Jan 29, 2018 — pdf (data 2015). CUTS data. 3.7 Abortion rates. Introduced in the EHCI 2013. The scoring of this indicator is somewhat complex
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3 Euro Health Consumer Index 2017 Professor Arne Björnberg, Ph.D arne.bjornberg@healthpowerhouse.com Health Consumer Powerhouse 2018 – 01 – 29 Number of pages: 100 This report may be freely quoted, referring to the source. © Healt h Consumer Powerhouse Ltd., 2018 . ISBN 978 – 91 – 980687 – 5 – 7 Health Consumer Powerhouse Euro Health Consumer Index 2017 Report
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4 Euro Health Consumer Index 2017 Contents NO SIGN OF AN EU HEA LTHCARE ROLE MODEL AND MAYBE THAT IS A GOOD THING? . 5 1. SUMMARY .. .. .. .. 6 1.1 G ENERAL OBSERV ATIONS E UROPEAN HEALTHCARE I MPROVING .. .. .. 6 1.2 C OUNTRY PERFORMANCE .. .. .. . 7 1.3 C OUNTRY ANALYSIS OF T HE 35 COUNTRIES .. .. .. .. 9 1.4 T IGHTER O UTCOMES CRITERIA SHO WS WEALTH GAP IN E UROPEAN HEALTHCARE .. 21 1.5 BBB; B ISMARCK B EATS B EVERIDGE NOW A PE RMANENT FEATURE .. .. . 21 2. INTRODUCTION .. .. .. .. .. 22 2.1 B ACKGROUND .. .. .. .. .. 23 2.2 I NDEX SCOP E .. .. .. .. . 24 2.3 A BOUT THE AUTHOR .. .. .. .. 24 3. RESULTS OF THE EU RO HEALTH CONSUMER I NDEX 2017 .. .. 25 3.1 R ESULTS S UMMARY .. .. .. .. . 27 4. BANG – FOR – THE – BUCK ADJUSTED SCORES .. .. 31 4.1 BFB ADJUSTMENT METHODOL OGY .. .. .. . 31 4.2 R ESULTS IN THE BFB S CORE SHEET .. .. .. . 32 5. TRENDS OVER THE 1 0 YEARS .. .. .. .. 33 5.1 S CORE CHANGES 2006 – 2016 .. .. .. 33 5.2 H EALTHCARE Q UALITY M EASURED AS O UTCOMES .. .. . 35 5.3 W AITING LISTS : A M ENTAL C ONDITION AFFECTING H EALTHCARE STAFF ? .. . 37 5.4 U NDER – THE – TABLE PAYMENTS .. .. .. . 40 5.5 “MDD – THE E NDEMIC C ONDITION C RIPPLING E UROPEAN H EALTHCA RE ” .. .. 41 6. HOW TO INTERPRET THE INDEX RESULTS? .. .. . 45 7. EVOLVEMENT OF THE EURO HEALTH CONSUME R INDEX .. .. . 46 7.1 S COPE AND CONTENT OF EHCI 2005 .. .. .. . 46 7.2 S COPE AND CONTENT OF EHCI 2006 2015 .. .. 46 7.3 EHCI 2017 .. .. .. .. .. 47 7.4 I NDICATO R AREAS ( SUB – DISCIPLINES ) .. .. .. .. 47 7.5 S CORING IN THE EHCI 2017 .. .. .. 48 7.6 W EIGHT COEFFICIENTS .. .. .. .. 49 7.7 I NDICATOR DEFINITIONS AND DATA SOURCES FOR THE EHCI 2017 .. .. 50 7.8 T HRESHOLD VALUE SETTI NGS .. .. .. 57 7.9 DATA SOURCES .. .. .. 58 7.10 C ONTENT OF INDICATORS IN THE EHCI 2016 .. .. .. 59 7.11 E XTERNAL EXPERT REFER ENCE PANEL .. .. .. 98 8. REFERENCES .. .. .. .. . 99 8.1 M AIN SOURC ES .. .. .. .. . 99 APPENDIX 1. THE TRUE HIP JOINT, OR WHAT WAITING TIMES SHOULD BE IN ANY HEALTHCARE SYSTEM .. .. .. .. 100
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5 Euro Health Consumer Index 2017 No sign of an EU healthcare role model and maybe that is a good thing? If the results of the Euro Health Consumer Index since more than ten years are st udied, some conclusions could be drawn: European public healthcare keeps improving, counting treatment outcomes as well as the position of the patient/consumer. The correlation between money spent and healthcare performance is obvious for treatment res ults, but non – existent for Accessibility/Waiting Times. Major countries seem to benefit from purchaser – particularly if not fragmented b y regionalisation. There are growing European mountains of healthcare data and statistics that are often used to successfully improve medical procedures. Little learning progress is made on health systems reform; doctors and some managers implement chang e, politicians and administrators more rarely do. Once upon a time the HCP thought that the EU would play a role in advancing health systems performance to the benefit of Europeans. The cross – border care initiative could have become a powerful driver for c are transparency and integration. But reality tells us that very little has happened. Maybe the Brussels lesson is that national government enthusiasm for global healthcare is as limited as the willingness to welcome refugees distributed by the