High prices, not waste or over-use, drive high health care costs in the US

The US spends nearly 18 percent of its GDP on health care, making it a real outlier among high-income countries in this area. But what is behind this unusually high level of health care spending? Irene Papanicolas investigates common beliefs about why spending is so high, including that US residents use more health care services, have poorer quality of care, and use 'too much' inpatient care. She finds that higher costs in the US are largely driven by higher prices across a wide range of health care services such as surgical procedures and drugs, as well as administrative complexity and costs

The new NHS: financial incentives for quality?

In April 2002, five years after the Blair government’s proposals to create a ‘New NHS [National Health Service]’, the government outlined the key priorities that would mark the NHS reform. The main reforms involved patient choice supported by a system of ‘Payment by Results’ (PbR) under which hospitals would be funded on the activity they undertook. PbR is a case based payment system, a type of system increasingly being adopted as the main form of provider payment across industrialised countries. The literature on this type of payment system and experiences from other countries identifies many di!erent behavioural incentives that can have both positive and negative impacts on quality of care. This thesis investigates the quality implications observed so far in England, for seven conditions which represent a spectrum of important clinical areas that are admitted through both emergency and elective admissions. In order to identify changes in quality, this thesis first considers how to construct an appropriate measure of quality. The first part of the thesis utilizes two di!erent methodological techniques used for quality measurement; a latent variable approach and a technique put forward by McClellan and Staiger (1999) using Vector Autoregressions. The results from these techniques indicate that quality measurement approaches di!er markedly with regards to how much measurement and systematic error they are able to filter out of raw outcome data. Finally, the new indicators created by these techniques are used to evaluate the quality impact the introduction of PbR as the main form of hospital payment has had in England. The analysis indicates that since the policy’s implementation, there have been di!erential quality e!ects on the di!erent conditions. However, for the most part this indicates an improvement in mortality outcomes, and a reduction in the variation of outcomes across hospitals. As found, the interpretation of readmissions has to be approached with caution as more severe patients being kept alive through quality improving measures on mortality create more mixed signals for the readmission indicators. In two conditions we find changes in activity that are indicative of e"ciency gains, in the form of better coding and adoption of new technology, both as a result of differences in reimbursement categories

The challenges of using cross-national comparisons of efficiency to inform health policy

Many comparative efficiency metrics focus on scrutinising the operation of specific parts of a single health system. This article reviews the key issues involved in international comparisons of various aspects of efficiency. It examines data sources and analytic techniques used to create comparative indicators, and discusses approaches to interpreting variations. It also highlights key challenges and promising new initiatives, such as the consistent use of international definitions and technical developments, such as data linkages, which hold the potential to enhance work in this area

Perceptions of health care access in Europe: How universal is universal coverage?

The past decade has witnessed a growing interest in the ability of health systems to protect citizens from the financial consequences associated with ill health and the use of medical care. In order to improve financial protection and access to care the WHO World Health Report 2010 firmly emphasizes that health systems move towards universal coverage of their populations. Of all regions, Europe has shown the most commitment to the goal of universal coverage. However, not all Europeans may feel as though they are able to access care if in fact they should need it. It is therefore important to investigate how the citizens of different European countries perceive their access to health care in order to better understand who these individuals are and what role different systems can play in providing better access to care

Do financial incentives trump clinical guidance? Hip replacement in England and Scotland

Following devolution in 1999 England and Scotland's National Health Services diverged, resulting in major differences in hospital payment. England introduced a case payment mechanism from 2003/4, while Scotland continued to pay through global budgets. We investigate the impact this change had on activity for Hip Replacement. We examine the financial reimbursement attached to uncemented Hip Replacement in England, which has been more generous than for its cemented counterpart, although clinical guidance from the National Institute for Clinical Excellence recommends the later. In Scotland this financial differential does not exist. We use a difference-in-difference estimator, using Scotland as a control, to test whether the change in reimbursement across the two countries had an influence on treatment. Our results indicate that financial incentives are directly linked to the faster uptake of the more expensive, uncemented Hip Replacement in England, which ran against the clinical guidance

An analysis of perceived access to health care in Europe: how universal is universal coverage?

