Tackling Wasteful Spending on Health (Volume 2016)

306 Pages·2017·3.687 MB·English

by  Organization for Economic Cooperation and Development

Tackling Wasteful Spending
on Health
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Tackling Wasteful
Spending on Health
ThisworkispublishedundertheresponsibilityoftheSecretary-GeneraloftheOECD.The
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Pleasecitethispublicationas:
OECD(2017),TacklingWastefulSpendingonHealth,OECDPublishing,Paris.
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FOREWORD
Foreword
A
cross OECD countries, a significant share of health care system spending and activities are
wasteful at best, and harm our health at worst. One in ten patients in OECD countries is
unnecessarily harmed at the point of care. More than 10% of hospital expenditure is spent on
correcting preventable medical mistakes or infections that people catch in hospitals. One in three
babies is delivered by caesarean section, whereas medical indications suggest that C-section rates
shouldbe15%atmost.Meanwhile,themarketpenetrationofgenericpharmaceuticals–drugswith
effectsequivalenttothoseofbrandedproductsbuttypicallysoldatlowerprices–rangesbetween
10-80%acrossOECDcountries.AndathirdofOECDcitizensconsiderthehealthsectortobecorrupt
orevenextremelycorrupt.
Atatimewhenpublicbudgetsareunderpressureworldwide,itisalarmingthataroundone-
fifthofhealthexpendituremakesnoorminimalcontributiontogoodhealthoutcomes.Putinother
words,governmentscouldspendsignificantlylessonhealthcareandstillimprovepatients’health.
Effortstoimprovetheefficiencyofhealthspendingatthemarginarenolongergoodenough.
Thisreportsuggeststhatpolicymakerscanmakesmarteruseofhealthcarebudgetsandcut
wastewithsurgicalprecision,whileimprovingpatients’health.Actionstotacklewasteareneeded
inthedeliveryofcare,inthemanagementofhealthservices,andinthegovernanceofhealthcare
systems.Strategiesincludestoppingspendingonactionsthatdonotresultinvalue–forexample,
unnecessary surgeries and clinical procedures. Swapping inputs or changing approaches when
equivalent but less pricy alternatives of equal value exist are valid strategies, too– for example,
encouragingtheuseofgenericdrugs,developingadvancedrolesfornurses,orensuringthatpatients
whodonotrequirehospitalcarearetreatedinlessresource-consumingsettings.
Ofcourse,thisagendaiscomplexanddifficult.Changerequireschallengingembeddedhabits
and vested interests and investing in credible alternatives to existing costly solutions. Crucially, it
also requires development of better, more appropriate data systems to monitor progress. Patients,
providers, managers and regulators all play a role in generating waste and ineffective spending.
Withasmuchas9%ofGDPspentonhealthcaresystemsacrosstheOECD,three-quartersofwhich
is by governments, all stakeholders must now contribute to the solution.The evidence of waste in
healthcareisindisputable.Nowisthetimetoactuponit.
TACKLINGWASTEFULSPENDINGONHEALTH©OECD2017 3
ACKNOWLEDGEMENTS
Acknowledgements
T
he preparation of this report was a joint effort of a team of authors from the OECD
Health Division.The report was co-ordinated by Agnès Couffinhal, who also authored
severalchapters.Chapter1waswrittenbyAgnèsCouffinhalandKarolinaSocha-Dietrich,
Chapter2 by Ian Forde and Carol Nader (currently with the Department of Premier and
Cabinet, Victoria State Government, Australia), Chapter3 by Michele Cecchini and
SherryLee (currently at the École des hautes études en santé publique), Chapter4 by
Karolina Socha-Dietrich, Chris James and Agnès Couffinhal, Chapter5 by Chris James,
CarolineBerchetandTimMuir,Chapter6byMichaelMueller,LucHagenaars(currentlyat
the Dutch Ministry of Health, Welfare and Sport) and David Morgan, and Chapter7 by
Agnès Couffinhal and Andrea Frankowski (currently at the Netherlands School of Public
AdministrationandTilburgUniversity),withresearchassistancefromJulienDaviet.
The team would like to acknowledge all the country delegates and experts for their
responsestothepolicyquestionnaire,commentsonthedraft,andsuggestionsatvarious
stagesoftheproject,inparticularduringtheexpertmeetingof8April2016,andtheOECD
HealthCommitteemeetingof28-29June2016.
