Health reform the debate goes public

Health reform The debate goes public Commissioned by Philips The third report in a series of four from the Economist Intelligence Unit Health reform The debate goes public Contents Preface Executive summary In search of the grand bargain The need for reform A unique opportunity in the US 10 Germany: post-reform pessimism 10 Prodding an elephant in the UK 13 A new role for citzens 15 Citizens as consumers of healthcare 16 The rise and rise of citizen advocacy 16 But what they want? 19 Steps forward for patients in the UK 22 Indian healthcare: seeking a new route 22 Conclusion—Policymakers’ grand bargain 25 Appendix: Survey results 27 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Preface H ealth reform: The debate goes public is an Economist Intelligence Unit report commissioned by Philips, the third in a series of four to be published in 2009 The Economist Intelligence Unit bears sole responsibility for the content of this report The findings and views expressed within not necessarily represent the views of Philips Our research drew on two main initiatives l In June and July 2009 we conducted a major survey of citizens across four key economies: the US, UK, Germany and India In total, 1,575 respondents took part in the survey, with an equal gender split All respondents were of working age, with the sample including full- and part-time employees, students, the unemployed and retirees l To supplement the survey results and help interpret their implications, we also conducted indepth interviews with numerous leading figures in the healthcare sector, including policymakers, practitioners and other experts Of the respondents, 481 were in the US, 461 in Germany, 360 in the UK and 273 in India The survey sought to be broadly representative of each country’s population, across a range of age groups, levels of education and employment status In the case of India, most respondents fell into the 18-55 age group, with only a small percentage aged 56 and over Similarly, in line with demographic trends, the US cohort included the largest proportion of respondents aged 56 and over Almost 40% of US and UK respondents, and 23% of Germans, were retired The report was written by Julie Sell and edited by Iain Scott and Gareth Lofthouse We would like to thank everyone who participated in the survey, and all the interviewees, for their time and insight © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Interviewees Eric Odom—Executive director, American Liberty Alliance (US) Dr James Rohack—President, American Medical Association (US) Sophia Schlette—Health programme director, Bertelsmann Foundation (Germany) and senior international advisor, Kaiser Permanente Institute for Health Policy (US) John Castellani—President, Business Roundtable (US) Dr Richard Freeman—Professor, University of Edinburgh School of Social and Political Science (UK) Monika Sood—Vice-president of corporate advisory services, Feedback Ventures (India) Kavita Ramdas and Anasuya Sengupta—CEO and President, and Asia and Oceania programme director, respectively, The Global Fund for Women (US/India) Professor John Appleby—Chief economist, The King’s Fund (UK) Dr Peter Reader—Clinical director, Humana Europe (UK) Stefanie Ettelt—Research fellow, London School of Hygiene and Tropical Medicine (UK) Mary Wilson and Betsy Lawson—President and senior lobbyist, respectively, League of Women Voters (US) R T Rybak—Mayor of Minneapolis, Minnesota (US) Professor Laura Carstensen and Jane Hickie—Director and senior research scholar, respectively, Stanford University Centre on Longevity (US) Jenn Brown—Minnesota state director, Organizing for America (US) Ted Marmor—Emeritus professor of public policy and management, Yale University (US) © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Executive summary H ealthcare systems are complex, enormous and unwieldy, whether they are state-managed monoliths such as the UK’s, or dominated by the private insurance sector, as in the US They are traditionally slow to adapt to change, but now those immovable objects are being forced to confront not just one, but several irresistible forces: demographic (ageing populations), epidemiological (increasing incidence of chronic diseases), technological (more expensive drugs and technologies) and economic (global recession, high public debt, smaller pensions) The price for ignoring these forces could be disastrous— the US president, Barack Obama, has warned that if it is allowed to continue down its present course, the US healthcare system will bankrupt the entire country Try telling the end-users of healthcare about these pressures, and they will be nonplussed In a major survey for this report, the Economist Intelligence Unit set out to ascertain just what the citizens in four large economies—the US, UK, Germany and India—think about their healthcare systems The findings show clearly the kinds of dilemmas faced by healthcare policymakers who seek to implement reforms The starkest example emerges when respondents were asked in basic terms about their expectations for choice and cost in healthcare Globally, 83% of respondents say that they would prefer to shop between a range of options in order to get the best treatment At the same time, however, more than half say that they are not prepared to pay more to get a better healthcare service, whether in the form of taxes, fees at point of provision or fees to insurers Consumers want choice—but are not prepared to pay for it Our survey shows that citizens’ expectations for healthcare are high—not just in developed countries, which have been used to high standards of care, but also in developing countries such as India, where people are becoming accustomed to better standards They want access to the latest treatments, timely, affordable care, and a range of choices They are better informed than ever about their health and their treatment options They are prepared to take some responsibility for their own health, but broadly they not want to have to pay a lot more than they already are for their healthcare If they are unhappy with aspects of their healthcare, they