Cite this article as: K N Lohr, K Yordy, P F Harrison and A C Gelijns Health care systems: lessons from international comparisons Health Affairs 11, no.4 (1992):239-241 doi: 10.1377/hlthaff.11.4.239
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/11/4/239 .citation
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At the Intersection of Health, Health Care and Policy
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Health Care Systems: Lessons From International Comparisons by Kathleen N. Lohr, Karl Yordy, Polly F. Harrison, and Annetine C. Gelijns Experts engaged in the current vigorous debates over possible reforms of the U.S. health care system frequently refer to possible lessons from the experiences of other nations. Members of the Institute of Medicine’s (IOM’s) Council and Board on Health Care Services have debated the growing problems of the U.S. health care system and suggested that careful comparisons with the experiences of other nations might shed light on current policy debates concerning the organization, financing, costs, effectiveness, and quality of health care in the United States. To explore these ideas further, the IOM convened a small group of international experts for a one-day meeting in February 1992 for two purposes: to discuss which aspects of health care could benefit from careful international comparisons, and to identify specific topics that should receive high-priority attention in fu1 ture IOM work. Although the primary focus of the meeting was on lessons the United States might learn from the other industrialized nations, the group also touched on potentially rewarding comparisons with second-tier nations (for example, selected Latin American / Caribbean and Asian Kathleen Lohr, Karl Yordy, and Annetine Gelijins are with the Division of Health Care Services at the National Academy of Sciences’ Institute of Medicine (IOM) . Polly Harrison is with the IOM Division of International Health.
countries); this report briefly summarizes the themes and outcomes of the meeting that pertain chiefly to the former focus. Deliberations Of The Expert Panel A premeeting “homework exercise” produced a preliminary group of “top twenty” high-priority topics from a list of seventy potential topics. This top-twenty list ranged from “criteria for making health care coverage or payment decisions” at the top to “integration of health and social services” at the bottom. Much of the remaining discussion concerned which among these issues were of the highest priority, whether any other issues not included in the initial listing deserved attention, and questions about the most potentially productive level of analysis. The panelists debated at some length the question of how finely detailed any IOM study should be. That is, some committee members believed that although a good deal of broad-stroke comparative or descriptive work (“macro” comparisons) has been done in a cross-national ot international framework, sufficient work has not been done with clear definitions of terms and concepts (especially economic ones, such as “utilization” or “hospital”) and with reliable and valid data corresponding to those definitions. Thus, there was some sentiment for “micro” studies; these would pursue relatively narrow topics (such as provision of prenatal care or negotiating fee schedules in a national global-budget environment) in depth and would supplement sound, timely quantitative data with qualitative analyses to take social and cultural values and traditions mote into account. There was also some support for what were characterized as
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 21, 2016 by HW Team
I. SPECIAL REPORT
240
HEALTH AFFAIRS | Winter 1992 delivery (for example, focusing less on mortality or crude expenditures data); (2) pose hypotheses; and (3) look. for explanatory factors and correlations between processes and outcomes. Future IOM Work Ultimately, the conclusions of this expert panel, coupled with the policy concerns being addressed by other IOM groups, led to the choice of cost containment schemes as the issue having the greatest chance of being useful in the current policy debates both here and in other countries. To that end, the IOM proposes to conduct an intensive twenty-six-month study to examine, compare, and contrast models of cost containment in several nations. The aim is to produce a series of timely, in-depth analytic reports that will contribute to the reform debate during the next two to three years by providing substantive guidance on approaches to health care financing, coverage, and reimbursement and their implications for efficiency, equity, and health outcomes. Among specific topics that might be addressed are approaches to global budgeting, setting provider payments, enforcing expenditurc targets, regulating a competitive market for health insurance, or rationalizing the distribution of costly technologies. A study committee will convene two workshops to examine some of these specific topics in considerable depth. A final conference will explore the issues in the broader context of efforts in the United States and elsewhere to reform their health care system. Summaries of the workshops and conference will be widely and quickly disseminated during the project. Policy Issues U.S. experts and pundits commenting on reform of the U.S. health care system frequently assert that useful lessons can be learned from the experiences of other nations. They see this as especially true in relation to cost containment and, derivatively, how to finance health care and pay