European Co mmission. Since years there is an EU project, said to exist, to form a joint assessment platform targeting member state health systems. Brussels is well aware that the sheer size of health activities, generally absorbing more than ten percent of national G DP and an even larger share of the workforce, makes effective spending a key issue. How make it plausible that also the next generation of Europeans will access good health and healthcare? Piling up health indicators and engaging expert teams, carefully av oiding any indicators that an identifiable group of people (such as a government) could be expected to improve, is academic pastime. Implementing a real – life assessment vehicle something different indeed. Perhaps it is as well that EU co – ordination of stra tegies and methods never took off? The Euro Health Consumer Index points every year to a number of successful national initiatives; this year, to pick a few examples, how Slovakia radically has improved access to treatment, how tiny players such as Macedon ia and Montenegro have used e – health to abolish patient waiting and how low – key Finland climbs in the Index year by year (by avoiding to repeat Swedish mistakes, a good way to learn from others?). Maybe a joint EU health systems strategy would have delayed and complicated such behaviour? Maybe the lesson is that no co – ordination at all is better than a half – baked, lukewarm one? Johan Hjertqvist HCP Founder and President The EHCI 2017 was produced with no outside financial support, i.e. 100% of the costs were borne by the Health Consumer Powerhouse, Ltd.
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6 Euro Health Consumer Index 2017 1. S ummary In spite of financial crisis – induced austerity measures, such as the much publicized restrictions on the increase of healthcare spend, European healthcare keeps producing bette r results. Survival rates of heart disease, stroke and cancer are all increasing, even though there is much talk about worsening lifestyle factors such as obesity, junk food consumption and sedentary life. Infant mortality, perhaps the most descriptive sin gle indicator, also keeps going down, and this can be observed also in countries such as the Baltic states, which were severely affected by the financial crisis. The previous editions of the Euro Health Consumer Index (EHCI), 2006 2016, have shown this i mprovement beyond reasonable doubt (see Section 5.) the EHCI was started today, almost every country has them. Infant mortality when first introduced had 9 countries scorin g Green today, 24 countries do that, with the same limit of less than 4 deaths per 1000 births for a Green. Similar observations can be made for many indicators. In order to keep the EHCI challenging, the EHCI 2017 has to some degree sacrificed the longi tudinal analysis aspect by raising the cut – off limits between Red/Yellow/Green s cores on a number of indicators, and by the introduction of more stringent data such as 30 – day case fatality for heart infarct and stroke. 1.1 General observations European hea lthcare improving 800 Club countries scoring more than 800 points out of the maximum 1000 has had an increased number of members in 2017: 12 countries , all Western European, now score above 800 points (up from 11 in 2016) of the maximum 1000. The tightening of the score criteria, particularly for treatment results, seems to have created a gap between wealthy and less wealthy countries; previous EHCI editions have shown that money does help to provide the best treatment, and also to allow hospital admissions on lighter indications, which might not be cost – effective but does provide better outcomes. The last member of the 800 Club, Sweden in 12 th place at 807 points leads surprise climber Slovakia in 13 t h place with a gap of 58 points . 1.1.1 N o correlation between accessibilit y to healthcare and money spent1 I t is inherently cheaper to run a healthcare system without waiting lists than having waiting lists! Contrary to popular belief, not least among healthcare politicians, waiting lists do not save money they cost money! Healthcare is basically a process industry. As any professio nal manager from such an industry would know, smooth procedures with a minimum of pause or interruption is key to keeping costs low! In the EHCI 2017 there are some surprising newcomers among countries having no or minimal waiting lists in healthcare. Tiny Montenegro has achieved a similar improvement to what Macedonia did in 2013 by introducing a national real time e – referral system, and