largely lay responsibility at the feet of their governments Key findings from the survey include the following: l Governments get a thumbs-down on their handling of healthcare Not surprisingly, the economy and jobs are seen by respondents as the most important issues for their government, but healthcare takes second billing in the US, Germany and India—ahead of education, the environment, crime, defence and housing In the UK it comes third, after crime, but 29% of Britons are generally more inclined to agree © Economist Intelligence Unit Limited 2009 Health reform The debate goes public that their government has the right approach to healthcare By contrast, just 8% of Germans think their country is on the right track, whereas 62% think their government has the wrong approach, as nearly half of American respondents l If patients are now customers, they are not happy ones When it comes to healthcare, Americans, arguably, have more choices than citizens of most other countries However, when asked to indicate their levels of satisfaction with a range of aspects of healthcare (such as waiting times, quality and availability of care and doctors, cost of treatment and medicine), almost one-quarter of Americans say they are not satisfied with any That was an even higher figure than in the UK (15%), where patients have far less choice That does not mean Americans believe they receive poor-quality care—compared with other countries, more US respondents are satisfied with the quality of their doctors, with waiting times and with general quality and availability of healthcare—but the finding does indicate a high level of general dissatisfaction Strikingly, about one in five respondents across the global sample say they are not satisfied with any aspect of their country’s healthcare system l Some patients are more empowered than others Only one-quarter of UK respondents feel they have much control and influence over where and how they are treated, compared with 64% of Americans Nearly 60% of British respondents say that they are not encouraged to choose from a range of doctors or hospitals for their treatment The UK government’s recent about-face, allowing patients to choose between public and private healthcare, without losing access to the National Health Service (NHS), appears to be a welcome one—three out of four respondents say that they would compare services to get the best possible treatment Meanwhile, US residents are more optimistic (74%) than those in the UK (61%) or Germany (38%) that they will get prompt, effective treatment if they become ill Some 74% of Americans, however, say they are concerned about being able to afford that treatment—far more than Germans (55%) or Britons (50%) l Britons are not keen on fees, but are more relaxed about tax UK citizens are less keen than people elsewhere on the idea of paying fees at the point of provision (co-payments), or to insurers, for an improved healthcare service However, the survey found that more Britons (27%) would be willing to pay higher taxes for improved healthcare services than would Americans (15%) or Germans (9%) Meanwhile, nearly 45% of Britons say that they would not be willing to pay anything extra, compared with 61% of Americans and 64% of Germans The British are also wary of the notion that greater private-sector involvement would improve the country’s healthcare system, perhaps not surprising given that private healthcare takes up a relatively small amount of the country’s healthcare expenditure l German gloom spells a warning to reformers Germany began reforming its healthcare system a decade ago Since then, according to Economist Intelligence Unit data, Germans are living longer and pay less for their healthcare than many of their neighbours However, German citizens’ doubts about their healthcare system permeate the survey, just as German healthcare professionals revealed their pessimism in a separate Economist Intelligence Unit survey earlier this year1 Far fewer German citizens (38%) than © Economist Intelligence Unit Limited 2009 Health reform The debate goes public those elsewhere are optimistic that they will get prompt, effective treatment, more than half are worried about the costs of getting treatment, and far more (79%, compared with 57% in the UK and 36% in the US) feel their healthcare professionals are working too many hours to be effective In search of the grand bargain Against all this, policymakers are floundering to come up with solutions They need to find a way to strike a grand bargain with patients, who are no longer simply passive recipients of care, but increasingly active consumers of health services The key issue is not necessarily one of knowing which reforms to implement No matter how sensible reform plans may sound, there is generally one important stakeholder who remains unconvinced: citizens There is a big gap between policymakers and consumers when it comes to appetite for health reform The first group sees it as an essential way to relieve financial and social pressures, while the second is afraid that they might lose what they currently have Consequently, selling healthcare reform is not a task for the faint-hearted Even Mr Obama, who campaigned successfully on the issue in his presidential campaign, has struggled in his bid to implement a fairer system in the US The example of Germany— which implemented major reforms a decade ago, but whose citizens remain broadly pessimistic about their healthcare and distrustful of those who manage it—serves as a warning to would-be reformers If they are to be successful, policymakers must be prepared to be thick-skinned and patient, and to avoid quick fixes The results of broad-based reforms are unlikely to be seen overnight: South Korea’s plan to introduce universal healthcare coverage began in 1977, and is still being developed today The UK has pumped millions of extra pounds into its NHS in the last decade, but it may be that the country’s more subtle reform strategies, such as patient-reported outcome measures, will be the ones that have most impact on cost containment and patient satisfaction in the long term Fixing