Thisreportalsobenefited fromtheexpertise,materialand commentsreceivedfrom
Torfinn Aanes (Norwegian Drug Cooperation –LIS), Hanne Bak Pedersen (World Health
OrganizationRegionalOfficeforEurope),ReinhardtBusse(TechnischeUniversitätBerlin),
Alessandro Cassini (European Centre for Disease Prevention and Control), Mark Cormack
(AustralianDepartmentofHealth),EricdeRoodenbeke(InternationalHospitalFederation),
Triin Habicht (Estonian Ministry of Social Affairs), John Henderson (UKDepartment of
Health), Hyoung-Sun Jeong (Yonsei University), Ruth Lopert (Pharma Policy &Strategy,
Management Sciences for Health), Øyvind Melien (Norwegian Directorate of Health),
Martin Mielke (Robert Koch-Institut), Sophie Peresson (Pharmaceuticals & Healthcare
Programme, Transparency InternationalUK), Charles Price (European Commission),
PeterSmith (Imperial College London), Agnès Soucat (World Health Organization),
MarianneVan den Berg (European Commission) and PaulVincke (European Healthcare
FraudandCorruptionNetwork).Neithertheynortheirinstitutionsareresponsibleforany
oftheopinionsexpressedinthisreport.
At the OECD, the authors wish to thank Annalisa Belloni, Ian Brownwood,
AllisonColbert, Francesca Colombo, Niek Klazinga, Valérie Paris, Mark Pearson and
StefanoScarpetta from the Directorate of Employment, Labour and Social Affairs, all of
whom provided valuable contributions through their numerous comments and
viewpoints.RonniGamzu(currentlyattheTelAvivSouraskyMedicalCenter)preparedthe
report’s initial outline.Thanks also go to Natalie Corry, Duniya Dedeyn, Susannah Nash
and IsabelleVallard for their administrative support and to Gaëlle Balestat for statistical
support.ThereportwaseditedbyAmyGautam.TheteamalsothanksMarlèneMohierfor
herhelpinpreparingthemanuscript.
4 TACKLINGWASTEFULSPENDINGONHEALTH©OECD2017
TABLEOFCONTENTS
Table of contents
Executivesummary......................................................... 11
Acronymsandabbreviations................................................. 15
Chapter1.Ineffectivespendingandwasteinhealthcaresystems:Framework
andfindings ........................................................... 17
Introduction:Whytacklingwasteisaneffectivevalue-enhancingagenda
forhealthcaresystems.................................................. 18
1. Framing“waste”:Definition,classificationofwastefulactivities,
andpolicyoptions .................................................... 19
2. Wastefulclinicalcare:Whenpatientsdonotreceivetherightcare .......... 22
3. Operationalwaste:Whencarecouldbeproducedusingfewerorcheaper
resources............................................................ 31
4. Governance-relatedwaste ............................................. 40
Conclusion:Additionalbenefitsoftacklingwaste............................ 51
Notes.................................................................. 53
References ............................................................. 54
PartI
Wastefulclinicalcareinhealthcaresystems
Chapter2.Producingtherighthealthcare:Reducinglow-valuecare
andadverseevents ..................................................... 63
Introduction............................................................ 64
1. Low-valuecareinOECDhealthcaresystems ............................. 65
2. AdverseeventsinOECDhealthcaresystems ............................. 77
3. Informationsystemstodetect,characteriseandpreventwasteful
clinicalcare.......................................................... 83
4. Initiativestopreventandmitigatewastefulclinicalcare ................... 91
Conclusion............................................................. 105
References ............................................................. 106
Chapter3.Low-valuehealthcarewithhighstakes:Promotingtherationaluse
ofantimicrobials ....................................................... 115
Introduction............................................................ 116
1. Stabilisedantimicrobialconsumptionbuthighlevelsofinappropriateuse.... 116
2. Consequencesofinappropriateantimicrobialuse:Asignificanthealth
burdenandincreasedhealthcarecosts.................................. 119
3. Determinantsofinappropriateantimicrobialuse.......................... 124
TACKLINGWASTEFULSPENDINGONHEALTH©OECD2017 5
TABLEOFCONTENTS
4. Tacklinginappropriateantimicrobialuse:Policyapproaches
acrossOECDcountries................................................. 126
Conclusion............................................................. 143
Notes.................................................................. 144
