
 Limited private insurance to
complement/supplement defined
benefits 4

5. Variations: Organization
 Automatic  Enroll with fund
enrollment  Community rated
 General/earmark premiums
tax financed  Private purchasers
 Public purchasers  No waiting times
 Waiting times
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6. Push toward greater equity
 Mandates for coverage
 Growing public share of spending
 Risk adjustment across purchasers
 Nationally pooled financing
 Low income subsidies
6

7. Financing and Purchasing
 Risk adjusted capitated financing to
insurance funds or regional
purchasers
• Defined benefits
• Regulated provider fees
• Regulated, community rated premiums
• Very little selective contracting
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8. Physicians
 UK, Denmark, Netherlands, (Sweden)
• Primary/specialty care
 Direct service provision
 Care coordination and navigation
 Gatekeeping
 Mainly capitated or salaried payment
 France, Germany, Switzerland, (Sweden)
• Outpatient/inpatient
 Some gatekeeping incentives
 Fee-for-service practice
8

9. Increased use of non-MDs
 Particularly in gatekeeping countries
• Not all nurse-practitioners – chronic
care nurses, pharmacists, etc.
• Rx, immunizations, care coordination,
outpatient clinics, chronic care clinics
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10. Quality and satisfaction
 Routine patient feedback
 Integration
 Recertification of providers
 Performance reporting
 P4P in UK
• Quality, organization, experience
 Extra pay for
• After hours, home visits, prevention
• Capitated pay for disease management
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11. Information technology
 National IT strategy
 Main element is EHRs
• Centralized
 UK
• Local development, central coordination
 Denmark, Netherlands, Sweden
 Standards, portals, cards, etc. to
facilitate interoperability
11

12. Commonality: Financing
 Provider pays (except UK)
• Some direct subsidies
• Some enhanced fees
 Costly national efforts
• Evidence for cost-saving is meager
12

13. Commonality: Privacy
 Issue everywhere
 EU rules and national rules
 Access to own records, discretion as
to what is included
13

14. Variability: Extent of e-use
 EHRs
 Decision support, drug alerts
• E-prescribing
 E-labs, E-radiology
• E-mail with patients
 E-referrals
∗ E-discharge notes
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15. Pharmaceuticals
 Health technology assessment
• Effectiveness and cost-effectiveness
 Reference pricing within a
therapeutic class
• Very broad
 Marketing restrictions
• No DTCA
• Limits on provider promotion
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16. Common Challenges
 Speeding up drug approval process
• EU rules
• High priority drugs
 Involving stakeholders
 Delisting existing drugs
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17. Innovations
 Sweden
• Value-based pricing for drugs
• Compared to therapeutic class
 UK
• Velcade risk sharing agreement
17

18. Watch this space
 IT expansions
 Further primary care innovations
• Physician- and nurse-led disease
management
 Purchasing and financing
 Costs are growing faster than
incomes
• Rising share of health care in GDP
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