Strategies to control health care expenditure and increase efficiency : recent developments in the French health care system Dominique POLTON National Health Insurance Fund November 2011
In the recent years France has been more successful than previously in controlling the rate of growth of health care expenditure. Examples of steps that have been taken : New mechanisms and governance to ensure the compliance with financial constraints Price regulation and efficiency gains as the main levers of the control of HC expenditure Innovations in collective agreements with HC professionals : example of the P4P scheme 2 2
Switzerland Italy France Hungary Germany Belgium Austria Finland Sweden Ireland Luxembourg Israel United Canada Norway Denmark Spain United Mexico Slovenia Netherlands Iceland Czech New Korea Poland Chile Slovak Estonia A better control of health care expenditure in the recent years 14,0% Average annual growth rate of per capita expenditures (national currency unit) 12,0% 10,0% 8,0% 6,0% 4,0% 2,0% 0,0% 3 3
1. Mechanisms and governance to ensure the compliance with financial constraints [1] 1. 1996 reform The Parliament annually sets a projected target (ceiling) for health insurance spending for the following year, known as the national ceiling for health insurance expenditures (objectif national des dépenses assurance maladie); The target was met the first year (1997) but not the subsequent years. 2. New steps taken in 2004 : 1. alert committee giving an independent advice on the forecasts 2. if the ceiling is expected to be exceeded by more than 0,75%, SHI has to propose measures to make savings 3. 6 months delay to implement tariffs increases 4 4
1. Mechanisms and governance to ensure the compliance with financial constraints [2] 3. New steps taken in 2008 and 2010 (report of a task force) 1. New governance, better monitoring, increased intervention of the alert committee 2. Threshold 0,5% 3. New tools : amounts set aside (part of hospital budgets), tariffs increased canceled in case of alert 5 5
Evolution of the annual ceiling (in absolute terms and growth rate) the size of the circles indicate the amount of expenditure in excess (in blue) or below (in grey) 0,1 0,08 2000 2002 0,06 0,04 1998 2001 2003 2004 2005 2007 2009 2011(p) 0,02 1997 1999 2006 2008 2010 0 85 95 105 115 125 135 145 155 165 175 6-0,02 En Md 6
2. Main levers of the French control of health expenditure [1] 1. Regulation of prices Drugs: price decrease of 11% in the last five years Radiology: -9% between 2007 and 2011 Lab tests: -13% between 2008 and 2011 7 7
janv-99 janv-00 janv-01 janv-02 janv-03 janv-04 janv-05 janv-06 janv-07 janv-08 janv-09 janv-10 janv-11 janv-99 janv-00 janv-01 janv-02 janv-03 janv-04 janv-05 janv-06 janv-07 janv-08 janv-09 janv-10 janv-11 Médicaments Public expenditure - pharmaceuticals (indice base 100 janvier 1999) 2,30 2,10 1,90 Drugs : Price reduction + slowdown of volume 1,70 1,50 1,30 1,10 0,90 cjo-cvs cjo-cvs corrigé des tarifs Laboratoires Public expenditure laboratory tests (indice base 100 janvier 1999) 2,20 2,00 Lab tests : Price reduction, rapid growth of volume 1,80 1,60 1,40 1,20 1,00 0,80 cjo-cvs cjo-cvs corrigé des tarifs 8 value volume 8
2. Main levers of the French control of health expenditure [2] 1. Regulation of prices Drugs: price decrease of 11% in the last five years Radiology: -9% between 2007 and 2011 Lab tests: -13% between 2008 and 2011 2. Efficiency gains: slowdown of drug consumption, increase of generic substitution, development of ambulatory surgery (although our performance could be higher in these two fields), better control of sick leave expenditure, 9 9
