BMJ 2014;348:g1812 doi: 10.1136/bmj.g1812 (Published 4 March 2014)
Page 1 of 3
Feature
FEATURE HEALTH SPENDING DECISIONS
Should healthcare be guaranteed for cancer but not diabetes? As healthcare costs spiral, debate is growing over whether countries should limit their healthcare coverage to certain medical conditions. Andrew Jack examines why Chile’s attempt is meeting a mixed reception and looks at the other options Andrew Jack deputy editor, analysis Financial Times, London, UK
Ten years ago Chile introduced a groundbreaking health insurance system designed to improve access, quality, and speed of medical treatment for its citizens. Auge (the Spanish acronym for Universal Access with Explicit Guarantees) offered legally enshrined coverage for several medical conditions. Today, that system—like its equivalents in other countries around the world—is generating both interest and criticism as policy makers seek ways to balance ever rising demands for better and fairer access to healthcare against intensifying pressures on costs.
Auge, approved under Chile’s socialist president Ricardo Lagos in 2004, sought to expand coverage across the country with a pioneering system that incorporates the principles of access, quality, opportunity, and financial protection, funded through a mixture of taxes and copayments by patients. The scheme lists the conditions that will be covered, which now number about 80, ranging from breast cancer to hepatitis C.1 This has triggered criticism that it discriminates against people with conditions outside the defined categories. “On the positive side, it has created in public opinion a consciousness of the importance of health as a right,” says Vivienne Bachelet, editor in chief of Medwave, a Chilean medical journal. “But Auge has come to the detriment of those conditions that are not covered, and in order to meet treatment guarantees it has forced providers to outsource the covered conditions to the private sector at four to ten times the cost. It has led to the impoverishment of the public health system.”
Inclusion or exclusion?
Chile is not alone. It is one of several countries that are debating or experimenting with an “inclusion list” of reimbursed or government funded medical services. Others have chosen to exclude some conditions instead. Still more have veered away
from any formal commitments, restricting access in other ways such as through price, waiting times, or professional discretion. As demand for healthcare grows, expenditures rise, and resources tighten, there is a growing debate over whether it makes sense to create a basket of approved medical services or find other ways to try to ensure they remain sustainable and widely accessible.
Peter Smith, emeritus professor of health policy at Imperial College Business School, says that restrictions on coverage are “increasingly seen as the fundamental challenge confronted by systems of national health insurance.” He adds: “It is caused by ever growing demands, fuelled by population ageing, new technologies, and limited willingness or ability by citizens to pay increased taxes.” With both population and life expectancy increasing around the world—driven by improved living standards and sanitation, expanding immunisation, and the broader use of effective medical services—the numbers seeking treatment and the complexity of interventions required are growing.
Higher and more vocal public expectations globally, coupled with political pressure to meet the 2015 millennium development goals in low income countries, are helping spur a push for improved and expanded access. That is reflected in calls for health to be enshrined as a constitutional right in many countries, and urging from the World Health Organization and the World Bank for universal health coverage. The National Health Service constitution in the UK, and its equivalents elsewhere, has triggered political and legal pressures by patients to demand cover. Even with a fixed number of patients, the costs of many interventions are rising, including the salaries of medical staff, which are generally the largest component of health spending. Ever more expensive drugs are being launched, not least for cancer and, most recently, hepatitis C infection, for which the
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BMJ 2014;348:g1812 doi: 10.1136/bmj.g1812 (Published 4 March 2014)
Page 2 of 3
FEATURE
cost of newly launched sofosbuvir is $84 000 (£50 000; €61 000) for a three month course in the US. Bills for medical devices and diagnostics are also escalating.
A recent estimate by the Organisation for Economic Cooperation and Development (OECD), the club of industrialised countries, forecast that in the period 2010-60 health spending as a proportion of gross domestic product for most of its member nations would continue to rise by between 2 and 10 percentage points.2
Balancing the books Yet societies are struggling to pay such rising expenditures. For Hans Kluge, director of the health systems division at WHO’s regional office for Europe, the debate has been catalysed by the economic crisis since 2008. “There is more and more discussion about the shape of the healthcare delivery system,” he says. “We have reached the limits, and the US has gone beyond the limits,” says Panos Kanavos, reader in international health policy at the London School of Economics. He sees two principal ways to fund the continued growth. The first is collective: raising overall contributions through taxation or insurance premiums.
