In 2016, the federal government announced that it will implement “health care homes” for the 20 percent of patients with multiple chronic conditions who are most in need of support. Patients will enroll with a GP, who will be paid a bundled payment for their care. The first of these patients are due to begin treatment in a health care home by July 2017.
The federal government has committed to doubling its investment in the public dental program to AUD5.0 billion (USD3.25). It is estimated that the Child and Adult Public Dental Scheme, implemented by states and territories, will help more than 10 million Australians, providing coverage for the 5.3 million children under age 18 and some 5 million low-income adults.
In June 2016, the federal government introduced legislation that amended the criminal code to allow eligible adults to request medical assistance in dying from a physician or nurse practitioner.
Provincial health system governance: Provinces and territories continue to implement structural reforms to improve efficiency. For example, in August 2016 the new Northwest Territories Health and Social Services Authority became operational, consolidating eight former regional authorities to improve care coordination across health and social services. In June 2016, Ontario announced a proposal to transfer responsibility for the contracting and coordination of home and community care from Community Care Access Centres to the Local Health Integration Networks. The provincial government also announced it will increase the integration of primary care and public health within health regions.
As discussed throughout this profile, the Health2020 strategy outlines important national topics, objectives, and measures for improving the quality of life, promoting equal opportunity and self-responsibility, ensuring and enhancing the quality of care, and creating more transparency, better governance, and closer coordination. In concrete terms, the Swiss Federal Council (SFC) is pursuing the following 10 priorities in 2016:
- Adoption of the revised radiation protection regulations
- A decision on how to proceed with the total revision of the Federal Act on the Genetic Testing of Human Beings
- Adoption of the national strategy for the prevention of noncommunicable diseases
- Adoption of the revised regulation of risk adjustment in health insurance
- Consultation on the modification of the federal law on health insurance for the introduction of a reference price system
- Adoption of resources to create a health technology assessment unit
- Consultation on revision of the inclusion of complementary medical services in mandatory health insurance
- A decision on the introduction of the federal law on electronic patient records
- Adoption of the Suicide Prevention Action Plan
- Adoption of the dispatch on the approval and implementation of the Medicrime Convention of the Council of Europe.
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 the markup of prescription drug prices. At the same time, 224 prefectures and cities in 21 provinces adjusted the prices of health care services upward to reflect true costs. In 2016, more public city hospitals participated in the zero-markup drug policy. For example, all public city hospitals in Beijing and Hunan Province were to end markups by the end of 2016, and by 2020 all public hospitals in the country are to do so as well. Where it has been implemented, zero markup 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, that 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 current rural 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. In 2016, the central government provided CNY16 billion (USD4.5 billion) in subsidies to severe-disease insurance. By 2016, severe-disease insurance is expected to be available throughout China.
A plan for reorganization of the central governance structure was implemented by the incoming government in the fall of 2015. The reorganization created four agencies, dealing with health, medicines, patient safety, and IT, to replace the previous Health and Medicines Agency. The intent is to provide a clearer division of labor and more transparency and to improve the overall surveillance and accountability structure.
A new regional “medicines council” will be established in 2017 to evaluate the cost-effectiveness of new pharmaceuticals. The new council will replace the existing assessment structure, which does not include economic evaluation. The council will provide guidance for regional decision-making and the administration of tenders within Amgros, the joint regional purchasing organization.
The Danish government and the regions have agreed to implement a new quality management scheme for hospitals in 2017 to replace the existing accreditation-based model. The new scheme includes a set of national indicators to be published annually and will allow more freedom for the regions and hospitals in designing their internal quality procedures and standards. The new model accommodates input from health professionals and hospitals that considered the accreditation-based scheme too burdensome and inflexible. The new scheme is based on the ideas of “permanent improvement culture” and “value-based health care.” The existing accreditation-based scheme will continue to operate for primary care and municipalities.
Since 2012, the German health care system has been undergoing a period of active reform in several areas. The most influential reform in the past year was the Second Act to Strengthen Long-Term Care, which went into effect in January 2016; this followed the First Act, which significantly expanded support for individuals in need of long-term care and for their families. The Second Act, set to start in 2017, will broaden eligibility for long-term care services, which previously have been granted only to people with considerably restricted daily functions. The new act aims to provide services more equitably, by expanding eligibility to people with physical, mental, and psychological impairments. The new benefits are being integrated into the standard legislation on benefits.