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 21, 2016 by HW Team
“meso-level” studies that would strike a practical balance between macro and micro analyses. The group returned several times and in various ways to three main categories of issues. The first concerned economics: health care financing and reimbursement and approaches to cost containment. Specific subjects included global budgeting, expenditure targets, and fee negotiating; in addition, basic benefit packages (specifically, what should be in, what should be out, and how those decisions get made from country to country) were of considerable interest. The second issue grouping related to primary care, including such areas as prenatal care and care for the elderly. The third set concerned medical innovation and technology assessment-that is, the development, introduction, and use of medical technology-and how health care technology may be at risk from unforeseen side effects of health care reform efforts. Another pervasive theme was “outcomes” of “processes” or “systems” in the health care sectors of other countries. For instance, a study should not just describe efforts at cost containment or programs for the delivery of prenatal care (recognizing that even reliable, adequately detailed descriptions would not be “simple” to do). To be optimally productive, a study should also examine the negative and positive, and anticipated and unanticipated, results of such efforts, in terms of access, treatment patterns, costs and expenditures, and health outcomes. Most of the panel concurred that future investigations “should not be all anatomy (that is, taxonomy) and no physiology." The group converged on the proposition that IOM work should be concerned with both “processes” (how various countries got to where they are and how their decisions got made) and “outcomes” (better understanding of the short- and long-term consequences of those programs, approaches, and processes). In short, the field of international comparative work has moved to a level of maturity in which research can now (1) focus more on broader sets of outcomes and consequences of changes in health care
U P D ATE 2 4 1 providers while simultaneously controlling aggregate expenditures on health care and ensuring that those expenditures are directed to appropriate, high-quality care. Other problems are equally vexing-poor access to care across a wide band of the population; disquiet about the quality of health care; and anxiety about a considerable set of social problems that intersect with health care. Nonetheless, observers in many countries believe that the concerns about uncontrolled health care costs drive or at least influence all the rest; hence, cost and cost containment come to command highest-priority attention. Efforts to lower the rate of cost increase have been at the forefront of U.S. health policy for more than two decades. Our efforts have not succeeded. Other countries appear to have done better-even if imperfectly, in our view or theirs, and in ways not thought to be entirely compatible with-U.S. culture. At the same time, the issue has become so volatile in this country, and so seemingly intractable, that looking outside our borders for instruction has great appeal. International comparisons done to date provide a useful starting point for deeper probes of pieces of models and mechanisms that might, if reassembled here, contribute to a more workable, affordable, available health care delivery system in the United States. Other countries-notably those of a newly configured Europe-are engaged in the same task and, in differing degrees and for varying purposes, are looking outside their own frontiers for information and new perspectives to address the problem of cost containment. In sum, the IOM believes that a comparative study of cost containment experiments and experiences in a set of thoughtfully selected countries promises constructive insights into our own options as well as valuable information for those nations as they deal with modifications of their own systems. Further, the high degree of interaction among international and country-specific experts planned for this project is expected to furnish its own rewards, in the form of improved communications and a solid network of active, involved parties. Finally, the
attention to be given in this work to both mcthodologic detail and cultural and social values and traditions can advance the field of international comparisons and set the stage for similar work in the other areas that the panel flagged as priorities: primary care, services for special populations, medical innovation, technology assessment, and quality of care. Preparation of this report was supported in part by internal Institute of Medicine (IOM) funds and in part by a cooperative agreement award to the IOM from the Departments of Health and Human Services and Veterans Affairs for support of the IOM’s Boards on Health Care Services and International Health and Committee on Clinical Evaluation. The workshop was supported by internal funds of the National Academy of Sciences. The statements in this report are those of the authors and do not necessarily reflect the views or policies of the Institute of Medicine, the National Academy of Sciences, any of their constituent parts, or sponsors of their work. NOTE 1. Participants at the meeting were John Iglehart (chair), Linda Aiken, Nicholas Black, Jan Blanpain, Carolyne Davis, Julio Frenk, Thomas Hail, Dean Jamison, Steven Joseph, Bryan Luce, Walter McNerne): Philip Musgrove, Jean-Pierre Poullier, Uwc Reinhardt, and George Schieber.
