1. Doing more with less: New Zealand’s response to the health care sustainability challenge
Toni Ashton
Professor in health economics
School of Population Health, University of Auckland
School of Population Health

2. Average spending on health per capita ($US PPP)

3. Real growth in public health expenditure 1950 - 2010
Key issue is growth in PUBLIC expenditure

4. Inputs New Zealand Netherlands % GDP on health (2010) 10.1 12.0
Expenditure per capita (US$PPP )
3022
5056
Annual growth rate
5.5%
5.4%
Physicians per 1000
2.6
2.9
Nurses per 1000 10
8.4
Hospital beds per 1000
2.7
4.7
Pharm. Expenditure per cap (US$PPP)
285
481
Source: OECD Health Data 2012

5. Outputs New Zealand Netherlands Doctor consults per year 2.9 6.6
MRI exams per 1000
3.6
49.1
CT scans per 1000
22.4
66.0
Hospital discharges per 1000
1469
1158
Caesarean sections per 1000
235
148
Source: OECD Health Data 2012

6. NZ health system 82% public funding (74% tax, 8% SI)
Risk-adjusted population-based regional funding
Free care in public hospitals - specialists salaried
GPs paid by capitation + copayments
Supplementary private insurance
Strong central guidance
SI = ACC. Covers all accident-related injuries in and out of the workplace.
Unlike, Finland, GPs run as private businesses.
Specialist and hospital care: parallel private system. Insurance or OOP. Many specialists work in both sectors.

7. Waves of “reform” in NZ 1938: 1993: 2000:
Introduction of public health system
Locally-elected hospitals boards
1993:
Purchaser/provider split and provider competition
Commercialisation of hospitals
2000:
Back to locally-elected district health boards
Emphasis on primary health care

8. 20 District Health Boards PHOs, NGOs, Other private providers
Ministry
of Health
Population-based
Funding
Accident
Compensation
Corporation
20 District Health Boards
“Service agreements”
Ownership
Single-funder – our Ace card in terms of fiscal restraint. Challenge is therefore more around maintaining access and quality, subject to a hard budget constraint.
DHBs are both purchasers and providers of services
Money includes Social care
Private providers:
GPs
Pharmacists,
Maternity care
Home care
Long term care
Community-based mental health services
PHOs, NGOs, Other private providers
Public
Hospitals

9. Budget May 16 2013 NZ$1.6 billion extra over next 4 years
“While many developed countries are freezing or reducing health funding, this government is committed to protecting and growing our public health services ”
NZ$1.6 billion extra over next 4 years

10. “We need to see further improvement in efficiency gains and containing costs..... We must do more with less”
1 billion is to offset population and cost increases. This leaves about $35 (€21) extra per person per year and most of this is already ear-marked for aged and social care.

11. Doing more with less: Macro (policy) level
Regionalisation/centralisation
Regional planning
Regional provider networks
Regional procurement of supplies
Centralisation of DHB ‘back office’ functions, IT, workforce
Fewer DHBs??
HTA and prioritisation
Extension of PHARMAC to medical devices
National health committee
Charged with prioritising new and existing technologies -

13. Impact of PHARMAC on drug expenditure

14. Meso (organisational) level
Concentration of specialised hospital services
Shift of care from hospitals into the community
Improved integration of services
Micro-level:
Considerable focus on the micro-level during the 1990s and 2000s
Development and use of clinical guidelines to try to reduce clinical practice variations
Change in payment mechanisms (eg from FFS to capitation to change financial incentives of GPs
NOW:
Task-shifting – greater use of nurses, pharmacists.
But what else??
Little effort being made to directly influence resource use by doctors or demands by patients

15. Integrated Family Health Centres: The vision
Co-location of a wide range of services provided by multi-disciplinary teams
Minor surgery
Walk-in clinic
Nurse-led clinics for chronic care
Full diagnostics
Specialist assessments
Allied health services
Some social care

16. Integrated Family Health Centres: The practice
Development patchy – and slow
Lack of start-up capital
Collaboration more important than co-location

17. Meso (organisational) level
Concentration of specialised hospital services
Shift of care from hospitals into the community
Improved integration of services
Productivity of hospital wards
Micro-level:
Considerable focus on the micro-level during the 1990s and 2000s
Development and use of clinical guidelines to try to reduce clinical practice variations
Change in payment mechanisms (eg from FFS to capitation to change financial incentives of GPs
NOW:
Task-shifting – greater use of nurses, pharmacists.
But what else??
Little effort being made to directly influence resource use by doctors or demands by patients

18. Productivity of public hospitals
Doctors and nurses
Med and Surg outputs
Productivity

19. “Releasing time to care”
Time spent with patients increased by over 10%. Sometimes doubled.
Cost savings: eg: reduced stock levels, laundry
Fewer patient complaints, increased patient safety, improved staff morale
Some wards, time spent with patients has doubled from around 28% to over 50%

20. Meso (organisational) level
Concentration of specialised hospital services
Shift of care from hospitals into the community
Improved integration of services
Productivity of hospital wards
Long term care
Micro-level:
Considerable focus on the micro-level during the 1990s and 2000s
Development and use of clinical guidelines to try to reduce clinical practice variations
Change in payment mechanisms (eg from FFS to capitation to change financial incentives of GPs
NOW:
Task-shifting – greater use of nurses, pharmacists.
But what else??
Little effort being made to directly influence resource use by doctors or demands by patients

21. Long-term care New Zealand Netherlands Pop >65 years 13.5% 15.2%
3.4%
3.9%
65+ in residential care
3.6%
6.7%
65+ receiving home care
11.6%
12.9%
%GDP on long-term care
1.4%
3.5%
Source: OECD

22. Long-term care “Aging in place” Standardised needs-assessment
Assisted living arrangements??
Stricter income and asset testing??
Increase pre-funding??
Compulsory insurance
Incentives for private saving
Micro-level:
Considerable focus on the micro-level during the 1990s and 2000s
Development and use of clinical guidelines to try to reduce clinical practice variations
Change in payment mechanisms (eg from FFS to capitation to change financial incentives of GPs
NOW:
Task-shifting – greater use of nurses, pharmacists.
But what else??
Little effort being made to directly influence resource use by doctors or demands by patients

23. Micro-level (doctors and patients)
Task-shifting
Nurses, pharmacists, physician assistants
Improve patient self-management
Prevention
CVD and diabetes risk assessment
Immunisation
Smoking
Micro-level:
Considerable focus on the micro-level during the 1990s and 2000s
Development and use of clinical guidelines to try to reduce clinical practice variations
Change in payment mechanisms (eg from FFS to capitation to change financial incentives of GPs
NOW:
Task-shifting – greater use of nurses, pharmacists.
But what else??
Little effort being made to directly influence resource use by doctors or demands by patients

24. What is NOT being discussed?
Increasing copayments
Greater use of private insurance
Increasing competition and choice
Methods of reducing “unneccessary” care

25. Dank u wel!