healthcare: The professionals’ perspective, Economist Intelligence Unit, March 2009 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public The need for reform F Dealing with the Downturn, The NHS Confederation, June 2009 The Clock Is Ticking: More Americans Losing Health Coverage, Families USA, July 2009 or all the different permutations in healthcare systems around the world, policymakers face several broadly similar challenges: spiralling costs and increased demand are putting these systems under growing pressure, just as the worst economic downturn in decades is stretching budgets even thinner The need for healthcare reform is evident and in some countries, including the US and the UK, increasingly urgent Unless major changes are implemented soon, President Obama has suggested, escalating healthcare costs could severely cripple—or even bankrupt—the world’s biggest economy In the UK, the NHS Confederation, an independent body representing healthcare organisations, has warned that the National Health Service (NHS) could face real-term funding reductions of up to £10bn (US$15.5bn) from 20112 For political leaders grappling with tight budgets in a financial downturn, health is simply too big an issue to ignore Healthcare is forecast to account for a whopping 16.3% of GDP in the US in 2009, about 10.6% of GDP in Germany and 9.9% of GDP in the UK Even in India, a country long criticised for underinvesting in health and social services, the World Health Organisation (WHO) forecasts that healthcare will account for about 5% of GDP in 2009 Demographic changes compound the problem Population growth in many countries—not least India—is exacerbated in the US and UK by an ageing population The wave of “baby boomers” (those born roughly between 1945 and 1960) is moving towards the inevitable increase in health problems that come with age Germany, which faces a population decline, is confronted with an even starker demographic picture as the ratio of senior citizens to young workers steadily climbs Yet unlike other complex policy topics facing political leaders, healthcare is also an intensely personal issue The emotional response from many Americans to the healthcare reform debate in recent months is in part the result of their personal circumstances More than 45m people across the country—many of them in working families—lack health insurance and the problem is escalating According to a report by Families USA3, more than 44,000 people in the US are losing health coverage each week, equating to some 2.3m each year Without healthcare reform, the report estimates, 6.9m more Americans will lose health coverage by the end of 2010 “The status quo is not acceptable,” says James Rohack, a cardiologist who serves as president of the American Medical Association (AMA), the nation’s leading physicians’ group In addition to endangering individuals’ health, the gaps in health coverage have knock-on effects on the wider system: growing © Economist Intelligence Unit Limited 2009 Health reform The debate goes public numbers of uninsured people turn up at hospital emergency rooms to be treated, for instance, an expensive solution that is driving up healthcare costs for the majority of Americans who are insured Even in countries with universal health coverage, there is a clear public concern about healthcare A survey of citizens across four countries conducted for this report reveals that if people were asked to vote tomorrow, they would rank healthcare as one of their top priorities for government—second only to the economy and jobs in the US, Germany and India In the UK, healthcare is the third-highest priority of those polled, behind the economy and crime If you had to vote tomorrow, which of the following issues would be most important to you, in terms of your government’s priorities? Please select up to two (% respondents) Economy and jobs 65 Healthcare 41 Crime 17 Education 15 Environment and climate change 13 Defence and terrorism 13 Other Housing None of the above I not have an opinion Source: Economist Intelligence Unit survey, July 2009 While people in the US and the UK are generally optimistic that they would receive prompt and effective treatment if they or a family member were to become seriously ill, the survey reveals that many people have doubts about their governments’ approaches to healthcare Among those surveyed, Germans were the least likely to have confidence in their government’s approach (see box Germany: postreform pessimism) If you or a member of your family fell seriously ill, how optimistic are you that they would receive prompt and effective treatment? (% respondents) Germany US Very optimistic 32 Somewhat optimistic 10 Somewhat pessimistic Very pessimistic Don’t know what quality of treatment would be received © Economist Intelligence Unit Limited 2009 India 19 42 Neither optimistic nor pessimistic UK 30 42 33 35 22 16 44 12 4 Source: Economist Intelligence Unit survey, July 2009 Health reform The debate goes public In your country, would you say that people are encouraged to choose from a range of hospitals and/or GPs/physicians for their treatment? (% respondents) Germany US Yes UK 69 No 48 23 Don’t know India 31 74 39 58 13 11 20 Source: Economist Intelligence Unit survey, July 2009 How strongly you agree or disagree with the following statement? I feel I have a lot of control and influence over my choices of where and how I am treated (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 21 43 15 14 Germany 31 17 30 11 UK 18 31 32 11 India 36 44 14 21 Source: Economist Intelligence Unit survey, July 2009 American politicians across the spectrum have acknowledged that retaining a choice in providers and insurers is important to the American people, whose cultural values tend to favour individual decisions over the sort of collective decision-making that prevails in places like Europe In general, Americans are used to having a choice in many aspects of life; Europeans perhaps less so Indeed, our survey reveals that Americans feel more encouraged to choose from a range of hospitals and doctors for their treatment than people surveyed in other countries, which