Health Care in Denmark 24 October 2014 Danish Regions

Basic principles of Danish Health Care A public health care system Equal and free access for all citizens Freedom of choice Mainly financed through general taxes Decentralized organization General Practice (family doctor) as gatekeeper Free choice: The danish patients can choose whatever a hospital in Denmark as long as it is about basic treatment. Extended free choice: And if a patient shall wait more than 2 months it is possible to use the right of excented free choice. That means that the patient can choose to be treated on one of the 180 private clinics and hospital tha Danish Regions aktually have an agreement with. And the public will pay for the treatment. 24 October 2014 Danish Regions

Political and administrative levels Danish Parliament/Government Ministry of Health, National Board of Health etc. 5 Regions 5 Boards with 41 elected politicians 98 Municipalities 98 Boards with between 9 and 31 elected politicians General elections to regional and municipality boards every 4 years 24 October 2014 Danish Regions

The Danish Health Care Who is responsible for what? State Legislation National health care policy The overall framework of the health care economy Regions Hospital (somatic and psychiatric, in- and outpatient) Primary healthcare contracts (GP, specialists in private practice, adult dental services, physiotherapists, psychologists, chiropodist, chiropractor) Reimbursement of medicine Municipalities Home care Rehabilitation services outside hospitals, Treatment of drug and alcohol abuse Prevention and health promotion District nurses Children's dental services 24 October 2014 Danish Regions

The Danish Health Care Plans and the Bermuda Triangle Plan for highly specialised care Hospital plans Plans for GP’s, specialists etc. Health Care plan Agreements between regions and municipalities Contracts with GP etc. Hospitals Municipality services (e.g. rehabilitation, home care) General Practice How do we make it work? And does it work? 24 October 2014 Danish Regions

The Danish Health Care Five Regions North Denmark Region Danish population: 5,6 mio. Central Denmark Region Capital Region of Denmark Region of Southern Denmark Region Zealand Geografi: The regions have between 0.6 and 1.6 million inhabitants. The smallest geographical region, Capital Region of Denmark covers 2,561 square kilometers, whereas the largest, Central Denmark Region covers 13,142 square kilometers. The regional council is headed by a president who is elected by the regional council from among its members. The regional council elects an executive committee with 11-19 members. The regional council can decide to establish ad hoc committees to assist and advise the council in its work.

The Danish Health Care Capacity 52 public hospitals 107.000 FTE 3.600 GP’s and 1.100 specialists in private practices Ansatte: Der arbejder 106.870 FTE på de offentlige sygehuse, fordelt på 14 procent læger (u. praktiserende læger) 33 procent sygeplejersker 10 procent sosu-assistenter 12 procent andet sundhedsfagligt personale 30 procent øvrigt personale, herunder blandt andet psykologer, administrativt personale, rengøring, teknisk personale m.v. 3.600 alment praktiserende læger og 1.195 speciallæger har overenskomst med regionerne. 24 October 2014 Danish Regions

The Danish Health Care Trends Reduction in number of hospitals and beds Centralization and specialization Fewer hospitals with ED’s Focus on pre hospital emergency care Focus on intermediate care Hospitals to be renovated + new hospitals built (41 billion DKR to be spent) GP’s collaborating in larger clinics 24 October 2014 Danish Regions

The Danish Health Care Activity Each year 95 out of 100 Danes have contact with the health care system, either through the hospital, family doctor, specialists or dentists Each year 2.6 million Danes are treated at a somatic hospital and in addition are 120,000 patients in psychiatric treatment There is an annual 40.5 million visits to GP 11.5 million visits to specialists 95 ud af 100 danskere er hvert år i kontakt med sundhedsvæsenet enten via sygehuset, egen læge, speciallæger eller tandlæger 2,6 millioner danskere behandles hvert år på et somatisk sygehus og herudover er 120.000 patienter i psykiatrisk behandling 1,1 millioner indlæggelser er der hvert år på de somatiske sygehuse - og ca. 50.000 indlæggelser er der på de psykiatriske sygehuse Der foretages hvert år 11,5 millioner ambulante somatiske behandlinger på de danske sygehuse. Derudover er der 1,1 million ambulante besøg på psykiatriske sygehuse Aktiviteten er steget med cirka 30 procent mellem 2006 og 2012 Der er årligt 40,5 millioner kontakter hos alment praktiserende læger og 11,5 millioner besøg hos privat praktiserende speciallæger  I 2012 blev 30 procent af patienterne, der modtog behandling i almen praksis, ikke behandling mv. andre steder i det regionale sundhedsvæsen. 24 October 2014 Danish Regions

