How Denmark, England, Estonia, France, Germany, and the USA Pay for Variable, Specialized and Low Volume Care: A Cross-country Comparison of In-patient Payment Systems.

BACKGROUND: Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]). METHODS: Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries. RESULTS: Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers. CONCLUSION: Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.

Estonia: Health System Review.

This analysis of the Estonian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In 2017, the Estonian government took the historic step of expanding the revenue base of the health system, which has been a longstanding challenge. However, in terms of percentage of GDP it remains a small increase and long-term financial sustainability could still pose a problem. That said, if these additional funds are invested wisely, they could play a positive role in further improving the health system. Indeed, although Estonia has made remarkable progress on many health indicators (e.g. the strongest gains in life expectancy of all EU countries, strongly falling amenable mortality rates), there are opportunities for improvements. They include overcoming the large health disparities between socioeconomic groups, improving population coverage, developing a comprehensive plan to tackle workforce shortages, better managing the growing number of people with (multiple) noncommunicable diseases and further reaping the benefits of the e-health system, especially for care integration and clinical decision-making. Also in terms of quality, large strides have been made but the picture is mixed. Avoidable hospital admissions are among the lowest in Europe for asthma and chronic obstructive pulmonary disease (COPD), about average for congestive heart failure and diabetes, but among the worst for hypertension. Moreover, the 30-day fatality rates for acute myocardial infarction and stroke are among the worst in the EU. These outcomes suggest substantial room to further improve service quality and care coordination. The new NHP, which is currently being revised will be play a crucial role in the success of future reform efforts.

Eesti: tervisesüsteemi ülevaade

Eesti tervisesüsteemi analüüs käsitleb viimast arengut tervisesüsteemi korralduses,juhtimises ja rahastamises, tervishoiuteenuste osutamises, tervisesüsteemireformides ja tulemuslikkuses. Eesti valitsus astus 2017. aastal ajaloolisesammu ja laiendas tervisesüsteemi tulubaasi, mis on pikka aega olnudprobleem. Lisanduv raha on protsendina SKPst siiski väike ning pikaajalisestabiilsuse saavutamine võib endiselt jääda probleemiks. Kui lisaraha investeeritaksetargalt, võib see tervisesüsteemi täiustamisele positiivselt mõjuda.Ehkki Eestis on paljud tervisenäitajad oluliselt paranenud (nt oodatava elueasuurim pikenemine kõigist ELi riikidest, välditava suremuse oluline vähenemine),on nii mõndagi veel saavutada. Näiteks tuleks ületada suured erinevusedsotsiaal-majanduslike rühmade tervises, parandada elanikkonna kindlustuskatet,koostada põhjalik kava tööjõupuuduse lahendamiseks, pareminitegeleda kasvava hulga inimestega, kes põevad (mitut) mittenakkushaigust,ning paremini ära kasutada e-tervise süsteemi, eriti arstiabi integreerimiseksja kliiniliste otsuste tegemiseks. Kvaliteedi osas on tehtud suuri edusamme,kuid üldpilt on jätkuvalt ebaühtlane. Välditavate hospitaliseerimiste arv onüks Euroopa madalamaid astma ja kroonilise obstruktiivse kopsuhaigusepuhul, keskmine südamepuudulikkuse ja diabeedi puhul, kuid üks suuremaidkõrgvererõhktõve puhul. Lisaks on südameinfarkti ja insuldi 30-päevasesuremuse näitaja Eestis üks Euroopa halvimaid. Need tulemid viitavad sellele,et teenuste kvaliteedi ja ravi koordineerimise parandamiseks on veel paljuteha. Uuel rahvastiku tervise arengukaval, mis on praegu läbivaatamisel, ontulevaste reformide edukuses otsustav roll.

Estonia: health system review

This analysis of the Estonian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In 2017, the Estonian government took the historic step of expanding the revenue base of the health system,which has been a longstanding challenge. However, in terms of percentage of GDP it remains a small increase and long-term financial sustainability could still pose a problem. That said, if these additional funds are invested wisely, they could play a positive role in further improving the health system. Indeed, although Estonia has made remarkable progress on many health indicators (e.g. the strongest gains in life expectancy of all EU countries, strongly falling amenable mortality rates), there are opportunities for improvements. They include overcoming the large health disparities between socioeconomicgroups, improving population coverage, developing a comprehensive plan to tackle workforce shortages, better managing the growing number of people with (multiple) noncommunicable diseases and further reaping the benefits of the e-health system, especially for care integration and clinical decision-making. Also in terms of quality, large strides have been made but the picture is mixed. Avoidable hospital admissions are among the lowest in Europe for asthma and chronic obstructive pulmonary disease (COPD), about average for congestive heart failure and diabetes, but among the worst for hypertension. Moreover, the 30-day fatality rates for acute myocardial infarction and stroke are among the worst in the EU. These outcomes suggest substantial room to further improve service quality and care coordination. The new NHP, which is currently being revised, will play a crucial role in the success of future reform efforts.

Estonia: health system summary, 2022

This Health system summary is based on the Estonia: Health System Review published in 2018 in the Health Systems in Transition (HiT) series, and is significantly updated, including data, policy developments and relevant reforms as highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in July 2022 unless otherwise stated. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.