helps to explain some of the current public concerns about reforms that would reduce their choices The survey shows that Americans also feel they have much more control and influence over how they’re treated than their British counterparts—about seven in ten respondents feel they are encouraged to shop around for doctors and hospitals In the UK, by contrast, nearly six in ten respondents say they are not A recent study by Stanford University’s Center on Longevity on specific consumer preferences regarding healthcare reform revealed that there is a good deal of ambivalence among voters on these issues, according to centre director, Professor Laura Carstensen When presented with a series of detailed healthcare reform proposals, the people polled showed no clear preference12 The Stanford results revealed that when it comes to healthcare coverage, a majority of Americans are “pretty happy with their own, but they know the system is broken,” says Professor Carstensen In her view, the results seem to reinforce the status quo Another significant finding was a deep partisan divide over health policy issues: Democrats showed a strong concern for uninsured Americans, whereas Republicans were much more worried about preventing greater government involvement in the healthcare system 12 Stanford Centre on Longevity, Health Security Project: Building Sensible Health Care Solutions, 2009 © Economist Intelligence Unit Limited 2009 21 Health reform The debate goes public Steps forward for patients in the UK Healthcare reform in the UK is unlikely to be on the same scale as that proposed in the US Nonetheless, two relatively recent strategic reforms may have a more direct, immediate impact on how healthcare is delivered to better meet patient needs One of them, at least, involves a closer role for patients as part of the process of improving healthcare, as the NHS aims to live up to the “patients as partners” ethos espoused by the former health minister, Lord Darzi The NHS’s new patient-reported outcome measures (PROMs) are a tool for compiling patient-reported satisfaction outcomes on specific medical procedures Launched in early 2009, the system is still in its infancy, but the aim is to report health outcomes that are significant to patients, and may differ from what doctors, nurses or NHS managers think are important In theory, this will lead to a more equitable distribution of health resources Indian healthcare: seeking a new route “India is a goddess with many faces,” says Kavita Ramdas, CEO and president of the Global Fund for Women The statement rings as true in healthcare as in many other sectors affected by variations in income, education, caste, gender and geography across a country of more than 1bn people Rich urbanites (and “medical tourists” from abroad) plump for elective treatments in private clinics, the growing middle class has rising expectations about the quality and speed of its care, and poor Indians (the majority) are served by an overstretched and underfunded network of government-run primary health centres that is woefully short of skilled medical staff, especially in rural areas where 70% of the population lives The challenges include a shortage of skilled medical personnel, and feeble expenditures on healthcare by some states Grim statistics on average life expectancy and infant mortality—sobering even by standards in the developing world—reveal how far India lags behind much of the world in health 22 Yet the Economist Intelligence Unit’s citizen survey also finds glimmers of hope The Indians surveyed (mostly urban dwellers, more than three-quarters of them with college degrees) were more optimistic than people surveyed in the US, UK or Germany that they would receive “prompt and effective treatment” if they or a member of their family were to be ill While they expressed more concern than their foreign counterparts about the cost of such care, they also voiced a greater willingness to pay more for better and faster hospital treatment The growth of private healthcare providers and insurance plans is one factor improving the outlook and choices for patient care It may be out of reach for the rural masses in India, but a growing middle class of some 250m people (larger than the combined populations of western Europe’s three biggest countries) is increasingly turning to private care The government, accordingly, sees the private sector as a key element in its aim to increase the country’s healthcare capacity As more middle and upper-class Indians get treated privately, more space becomes available in the government health service for poorer people who have no alternatives The current government is “fairly bullish” Which of the following would you be willing to pay (more) for, in order to receive a faster and/or higher quality of service? Select up to two (% respondents) India Quality of hospital treatments/operations 55 Doctor/GP consultations 48 Medicines 28 Quality of hospital staff and environment 26 Advice on healthcare and preventive medicine (eg, via Internet, phone, etc) 11 Waiting time for operations Other None of the above: I would not be willing to pay more Source: Economist Intelligence Unit survey, July 2009 on healthcare, says Monika Sood of Feedback Ventures, an advisory company that works with government and private clients in the sector, noting campaign pledges to cut the inequalities in care between urban and rural areas She points to additional funding for a national insurance plan for the poor, and an increasing role for government as a © Economist Intelligence Unit Limited 2009 Health reform The debate goes public The rollout of PROMs is expected to have a dramatic impact on how patients and clinicians assess the effectiveness of healthcare An example of how patient feedback can be used involves cataract patients, who were asked about the change in their quality of life after surgery Despite the expectations of clinicians that the changes would be profound, about half the cataract patients surveyed said that they had not experienced any improvement in quality of life as a result of surgery The data, collected for the UK’s Department of