The Danish Health Care Trends A slight increase of the number of discharges over the last 10 years Average length of hospitalization at somatic hospitals is below 3.8 days in average Decrease from 4.4 days in 2008 Average length of hospitalization in psychiatry is in average 19 days for adults and 31 days for kids Decrease of 16 % (adults) and 7 % (kids) since 2009 Reorganization of patients Increase of outpatient visits (74 % of all visits) 24 October 2014 Danish Regions

The Danish Health Care Operating expenses Budget 2014: 102,7 billion DKR (17 billion USD) Driftsudgifter Det danske sundhedsvæsen koster årligt ca. 103 milliarder kr. Det er ca. 18.500 kroner pr. dansker. Udgifterne er fordelt således: Sygehusområdet: 80 procent, dvs. ca. 82 milliarder kr. Praktiserende læger: 15 procent, dvs. ca. 15 milliarder kr. Medicintilskud: 5 procent, dvs. ca. 5,5 milliarder kr. 24 October 2014 Danish Regions

The Danish Health Care Financing The regions cannot levy their own taxes Financing consists of: State Grant – 75 Percent State activity related grant– 5 Percent Municipality basic grant – 5 Percent Municipality activity related grant – 15 Percent Annual agreements between Danish Regions and government 24 October 2014 Danish Regions

The Danish Health Care Financial set-up ACTIVITY RELATED GRANT (5 %) Regions State BLOCK GRANT (75 %) CO-FINANCING (20 %) BLOCK GRANT DIRECT TAXES Citizens Municipalities DIRECT TAXES 24 October 2014 Danish Regions

Private Practice Practice sector consists of a number of small self-employed businesses It is important that the private practice sector is an integral part of whole health care system General practice Specialists (e.g. ear and eye specialists) Adult dental services Physiotherapists Psychologists Chiropodist Chiropractor 24 October 2014 Danish Regions

Private Practice The regions' Wages and Tariffs Board (RLTN) enters into an agreement with each professional organizations and practitioners in relation to the health services they need to deliver to patients, the service demands, as well as the pay which they get for it The private practice is allowed to offer other health services, than those which are founded by the regions It is written in in the Health Act in which areas there are user fees, and which is fully funded by the regions The regions provide financial founded for the private practice 24 October 2014 Danish Regions

Co-operation with the Private Sector The supply of health care is the Regions responsibility NON-PROFIT HOSPITAL PRIVATE HOSPITAL PUBLIC HOSPITAL If the region is not able to offer the treatment needed within 2 (1) months, the patient can choose treatment at a private hospital (§87) Four out of five regions have agreements with private hospitals through public procurement (e.g. orthopaedic operations, eye operations) At the moment Danish Regions have agreements with 119 private hospitals and clinics A region can also cooperate with non-profit hospitals, that provided services for patients with epilepsy, gout, brain and also traumatised refugees and care of terminally ill patients 24 October 2014 Danish Regions

Co-operation with the Private Sector Number of public patients at Private Hospitals and Clinics Source: Landspatientregisteret § 75 + § 87, please note, that 2014 is an estimate 24 October 2014 Danish Regions

Co-operation with the Private Sector The Regions Expenses Mio. kr. 2007 2008 2009 2010 2011 2012 2013 The extended free choice (§ 87) 728 1.273 877 916 596 495 332 Public procurement (§75) 73 94 199 258 168 116 134 Non-profit private hospital (§79 stk. 2) 414 417 416 425 532 552 551 Other healthcare supplied by private hospitals 25 56 96 99 62 52 91 Total expenses 1.240 1.839 1.588 1.698 1.359 1.214 1.109 Source: The Regions Financial Statement   24 October 2014 Danish Regions

