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What major innovations and reforms have been introduced?

  • Australia

    In 2015, the federal government announced a number of reforms to primary care, including implementation of the Primary Health Networks (PHNs) and the Medicare Benefits Scheme (MBS) Review. In addition, the government has established the Primary Health Care Advisory Group to consider innovations to funding and service delivery for people with complex and chronic illness, including mental health. Together, these three reforms seek to ensure that primary care is being delivered efficiently and effectively and that Medicare is put on a sustainable funding trajectory. The group’s advice, which will be submitted to the government by the end of 2015, will consider how to best utilize the Primary Health Networks (PHNs). The primary care reforms come on the heels of the 2014 announcement of a new copayment for GP visits (AUD5.00, or USD3.26), to serve as a price signal to patients and a source of revenue.

    The government is also reforming care for the aging. In addition to the implementation of the Commonwealth Home Support program outlined above, a new funding model is pursued whereby allocations will be made directly to consumers based on their care needs instead of directly to service providers, affording them greater choice in providers and stimulating provider competition. This reform will take effect in February 2017.

  • Canada

    At the annual meeting of Canada's provincial premiers in July 2015, national health care priorities included pharmaceuticals, appropriateness of care, senior care, and dementia. There has not been a meeting between the first ministers of the federal and provincial governments on health care since 2009. In its 2015 election platform, the Liberal Party committed to a CAD3 billion (USD2.4 billion) investment in home care services and proposed a pan-Canadian collaboration to improve access to prescription medication.

    In 2015, the Canadian government expanded the National Anti-Drug Strategy to include prescription drug abuse. This strategy focuses on reducing the supply of and demand for illicit drugs. Also introduced in 2015 was the Protecting Canadians from Unsafe Drugs Act (Vanessa’s Law), which strengthens regulation on therapeutic products to promote reporting of adverse reactions by health care institutions.

    Provincial health system governance: Several provinces have reformed or are in the process of reforming their health system governance structures, mostly in an attempt to achieve efficiencies and reduce costs. Quebec is merging 182 Health and Social Centres, which include hospitals, clinics, and long-term care facilities, into just 28. In April 2015, Nova Scotia passed legislation to consolidate 10 district health authorities into two: the Nova Scotia Health Authority and the IWK Health Centre. The two merged authorities will work together to plan and deliver primary care, community health services, and acute care across the province. The 2015 Newfoundland and Labrador provincial budget announced the consolidation of administrative service for the health care system into one shared services organization. The regional health authorities will remain in place, while the shared services organization will provide them with support for human resources, information technology, telecommunications, marketing, communications, finance, and payroll. The government appointed an implementation team in August 2015.

  • China

    Sales of prescription drugs have been a major revenue source for hospitals, which are allowed a 15 percent markup, and providers have strong financial incentives to induce demand for more and expensive drugs. Prices for services, on the other hand, are rather low, in accordance with traditional health practice in China. However, as of 2015, 3,077 public county hospitals and 446 public city hospitals were participating in a government-financed pilot program to eliminate markup of prescription drug prices. At the same time, 224 prefectures and cities in 21 provinces adjusted prices of health care services upward to reflect true costs. The zero-markup policy has been found to have significantly reduced total medical spending.

    Another important health reform was the introduction in 2015 of special health insurance for severe diseases, such as cancers, kidney disease, and acute myocardial infarction, which supplements the regular publicly financed schemes. Severe-disease health insurance provides reimbursement beyond the rather low reimbursement ceilings. It is also mostly publicly financed, particularly for urban resident basic insurance and the rural new cooperative medical scheme, and administrated by local health authorities. However, private commercial health insurance companies, given their experience in providing complementary insurance, are heavily involved as well. By 2017, severe-disease insurance is expected to be available throughout China.

  • Denmark

    A reorganization of the hospital infrastructure is currently under way. All five regions are in the process of closing or amalgamating small hospitals and building new hospitals, at a total cost of DKK40.0 billion (USD5.3 billion). A central part of this process is the reorganization of acute care, with stronger pre-hospital services and larger specialized emergency departments with senior medical specialists at the front end.

    The third generation of mandatory “health agreements” for coordination between municipalities and regions came into force in 2014. These agreements cover 2015–2018, and are based on a slightly revised format that resulted from a formal evaluation published in 2011.