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8 Euro Health Consumer Index 2017 Switzerland has for a long time had a reputation for having an excellent , although expensive, healthcare system, and it therefor e comes as no surprise that rewarding clinical excellence results in a prominent position in the EHCI. Bro nze medallists are Denmark at 864 points. Denmark was silver medallist some years ago, and has had a dip in the ranking, which was probably linked to the tightening of regulations for access to healthcare services. In 2017, with clinical excellence being more obviously rewarded, Danes seem to have learned to live with the access rules and are back on the podium. Norway (4th, 850 points) , is l osing 100 o ut of the missing 150 points from a perfect 1000 on their totally inexplicable waiting list situation ! Luxembourg is sharing the 4 th position at 8 5 0 points . The very wi se decision not to provide all forms of care at home, even though LUX could afford it, and allow their citizens to seek care in other EU countries, makes data availability slightly troublesome it is likely that perfect data availability would give Luxembourg a higher s core. Finland (6th, 846 points) seems to have used traditional Finnish pragmatism to get out of the Waiting List swamp of a few years ago , and treatment results have als o become first class. The Swedish score for technically excellent healthcare services i s, as ever, dragged down by the seemingly never – ending story of access/waiting time problems, in spite of national efforts such as Vårdgaranti (National G uaranteed Access to Healthcare). Out of the Swedish gap of 193 to a perfect 1000, 113 points are lost due to an abysmal waiting time situation. Thanks to clinical excellence, in 2017 , Sweden is still in 12 th place but at 807 points, 21 up since the previous year. The only countries scoring lower on Accessibility are Ireland (alone in the bottom position of this sub – discipline) and the U.K. media reports about a worsening waiting time situation in Britain seem to be confirmed in the EHCI. Portugal, still 14 th at 7 35 points (28 down from 2016) , ties this position with the U.K. well done! In southern Europe, Spain and Italy provide healthcare services where medical excellence can be found in many places. Real excellence in southern European healthcare seems to be a bit too much dependent on the consumers’ ability to afford private healthcar e as a supplement to public healthcare. Also, both Spain and Italy show large regional variation which tends to result in a lot of Yellow scores for the se countries. Some eastern European EU member systems are doing surprisingly well , particularly Slovakia due to improved Accessibility, Slovenia, the Czech Republic , and Estonia , considering their much smaller healthcare spend in Purchasing Power Parity (PPP) ad justed dol lars per capita. In 2014, t he FYR Macedonia made the most remarkable advance in the EHC I scoring of any country in the history of the Index, from 27 th to 16 th place, largely due to more or less eliminating waiting lists by implementing their real time e – Booking system! The title ame reason, with a domestic IT solution no Macedonian license. Montenegro climbs from 34 th to 25 th ! The fact that Montenegro is a small country with 600 000 people does not diminish this achievement large countries could do the same, regionalised if no t nationwide.