France Allemagne Espagne Italie Pays-Bas Suisse RU France Allemagne Espagne Italie Pays-Bas Suisse RU Efficiency gains Annual growth 2006 2009, in standard units per inhabitant (data IMS health) Taux de croissance annuel moyen Statines 2006-09 12% 10,7% 10,4% 10,9% 10% 8% 7,1% 7,8% 6% 4,5% 5,2% 4% 2% 0% Taux de croissance annuel moyen 18% 17,1% 2006-09 IPP 17,1% 16% 14% 12,5% 12,7% 12% 10,9% 11,4% 10% 8% 6% 4% 3,6% 2% 0% Generic substitution, 2004-2011 Number of sick days, 1997-2010 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 10 45,4% 53,6% Taux dans de le répertoire générique conventionnel hors en cours DOM dans le répertoire conventionnel(*) 61,6% 70,0% 40% janv-04 janv-05 janv-06 janv-07 janv-08 janv-09 janv-10 janv-11 81,6% 82,0% 77,2% 79,0% (*) sur la période janvier 2004-décembre 2005, en l'absence de répertoire conventionnel, c'est celui du 31 décembre 2005 qui est considéré. 150,0 140,0 130,0 120,0 110,0 100,0 90,0 Evolution of the number of days of sick leave from 1997 to 2010 Evolution of the number of days of sick leave -11% in 3 years Salaried workers 10 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Efficiency programs : new developments 11 Numerous efficiency programs have been developed over recent years (role of NHI as purchaser of care in 2004, new Regional health agencies with broad responsabilities in 2009) academic detailing and information feedback to health care professionals to promote quality of care and efficient practices, development of guidelines, disease management programs, outreach campaigns towards patients, information, web services (choice of provider, promotion of prevention, ), prior authorisation for targeted hospitals (ambulatory surgery, rehabilitation, ), design of financial incentives for health care professionals (payment for performance), Promotion of cost-effective services for patients discharged from acute care hospitals, 11
Combining tools to achieve results 3 examples (1) Improving the health status of diabetic patients & the quality of care, preventing complications P4P guidelines on the follow up of diabetic patients Mass disease management program patient driven strategy Development of therapeutic education (financing + supply) 12 12
Combining tools to achieve results 3 examples (1) Developing generic substitution Collective agreement with pharmacists Individual targets + alignment of margins (avoid perverse financial incentive) Repeated visits of pharmacists with a low substitution rate by NHI representatives Financial incentives for patients (threat of advancing drug costs) 13 13
Achievement : a rapid increase of generic substitution between 2004 and 2009 90% 85% Taux dans de le répertoire générique conventionnel hors en cours DOM dans le répertoire conventionnel(*) 80% 81,6% 82,0% 77,2% 79,0% 75% 70% 65% 60% 55% 50% 45% 45,4% 53,6% 61,6% 70,0% 80.0% 70.0% 60.0% (*) sur la période janvier 2004-décembre 2005, en l'absence de répertoire conventionnel, c'est celui du 31 décembre 2005 qui est considéré. 50.0% Taux de réussite selon le niveau de départ découpage en classe d'amplitude 10 49.5% 58.8% 70.4% 72.2% 73.5% 40% janv-04 janv-05 janv-06 janv-07 janv-08 janv-09 janv-10 janv-11 40.0% 34.8% 14 Visits by HI representatives and HI pharmacists targeted towards pharmacists with a low subsitution rate + financial incentives for patients (third party payer) 30.0% 20.0% 10.0% 0.0% 0.0% 11.3% 14.1% 22.4% [0% et 10%[ [10% et 20%[ [20% et 30%[ [30% et 40%[ [40% et 50%[ [50% et 60%[ [60% et 70%[ [70% et 80%[ [80% et 90%[ [90% et 100%] 14
Combining tools to achieve results 3 examples (1) 15 Better use of physiotherapy in ambulatory care Guidelines Prior authorization linked to guidelines (thresholds) Control of professionals with excessive prescription 15 15
Variations in the average number of sessions of physiotherapy in ambulatory care for the same surgical procedures (carpal tunnel syndrome, hip replacement) : from 1 to 4 Prior autorisation above a threshold depending on the medical situation 16 16
2. Main levers of the French control of health expenditure [3] 1. Regulation of prices Drugs: price decrease of 11% in the last five years Radiology: -9% between 2007 and 2011 Lab tests: -13% between 2008 and 2011 2. Efficiency gains: slowdown of drug consumption, increase of generic substitution, development of ambulatory surgery (although our performance could be higher in these two fields), better control of sick leave expenditure, 3. + increase in cost-sharing requirements (paid by complementary health insurance or patients) (about 1/5th of total savings in the last 5 years, according to the High Coucil on the future of health insurance) 17 17