    Upscaling of municipal health services with “temporary care units” and various types of health centers is occurring, with colocation of municipal, private, and regional health providers. At the same time, municipalities are employing more nursing staff and public health specialists to provide more systematic services for population health.

    A plan for reorganization of the central governance structure was decided on by the incoming government in August 2015, and was implemented in the fall of 2015. The reorganization will split the existing Health and Medicines Agency into four separate agencies, dealing with health, medicines, patient safety, and IT/data, to provide more clarity and improve the overall surveillance and accountability structure.

  • England

    In October 2014, National Health Service (NHS) bodies, led by NHS England, published the Five Year Forward View, which sets out the challenges facing the NHS and a series of strategies to address them (NHS England, 2014a). These included setting up a number of pilot programs across England to test new models of care known as “vanguards.” To date there are 37 vanguard sites, which focus on scaled-up primary care, enhanced health care in long-term care homes, vertically integrated hospital and community care, and networks to improve emergency care. NHS England hopes that, among other benefits, evaluations of the program will lead to better tools for identifying those at risk of becoming high-cost, high-need patients, and to the development of capitated contracts to incentivize providers to collaborate in the care of complex patients. The Five Year Forward View also sets out strategies to improve health and well-being, including a diabetes prevention initiative.

    The primary challenge facing the NHS is finding a way to redesign services and invest in prevention while at the same time generating efficiencies without compromising service quality or access. In November 2014, the National Audit Office reviewed the financial health of hospital providers in the NHS and warned that the trend of increasing financial distress was unsustainable. The new Conservative government elected in May 2015 endorsed the Five Year Forward View and committed an additional GBP8 billion (USD11 billion) per year. But measured against the GBP30 billion (USD42 billion) gap identified by NHS England, this additional funding equates to an annual savings target of GBP22 billion (USD31 billion). Moreover, this funding will need to cover the implementation of new pledges, made in the election manifesto, to implement full seven-day working weeks in hospitals and general practice by 2020.

  • France

    The new Health Law, based on the 2012 pledge by the newly elected government to reduce health inequities and on the 2014 health strategy, was passed in April 2015 to replace the previous law, dating back to 2004. It has 57 articles, the most prominent being the deployment of direct statutory health insurance (SHI) payments to self-employed GPs and a strong commitment to public health and prevention. The direct GP payments have been strongly opposed by physicians’ unions on the grounds that such payments might be delayed by software dysfunction (versus immediate payment at the end of the consultation) and that physicians would become SHI “employees,” and could be pressured into giving cheap care instead of appropriate care. The timetable is to have a full deployment by 2017 (the year of the presidential election).

    Prevention and public health measures aim to reduce addictions, eating disorders, and obesity, and include measures to fight binge drinking and anorexia. They support the mandatory neutral cigarette pack, the ban on soda fountains, experimentation with medically supervised IV drug injecting facilities, and mandatory nutrition information on packaged foods.

  • Germany

    In June 2015, parliament passed the Act to Strengthen Statutory Health Insurance (SHI) Health Care Provision. This act is based on the 2011 SHI Care Structures Act, and takes measures to further strengthen service provision structures for SHI patients, particularly in underserved rural areas. These measures include a right for municipalities to establish medical treatment centers, a ban on transferring SHI-accredited practices to successors in overserved areas, the establishment of appointment service centers that would guarantee a specialist appointment within four weeks, and the promotion of innovative forms of care, especially through the establishment of an Innovation Fund at the Federal Joint Committee endowed with EUR300 million (USD381 million) annually from 2016 to 2019.

    The Act to Strengthen Health Promotion and Prevention passed parliament in July 2015. In an upcoming National Prevention Conference, the social security schemes, in collaboration with federal, state, and local governments, as well as the Federal Employment Agency, will agree on common goals and approaches. Furthermore, the act aims to improve prevention and health promotion by regulating vaccination policy and by expanding health checkups. Sickness funds and long-term care funds invest EUR500 million (USD635 million) annually, of which about EUR300 million is earmarked for health promotion in children’s day-care facilities, schools, the work environment, and long-term care facilities.