To finance these reforms, the contribution rate for long-term care insurance (LTCI) will increase by 0.2 percentage points, up to 2.55 percent of income for people with children and 2.80 percent for people without children. According to the government, the increase in contribution rates will generate about EUR6.0 billion (USD7.6 billion) in additional revenue, which should cover the additional spending on long-term care by 2022.
The two major reforms of 2016 have been the universal access to statutory health insurance (effective January 2016) and the deployment of third-party payment for physicians’ consultations (to go into effect in 2017). Both reforms have a clear Beveridgian inspiration and are part of the policy to reduce social inequities in access to care; the latter has also been denounced by physicians’ unions as the “nail in the coffin” for private providers. Reducing health inequities was part of the 2012 presidential campaign platform and has been a recurrent theme for a number of years. While universal insurance access was implemented at once and without political difficulty, third-party payment is being implemented in stages. Starting in July 2016, patients with chronic conditions and pregnant women can obtain it, and by January 2017 all patients will be able to do so, with use becoming mandatory in November 2017. The impact on health inequities will be assessed by monitoring the uptake and patients’ use of medical resources.
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 strategies to address them. These include pilot programs across England to test new models of care known as “vanguards.” To date, there are 50 vanguard sites testing such innovations as 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 these will lead to better tools for identifying those at risk of becoming high-need, high-cost patients, and to the development of capitated contracts to encourage 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. All NHS areas are also expected to implement full seven-day working weeks in hospitals and general practice by 2020, as pledged in an election manifesto in 2015.
To accelerate the process of reform, in December 2015 the government announced a new approach that involves all local purchasers and providers coming together across 44 local “footprints” to create multiyear plans to transform services, based on a conglomerated budget for their local populations. Although the legal responsibility of individual NHS organizations to break even remains unchanged, this approach calls for organizations to collaborate, and represents an important break with the previous policy of competition.
The most important recent reform undertaken in India is the National Health Mission, which seeks to strengthen health systems as described above and sets national priorities for efforts such as disease control.
The Ministry of Labor and Employment’s effort to expand health coverage through the RSBY insurance scheme has also been important. In fact, the Prime Minister has recently announced a similar scheme, the National Health Protection Scheme, to extend health coverage to more of India’s poor citizens. However, it has not yet been implemented.
In addition, ongoing fiscal restructuring and program cuts are likely to have significant impacts on the health sector in the future.
Voluntary health insurance: In 2016, the government introduced several changes to the regulation of VHI, with an eye toward restraining growth in this coverage and providing consumers with greater value for the premiums they pay. Key components include the standardization of commercial insurance coverage for surgical operations and the requirement that VHI payments to surgeons be channeled through the hospitals in which they work.
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. 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.
Comparative data on hospital performance: In 2015, the Ministry of Health (MoH) began publishing comparative data on hospital quality, and the indicator set is rapidly being expanded. In 2014, the ministry published the results of nationwide surveys of hospitalized patients regarding their care experience, and a similar survey has been carried out in 2016. The ministry has also assembled a database of waiting times for surgical operations, with the intention of publishing updated comparative data in the near future. The objectives of all these efforts are to provide hospitals with information to help identify problem areas, to enhance consumer choice of hospitals, and to 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 raise public confidence in the publicly financed health care system and to improve quality of care, the MoH is planning a major initiative to reduce surgical waiting times. This will involve additional funding to expand the hours of operation for surgical theaters, as well as a series of organizational changes to improve efficiency.
Improving service levels in hospital emergency departments (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 staffing of physicians and nurses, the introduction of physician assistants into the EDs, and the engagement of operations management experts to improve workflow.
Long-term care insurance: Israel’s long-term care (LTC) 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 LTC to the set of NHI benefits for which the health plans are responsible, with the plans also serving as the LTC budget holders.
Full-timer program: In mid-2016, the MoH launched an initiative in which voluntarily selected physicians in public (i.e., government and nonprofit) hospitals will receive significantly enhanced pay in return for 1) working additional hours in a public hospital and 2) agreeing not to work in the private sector. The overall objective of the full-timer initiative is to strengthen Israel’s publicly financed health care system by improving its availability, quality, and safety.