Surveys he has conducted suggest that “people are becoming a lot more selfish, especially if they believe they are cosponsoring bad behaviour.” Some opinion polls suggest those taking responsibility for their own health through improved lifestyles—such as not smoking, keeping fit, and healthy eating—are reluctant to pay more to subsidise people who do not.
That points to a second more targeted approach: the use of individual copayments by patients based on their use of medical services. This approach transfers additional costs to the high users and—according to some views—acts as a deterrent to frivolous and unnecessary demands for medical assistance. Patients in countries such as Belgium, the Czech Republic, Finland, France, Iceland, Norway, Portugal, and Sweden already pay for doctors’ visits. Drug copayments are also widespread, including in Australia, Austria, the Czech Republic, Ireland, Italy, New Zealand, and the UK.
At the extreme, policy makers are discussing a shift towards a national health system that covers the most costly “catastrophic” expenses, such as for surgery and cancer care. More regular support and therapy for long term conditions such as cardiovascular disease and diabetes—for which drugs are cheaper—would be paid for at least in part by patients. To some degree, that approach already exists. In the NHS in England, for instance, the basic prescription charge of £7.85 for those without exemptions is higher than the cost of many generic medicines. Eye and dental care requires out of pocket funding. An OECD study showed that in 2009-11, in the wake of the financial crisis, out of pocket spending as a proportion of total health spending had risen in most member states, led by Spain, Ireland, Greece, and Chile.3 One drawback of copayments is the lack of equity, as people who are unable or unwilling to pay are excluded from services available to those who are better off or more motivated. A second problem is that patient contributions provide a disincentive to early identification and treatment of disease, deferring interventions and leading to still costlier treatment once conditions have become more advanced and difficult to treat. “Copayments can be a sledgehammer,” says Kluge. “They decrease the use of unnecessary services but decrease the use For personal use only: See rights and reprints http://www.bmj.com/permissions
of core services too. There is a limit on how much and how quickly you can have savings without hurting people.”
That leaves a third option: a defined package of benefits such as Chile’s Auge. In the UK, the Nuffield Trust, a health think tank, issued a report in 2012 examining whether the NHS should introduce a national benefits package.4 It highlighted the tensions caused by the current sharp fall in the historical pattern of rising investment in health. It explored the idea of a nationally set benefits package as a way to respond. The UK has long had aspects of a defined package, including the exclusion of social care from NHS cover despite its close link to health. The National Institute for Health and Care Excellence (NICE) scrutinises a growing range of interventions and recommends against the use of therapies judged not cost effective. In vitro fertilisation is an example of a service limited in other ways, through an upper age limit for eligibility. The Nuffield report highlighted countries, including Russia, Armenia, Estonia, the Czech Republic, Slovakia, and Switzerland, that have a “positive list” or catalogue of defined services. The health plan introduced in Oregon in the US in the 1990s for low income Medicaid recipients was an early example.
Smith says: “The key challenge is how to define and enforce the health basket. Most countries have an inclusion list but . . . these are of limited usefulness because they do not specify who is clinically entitled to the treatment. Many are only cost effective for a subset of patients, which is difficult to specify and limit.”
Is efficiency the answer? A final option to fund rising healthcare costs without such exclusions is improved efficiency. The OECD highlighted wide variations between countries in medical services, approaches to delivery, and outcomes—from rates of caesarean section and the number of doctors per capita to cancer screening and levels of generic prescribing. This suggests that there is scope for more rational use of existing resources. The Nuffield Trust’s report rejected the idea of an explicit national health benefits package for England but argued for the establishment of a formal list of principles including cost effectiveness, transparent decision making, and ways to encourage patients to make the right choices through more public information. Improvements in efficiency will cause pain but offer prospects for gains that could be better spent on improved health. Discussions over different approaches are set to provoke fierce debate. Yet greater use of assessments that will narrow the conditions, subgroups of patients, or interventions offered are only set to grow. The alternatives risk being still more painful, divisive, and inequitable. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4
Missoni E, Solimano G. Towards universal health coverage: the Chilean experience. WHO, 2010. http://digicollection.org/hss/documents/s18282en/s18282en.pdf. Pearson M. Health systems and cost evolution. http://negocios.udd.cl/files/2013/07/Chilehealth-future.pdf. OECD. Out of pocket expenditure on health. 2013. www.oecd-ilibrary.org/content/table/ oopexphtl-table-en. Nuffield Trust. Rationing health care: is it time to set out more clearly what is funded by the NHS? 2012. www.nuffieldtrust.org.uk/publications/rationing-health-care.