    The Hospital Care Structure Reform Act comes into force in January 2016. The law provides for the introduction of quality aspects in hospital planning (legally defined minimum volumes) and payment (quality-related supplements and reductions), as well as a more patient-friendly design for hospital reports. In order to strengthen nursing care of patients and to create new nursing jobs, a subsidy program will provide up to EUR660 million (USD839 million) in 2016–2018, and, starting in 2019, EUR330 million (USD419 million) per year. Hospital financing will be developed further and the reallocation pool will earmark EUR500 million to support measures to improve hospital care structures.

    Several other bills are pending in the legislative process, e.g., the E-Health Act and the Hospice and Palliative Care Act.

  • India

    A key goal of the 12th five-year plan is to move toward universal coverage to provide universal access to equitable, affordable, and quality health care, with supplementation from the private sector. Toward this end, the National Health Mission and its two Sub-Missions, the National Rural Health Mission and the National Urban Health Mission, was approved by the Cabinet in May 2013. The main components include health system strengthening in rural and urban areas; the Reproductive, Maternal, Newborn, Child and Adolescent Health strategy; and control of communicable and noncommunicable diseases.

    A number of initiatives are being introduced with respect to quality of care, as described in the section on quality, above.

    An example of health system integration reform is the RSBY scheme. This scheme, now under the Ministry of Health & Family Welfare, is helping the state and central ministry move to a tax-financed, single-payer system.

    Reforms have also been introduced to ensure equity in resource allocation. Allocation decisions are to take into account financial ability, developmental need, and high-priority districts, targeting specific population subgroups, geographical areas, health care services, and gender-related issues. A risk equalization formula based on health care need could be developed, with built-in financial incentives for facilities providing a certified quality of care.

    Other initiatives being introduced include the India Newborn Action Plan, to reduce preventable newborn deaths and stillbirths; the provision of providing free drugs and diagnostic services; the aforementioned National eHealth Authority; and a new health rights bill to ensure health as a fundamental right.

  • Israel

    Mental health: In July 2015, mental health care was added to the set of services that the health plans must provide within the national health insurance (NHI) framework, making access a legally guaranteed right rather than a government-supplied service whose availability is subject to budget constraints. Because of this new mandatory package of mental health services, government funding for health plans has been increased substantially to cover the additional costs. The main objectives of the reform are to improve the linkage between physical and mental care, increase the availability of mental health services, and increase efficiency. An external evaluation will ascertain the extent to which the objectives are achieved and whether various concerns are realized.

    Comparative data on hospital performance: In 2015, the MoH began publishing comparative data on hospital quality, and there are plans to rapidly expand the indicator set in the years ahead. In 2014, the Ministry published the results of a nationwide survey of hospitalized patients regarding their care experience. It is also assembling a database of waiting times for surgical operations, with the intention of publishing comparative data in 2016. The objectives of all these efforts are to provide hospitals with information to help identify problem areas, enhance consumer choice of hospitals, and provide hospitals with incentives to improve performance.

    Reducing surgical waiting times: Long waiting times are perceived as one of the major causes of the recent growth in private financing and care provision. Motivated by a desire to improve public confidence in the publicly financed health care system as well as quality of care, the Ministry of Health (MoH) is planning a major initiative to reduce surgical waiting times. This will involve additional funding to expand hours of operation for surgical theaters as well as a series of organizational changes to improve efficiency.

    Improving service levels in hospital EDs: As part of a broader effort to improve patient-centered care and service levels, the MoH is launching a major effort to reduce waiting times between patient arrival and the first contact with a health care professional. Strategies are to include enhanced physician, nurse, and physician assistant staffing, as well as engaging operations management experts to improve workflow.

    Long-term care insurance: Israel’s long-term care system is seriously fragmented, with service gaps, duplication of care, inefficient incentives, and inadequate investment in prevention and rehabilitation. The government is working on a plan to add institutional long-term care to the set of NHI benefits for which the health plans are responsible, with the plans also serving as the budget holders for institutional long-term care insurance.

  • Italy

    Because of the regionalization of the health system, most innovations in the delivery of care take place at the regional rather than the national level, with some regions viewed as leaders in innovation. Significant innovations can be found in:

    • Pharmaceuticals: Both the National Drugs Agency and the regions are particularly active in coordinating guidelines and rules to promote appropriate and cost-effective prescribing.
    • Hospital care: Various innovations have been introduced concerning the overall organization, management of operations (e.g., planning of surgical theaters and delivery of drugs), and health information technology (e.g., electronic medical records, automation of administrative and clinical activities).