Patient Rights Part of the DNA The right to a quick assessment (within 30 or 60 days) Access to your own medical record Guarantee for treatment of life-threatening diseases Freedom of choice The right to have a contact person within 48 hours if needed If you are subjected to coercive measures, you have the right to have a patient counselor Staff must maintain secrecy – also towards the nearest family members Access to your own medical record: If you are 15 years of age or more, you have the right to see or get a copy of your medical record. You must contact the department, which must reply to your request within ten days. Freedom of choice: Between all public hospitals when you need to be examined or treated. The same applies to a number of private hospitals which the regions cooperates with. Waiting time: If you are referred to an medical examination or treatment at a hospital there shall be no more than one-month waiting time. If the waiting time is longer than a month, your free choice of hospital will be expanded. The hospital will now give you the offer to be referred to another hospital (private sector or in another region). Free treatment: If you have a Health Card you have access to free treatment from your own doctor or specialist. Moreover, you can get reimbursement for medicine, dental care, dental care, physiotherapy, podiatry, chiropractic care and psychological support. The right to receive information: about treatment options, the expected outcome of treatment, complications and side effects, the significance it will have if you choose not to receive treatment The right to a quick assessment: You can read about your right to being assessed within 30 days In psychiatry the personnel must try to achieve the patient’s voluntary participation before use of coercion No more than one-month waiting time for treatment The right to receive information 24 October 2014 Danish Regions

Challenges What is facing us? An increasing elderly population More people suffers from chronic conditions Keeping up with the development of new technologies and medicines New kinds of treatments Documentation of quality Limited resources Increasing expectations and demands ……will put the health services under tremendous pressure 24 October 2014 Danish Regions

The Quality Agenda Part of the DNA Effect: Patients should be given the treatment that works best Equality: There should be equality in care and treatment Patient safety: Treatment should be safe for patients The patient in focus: Patients and caregivers should be in focus and be involved Punctuality: Treatment must take place in a timely manner Cost-effective: The best possible health value for money QUALITY Punctuality Effect Patient safety Cost-effective Equality The patient in focus 24 October 2014 Danish Regions

The Quality Agenda Quality is a part of the solution A new agenda that requires a massive change Changes to be implemented systematically and in depth Quality in health care means: Doing what is right the first time Having coherence in the action Focus on the patient Good quality is not an additional expenditure but bad quality is! 24 October 2014 Danish Regions

The Quality Agenda Quality is a part of the solution Quality initiatives Savings Increasing costs Cost-neutral Quality improvement Decreasing costs Quality-neutral Quality reduction 24 October 2014 Danish Regions

Out-of-pocket payment Without a referral from a doctor, there is a user fee to services provided by specialists such as physiotherapists, psychologists, etc. Co-payment to dentist treatment (over the age of 18) User fees for medicine However, you have the opportunity to receive reimbursement for prescription medications when medical expenses exceed a certain amount per year Alternatively private health insurances can provide subsidies or grants 24 October 2014 Danish Regions

Patient as Partner Part of the DNA More and better information on treatment choices, clinical results and evidence Patients have knowledge, abilities and trust in managing their disease and health A relation build upon clear communication, continuity and shared decision making Partnership between patient and staff The center of decision making Diagnosing patients preferences ”The silent misdiagnosis” Agreement in relation to goals and results from the treatment Patient engagement is the new ”blockbuster drug” Supported self management and active participation in treatment and care equals an effective method 24 October 2014 Danish Regions

Comparison Denmark-USA 9,3 % 11 % 16,9 % 2,867 USD 3,547 USD 4,810 USD DENMARK 6,7 % 8 % 9,4 % 2,088 USD 3,042 USD 3,644 USD USA Middel levetid (hele befolkningen) 80,1 år DK 78,7 år USA 80,2 år OECD Middel levetid (Kvinder) 82,1 år DK 81,1 år USA 82,9 år OECD Middel levetid (Mænd) 78,1 år DK 76,3 år USA 77,5 år OECD 81,1 82,1 82,9 76,3 77,5 78,1 24 October 2014 Danish Regions Source: http://www.oecd.org/statistics