RAPPORTI INTERNAZIONALI – UEHP position on transparency in health care financing

di Alberta Sciachì - 12.06.2013 16:56

Alberta Sciachì

To tackle the sensitive problem of transparency in healthcare financing, it is important to make reference to the Social Investment Package for growth and cohesion, recently adopted by the European Commission to help Member States to use their social and health budgets more efficiently and effectively. At this regard it is very interesting that the accompanying paper, Investing in Health (Commission Staff Working Document), establishes the role of health as integral to the Europe 2020 strategy. The paper significantly states that health is a value in itself as well as healthcare is a precondition for the economic prosperity and for a job-rich recovery. Health spending is a “growth friendly” expenditure and the UEHP fully agrees with this point of view.

Nevertheless, the mentioned Paper does concede that financial sustainability may require cuts to healthcare budgets because of the need to curtail health costs in the short term. Actually, in response to the economic crisis, a few Member States have reduced their healthcare budgets.

According to OECD Health Data 2012, “as a result of the global economic crisis … a zero growth in health expenditure was recorded on average” and estimates for the future suggest that low or negative growth in health spending will continue. By consequent, it is crucial to implement a long-term strategy for health care issues since this sector requires stable resources and long-term prospects.”

From the same point of view, the Commission’s Working Paper warns that “sudden significant reductions in healthcare budgets risk creating new inefficiencies, undermining access to and the quality of care, damaging health outcomes and ultimately jeopardising the sustainability of the health system even more by increasing costs”.

By consequent the Commission rightly recommends a careful assessment of effectiveness of measures and it proposes to assess the efficiency of health system also through a better understanding of how health policies affect health outcomes.

For instance, the Paper notes that the introduction of user charges in some health reforms could have a negative impact on health inequalities and reduce access to healthcare. Thus, these measures have to be carefully assessed.

Fundamentally, the Commission reaffirms the necessity of investing in people’s health, in the health workforce, as suggested in the Action Plan 2012, and in reducing inequalities. At this regard efficient healthcare services are essential to guarantee universal access to safe, high quality services.

Also if EU countries are responsible for the organization and delivery of their own health services and care, health system reforms are recommended as part of the European Semester, and some Member States include this in their National Reform Programmes. Within this framework, there is an exchange of best practices taking part in the reflection process on modern, responsive and sustainable health systems. To this end, the Commission is also planning a number of studies, included the evaluation of public-private partnerships in healthcare delivery. On this point, the European private hospital sector is ready to offer its contribute to any future initiative.

As member of the Health Policy Forum, UEHP shares the Forum position urging DG SANCO to continue its participation and to increase its capacity to work on health system reform. The EUHPF also emphasises that collaboration between DG SANCO and DG EC FIN should be scaled up. Additional actions should be envisaged to produce transparent, clear and understandable criteria for any decrease in spending in health systems based on evidence. The Forum has long warned that reducing budgets for health and social expenditure would lead to increasing social and health inequalities and will have dire impact on economic effectiveness and social cohesion. The EUHPF commends the Commission for its novel proposal for a three-pronged analytical framework to assess the efficiency of health systems and it encourages Member States, with the support of the Commission, to increase their data-collecting capabilities in the field of health and to improve efficiency, also developing clear and justifiable incentives.

After having underlined our full accord with these HPF statements, let me illustrate shortly, but more in detail the particular UEHP position on healthcare financing and austerity.

In pour opinion, to optimize the health systems, it is of the main importance to assess the improvement in value for money and in health outcomes in the interest of an all-inclusive society. In such a situation, freedom of choice - through the offer of an alternative set up by a plurality of providers – is to be considered not only as a fundamental EU citizens’ right, but also a driver for the economic recovery.

Facing the present crisis, it is essential to consider the overall cost of disease and the broader economic consequences of health protection, because increasing health equates to increasing wealth. If costs constraint is the major or the only concern, health care sector is considered an unproductive investment and not an important employer, consumers of goods and leader in the field of innovation, research and development, as it is in fact. Although it is necessary to improve the cost efficiency, no EU country can afford to consider its health system only as a burden and an expenditure to curb or even to cut down, without previous and accurate analysis. At this regard, a possible involution of the policy trends is very dangerous, as long periods of budget restraint may make it more difficult to create conditions for making progress, as documented by the OECD.