Health, found that many of them in fact had a fairly good quality of life before their operations The result raised questions about how high a priority cataract surgery should be going forward “If the NHS has switched from making Trabants to Rolls Royces […] we’re still only counting cars,” says Professor Appleby of The King’s Fund But PROMs, he adds, can show healthcare administrators where productivity improvements are most needed Measuring patients’ views of the impact of treatment on their own health will in turn show where the NHS is making the greatest impact Initially, the tool will buyer of healthcare services—not simply as a provider—as indications of its willingness to become more active in the sector Still, there are limits on how far the government can go One issue is funding: Rajat Gupta, who was instrumental in setting up the Public Health Foundation of India, has noted that spending on hospital infrastructure will probably only increase by 2% per year over the next decade13 While there is clearly a temptation to encourage more private-sector development, savvy officials also recognise the politically tricky nature of privatising health services, especially given the tradition of free government healthcare Ten years ago, “the mindset was ‘healthcare is free’,” said Ms Sood Now there is a greater willingness to pay for quality care, as borne out by our survey: more than half (55%) of Indian respondents stated they would pay more for better quality hospital treatments, and nearly as many (48%) would the same for better doctor consultations Officials, though, are still wary of touching the core of the free system Privatisation efforts have instead focused on allowing the private sector to operate new hospitals with the government supplying the buildings, © Economist Intelligence Unit Limited 2009 offering “greenfield routes” with public land provided for private investors to build and operate health facilities Tensions remain, though: one current problem is the drift of doctors to the private sector, where they can earn four or five times as much money Moreover, the knotty problem of underserved rural areas—the least appealing assignments for many doctors—remains Rural women are especially affected, as they and their families regard their health as a low priority for the family—a contributing factor in India’s high rate of maternal mortality While the government is encouraging more privatesector investment in rural and semi-urban areas, it is unlikely that rural areas will ever be adequately served by private firms “Health is one area where it can’t just be left to the private sector,” says Ms Sood Anasuya Sengupta, Asia and Oceania director of the Global Fund for Women, says rural populations face particular challenges with access, awareness and accountability in healthcare Accordingly, more nongovernment entities, citizens’ groups and communities are taking matters into their own hands, emboldened by past successes in pressuring the government on issues like HIV/ AIDS The state government of Karnataka, the Indian Institute of Management and a local non-profit group, for instance, have collaborated to bring theatre performances to rural villages, trying to raise awareness about health issues and encourage local dialogue A growing number of community groups, as well as medical staff, are supporting such outreach efforts as a way to reach the poor, uneducated and most vulnerable Indians Amid the many challenges, there are other signs of hope Mr Gupta claims India is wellplaced to tackle its health challenges for two key reasons: it can learn from and avoid “the costly errors” of more advanced economies, and create its own, new models by integrating the strengths of business and the non-profit sector Ms Sood concurs that there are lessons to be learned “In the US, there was a lot of money available for healthcare Investment went into things like diagnostics Insurance rates are also driving the US, and the result is fairly high costs of healthcare delivery,” she says In India, where pricing is an important variable in uptake of services, policymakers are asking how they can avoid some of those pitfalls “In India we’re wondering how we ensure we don’t face the same issues the US is facing today.” 13 McKinsey Quarterly, A Healthier Future for India, January 2008 23 Health reform The debate goes public be used to assess just a handful of common procedures—involving hips, knees, cataracts and varicose veins—but proponents are understandably pushing for an expansion into other areas as well For a public that tends to assume a degree of relatively consistent quality across the system, the results could be a real eye-opener A more established NHS procedure, aimed at offering a sort of best-buy guide for healthcare products and services, is the National Institute for Clinical Excellence (NICE) The goal of this body, set up a decade ago, is methodically and independently to assess the value for money of different approaches The goal is to make NHS decision-making more transparent and public When patients want to challenge its judgements—about payment for cancer drugs, for instance, or limits on end-of-life care—they have an ability to take their cases to court While this is a useful mechanism for keeping a lid on costs, the political reality has at times been too much to bear The uproar surrounding certain contested cases has meant that NICE’s standards for end-of-life care have been relaxed under pressure; in February this year, for example, NICE was forced to reverse a decision it had made and to allow the cancer drug, Sutent, to be used on the NHS This political reality—the hard trade-offs that policymakers face—can undercut even the most carefully crafted strategy Indeed, by the time Lord Darzi resigned as health minister to focus solely on his medical work, some were questioning whether his focus on quality was at odds with the government’s focus on targets The grand bargain that policymakers must strike with the public over healthcare is not an easy one in these difficult times This is as true in countries like the US and UK as it is in strikingly different markets, such