References ............................................................. 144
Annex3.A1.Listofarticlesfortheestimationoftheproportionofinappropriate
usebytypeofhealthcareservice(Figure3.2) ........................... 152
Annex3.A2.Listofrecommendationspromotingrationaluseofantibiotics
issuedbytheChoosingWisely®initiative................................ 155
Annex3.A3.Guidelineforantimicrobialstewardshipstrategiesbytheinfectious
diseasesocietyandsocietyforhealthcareepidemiologyofAmerica........ 157
PartII
Addressingoperationalwasteinhealthcaresystems:
Opportunitiestospendlessonpharmaceuticalsandhospitalcare
Chapter4.Reducingineffectivehealthcarespendingonpharmaceuticals.......... 161
Introduction............................................................ 162
1. Discardofunusedpharmaceuticalsandothermedicalsupplies............. 162
2. Theuntappedpotentialforgenericdrugsubstitution...................... 165
3. Procurementasacorestrategicinstrument .............................. 172
Conclusion............................................................. 188
Notes.................................................................. 189
References ............................................................. 189
Chapter5.Addressingoperationalwastebybettertargetingtheuseofhospital
care................................................................... 193
Introduction............................................................ 194
1. Wastefuluseofhigh-costhospitalcareinOECDcountries.................. 195
2. Driversofhospitaloveruse............................................. 202
3. Policyleverstoreducehospitaloveruse.................................. 205
Conclusion............................................................. 219
Notes.................................................................. 220
References ............................................................. 220
PartIII
Governance-relatedwasteinhealthcaresystems
Chapter6.AdministrativespendinginOECDhealthcaresystems:Whereisthefat
andcanitbetrimmed?.................................................. 229
Introduction............................................................ 230
1. Atthemacrolevel:Widevariationinspendingongovernance
andadministration ................................................... 232
2. Unpackingadministrativecostsatthehealthcareproviderlevel............ 238
3. Policiestargetedatreducingadministrativecosts ......................... 247
Conclusion............................................................. 259
6 TACKLINGWASTEFULSPENDINGONHEALTH©OECD2017
TABLEOFCONTENTS
Notes.................................................................. 261
References ............................................................. 261
Chapter7.Wastingwithintention:Fraud,abuse,corruptionandotherintegrity
violationsinthehealthsector............................................ 265
Introduction............................................................ 266
1. Settingthescene:Whyworryaboutfraud,abuseandcorruption? ........... 266
2. VariablelevelsofeffortbyOECDcountriestotackleintegrityviolations
inservicedeliveryandfinancing........................................ 277
3. Inappropriatebusinesspractices:Openingthegovernancedebate........... 285
Conclusion............................................................. 296
Notes.................................................................. 297
References ............................................................. 298
Tables
1.1. Who,whyandwhattodo?Summaryoffindingsonwastefulclinicalcare... 30
1.2. Who,whyandwhattodo?Summaryoffindingsonoperationalwaste...... 41
1.3. Examplesofintegrityviolationsinhealthlinkedtopotentialperpetrators... 47
1.4. Who,whyandwhattodo?Summaryoffindingsongovernance-related
waste .............................................................. 50
2.1. Wastefulclinicalcare:Conceptualframeworkandterminology ............ 65
2.2. Examplesofpreventableclinicalerrorsinemergencydepartments......... 78
2.3. Selectedstudiesofadverseeventsinhospitals,1991to2016............... 79
2.4. JointCommission’s“DoNotUse”listofmedicalabbreviations............. 93
3.1. Targetbenchmarksforrationalisingantimicrobialconsumption ........... 128
4.1. Policytoolstopromoteuseofgenerics ................................. 170
6.1. Functionsofvariousadministrativetasksacrosshealthfinancingsystems.. 236
6.2. Conceptualoverviewofadministrativeactivitiesinhealthcaresettings..... 240
6.3. Hospitaladministrativecostsandspendingineightnations,2010.......... 242