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/11/4/239 .citation
For Reprints, Links & http://content.healthaff Permissions : airs.org/1340_reprints. php Email Alertings :
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Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 21, 2016 by HW Team
At the Intersection of Health, Health Care and Policy
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 21, 2016 by HW Team
https://fulfillment.healthaffairs .org
UpDate
Health Care Systems: Lessons From International Comparisons by Kathleen N. Lohr, Karl Yordy, Polly F. Harrison, and Annetine C. Gelijns Experts engaged in the current vigorous debates over possible reforms of the U.S. health care system frequently refer to possible lessons from the experiences of other nations. Members of the Institute of Medicine’s (IOM’s) Council and Board on Health Care Services have debated the growing problems of the U.S. health care system and suggested that careful comparisons with the experiences of other nations might shed light on current policy debates concerning the organization, financing, costs, effectiveness, and quality of health care in the United States. To explore these ideas further, the IOM convened a small group of international experts for a one-day meeting in February 1992 for two purposes: to discuss which aspects of health care could benefit from careful international comparisons, and to identify specific topics that should receive high-priority attention in fu1 ture IOM work. Although the primary focus of the meeting was on lessons the United States might learn from the other industrialized nations, the group also touched on potentially rewarding comparisons with second-tier nations (for example, selected Latin American / Caribbean and Asian Kathleen Lohr, Karl Yordy, and Annetine Gelijins are with the Division of Health Care Services at the National Academy of Sciences’ Institute of Medicine (IOM) . Polly Harrison is with the IOM Division of International Health.
countries); this report briefly summarizes the themes and outcomes of the meeting that pertain chiefly to the former focus. Deliberations Of The Expert Panel A premeeting “homework exercise” produced a preliminary group of “top twenty” high-priority topics from a list of seventy potential topics. This top-twenty list ranged from “criteria for making health care coverage or payment decisions” at the top to “integration of health and social services” at the bottom. Much of the remaining discussion concerned which among these issues were of the highest priority, whether any other issues not included in the initial listing deserved attention, and questions about the most potentially productive level of analysis. The panelists debated at some length the question of how finely detailed any IOM study should be. That is, some committee members believed that although a good deal of broad-stroke comparative or descriptive work (“macro” comparisons) has been done in a cross-national ot international framework, sufficient work has not been done with clear definitions of terms and concepts (especially economic ones, such as “utilization” or “hospital”) and with reliable and valid data corresponding to those definitions. Thus, there was some sentiment for “micro” studies; these would pursue relatively narrow topics (such as provision of prenatal care or negotiating fee schedules in a national global-budget environment) in depth and would supplement sound, timely quantitative data with qualitative analyses to take social and cultural values and traditions mote into account. There was also some support for what were characterized as
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 21, 2016 by HW Team
I. SPECIAL REPORT
240
HEALTH AFFAIRS | Winter 1992 delivery (for example, focusing less on mortality or crude expenditures data); (2) pose hypotheses; and (3) look. for explanatory factors and correlations between processes and outcomes. Future IOM Work Ultimately, the conclusions of this expert panel, coupled with the policy concerns being addressed by other IOM groups, led to the choice of cost containment schemes as the issue having the greatest chance of being useful in the current policy debates both here and in other countries. To that end, the IOM proposes to conduct an intensive twenty-six-month study to examine, compare, and contrast models of cost containment in several nations. The aim is to produce a series of timely, in-depth analytic reports that will contribute to the reform debate during the next two to three years by providing substantive guidance on approaches to health care financing, coverage, and reimbursement and their implications for efficiency, equity, and health outcomes. Among specific topics that might be addressed are approaches to global budgeting, setting provider payments, enforcing expenditurc targets, regulating a competitive market for health insurance, or rationalizing the distribution of costly technologies. A study committee will convene two workshops to examine some of these specific topics in considerable depth. A final conference will explore the issues in the broader context of efforts in the United States and elsewhere to reform their health care system. Summaries of the workshops and conference will be widely and quickly disseminated during the project. Policy Issues U.S. experts and pundits commenting on reform of the U.S. health care system frequently assert that useful lessons can be learned from the experiences of other nations. They see this as especially true in relation to cost containment and, derivatively, how to finance health care and pay