as India (see box, Indian healthcare: seeking a new route) 24 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Conclusion—Policymakers’ grand bargain T he challenge for policymakers is how to strike a grand bargain with patients who are no longer passive recipients of care, and are increasingly active consumers of health services Patients are armed with more information, new networks and outlets to make their voices heard, and a greater sense of entitlement than ever before Will policymakers be able to set a course that maintains (or preferably improves) current standards of care as demanded by patients without going further into debt? Such a grand bargain is possible, but challenges loom The first is a disconnect between consumers and policymakers on the need for radical reform The latter face an immediate and escalating financial dilemma Meanwhile, consumers have complaints about their own care and the way governments are handling health policy, but when push comes to shove, fears about losing what they currently have— whether it’s an American insurance plan or a British NHS programme—outweigh the desire for major systemic change for many consumers This is partly attributable to the hidden costs of the current health system Neither Americans who are covered by employer-backed insurance plans nor Britons getting care through the NHS see the true costs of their current care, or the risks of inaction by policymakers Given that such risks are real, reform is indeed desirable A second challenge is how then to make it palatable to consumers Efforts at reform should start promptly and policymakers will need to change the language they are using with the public The need for prompt action in some countries is driven not only by an increasingly bleak financial picture, but also by the political calendar A general election in the UK—to be called by June 2010—and US congressional elections in November 2010 will affect politicians’ willingness to advocate bold action in those countries As elections draw closer, the window of opportunity for significant reform will narrow and then close Even then, the German experience shows that reforms can take years to work their way through a healthcare system To be most effective, policymakers must link patients’ personal healthcare experiences with a demonstrated ability to see improvements in treatment The UK is taking steps in this direction with PROMs, a programme designed to improve care in ways that are most meaningful to patients, and shift limited healthcare resources accordingly PROMs is still in its infancy, and thus far narrowly focused on a handful of procedures, but the concept is a good one It is designed to measure what patients, not necessarily payers or providers, value most To succeed, reform initiatives should also align incentives to pay for value and outcomes, not quantity of care In the US, for instance, financial incentives are aligned to promote cancer screening technologies that result in good health outcomes and also save money in the long run In the UK, if admission to © Economist Intelligence Unit Limited 2009 25 Health reform The debate goes public hospital were treated as a failure and incentives aligned accordingly, for instance, it would put pressure on the system to invest in preventive care and more cost-effective treatment methods Finally, a move towards more integrated care would also help to bridge the disconnect between patients and policymakers In order to put patients first, some of the traditional walls that have historically separated primary and secondary care should come down The result, although challenging clinicians to realign the way they work, would improve the patient experience while reducing inefficiencies and administrative costs The particular ways in which reforms are pursued—and the language used to sell them to the public— will undoubtedly differ from country to country, not least because of their different starting points They will only succeed if policymakers take national social norms and values into account The underlying challenges are remarkably similar though, and given what is at stake, policymakers cannot afford to duck their responsibilities in trying to strike a grand bargain 26 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Appendix Survey results Appendix: Survey results Are you male or female? (% respondents) Male Female US 55 45 Germany 47 53 UK 48 52 India 51 49 What age group you fall into? (% respondents) US Younger than 18 18-25 26-35 UK India 0 11 36-45 13 46-55 15 30 33 15 30 28 29 16 20 66-75 19 16 18 56-65 Older than 75 Germany 15 18 27 1 Which of the following best describes your employment status? (% respondents) Germany US Full-time employed Part-time employed/freelance Unemployed India 42 14 33 11 18 © Economist Intelligence Unit Limited 2009 15 15 39 67 11 19 Student Retired UK 25 23 38 27 Appendix Survey results Health reform The debate goes public Which of the following best describes your highest level of education? (% respondents) Germany US Some primary and/or secondary schooling UK High school graduate Some college/technical/ graduate studies, but no degree Bachelors degree 19 14 12 30 Masters degree 20 22 40 39 Doctorate degree India 54 18 8 48 37 If you had to vote tomorrow, which of the following issues would be most important to you, in terms of your government’s priorities? Please select up to two (% respondents) Germany US Crime Economy and jobs 76 Healthcare 48 Housing Other, please specify 28 31 17 19 52 11 39 14 57 18 Defence and terrorism India 37 67 Education Environment and climate change UK 12 44 12 14 13 18 6 If you or a member of your family fell seriously ill, how optimistic are you that they would receive prompt and effective treatment? (% respondents) Germany US Very optimistic 32 Somewhat optimistic 10 Somewhat pessimistic Very pessimistic Don’t know what quality of treatment would be received 28 India 19 42 Neither optimistic nor pessimistic UK 30 42 33 35 22 16 44 12 4 1 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Appendix Survey results If you or a member of your family fell seriously ill, how concerned