Cite this as: BMJ 2014;348:g1812 Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1812 doi: 10.1136/bmj.g1812 (Published 4 March 2014)
Page 3 of 3
FEATURE
© BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Feature
FEATURE HEALTH SPENDING DECISIONS
Should healthcare be guaranteed for cancer but not diabetes? As healthcare costs spiral, debate is growing over whether countries should limit their healthcare coverage to certain medical conditions. Andrew Jack examines why Chile’s attempt is meeting a mixed reception and looks at the other options Andrew Jack deputy editor, analysis Financial Times, London, UK
Ten years ago Chile introduced a groundbreaking health insurance system designed to improve access, quality, and speed of medical treatment for its citizens. Auge (the Spanish acronym for Universal Access with Explicit Guarantees) offered legally enshrined coverage for several medical conditions. Today, that system—like its equivalents in other countries around the world—is generating both interest and criticism as policy makers seek ways to balance ever rising demands for better and fairer access to healthcare against intensifying pressures on costs.
Auge, approved under Chile’s socialist president Ricardo Lagos in 2004, sought to expand coverage across the country with a pioneering system that incorporates the principles of access, quality, opportunity, and financial protection, funded through a mixture of taxes and copayments by patients. The scheme lists the conditions that will be covered, which now number about 80, ranging from breast cancer to hepatitis C.1 This has triggered criticism that it discriminates against people with conditions outside the defined categories. “On the positive side, it has created in public opinion a consciousness of the importance of health as a right,” says Vivienne Bachelet, editor in chief of Medwave, a Chilean medical journal. “But Auge has come to the detriment of those conditions that are not covered, and in order to meet treatment guarantees it has forced providers to outsource the covered conditions to the private sector at four to ten times the cost. It has led to the impoverishment of the public health system.”
Inclusion or exclusion?
Chile is not alone. It is one of several countries that are debating or experimenting with an “inclusion list” of reimbursed or government funded medical services. Others have chosen to exclude some conditions instead. Still more have veered away
from any formal commitments, restricting access in other ways such as through price, waiting times, or professional discretion. As demand for healthcare grows, expenditures rise, and resources tighten, there is a growing debate over whether it makes sense to create a basket of approved medical services or find other ways to try to ensure they remain sustainable and widely accessible.
Peter Smith, emeritus professor of health policy at Imperial College Business School, says that restrictions on coverage are “increasingly seen as the fundamental challenge confronted by systems of national health insurance.” He adds: “It is caused by ever growing demands, fuelled by population ageing, new technologies, and limited willingness or ability by citizens to pay increased taxes.” With both population and life expectancy increasing around the world—driven by improved living standards and sanitation, expanding immunisation, and the broader use of effective medical services—the numbers seeking treatment and the complexity of interventions required are growing.
Higher and more vocal public expectations globally, coupled with political pressure to meet the 2015 millennium development goals in low income countries, are helping spur a push for improved and expanded access. That is reflected in calls for health to be enshrined as a constitutional right in many countries, and urging from the World Health Organization and the World Bank for universal health coverage. The National Health Service constitution in the UK, and its equivalents elsewhere, has triggered political and legal pressures by patients to demand cover. Even with a fixed number of patients, the costs of many interventions are rising, including the salaries of medical staff, which are generally the largest component of health spending. Ever more expensive drugs are being launched, not least for cancer and, most recently, hepatitis C infection, for which the
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1812 doi: 10.1136/bmj.g1812 (Published 4 March 2014)
Page 2 of 3
FEATURE
cost of newly launched sofosbuvir is $84 000 (£50 000; €61 000) for a three month course in the US. Bills for medical devices and diagnostics are also escalating.
A recent estimate by the Organisation for Economic Cooperation and Development (OECD), the club of industrialised countries, forecast that in the period 2010-60 health spending as a proportion of gross domestic product for most of its member nations would continue to rise by between 2 and 10 percentage points.2
Balancing the books Yet societies are struggling to pay such rising expenditures. For Hans Kluge, director of the health systems division at WHO’s regional office for Europe, the debate has been catalysed by the economic crisis since 2008. “There is more and more discussion about the shape of the healthcare delivery system,” he says. “We have reached the limits, and the US has gone beyond the limits,” says Panos Kanavos, reader in international health policy at the London School of Economics. He sees two principal ways to fund the continued growth. The first is collective: raising overall contributions through taxation or insurance premiums.
Surveys he has conducted suggest that “people are becoming a lot more selfish, especially if they believe they are cosponsoring bad behaviour.” Some opinion polls suggest those taking responsibility for their own health through improved lifestyles—such as not smoking, keeping fit, and healthy eating—are reluctant to pay more to subsidise people who do not.