Downloaded from http://content.healthaffairs.org/ by Health Affairs on June 21, 2016 by HW Team
“meso-level” studies that would strike a practical balance between macro and micro analyses. The group returned several times and in various ways to three main categories of issues. The first concerned economics: health care financing and reimbursement and approaches to cost containment. Specific subjects included global budgeting, expenditure targets, and fee negotiating; in addition, basic benefit packages (specifically, what should be in, what should be out, and how those decisions get made from country to country) were of considerable interest. The second issue grouping related to primary care, including such areas as prenatal care and care for the elderly. The third set concerned medical innovation and technology assessment-that is, the development, introduction, and use of medical technology-and how health care technology may be at risk from unforeseen side effects of health care reform efforts. Another pervasive theme was “outcomes” of “processes” or “systems” in the health care sectors of other countries. For instance, a study should not just describe efforts at cost containment or programs for the delivery of prenatal care (recognizing that even reliable, adequately detailed descriptions would not be “simple” to do). To be optimally productive, a study should also examine the negative and positive, and anticipated and unanticipated, results of such efforts, in terms of access, treatment patterns, costs and expenditures, and health outcomes. Most of the panel concurred that future investigations “should not be all anatomy (that is, taxonomy) and no physiology." The group converged on the proposition that IOM work should be concerned with both “processes” (how various countries got to where they are and how their decisions got made) and “outcomes” (better understanding of the short- and long-term consequences of those programs, approaches, and processes). In short, the field of international comparative work has moved to a level of maturity in which research can now (1) focus more on broader sets of outcomes and consequences of changes in health care
U P D ATE 2 4 1 providers while simultaneously controlling aggregate expenditures on health care and ensuring that those expenditures are directed to appropriate, high-quality care. Other problems are equally vexing-poor access to care across a wide band of the population; disquiet about the quality of health care; and anxiety about a considerable set of social problems that intersect with health care. Nonetheless, observers in many countries believe that the concerns about uncontrolled health care costs drive or at least influence all the rest; hence, cost and cost containment come to command highest-priority attention. Efforts to lower the rate of cost increase have been at the forefront of U.S. health policy for more than two decades. Our efforts have not succeeded. Other countries appear to have done better-even if imperfectly, in our view or theirs, and in ways not thought to be entirely compatible with-U.S. culture. At the same time, the issue has become so volatile in this country, and so seemingly intractable, that looking outside our borders for instruction has great appeal. International comparisons done to date provide a useful starting point for deeper probes of pieces of models and mechanisms that might, if reassembled here, contribute to a more workable, affordable, available health care delivery system in the United States. Other countries-notably those of a newly configured Europe-are engaged in the same task and, in differing degrees and for varying purposes, are looking outside their own frontiers for information and new perspectives to address the problem of cost containment. In sum, the IOM believes that a comparative study of cost containment experiments and experiences in a set of thoughtfully selected countries promises constructive insights into our own options as well as valuable information for those nations as they deal with modifications of their own systems. Further, the high degree of interaction among international and country-specific experts planned for this project is expected to furnish its own rewards, in the form of improved communications and a solid network of active, involved parties. Finally, the
attention to be given in this work to both mcthodologic detail and cultural and social values and traditions can advance the field of international comparisons and set the stage for similar work in the other areas that the panel flagged as priorities: primary care, services for special populations, medical innovation, technology assessment, and quality of care. Preparation of this report was supported in part by internal Institute of Medicine (IOM) funds and in part by a cooperative agreement award to the IOM from the Departments of Health and Human Services and Veterans Affairs for support of the IOM’s Boards on Health Care Services and International Health and Committee on Clinical Evaluation. The workshop was supported by internal funds of the National Academy of Sciences. The statements in this report are those of the authors and do not necessarily reflect the views or policies of the Institute of Medicine, the National Academy of Sciences, any of their constituent parts, or sponsors of their work. NOTE 1. Participants at the meeting were John Iglehart (chair), Linda Aiken, Nicholas Black, Jan Blanpain, Carolyne Davis, Julio Frenk, Thomas Hail, Dean Jamison, Steven Joseph, Bryan Luce, Walter McNerne): Philip Musgrove, Jean-Pierre Poullier, Uwc Reinhardt, and George Schieber.