would you be about the costs of ensuring they received prompt and effective treatment? (% respondents) Germany US Very concerned 41 Somewhat concerned 16 61 40 Not all that concerned India 15 33 Neither concerned nor unconcerned Not concerned at all UK 33 20 18 15 Don’t know how costs would be affected 23 16 11 In your country, would you say that people are encouraged to choose from a range of hospitals and/or GPs/physicians for their treatment? (% respondents) Germany US Yes UK No 74 11 13 20 58 39 23 Don’t know India 31 48 69 If the choice existed, would you compare services at a range of hospitals and/or GPs/physicians in order to get the best possible treatment? (% respondents) Germany US Yes 81 No Don’t know UK 12 India 89 75 11 89 14 How strongly you agree or disagree with the following statement? My health is my own responsibility (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 44 44 31 Germany 36 45 15 1 UK 36 51 10 India 66 © Economist Intelligence Unit Limited 2009 28 29 Appendix Survey results Health reform The debate goes public How strongly you agree or disagree with the following statement? The pay of healthcare professionals should be linked to their performance (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 30 45 19 11 Germany 31 47 12 31 UK 20 43 23 3 India 35 53 11 How strongly you agree or disagree with the following statement? Healthcare professionals work too many hours to be truly effective in their jobs (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 28 40 20 3 15 Germany 38 43 UK 15 42 28 11 26 10 2 India 21 40 What are the biggest barriers for you in terms of living in a healthy way (thinking about your current level of health)? (% respondents) Germany US Don’t know what to Not enough time India 20 Not enough money 11 38 Lack of willpower 36 43 29 Other, please specify Don’t know what stops me from securing my long-term health UK 37 21 28 30 10 10 18 Which of the following sources you regularly consult for health information? Select all that apply (% respondents) Germany US My doctor TV/radio My family and friends India 58 Magazines/ newspapers Specialist healthcare websites General Internet searches 30 UK 76 39 14 62 10 48 32 47 28 39 31 29 15 28 32 73 29 33 31 33 29 50 Patient groups Other, please specify Don’t know what the best sources of information are 8 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Appendix Survey results Which of the following parties you believe should have automatic access to your patient data and history of access to healthcare? Select all that apply (% respondents) Germany US Only myself and those I have pre-authorised Insurers 36 27 15 29 76 39 48 68 52 Receptionists GPs/physicians 64 53 39 Nurses India 12 80 Hospitals UK 21 55 Government No one 2 18 Which of the following aspects of your country’s healthcare system are you satisfied with? Select all that apply (% respondents) Germany US Waiting times for operations 30 Quality and availability of healthcare information Quality and availability of healthcare 33 28 35 36 52 59 11 30 19 24 24 20 Don’t know 35 30 Other, please specify 32 27 12 State/government-sourced health advice and campaigns 45 63 10 None of the above 18 33 45 The cost of medicine India 18 46 Quality of your GP/physician The cost of hospital treatment UK 21 15 12 If you had to go to hospital, which of the following factors would be most important to you, assuming you could choose? Please select up to three (% respondents) Germany US Access to the latest technologies and treatments Clear and timely information from doctors and/or nurses Caring and supportive nurses and doctors General ambience of hospital, including food and comfort Proven or documented results in treating my condition I not have an opinion © Economist Intelligence Unit Limited 2009 25 14 20 24 30 53 78 17 Other, please specify 42 12 39 46 53 56 47 59 46 35 42 16 India 51 54 43 Cleanliness and hygiene Good value for money UK 57 65 0 31 Appendix Survey results Health reform The debate goes public Which of the following would you be willing to pay (more) for, in order to receive a faster and/or higher quality of service? Select up to two (% respondents) Germany US Doctor/GP consultations 17 India 14 18 Waiting time for operations 48 Quality of hospital staff and environment Quality of hospital treatments/operations 21 26 33 26 55 21 None of the above: I would not be willing to pay more 15 26 Medicines Advice on healthcare and preventive medicine (eg, via Internet, phone, etc) Other, please specify UK 1 28 11 51 49 49 In which ways would you be most willing to pay (more) for an improved healthcare service? Select up to two (% respondents) Germany US Increased taxes (Increased) fees at the point of provision (Increased) fees to healthcare insurer None of the above: I am not willing to pay more I have no opinion 15 14 12 11 UK India 27 21 13 12 36 11 61 40 64 45 23 10 11 How strongly you agree or disagree with the following statement? I feel I have a lot of control and influence over my choices of where and how I am treated (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 21 43 15 14 Germany 31 17 30 11 UK 18 31 32 11 India 36 44 14 How strongly you agree or disagree with the following statement? My country’s government has the right approach to healthcare (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 34 22 27 30 Germany 26 33 UK 22 32 25 12 India 10 32 30 30 18 11 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Appendix Survey results How strongly you agree or disagree with the following statement? A greater role by private operators would improve my country's healthcare system (% respondents) Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know US 25 35 14 11 10 Germany 26 32 16 UK 19 36 21 13 India 25 49 15 31 In your opinion, should the government takes steps, and if necessary pass laws on, particular activities (eg, smoking, drinking etc) in order to encourage people to adopt healthier lifestyles? (% respondents) Yes No Don’t know US 35 54 11 Germany 48 45 UK 53 38 India 87 12 Which of the following things you believe your government has done a good job of implementing and/or