6.4. Conceptualoverviewoffunctionscontributingtoadministrativeworkload
bornebyhealthworkers.............................................. 244
7.1. Whocommitswhichtypeofintegrityviolationinhealthcareservice
deliveryandfinancing?............................................... 278
7.2. Examplesofinstitutionsdetectingandrespondingtointegrityviolations
inhealthservicedeliveryandfinancinginOECDcountries................ 281
7.3. Levers,intermediarytargetsandultimatetargetsofinappropriatebusiness
practicesaimedatincreasingdemandformedicalproductsorservices..... 288
7.4. Leversusedtomanageinappropriatepractices:Examples
fromOECDcountries................................................. 291
Figures
1.1. Threecategoriesofwastemappedtoactorsinvolvedanddrivers........... 21
1.2. Postoperativesepsisinabdominalsurgeries,2013(ornearestyear)......... 23
1.3. TrendsingenericsmarketsharesbyvolumeinOECDcountries
between2005and2015(ornearestyear) ................................ 33
1.4. Diabetes-relatedadmissionsper1000patientswithdiabetes,2011
(ornearestyear)..................................................... 37
1.5. DelaysintransferringpatientsfromhospitalsinthreeOECDcountries
(totalnumberofdaysperyearper1000population),2009to2015.......... 38
TACKLINGWASTEFULSPENDINGONHEALTH©OECD2017 7
TABLEOFCONTENTS
1.6. Administrationasashareofcurrenthealthexpenditurebyfinancing
scheme,2014(ornearestyear)......................................... 42
1.7. PercentageofglobalandOECDcountries’populationthatconsiders
varioussectorscorruptorextremelycorrupt ............................ 47
2.1. Cholesterol-loweringdrugconsumption,2000and2014(ornearestyear).... 69
2.2. Changesincaesareansectionrates,2000to2014(ornearestyear).......... 72
2.3. Elderlypeopleprescribedlong-termbenzodiazepinesorrelateddrugs,2013
(ornearestyear)..................................................... 72
2.4. Elderlypeopleprescribedlong-actingbenzodiazepinesorrelateddrugs,
2013(ornearestyear) ................................................ 72
2.5. MRIexams,2014(ornearestyear)...................................... 74
2.6. CTexams,2014(ornearestyear)....................................... 74
2.7. KneereplacementrateacrossandwithinselectedOECDcountries,2011
(orlatestyear)....................................................... 75
2.8. Antidepressantconsumption,2000and2014(ornearestyear) ............. 76
2.9. Postoperativepulmonaryembolism(PE)ordeepveinthrombosis(DVT)
inhipandkneesurgeries,2013(ornearestyear) ......................... 81
2.10. Postoperativesepsisinabdominalsurgeries,2013(ornearestyear)......... 81
2.11. Foreignbodyleftinduringprocedure,2013(ornearestyear)............... 82
2.12. Obstetrictrauma,vaginaldeliverywithinstrument,2013(ornearestyear)... 82
2.13. Obstetrictrauma,vaginaldeliverywithoutinstrument,2013
(ornearestyear)..................................................... 83
3.1. Trendsinantimicrobialconsumptionforsystemicuseinselected
OECDcountriesandgroups ........................................... 117
3.2. Estimatedproportionofinappropriateuseofantimicrobialsbytype
ofhealthcareservice ................................................ 118
3.3. Shareofantimicrobialdrugsalesoutoftotalpharmaceuticalsales
acrossOECDcountries,2014 .......................................... 120
3.4. Trendsinantimicrobialconsumptionandantimicrobialresistance,
2000-14............................................................. 122
3.5. ChoosingWisely®recommendationstopromoterationaluseofantibiotics... 135
4.1. TrendsingenericsmarketsharesinvolumeinOECDcountries
between2005and2015(orthenearestyear)............................. 167
4.2. Levelsofcollaboration/consolidationofpurchasesinprocurementsystems . 176
5.1. Categoriesofhospitaloveruse......................................... 195
5.2. Numberofvisitstoemergencydepartmentsper100population,
2001and2011(ornearestyear) ........................................ 196
5.3. Diabetes-relatedadmissionsper1000patientswithdiabetes,2011
(ornearestyear)..................................................... 198
5.4. Shareoffourminorsurgeriescarriedoutasambulatorycases:Boxplots
ofOECDcountriesfor2014(ornearestyear)............................. 200
5.5. Shareofcataractsurgeriescarriedoutasambulatorycases,2000and2014
(ornearestyears).................................................... 200
5.6. Averagelengthofstayinhospital,2000and2014(ornearestyear).......... 201
5.7. DelaysintransferringpatientsfromhospitalsinthreeOECDcountries
(totalnumberofdaysperyearper1000population),2009to2015.......... 202
8 TACKLINGWASTEFULSPENDINGONHEALTH©OECD2017