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.
In April 2015, the Ministry of Health approved a decree for the reorganization of hospital care. The decree classifies public hospitals into three groups:
- Base hospitals (for populations of 80,000–150,000 residents), with emergency wards, internal medicine, general surgery, orthopedics, and on-call availability of radiology, laboratory testing, and blood bank
- First-level hospitals (150,000–300,000 residents), with the same wards as base hospitals and, in addition: obstetrics (based on the number of deliveries per year), pediatrics, cardiology with intensive care unit, neurology, psychiatrics, oncology, ophthalmology, otolaryngology, and urology
- Second-level hospitals (600,000–1,200,000 residents), with advanced emergency wards and facilities for treating highly complex patients (or conditions)
In addition, the decree introduces, for a few procedures, minimum levels of activity and quality thresholds. Examples include at least 75 surgical interventions per year for femoral fractures in second-level hospitals, and the requirement that at least 60 percent of patients age 65 and older admitted for femoral fractures must be operated on within 48 hours. Many of the law’s provisions are in the process of being implemented, and the effects have not yet been evaluated.
In January 2017, the government approved an updated version of the “essential levels of care.” The new document introduces significant public health changes: vaccination programs; outpatient specialist care, with a substantial revision of the treatments that can be delivered by the National Health Service; and hospital care, with a further shift of treatments to outpatient settings. The government estimates an additional expenditure of EUR 800 million (USD 860 million) per year.
The Social Security Council set priorities on the following four objectives for the 2016 revision of the fee schedule:
- developing an efficient comprehensive community care system;
- improving the quality and safety of patient care;
- developing high-priority services (e.g., cancer and dementia care); and
- making the health care system more efficient and sustainable.
The government has been promoting the idea of “preferred physicians” for the purpose of improving care coordination and continuity. The 2014 revision of the fee schedule introduced Continuous Care Fees (CCFs), which are monthly payments for providing continuous care (including referrals to other providers, if necessary) to outpatients with chronic diseases. A provider and a patient can opt for the CCF for services provided if they agree with the providers' preferred status. A top-up to the CCF in the case of patients with dementia was introduced by the 2016 revision.
With the 2015 amendment of the Medical Care Law, providers will be able to establish umbrella organizations to promote collaboration, for example, through partnership agreements, copurchasing of pharmaceuticals and medical devices, or sharing of resources.
After years of rapid spending growth, in January 2015 long-term care was 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 are as yet unknown. In 2015–2016, some mitigating policies have been adopted, and future amendments are expected to alleviate fiscal stress in nursing homes.
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. Affordability and the accessibility of expensive drugs have rapidly become prominent issues.
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.
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.
The new Agency for Hospital Construction (Sykehusbygg HF) was established in November 2014. Owned by the four regional health care authorities (RHAs), it will serve as a national center of competence for hospital planning and construction for all hospital trusts. There is no plan for evaluation.
The restructuring of the governmental health bureaucracy in 2016, with the integration of smaller agencies into the Institute for Public Health and the Directorate for Health, as well as the development of the new Directorate of eHealth, will continue in 2017 with the establishing of common information technology services for the governmental health bureaucracy through the National Health Network.
The updated New Zealand Health Strategy, launched in 2016, consists of two parts: the Future Direction, and the Roadmap of Actions 2016. The former lays out some of the challenges and opportunities the system faces and describes the desired future, including the underpinning culture and values. In addition, it identifies five strategic themes for driving change: 1) improving patient literacy and empowerment; 2) emphasizing prevention, early intervention, and community care; 3) improving system performance; 4) integrated and collaborative health care delivery; and 5) technological innovation.
The Roadmap of Actions 2016 identifies 27 areas for action over five years to implement the Health Strategy. These actions, organized under the five themes listed above, will ultimately contribute to the stated goal that “all New Zealanders live well, stay well, get well, in a system that is people-powered, provides services closer to home, is designed for value and high performance, and works as one team.”
Medisave use has been expanded gradually to cover chronic conditions such as diabetes and high blood pressure, as well as health screenings and vaccinations for selected groups. The Medisave Contribution Ceiling was increased in 2016, and there is no longer a Medisave Minimum Sum.