In fact, the misguided perspective in which health expenditure is conceived only as a cost and not as an investment has conditioned national governments, and, as a result, the rationalization of health expenditure has often resulted in the rationing of health services. At present the main concern is to analyze in depth the achievable solutions for fulfilling health priorities, assuring patient safety, reducing waiting times consistently with the financial boundaries. In view of the current containment of the budgets, the decisive challenge is to guarantee equity of access, quality standards and financial sustainability, even if money is tight. At this regard, the UEHP is seriously concerned about a possible regression, highlighting the importance to identify opportunities for patients’ involvement and increasing productivity in the health care sector, through a better use of the structural, technological and professional equipment, both public and private. In our opinion, only a rational and effective allocation of the resources will make European health systems able to guarantee a real improvement of the macroeconomic situation.

On the side of services production, the connection between cost - quality - benefits must be examined in depth, as the hospital sector still account for more than 40% of health spending on the average. Sustained enhanced productivity allows the same results to be obtained with lower costs, and consequently it is the appropriate answer to cost pressure. Considering public expenditure for health, the contribution of private resources is necessary as capital and human resources provided by private entrepreneurs play a key role in the provision of care services. Private hospitals help to balance public expenditure, as they take part in the supply of services for the social insurance or for the national healthcare service, increasing the opportunities of access and allowing a better protection of health. Moreover, they add complementary means allowing the State to save capital investment and to impose a tax on earnings and they play the role of moderator in costs, thanks to efficient management. Private initiative is supportive for healthcare systems especially if it is considered in order to build long-term medical infrastructure and not submitted to a short term planning.

The main thread in the reform initiatives implemented by many European countries in the last decades was to introduce entrepreneurial behavior in healthcare systems, in order to gain the advantages of efficiency, without neglecting the principles of universality, equity, solidarity, security guaranteed through the policy direction, control and responsibility exercised by the State. To reach these goals, private hospitals were incorporated into the general health system under public control or, sometimes, public hospitals’ management was entrusted to private operators and public-private partnerships came into operation, achieving good results. In spite of the differences of national healthcare systems, common principles are emerging within EU for a better model of healthcare service, which try to reach a balance between access, quality and viability, taking in due consideration the complexity of healthcare as a sector of considerable social values, but also of economic interest.

Nowadays, it is necessary to define and concretely implement the conditions for an impartial management of the public-private mix at the basis of many European health care systems. Only in this way it will be possible to improve the overall performance of the health care services. In the framework of a rigorous analysis of cost, quality and remuneration criteria, fair competition among providers - on the supply side - and consumer choice - on the demand side - can contribute to maintain a satisfactory quality level, squeezing out wastes caused by inefficiency. Consequently our Association is in favor of a mix and integrated system, where the State role should be to set the rules for facilitating:

  • equity in access conditions for citizens and in accreditation conditions for providers

  • transparent and widespread information for citizens about services supply

  • quality assurance through equal controls for all providers on the responsibility of independent organizations

  • financing, determined by correct and homogenous remuneration criteria both for private and public hospitals

  • transparency for the financing agency about quality and costs of providers.

However, if private hospitals accept the same obligations as public ones, they are entitled to the same rights. At this regard and in order to improve efficiency, public authorities should play a decisive role in ensuring that no actor in the healthcare sector bypasses the current regulations in order to benefit from various forms of granted privilege, for example in favor of public hospitals with a deficit position.

To sum up, the UEHP advocates a model of healthcare service, responding to the obligations of a general economic interest service, based on a public-private mix, sustainable, fairly managed and able to guarantee:

  • citizens’ right to freedom of choice and adequate answer to the demand

  • quality improvement and investments in innovation

  • effective use of all the resources

  • plurality and equality of providers, public or private, offering citizens concrete alternatives

  • fair competition based on quality, because in periods of budget constraints, institutions offering the best at compatible costs must be supported with stimulating incentives.

In a healthcare system where the State sets the rules of a fair and collaborative competition, the private sector can assure a function of general interest. As a result private hospitals’ sector can contribute to ensure not a formal, but a real protection of welfare principles, progressing from a theoretical declaration of rights to an adequate answer to citizens’ concrete needs, through the best possible use of the available resources, in the perspective of a sustainable growth.