January 15, 2015 katharina.janus

A full house for our 4th Forum and more news on the Health Affairs blog

This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

How Policy Makers In Emerging Health Systems Can Advance Innovative Care For The Chronically Ill
By Bruce Fried and Daniela O’Mara


Discussions of innovation in health care often focus on new technologies, big data, and refined population health strategies within the context of mature Western health care systems. But innovation is just as important, with perhaps greater impact, in evolving systems where more foundational opportunities exist to deliver affordable, quality care to the most expensive and challenging patients: those with chronic illnesses. In that context, public policy and regulation can spur innovation.

Opportunities for Innovation

No country has yet to create a perfect health care system; all face a myriad of challenges. Providing  accessible, high quality, and affordable care is a continual struggle, and given the breadth of cultural and social-economic diversity, there is no singular strategy that can be applied in all settings. And while strategies for meeting the needs of those with chronic illnesses may vary from nation to nation, the growing number of individuals with chronic disease remains a pressing global phenomenon.

These challenges are magnified in emerging economies, whose systems face unique resource limitations, especially as they build capacity and infrastructure for chronic disease care. But their policymakers and others have opportunities to innovate and implement public policies which improve quality and reduce the cost of chronic care. With proper allocation of resources and increased collaboration between stakeholders, these economies can confront structural challenges, such as a fee-for-service physician compensation system, by appropriately adapting the “best practices” of more established health care systems.

There will not be a “one-size-fits-all” solution, but investigating the best way to apply financial incentives, allocate resources, and coordinate care between health care entities can be a first step in developing suitable strategies to improve care.

Proper Resource Allocation and Financial Incentives To Align Provider Efforts

Western health systems often focus on giving providers financial incentives to generate desired improvements by moving beyond “traditional” fee-for-service or salaried approaches to provider remuneration. New incentive approaches to improve care for the chronically ill vary, typically focusing on either structure, processes, or outcomes of care. For instance, the United Kingdom’s incentives focus on realizing specific outcomes; Germany’s incentives focus on structures of care, such as integrated care. Recently, the United States’ Medicare program began offering financial incentives for primary care physicians to coordinate care provided by various clinicians to the chronically ill.

For evolving systems, resource allocation may be most effective when implemented as part of a broader systemic scheme or when employed as part of a project that specifically targets chronic diseases. For example, China will likely raise salaries to encourage providers to go into general medicine in an effort to expand its general practitioner system, an effort that although part of a much larger goal will have a direct impact on caring for the chronically ill. Alternatively, Russia has targeted cardiovascular disease and embarked on a quality improvement project for hypertensive patients that reallocated financial resources in order to meet a set of prescribed goals that improved care services.

Diverse Strategies in Coordinated Chronic Care

There are a variety of stakeholders with a role in chronic disease care: providers, payors, government, local communities, educational institutions, consumers, and corporations. In Western systems, coordination often occurs on a system-wide scale to promote collaboration that improves the quality of and access to care for the chronically ill while constraining costs.

Sweden increased continuity of care for the chronically ill through a system of “chains of care” – coordinating care between various providers and disciplines across acute, secondary, and tertiary provider settings. In Finland, the death rate from cardiovascular disease was reduced by at least 65 percent through the North Karelia Project, a collaborative system between community stakeholders, such as schools and consumers, and government services.

For evolving health care systems pursuing system-wide coordination capability, collaborative efforts on a smaller, community-based level may produce innovative initiatives that can later be scaled up. In Mexico, a project in Veracruz coordinated primary care services for patients with diabetes in a structured education program; the project led to positive outcomes, including an 11 percent increase in the number of people with diabetes and good control. Lessons learned from measurable outcomes of smaller-scale projects may then be used to implement more effective system-wide policies.

Tools for Driving Innovation in the Coordinated Care of the Chronically Ill

In meeting the challenges of chronic illness, nations are employing idiosyncratic strategies. Many Western nations have employed sophisticated public policy approaches using economic incentives and allocating budgetary resources to encourage improved provider performance and care coordination.

The emerging health care systems in South America, Africa, Eastern Europe, the Middle East and Asia  have their own unique opportunities to develop and execute innovative approaches to meeting the needs of the chronically ill. Like in Western systems, the objective should be providing high quality, affordable, coordinated care. Unlike some Western systems that are constrained by their historical practices, emerging health systems can avoid reimbursement methodologies, such as fee-for-service, that hamper collaboration.

One potentially fruitful approach would be to weave innovation into the fabric of the emerging system:  Through legislation and regulation, policy makers could require various health care stakeholders to explicitly develop and implement innovative strategies designed to meet the needs of the chronically ill through collaboration. We have taken such an approach during our representation of a major private purchaser of health insurance. In that instance, competing health insurance providers were required to include in their proposals a strategy for improving clinical quality and organizational efficiency in the provision of health care benefits. Such an approach, if employed by governmental purchasers of health care benefits, could engage the entire health care system in chronic care, both for individual patients and the broader population of the chronically ill.