Health systems worldwide are challenged by the growing costs of health care and the increasing demand for chronic illness management within aging populations. Innovation has become central to the agendas of most health systems to overcome these challenges and achieve sustainability. A recent analysis of seven OECD comparator countries identified numerous learning opportunities for Canada. When we looked at health system governance in these countries, what was most striking was the role of consumer choice in driving change and innovation within health care. The countries that fostered consumer engagement – that is, helped their patients take a more active role in managing their own health and wellness – were able to achieve significant health system quality outcomes such as low wait times for emergency care, lower hospital occupancy rates, and lower health system costs per capita.
These results should come as no surprise. Countries with social insurance models of health care (Germany, Netherlands, France) rely heavily on consumer choice to select health care services through private insurance companies. This active role of consumers drives market competition for health services. Even in universal health systems such as U.K. and Australia, which have a similar structure to the Canadian system (state-as-owner/operator model; principles of equality and universality, public insurance offered by the state in combination with co-payments, out-of-pocket payments and varied levels of private insurance), consumers purchase private insurance for specific health services, which empowers consumers to influence health care and services.
The Netherlands has implemented a community-based care model referred to as ‘Dutch Personal Health Budgets’, in which consumers are given personal health budgets to manage, allowing them to plan and negotiate their own health care services. In this model, consumers have a clear and active decision-making role and are able to make their own choices in selecting service providers and hiring care staff, using either spending vouchers/credits or the cash provided to help cover medical expenses. This may include assisted personal care and daily living, nursing care such as help taking medicines, support services such as daycare or rehabilitative care for managing a disability, and short stays away from home including respite care. The benefits for patients include choice of carer(s) and increased adherence to their prescribed regimens.
Evidence in comparator countries also suggests that a consumer-centric model of care encourages patients and doctors to better manage their health, curbing the likelihood people will end up in an emergency ward or costly acute-care hospital bed. For instance, in countries with social insurance models of health care (Germany, Netherlands, France), consumers and health providers are incentivized to participate in community based chronic illness management programs that focus on health, wellness and preventing exacerbations.
In 2002, Germany introduced disease management programs (DMPs) to its health system. Participation in DMPs is voluntary, but exemption from out-patient fees and co-payments encourages patient enrolment. Providers are also incentivized via lump sum payments. Given that primary care physicians take on the role of coordinating care for enrolled DMP patients, the programs are helping to reinforce the focus on primary care and chronic disease management in the German health system.
A DMP for the management of type 2 diabetes enrolled over 2.5 million active patient participants. Significant differences were found between patients who enrolled in this program compared to those who accessed usual care, including: significantly better involvement in decision-making, greater understanding of their care, improved goal setting, more confidence in their treatment plans based on their specific circumstance, and demonstrated improvements in follow up and coordination of care.
Even the aforementioned similarly structured health systems of the U.K. and Australia have system-wide community-based models of care that bring services closer to people in their communities and foster consumer engagement.
In Canada there has been little evidence to date of leveraging consumers to drive innovation in our health systems. As our OECD rankings on quality, outcomes and cost show, we can no longer afford to miss this mark. We need to create a new, consumer driven culture in our health care system, and it needs to happen now.
This isn’t about two-tier health care or privatization, it is about recalibrating the balance of power from the health provider to the consumer, so we can start to see some of the positive outcomes that our friends across the pond are enjoying.