    In August 2012 the parliament passed a law aimed at curbing and rationalizing public expenditure (the so-called spending review). The law promoted the prescription of generic drugs, cut the hospital bed ratio from 4 per 1,000 people to 3.7, and reduced public financing of the National Health Service by between €900M (USD1.2B) and €2.1B (USD2.8B) annually between 2012 and 2015. Many of the requirements of the law are still in the process of being implemented and effects have not yet been evaluated.

    In 2012, the government approved a decree (named after Renato Balduzzi, who was health minister at that time) to reorganize health care at the regional level, with the introduction of teams of primary health care professionals to ensure 24-hour coverage; to update health care fees; to restructure governance of hospitals and local health units; to revise the list of reimbursable pharmaceuticals; and to introduce health technology assessment as a tool for renegotiating the price of less effective medicines. Evaluations of the impact of both laws are not yet available as their implementation is still under way.

    The July 2014 Pact for Health defines funding (between €109B [USD143.4B] and €115B [USD151.3B] annually) for the years 2014 to 2016. In return, regions make explicit commitments to:

    • Reduce hospitalizations through appropriate use of hospitals, with progress toward home care and the creation of community hospitals offering subacute care.
    • Reorganize primary care: All regions will have to establish primary care complex units (Unità Complesse di Cure Primarie) (as described in the section on care integration) to replace all other forms of general practice networks (base group practice, network group practice, and advanced group practice).
    • Revise hospital and specialist care fees in line with health inflation and with the underlying structure of health care costs.
    • Revise copayments for outpatient specialist care to promote more equitable access.
    • Copayments currently represent a barrier for disadvantaged sectors of the population.
    • Strengthen the electronic records system.
  • Japan

    Community-based health insurance plans in the public health insurance system (PHIS), operated by municipalities, usually insure residents who are sicker and less well-off than those covered by employment-based insurance plans. The plans vary significantly in the number they insure, from fewer than 100 to more than half a million. To mitigate financial risk in small plans, the national government has gradually expanded cross-subsidies between community-based plans while keeping its and local governments’ subsidies. With increasing financial pressures and the development of region-based governance, plans are being restructured under the 2015 Health Care Reform Act: from 2018, regions will take overall administrative responsibility for community-based plans and work together with municipalities, which will still be insurers of their residents, to set premium rates and to collect premiums. Meanwhile, subsidies from the national government to the regions are to be slightly increased to help plans, and those with low incomes, with excessive financial burdens.

    A plan to strengthen the financial incentive for patients to use family physicians is intended to decrease demand on hospital outpatient departments. Although hospitals with 200 beds or more are currently allowed to charge additional fees to patients who have no referral for outpatient consultations, fewer than half of such hospitals have opted for this extra charge. Under the Health Care Reform Act of 2015, highly specialized large-scale hospitals with 500 beds or more will have an obligation to promote care coordination between providers in the community, as well as to charge additional fees to such patients.

  • The Netherlands

    After years of rapid spending growth, long-term care as of January 2015 is fundamentally reformed. The reform program’s main goals were to guarantee fiscal sustainability and universal access in the future and to stimulate greater individual and social responsibility. The new structure seems to be up and running, but its effects as yet are unknown, and future amendments may be needed.

    In curative health care, market reform and regulated competition remain somewhat controversial. The government, determined to continue stimulating competition between insurers and providers, undertook some measures to that effect, such as requiring insurers and providers to assume greater financial risk. In December 2014, however, the Dutch Senate rejected a new policy proposal restricting free provider choice in specific insurance policies. The accessibility of expensive drugs has rapidly become a prominent issue in 2015.

    As of the date of this report, the Health Insurance Act has undergone two evaluations. The latest evaluation pointed to an imbalance of power, with providers having an advantage over insurers.