3. Innovations in collective agreements with HC professionals Negotiation of efficiency targets, performance measurement and benchmarking, academic detailing HI practitioners (physicians, pharmacists, dentists) and HI representatives (since 2004) visit health professionals, giving them information on their practices and promoting efficient prescribing Examples of information feedback and tools for GPs 18 18
Some academic detailing efforts have been successful, e.g. statins 2,3 2,1 Expenditures on statins prescriptions Beginning of the program 1,9 1,7 1,5 1,3 1,1 volume (quantité+structure) Quantité en DDD Remboursable 0,9 0,7 janv-01 janv-02 janv-03 janv-04 janv-05 janv-06 janv-07 19 19
3. Innovations in collective agreements with HC professionals Development of a P4P component in the payment of physicians First pilot in 2009: CAPI (contrat d amélioration des pratiques individuelles) A new step: collective targets individual targets P4P (baseline = wide variations in practice) individual contracts, subscribed by GPs on a voluntary basis 40% have subscribed 16 indicators, mostly process measures, in 3 fields: Prevention (immunisation, cancer screening, ) / Follow up of chronic care patients (diabetes, hypertension) / Efficiency of drug prescription (prescription of generics) 20 20
3. Innovations in collective agreements with HC professionals The baseline : Practice variability among French GPs Distribution of French GPs according to % of their diabetic patients having 3 or more HBA1C tests during the year in the last 12 months - 40% for the average physician, target : 65% 20% 40% 60% 21 21
3. Innovations in collective agreements with HC professionals Results after 2 years (June 2011) More improvement for contracting GPs (statistically significant for all indicators) as compared to non contracting GPs For some indicators, the difference is important, e.g.: % of patients with 3 Hb1C controls per year: + 7 points vs + 2 points for non contracting GPs (level achieved in June 2011 : 47% on average vs 42%) % of statin prescription for diabetic patients with high cardiovascular risk: + 5 points vs + 3 points (59% on average vs 56%) % prescription of generic PPIs: +1 point vs -7 points 22 22
3. Innovations in collective agreements with HC professionals Generalisation Inclusion in the 2011 collective agreement The 2011 Act on social security has allowed the contract to be integrated in the new collective agreement. The agreement has been signed in July 2011 and P4P is now part of the basic remuneration of physicians. New indicators have been developed, with : an emphasis on outcomes (level of Hb1C, blood pressure, ), and a new field Practice organisation : use of EMR, use of a software labelled by HAS for prescribing, electronic exchanges with NHI, information for patients, annual synthesis of the medical record Although the scheme is more developed for GPs, it now includes specialists as well. 23 23
3. Innovations in collective agreements with HC professionals Other collective agreements selective contracting Professionals cannot set up their practice in the areas where the density is already very high They have incentives to set up their practice in underserved areas First profession involved = nurses, now physiotherapists 24 24
Conclusion France has succeeded in controlling health care expenditure in the recent years However there are still important efficiency gains that could be made in the system, as in all countries Development of new efficiency programs (better organisation, territorial levers with the Regional Health Agencies) Challenge of the professionalization of the health care system management, necessary to achieve our objectives Growing focus on the process of care - Need for more economic evaluation and health technology assessment 25 25