promoting? Select up to three (% respondents) Germany US Banning and enforcement of smoking in public places Banning of cigarette and alcohol-related advertising Banning of direct marketing of fast food to children (eg, TV advertising, school vending machines) Raising public awareness of behavioural risks (eg, alcohol, driving, drugs) Encouraging me to have regular medical check-ups Encouraging and/or subsidising vaccinations Encouraging a healthy diet and active lifestyle None of the above © Economist Intelligence Unit Limited 2009 23 13 19 12 14 33 18 47 11 15 21 13 38 18 17 52 27 32 42 73 41 22 13 13 India 67 42 32 Other, please specify Don’t know what the government has done UK 49 51 10 2 33 Cover image: iStockphoto.com Whilst every effort has been made to verify the accuracy of this information, neither the Economist Intelligence Unit Ltd nor the sponsors of this report can accept any responsibility for liability for reliance by any person on this report or any other information, opinions or conclusions set out herein LONDON 26 Red Lion Square London WC1R 4HQ United Kingdom Tel: (44.20) 7576 8000 Fax: (44.20) 7576 8476 E-mail: london@eiu.com NEW YORK 111 West 57th Street New York NY 10019 United States Tel: (1.212) 554 0600 Fax: (1.212) 586 1181/2 E-mail: newyork@eiu.com HONG KONG 6001, Central Plaza 18 Harbour Road Wanchai Hong Kong Tel: (852) 2585 3888 Fax: (852) 2802 7638 E-mail: hongkong@eiu.com [...]... differences at the moment between the UK’s two major parties on the NHS “It’s about competence rather than ideology.” 14 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public A new role for citizens A n email from the US president, Barack Obama, to millions of Americans on August 5th 2009, made it clear that he thinks citizens should be at the heart of the US healthcare debate The message,... news/politics/8199615.stm 15 Health reform The debate goes public The rise and rise of citizen advocacy The emotionally charged debate over US healthcare reform has prompted advocacy groups across the political spectrum to target citizens who, they hope, will in turn back different reform proposals The surge in volume of emails, calls, petition signatures and other contact with lawmakers during the summer congressional... Americans, whereas Republicans were much more worried about preventing greater government involvement in the healthcare system 12 Stanford Centre on Longevity, Health Security Project: Building Sensible Health Care Solutions, 2009 © Economist Intelligence Unit Limited 2009 21 Health reform The debate goes public Steps forward for patients in the UK Healthcare reform in the UK is unlikely to be on the same scale... systems vary by country People in the UK are significantly less satisfied than Americans with the time they have to wait for operations and the quality and availability of healthcare in general, but are notably more satisfied than Americans with the © Economist Intelligence Unit Limited 2009 17 Health reform The debate goes public Which of the following aspects of your country’s healthcare system are you satisfied... want to make choices about their healthcare Health- related websites, publications and support groups have proliferated in recent years Patients today go in to see their doctors armed with questions 16 © Economist Intelligence Unit Limited 2009 Health reform The debate goes public overwhelming,” says Jenn Brown, state director for the group that organised the event R T Rybak, the Democrat mayor of Minneapolis,... year in the US with minimal impact on quality of care6 While more stakeholders in the US healthcare system are advocating reform this year than at any time in the past, the finger-pointing between them—physicians blaming insurers and lawyers, insurers blaming drugmakers, and so on—is unlikely to be resolved anytime soon © Economist Intelligence Unit Limited 2009 Health reform The debate goes public Untangling... in the UK is different in the sense that healthcare costs per head are lower and taxpayers know they are footing the bill for the NHS, yet it is still fair to say that most patients do not know what their care actually costs The public s desire for healthcare reform, without clarity about costs and direction, presents clear challenges for policymakers This year “more people recognise the need for reform, ... Limited 2009 4 www.opensecrets.org/lobby/index php 11 Health reform The debate goes public in the negotiations over reform Some credited Mr Obama for convening a series of White House summits on healthcare to bring together long-time adversaries, but pragmatic self-interest is clearly a prime motivator for these stakeholders—and they are far from united on the specifics of what needs to be done For Business... so, their copayments are among the lowest in Europe As Sophie Schlette of the Bertelsmann Foundation points out, however, Germans are not comparing their healthcare with that of their neighbours, but to what they had before More reforms need to be made to the German healthcare system, no doubt leading to further mistrust from end-users If benchmarks such as life expectancy are any guide, though, the. .. cheers at the barbeque after he lambasted healthcare lobbyists trying to “protect the status quo” and asked the crowd to “fight for the change we need in Washington” As the audience broke into chants of “Yes we can, yes we can”, Mr Rybak told them the election was just a start—now we’re part of a movement” The mayor said later that as a local public official, he cannot afford to ignore the healthcare ... Limited 2009 21 Health reform The debate goes public Steps forward for patients in the UK Healthcare reform in the UK is unlikely to be on the same scale as that proposed in the US Nonetheless, two... 2009 Health reform The debate goes public that their government has the right approach to healthcare By contrast, just 8% of Germans think their country is on the right track, whereas 62% think their... Unit Limited 2009 Health reform The debate goes public The need for reform F Dealing with the Downturn, The NHS Confederation, June 2009 The Clock Is Ticking: More Americans Losing Health Coverage,