  • New Zealand

    Reforms over the past two years have been mostly adjustments to existing arrangements, with one standout. In mid-2013, a new national Primary Health Organisation contract was issued, with new minimum primary health organizations (PHO) standards and a requirement that district health boards (DHBs) and PHOs enter into alliances. The rationale for the requirement was to link together the parts of the health system—GPs and public hospitals in particular—that operate largely separately but with common populations in a region. The impetus for forming these alliances is the government’s increasing concern over chronic disease and care for complex patients, and its desire to better support patients and their providers in primary care settings.

    These alliances reflect an important shift in the governance model and structures for designing and delivering health services in New Zealand. Each alliance must take a whole-system approach, bringing together clinical leaders, managers, and community representatives from across the local health system to consider health services from a patient perspective. An alliance’s focus is primarily integration, with the alliance setting service priorities, generating consensus on how those priorities will be met, and then sharing financial and other resources to facilitate implementation. Many alliances are creating further clinically led “service level alliances” targeting different areas of care design; many also govern health pathway development, which is rapidly expanding across New Zealand.

  • Norway

    Municipality cofinancing of hospital care was abolished in 2015, as it was concluded that it did not have the intended effect of keeping patients out of the hospital.

    Availability of single occupancy for patients in nursing homes for those preferring it has been a goal for many years. The realization that the goal had not been met led the government to introduce reduced payments by patients for occupancy in double rooms as a financial incentive (or penalty) for the municipalities effective from January 2015. No plan is in place for evaluation of the effect.

    A new Agency for Hospital Construction (Sykehusbygg HF) was established in November 2014. Owned by the regional health care authorities (RHAs), the agency will serve as a national center of competence for hospital planning and construction for all hospital trusts. There is no plan for evaluation.

  • Singapore

    Government spending: Since 2012, Singapore has been conducting a major review of the health care financing framework. In the 2012 health care budget, the Minister of Finance announced the government would increase its annual share of expenditure on health care from SGD4 billion (USD4.6 billion) to SGD8 billion (USD9.1 billion) over four years (Ministry of Health, 2012). The contribution by the government will soon rise from one-third to approximately 40 percent of the total, with the prospect of future increases.

    Outpatient subsidies: To maintain affordability of health care, subsidies to lower- and middle-income patients at Specialised Outpatient Clinics in public hospitals were increased starting in September 2014. Subsidies for standard drugs will also be increased these patients beginning in January 2015. Increases are means-tested.

    Medisave: Medisave use has been expanded gradually to cover chronic conditions and health screening and vaccinations for selected groups. In early 2015, Medisave will also cover outpatient scans needed for diagnosis and treatment.

    MediShield Life: Changes to MediShield are being implemented to address the growing need for chronic disease care and long-term care. Coverage has become universal and compulsory, and now includes individuals with preexisting conditions. Previously ending at age 90, coverage is now for life. The lifetime cap on benefits has been removed, and the annual limit increased to SGD100,000 (USD114,000). Another recent change provides better protection from large hospital bills by reducing coinsurance payments below 10 percent, for the portion of the bill exceeding SGD5,000 (USD5,702) (Ministry of Health, 2014).

    Medifund: In 2013, the government added SGD1 billion (USD1.1 billion) to Medifund’s capital fund, which now totals SGD4 billion (USD4.6 billion). This increase will support the implementation of Medifund Junior, which will target assistance to needy children. It also allows for the extension of Medifund coverage in 2013 to primary care, dental services, prenatal care, and delivery. In the same year, annual assistance increased by almost 30 percent, to SGD130 million (USD148 million).

    Community Health Assist Scheme: Previously set at 40 years, the minimum age qualification for the program was removed in 2014. The household income ceiling for eligibility increased from SGD1,500 (USD1,711) to SGD1,800 (USD2,053) per capita per month. More chronic diseases were added, and subsidies for recommended health screening were introduced. These enhancements have enabled more lower- and middle income Singaporeans to benefit from the portable subsidies available at more than 1,000 medical and dental clinics.

  • Sweden

    Important policy areas that have been under scrutiny at both the local and the national level during the last two years include the quality and equity of care, coordination of care, and patients’ rights. Studies following Sweden’s 2010 market reform in primary care show that objectives related to accessibility have been achieved. Its effects on quality, equity, and efficiency, however, are unclear. Accurate reporting and monitoring to measure these criteria remain important challenges in Swedish primary care and are a concern for policymakers.