The objective of this paper is to examine variations in perceptions of access to health care across and within 29 European countries. Using data from the 2008 round of the European Social Survey, we investigate the likelihood of an individual perceiving that they will experience difficulties accessing health care in the next 12 months, should they need it (N = 51,835). We find that despite most European countries having mandates for universal health coverage, individuals who are low income, in poor health, lack citizenship in the country where they reside, 20-30 years old, unemployed and/or female have systematically greater odds of feeling unable to access care. Focusing on the role of income, we find that while there is a strong association between low income and perceived access barriers across countries, within many countries, perceptions of difficulties accessing care are not concentrated uniquely among low-income groups. This implies that factors that affect all income groups, such as poor quality care and long waiting times may serve as important barriers to access in these countries. Despite commitments to move towards universal health coverage in Europe, our results suggest that there is still significant heterogeneity among individuals’ perceptions of access and important barriers to accessing health care

What drives people’s perceptions of their health system? In the UK, overall satisfaction with the NHS is closely associated with GP performance

Surveys of satisfaction with the NHS tend to prompt discussion about reform. Research by Irene Papanicolas, Jonathan Cylus and Peter Smith investigates what determines people’s satisfaction with their health system and why it is oftentimes erratic. International comparisons show that overall satisfaction appears to represent something different in each health system, indicating that there is no panacea for improving satisfaction ratings in all countries. In the UK, they find that GP performance is closely linked to overall opinions of the NHS, and so policies that addresses GP responsibilities might have an important influence on satisfaction levels

Cross country comparisons in health price growth over time

Objective: To examine how the United States compares in terms of health price growth relative to four other countries - Australia, Canada, France, and the Netherlands. Data Sources and Study Setting: Secondary data on health expenditure were extracted from international and national agencies spanning the years 2000–2020. Study Design: International price indices specific to health were constructed using available international expenditure data and compared to existing health-specific national and general international price indices. Data Collection/Extraction Methods: Health expenditure data were extracted from the Organization for Economic Cooperation and Development (OECD) database. We obtained a time series of health price indices from the national agencies in each of the study countries. Principal Findings: We find meaningful variation across countries in the rate at which health prices grow relative to general prices. The United States had the highest cumulative health price growth compared to general price growth over the years 2000–2020 at 14%, followed by Canada and the Netherlands. Unlike the other study countries, health prices in France grew consistently in line with general prices. Price growth for health care paid for by public funds and households grew at different rates across countries, where price growth was higher for public payers. US households faced the greatest mean annual price growth. Conclusions: The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries

Motivating provision of high quality care: It is not all about the money

The inclusion of universal health coverage as a target in the sustainable development goal for health has boosted the global movement to improve access to healthcare services. To improve health, the services accessed must be high quality,1 yet there is mounting evidence that the quality of care delivered to populations in many low and middle income countries is inadequate.2345 Governments must consider strategies that will not only improve accessibility to care for their populations but also substantially improve quality. A priority in achieving universal health coverage is the recruitment, training, and retention of healthcare workers. However, there is widespread concern that health systems are not getting the most out of their workforce. Recent evidence shows that the quality of care provided by healthcare workers is often lower than what they are able to demonstrate in the context of a test2 or under the watchful eyes of an observer.6 The existence of such “know-do” gaps shows that substandard care cannot be fully explained by low competence or inadequate training. Low quality of care and medical errors occur more often when providers are demotivated, which can be fuelled by inadequate working conditions such as shortages of basic drugs and equipment or staff.789 Yet, although good working conditions are an important part of delivering good quality of care, they are not sufficient to ensure that health professionals are motivated and adhere to recommended treatment guidelines.1011 Here, we discuss the evidence on different approaches that can be used to increase provider motivation and ultimately improve quality of care

Identifying the causes of inefficiencies in health systems

Persistent growth in health expenditures coupled with fiscal pressures have led to widespread calls for efficiency improvements. However, identifying the sources of inefficiencies in health systems remains challenging. In this article, we provide an analytic framework to facilitate better understanding and interpretation of common health system efficiency metrics. To demonstrate its potential, we apply the framework to a simple efficiency metric comparing per capita health care expenditure to amenable mortality rates in the EU-28 Member States. This exercise highlights the information each metric can and cannot tell analysts and decision-makers. Going forward, more refined metrics should be developed based on more standardised and detailed cost accounting data and linked datasets and registries