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9 Euro Health Consumer Index 2017 1.3 Country analysis of the 35 countries 1.3.1 The Netherlands!!! The Netherlands is the only country which has consistently been among the top three in the total ranking of any European Index the Health Consumer Powerhouse has published since 2005. The 20 1 2 NL score of 8 72 points was by far the hi ghest ever seen in a HCP Index. The 9 2 4 points in 2016 are even more impressive , particularly as the score criteria have been tightened for the EHCI 2017 i n order to register differences. The NL wins three of the six sub – disciplines of the Index , and the large victory margin (to all competitors except Swit zerland) seems essentially be due to that t he Dutch healthcare system does not seem to have any really weak spots, except possibly some scope for improvement regarding the waiting times situation, wh ere some central European countries excel. Normally, the i.e. does not claim to measure which European state has the best healthcare system across the board. Counting from 2006, the HCP has produced not only the generalist Index EHCI, but also specialist Indexes on Diabetes, Cardiac Care, HIV, Headache, Hepatitis and other diagnostic areas. The Netherlands is unique as the only country consistently appearing among the top 3 4, regardless what aspect s of healthcare which are studied. This creates a strong temptation to actually claim that the winner of the EHCI 201 7 could indeed be 1.3.1.1 So what are the Dutch doing right? It has to be emphasized that the following discussion does contain a substantial amount of speculation outside of what can actually be derived from the EHCI scores : The NL is characterized by a multitude of health insurance providers acting in competition, and being separate from caregivers/hospitals. Also, the NL probably has the best and most structured arrangement for patient organisation participation in healthcare decision and policymaking in Europe. Also, the Dutch healthcare system has addressed one of its few traditional we ak spots , Accessibility, by se tting up 160 primary care centre s which have open surgeries 24 hours a day, 7 days a week. Given the small size of the country, this should put an open clinic within easy reach for anybody. Here comes the speculation: one important net effect of the NL healthcare system structure would be that healthcare operative decisions are taken, to an unusually high degree, by medical professionals with patient co – participation. Financing agencies and h ealthcare amateurs such as politicians and bureaucrats seem farther removed from operative healthcare decisions in the NL than in almost any other European country. This could in itself be a major reason behind the NL victory in the EHCI 2008 201 7 . 1.3.1.2 So w hat, if anything, are the Dutch doing wrong? The NL scores well or very well in all sub – disciplines, except possibly Accessibility and Prevention , where the score is more mediocre on the other hand, so are those of most other countries . The historic Dut ch problem of mediocre scores for Waiting times has to a gre at extent been rectified by 2016 2017 . As was observed by Siciliani & Hurst of the OECD in 2003/2004, and in the EHCI 2005 2016 , waiting lists for specialist treatment ,
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10 Euro Health Consumer Index 2017 paradoxically , exist ma referral from a primary care doctor to see a specialist). d to the HCP by a former Dutch M inister of H ealth and repeated in t he Dutch parliament November 2014 ) is widely believed to save costs, as well as providing a continuum of care, which is certainly beneficial to the patient. As can be seen from the reference s given in Section 7 .10.2 on indicator 2 .2, there is no evidence t o support the cost – reducing hypothesis. Also, as can be seen in Section 4 .1, the NL has risen in healthcare spend to having one of the highest healthcare costs in Europe . By 2014, The Netherlands are on par with Sweden and Germany for healthcare spend! Thi s has been extensively treated in the EHCI 2013 report 2 . The Dutch healthcare system is characterised by over – use of in – patient care (and institutionalised psychiatric care and elderly care ) . It seems that actual modes of operating the healthcare system in The Netherlands could explain the high per capita healthcare spend, i.e. not the multi – payor model. If the country can afford this, fine; but also for Outcomes and patient quality of life rea sons, a programme to reduce the share of in – patient care would be beneficial for the Dutch healthcare budget! According to Dutch government sources, and presented at the Irish Health Summit in May 2016, there is a strategy aimed at saving GEUR 12/year by s witching to less in – patient care. 1.3.2 Switzerland Silver medallists, 898 points ( down from 904 ) . Switzerland has enjoyed a solid reputation for excellence in healthcare for a long time. Therefore it is not surprising that when the n.a. ions have mainly been eliminated, Switzerland scores high. Considering the v ery respectable money plough ed into the Swiss healthcare sys t em, it should! Now along with Slovakia, the only country to score All Green on Accessibility. In 201 7 , Switzerland is o utdistancing 10 other Western European Countries scoring above 800 points! Swiss healthcare has probably been this good also before; the highly decentralised cantonal structure of the country has made data collection difficult. 