    In the area of specialized care, there have been recent efforts to foster greater equity. The government has committed to providing SEK500 million (USD55.87 million) per year from 2015 to 2018 to reduce waiting times in cancer care and to reduce regional disparities. This effort is to be built on work previously undertaken within the framework of the National Cancer Strategy and the six Regional Cancer Centers (RCCs). In addition, a commission on equitable health, established in 2015, is to submit a report (due by the end of May 2017) containing proposals for reducing health inequalities in society.

    To improve continuity and coordination of care, in 2014 the government launched a four-year national initiative for people with chronic diseases. Its three areas of focus are patient-centered care, evidence-based care, and prevention and early detection of disease.

    In 2015, a new law addressing patients’ rights went into effect, with the purpose of strengthening the rights of patients and enhancing patient integrity, influence, and shared decision-making. The law clarifies and expands providers’ responsibility in conveying information to their patients, patients’ right to a second opinion, and patients’ choice of provider in outpatient specialist care throughout the country. The government has commissioned the Swedish Agency for Health and Care Services Analysis to monitor and follow up on implementation of the new law until 2017.

  • Switzerland

    As discussed throughout this profile, the Health2020 agenda outlines important national topics, objectives, and measures for improving quality of life, promoting equal opportunity and self-responsibility, ensuring and enhancing quality of care, and creating more transparency, better governance, and more coordination. In concrete terms, the Swiss Federal Council (SFC) realized the following nine priorities in 2014:

    • Adoption of the message (i.e., official explaining text of SFC) concerning the federal law of cancer registries (implementation date of law: not before 2018;
    • Submission for public consultation of the preliminary draft of a federal law concerning a national health quality institute in statutory health insurance (SHI) (new proposal made by the SFC, with open date for implementation);
    • Submission for public consultation of a partial revision of the federal law on SHI concerning better control of the outpatient sector, more control of health care cost, and better assurance of health care quality (implementation date of law: mid-2016);
    • Submission for public consultation of the preliminary draft of a federal law concerning non-ionizing radiation and sound waves (implementation date of law: open);
    • Submission for public consultation of the preliminary draft of a federal law concerning tobacco products (implementation date of law: open);
    • Adoption of regulation on the adjustments of tariff structures in SHI (regulation introduced: October 2014);
    • Adoption of the results of a public consultation on the federal law concerning health professionals (implementation date of law: open);
    • Adoption of the results of a report on the current state of and need for action to support caring relatives;
    • Recognition of the results of the new constitutional article concerning primary health care and plans to enact it (implementation date: open).

    The Swiss Health Observatory is currently creating an indicator system to evaluate the effects of all measures proposed by the Health2020 agenda.

  • United States

    The Affordable Care Act (ACA), which ushered in a sweeping series of insurance and health system reforms aimed at achieving near-universal coverage, improved affordability, higher quality, greater efficiency, lower costs, strengthened primary and preventive care, and expanded community resources, has survived. There have been modifications to the law, however, as a result of several Supreme Court decisions since 2010. Perhaps most notable was the 2012 ruling that made the expansion of Medicaid optional for states: because of that decision, only 30 of 50 states (in addition to the District of Columbia) have pursued expansion as of late 2015.

    Still, since implementation of the ACA in 2013, the number of uninsured adults has declined by historic proportions. Groups that have been long been at greatest risk of being uninsured—young adults, Hispanics, blacks, and those with low income—have made the greatest coverage gains.

    In 2015, the Department of Health and Human Services announced a goal to move 50 percent of Medicare payments to alternative payment models, including ACO-based arrangements, by 2018. Medicare has also begun paying for doctors to coordinate the care of patients with chronic conditions. To be eligible for an extra $40 per patient, doctors must draft and help carry out a comprehensive plan of care for each patient who signs up for one. Under federal rules, those patients have access to doctors or other health care providers on a doctor’s staff 24 hours a day, seven days a week, to deal with “urgent chronic care needs”.

    In April 2015, the Senate passed the so-called Medicare “doc fix,” averting an imminent cut in Medicare physician fees that was scheduled to occur under the now-repealed sustainable growth rate formula (SGR). While the SGR was designed to counter the tendency toward spending growth inherent in the fee-for-service model, it was a flawed model. It was replaced by an approach focusing on rewarding high-performing providers and supporting alternative payment models.