That points to a second more targeted approach: the use of individual copayments by patients based on their use of medical services. This approach transfers additional costs to the high users and—according to some views—acts as a deterrent to frivolous and unnecessary demands for medical assistance. Patients in countries such as Belgium, the Czech Republic, Finland, France, Iceland, Norway, Portugal, and Sweden already pay for doctors’ visits. Drug copayments are also widespread, including in Australia, Austria, the Czech Republic, Ireland, Italy, New Zealand, and the UK.
At the extreme, policy makers are discussing a shift towards a national health system that covers the most costly “catastrophic” expenses, such as for surgery and cancer care. More regular support and therapy for long term conditions such as cardiovascular disease and diabetes—for which drugs are cheaper—would be paid for at least in part by patients. To some degree, that approach already exists. In the NHS in England, for instance, the basic prescription charge of £7.85 for those without exemptions is higher than the cost of many generic medicines. Eye and dental care requires out of pocket funding. An OECD study showed that in 2009-11, in the wake of the financial crisis, out of pocket spending as a proportion of total health spending had risen in most member states, led by Spain, Ireland, Greece, and Chile.3 One drawback of copayments is the lack of equity, as people who are unable or unwilling to pay are excluded from services available to those who are better off or more motivated. A second problem is that patient contributions provide a disincentive to early identification and treatment of disease, deferring interventions and leading to still costlier treatment once conditions have become more advanced and difficult to treat. “Copayments can be a sledgehammer,” says Kluge. “They decrease the use of unnecessary services but decrease the use For personal use only: See rights and reprints http://www.bmj.com/permissions
of core services too. There is a limit on how much and how quickly you can have savings without hurting people.”
That leaves a third option: a defined package of benefits such as Chile’s Auge. In the UK, the Nuffield Trust, a health think tank, issued a report in 2012 examining whether the NHS should introduce a national benefits package.4 It highlighted the tensions caused by the current sharp fall in the historical pattern of rising investment in health. It explored the idea of a nationally set benefits package as a way to respond. The UK has long had aspects of a defined package, including the exclusion of social care from NHS cover despite its close link to health. The National Institute for Health and Care Excellence (NICE) scrutinises a growing range of interventions and recommends against the use of therapies judged not cost effective. In vitro fertilisation is an example of a service limited in other ways, through an upper age limit for eligibility. The Nuffield report highlighted countries, including Russia, Armenia, Estonia, the Czech Republic, Slovakia, and Switzerland, that have a “positive list” or catalogue of defined services. The health plan introduced in Oregon in the US in the 1990s for low income Medicaid recipients was an early example.
Smith says: “The key challenge is how to define and enforce the health basket. Most countries have an inclusion list but . . . these are of limited usefulness because they do not specify who is clinically entitled to the treatment. Many are only cost effective for a subset of patients, which is difficult to specify and limit.”
Is efficiency the answer? A final option to fund rising healthcare costs without such exclusions is improved efficiency. The OECD highlighted wide variations between countries in medical services, approaches to delivery, and outcomes—from rates of caesarean section and the number of doctors per capita to cancer screening and levels of generic prescribing. This suggests that there is scope for more rational use of existing resources. The Nuffield Trust’s report rejected the idea of an explicit national health benefits package for England but argued for the establishment of a formal list of principles including cost effectiveness, transparent decision making, and ways to encourage patients to make the right choices through more public information. Improvements in efficiency will cause pain but offer prospects for gains that could be better spent on improved health. Discussions over different approaches are set to provoke fierce debate. Yet greater use of assessments that will narrow the conditions, subgroups of patients, or interventions offered are only set to grow. The alternatives risk being still more painful, divisive, and inequitable. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4
Missoni E, Solimano G. Towards universal health coverage: the Chilean experience. WHO, 2010. http://digicollection.org/hss/documents/s18282en/s18282en.pdf. Pearson M. Health systems and cost evolution. http://negocios.udd.cl/files/2013/07/Chilehealth-future.pdf. OECD. Out of pocket expenditure on health. 2013. www.oecd-ilibrary.org/content/table/ oopexphtl-table-en. Nuffield Trust. Rationing health care: is it time to set out more clearly what is funded by the NHS? 2012. www.nuffieldtrust.org.uk/publications/rationing-health-care.
Cite this as: BMJ 2014;348:g1812 Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1812 doi: 10.1136/bmj.g1812 (Published 4 March 2014)
Page 3 of 3
FEATURE
© BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