1.3.3 Denmar k 3 rd place, 864 points. Denmark was catapulted into 2 nd place by the introduction of the e – Health sub – discipline in the EHCI 2008. Denmark was in a continuous rise since first included in the EHCI 2006. Interestingly, when the EHCI 2012 was reverted to the EHCI 2007 structure, Denmark survived this with flying colours and retained the silver medal with 822 points! Denmark has also made dramatic advancement in the reduction of heart disease mortality in recent years. Denmark was one of only three countries scoring on e criteria were tightened to match the EU directive, and also on having a hospital registry on the Internet showing which hospitals have the best medical results. However, in 2013, the introduction of the Prevention sub – discipline did hot help Denmark, whi ch lost 20 points on this sub – discipline relative to aggressive competitors. Although the causality is hard to prove, that Danish score drop did coincide in time not only with the 2 www.healthpowerhouse.com/files/ehci – 2013/ehci – 2013 – report.pdf
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11 Euro Health Consumer Index 2017 removal of Outcomes data from its hospital quality information system. It al so coincided with the tightening of access to healthcare, with only two telephone numbers being available to Danish patients; the number of their GP, or the emergency number 112! In 2017, with clinical excellence being rewa rded higher, it seems that Danis h patients have learned to cope with the accessibility restrictions! 1.3.4 Norway 4 th place, 850 points. Norwegian wealth and very high per capita spend on healthcare seem to be paying off Norway has been slowly but steadily rising in the EHCI ranking over th e years. Traditionally, Norwegian patients complained about waiting times. This has subsided significantly, but is still where Norway loses most of the points missing: – 100 points compared with class leaders Switzerland and Slovakia ! The poor accessibility of Norwegian healthcare must be more or less entirely attributed to mismanagement, as lack of resources cannot possibly be the problem. The fact that it is cheaper to operate a healthcare system without waiting lists ( i.e. waiting li sts do not save money, the y cost money) could actually explain the Norwegian situation. Too much money can be a curse, hindering rationalization or the learning of efficient logistics. 1.3.5 Luxembourg Luxembourg ( 4 th , 850 points ), being the wealthiest country in the EU, could afford to build its own comprehensive healthcare system. Unlike Iceland, Luxembourg has been able to capitalize on its central location in Europe. With a level of common sense which is unusual in the in – sourcing – prone public sector, Luxemb ourg has not done this, and has for a long time allowed its citizens to seek care in neighbouring countries. It seems that they do seek care in good hospitals. Probably for this reason, Luxembourg loses points on the Abortions indicator for reasons of di scretion, many LUX women probably has that done outside of the small and intimate Grand Duchy. LUX patients probably get even better treatment than the EHCI shows, as being treated abroad makes data collection complicated. The HCP has received some protest from LUX about the bad score on cigarette consumption, on the argument that most of those cigarettes are smoked by other nationalities. From a European public health standpoint, peddling cheap fags to your neighbours is no better than smoking them all you rself. 1.3.6 Finland 6 th , 842 points (same as in 2016). As the EHCI ranking indicates, Finland has established itself among the European champions, with top O utcomes at a fairly low cost. In fact, Finland is a leader in value – for – money healthcare. S ome waiting as cataract surgery and dental care is limited and out – of – pocket payment, also for prescription drugs, is significantly higher than for Nordic neighbours. This probably means that the public payors and politicians traditionally were less sensitive put right in recent years, with Finland being among the top scorers for Range and Reach of Healthcare Services.
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