Changes initiated in November 2015 to MediShield Life aim to address the growing need for chronic disease care and long-term care. Coverage is now universal and compulsory and 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 (USD118,000). 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 (USD5,882). Less than 1 percent of Singaporeans will need to pay additional premiums.
In 2015, the Ministerial Committee on Ageing unveiled new features of an SGD3 billion (USD3.53 billion) national plan to help Singaporeans age with confidence, lead active lives, and maintain strong bonds with family and community. The plan encompasses about 60 initiatives covering 12 areas: health and wellness, learning, volunteerism, employment, housing, transport, public spaces, respect and social inclusion, retirement adequacy, health care and aged care, protection for vulnerable seniors, and research.
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, patients’ rights, and investment in e-health.
Studies following Sweden’s 2010 market reform in primary care show that objectives related to accessibility have been achieved. The reform’s 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 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) detailing 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 took effect that strengthens the rights of patients and encourages shared decision-making. The law clarifies and expands providers’ responsibility in conveying information to patients, guarantees patients the right to a second opinion, and ensures choice of provider in outpatient specialist care. The government has commissioned the Swedish Agency for Health and Care Services Analysis to monitor implementation of the new law until 2017.
Finally, in 2016, the government set out a vision of Sweden as world leader in e-health by 2025. The strategy involves: 1) coordination and communication among health care stakeholders; 2) development of common concepts in the field; 3) implementation of standards for health information exchange; and 4) creation of national drug lists that assist health care professionals in efforts to improve patient safety.
Important innovations and reforms in Taiwan’s single-payer health insurance system have been discussed in earlier sections. These include the global budget system, diagnosis-related group (DRG) payment for hospitals, pay-for-performance (P4P), National Health Insurance (NHI) card, PharmaCloud, My Health Bank, and various initiatives aimed at quality improvement and cost containment.
A major reform meriting special attention is the Second-Generation NHI Reform, which imposed a supplementary premium on six nonpayroll sources of income: rents, interest, dividends, large bonuses, professional incomes, and income from second and third jobs. Implemented in 2013 at an initial rate of 2 percent and reduced to 1.91 percent in 2016, the supplementary premium broadened the premium base and put the NHI system on sound financial footing (it now has a large surplus). Moreover, the reform improved equity in financing: the previous payroll-based premium system had weighed most heavily on Taiwan’s salaried class and thus favored the wealthy.
The Affordable Care Act (ACA) ushered in sweeping insurance and health system reforms aimed at achieving near-universal coverage, greater affordability of coverage and care, higher quality and efficiency, lower costs, more robust primary and preventive care, and a broader array of community resources. As of February 2017, the future of ACA is unknown, though it will most likely be repealed or altered by the new Congress. The exact nature of any replacement program is also unknown.
Since implementation of the ACA, the number of uninsured adults has declined by historic proportions. Groups that have long been at greatest risk of being uninsured—young adults, Hispanics, blacks, and those with low income—have made the greatest coverage gains, though inequalities remain.
In 2015, the U.S. Department of Health and Human Services announced a goal to move 50 percent of Medicare payments to alternative payment models, including accountable care organization (ACO)–based arrangements, by 2018. As of early 2016, the U.S. Department of Health and Human Services (HHS) had already reached an interim goal of 30 percent. Medicare has also begun paying for doctors to coordinate the care of patients with chronic conditions. To be eligible for an extra USD40 per patient, doctors must draft and help carry out a comprehensive care plan 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 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed by Congress to align financial incentives for providers with high-value care. The law overhauls how hundreds of thousands of clinicians are paid by Medicare, through two value-based provider payment pathways under Medicare Part B: Advanced Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS). The Advanced APM path aims to promote participation in existing APMs such as ACOs, medical homes, and bundled payments for joint replacement and cardiac care. MIPS adjusts traditional fee-for-service provider payment according to several factors: quality, cost, provider efforts to utilize health information technology, and practice improvement. The reforms under MACRA are meant to support the transition of the U.S. health care system from fee-for-service payment to payments based on the value and quality of care delivered; they are intended to generally promote approaches to care delivery focused on better care, efficient spending, and healthier patients.