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I G E S I n s t i t u t G m b H · w w w . i g e s . d eFriedrichstraße 180 · 10117 Berlin · Germany +49 30 230 80 90 · +49 30 230 80 911
Reducing Health InequalitiesWhat Do We Really Know About Successful Strategies?
BerlinMay 9, 2009
IGES Institut
Bertram Häussler
Early inequality in access can heighten efficiency in health care supply mid-term
Reducing Health Inequalities | Seite 2 Berlin | May 9, 2009
Constant increase of life expectancy (at birth in Germany from 1960-2006)
Source: OECD 2008
Reducing Health Inequalities | Seite 3 Berlin | May 9, 2009
Life expectancy in Germany by gender and east/west
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
male / eastmale / westfemale / eastfemale / west
1975
1960
1990
female
male
west
east
west
east
Reducing Health Inequalities | Seite 4 Berlin | May 9, 2009
Impact of health care on increase of health status / life expectancy?
Thomas McKeown 1976: The role of medicine: Dream, mirage oder nemesis?
"Health results from a combination of social, economic, and psychological as well as purely biological phenomena. Most doctors now understand this and so increasingly do politicians; this enhances their reluctance to invest heavily in health services when they have only a small effect on health." (Morrison und Smith 1994)
Contrary to what has been suggested by some authors, there appears to be a significantly positive relation between health expenditure and health, particularly for women. (Or, Z, 2000)
Reducing Health Inequalities | Seite 5 Berlin | May 9, 2009
Health care is not a static factor
Evidence-based Medicine:
„Burn your textbooks because knowledge renews every few years.“
Straus SE, Richardson WS, Glasziou P, Haynes RB (2005)
Reducing Health Inequalities | Seite 6 Berlin | May 9, 2009
Progress in pharmaceutical care (Germany, 1975: West Germany)
1975 20081 Acetyldigoxin Ibuprofen
2 Methyldigoxin Omeprazol
3 Chlordiazepoxid Diclofenac
4 Rachentherapeutikum Levothyroxin-Natrium
5 Phenacetin oder Paracetamol, ASS u.a. Metoprolol
6 Calcium u. Vit. D Simvastatin
7 Oxazepam Metamizol-Natrium
8 Metoclopramid Bisoprolol
9 Diazepam Ramipril
10 Reserpin und Butizid Metformin
11 Laxanz, Kombination Amlodipin
12 Schilddrüsenhormon (Kombi T3 u. T4) Enalapril
13 Indometacin Metoclopramid
14 Reserpin u. Clopamid Torasemid
15 Naftidrofudryl Allopurinol
16 Vermutlich Kombi mit Vitamin B-Komplex Xylometazolin
17 Dipyramidol und Oxazepam Amoxicillin
18 Codeinphosphat und Phenyltoloxamin Acetylsalicylsäure
19 Cinnarizin Paracetamol
20 Phenylephrin und Dimetinden (Nasentropfen) Salbutamol
21 Heute: Birkenblätter und Goldrutenkraut Ramipril und Hydrochlorothiazid
22 Retinol (Augentropfen) Furosemid
23 NSAR-Salbe Tramadol
24 Propyphenazon und Drofenin Prednisolon
proven efficacy, life saving
proven efficacy, not life saving
efficacy not proven,
efficacy not proven,
benzodiazepines
Reducing Health Inequalities | Seite 7 Berlin | May 9, 2009
2008 market shares of TOP25 drugs prescribed in 1975
0,00%
0,20%
0,40%
0,60%
0,80%
1,00%
1,20%
1,40%
1,60%
Anteil an allen VO in % (historisch)
Anteil VO Präparat 2008
market share in 1975
market share in 2008
Reducing Health Inequalities | Seite 8 Berlin | May 9, 2009
729
593
300
1.119
771
596
00
200
400
600
800
1.000
1.200
19
68
19
69
19
70
19
71
19
72
19
73
19
74
19
75
19
76
19
77
19
78
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Tod
esf
älle
(st
and
.) j
e 1
00
.00
0 E
inw
oh
ne
r
„War against heart disease“: Cardiovascular causes of death decline much faster since mid 80s (West Germany)
Herz-Kreislauf-Erkrankungen
Andere Todesursachen - 49%
- 23%
All other COD
Cardiovascular COD
771
593 596
300
DM
DR
(dea
ths
per 1
00,0
00
1985
1970
2000
2006
- 19%
- 31%
Reducing Health Inequalities | Seite 9 Berlin | May 9, 2009
0
2.000
4.000
6.000
8.000
10.000
12.000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Noch unbekannte Sonst AMD Asthma Knochenfusion
Autoimmun Krebs etc. Krebs Virusinfektionen Osteoporose
Wachstum ART Epo etc. Gerinnung Lyse etc.
Orphan Diabetes
Health care costs strongly influenced by expen-ditures for innovative services (here: biologicals)
4.014
6.022
9.690
Noch unbekannte AM
Autoimmun-krankheiten
Krebs
OrphanDiabetes
WachstumEpo
1,5
2,4
2,3
0,40,30,4
1,9
expe
nd. i
n 1,
000,
000
Euro
s
Reducing Health Inequalities | Seite 10 Berlin | May 9, 2009
Cost containment strategies frequently based on assessment and apraisal of new services (drugs)
price regulationafter utility
assessment
no noyes yes yes yes yes
„high equity countries“
Reducing Health Inequalities | Seite 11 Berlin | May 9, 2009
Countries with strong regulations („high equity countries“) show late penetration of new drugs
0%
20%
40%
60%
80%
100%
120%
140%
< 2 years 2 - 5 years 5 - 10 years > 10 years
USA
Canada
Great Britain
France
Danzon and Furukawa, 2003
mar
ket p
enet
ratio
n of
new
mol
ecul
es re
lativ
e to
USA
Reducing Health Inequalities | Seite 12 Berlin | May 9, 2009
13 4198
145 122 134180
225
314
469
582
689
872
994
1.203
1.362
1.485
1.775
0
200
400
600
800
1.000
1.200
1.400
1.600
1.800
2.000
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Mil
lio
ne
n D
DD
Verbrauch Statine (Millionen DDD, GKV, ambulant)
Late penetration deprives patients of (proven) health benefits (e.g. statins)
proof of efficacy
Reducing Health Inequalities | Seite 13 Berlin | May 9, 2009
equity
little choice
health for all
early penetration (for
few)
stimu-lus for innova-
tion
limited choice
late penetration (for
all)
finan-cial
limits
Reducing Health Inequalities | Seite 14 Berlin | May 9, 2009
From a different world:How the airbag penetrated the car market
1981Airbag verfügbar
1.800 DM (nur Fahrer-Airbag)5 % von 39.000 DM
Airbag NICHT verfügbar(1.800 DM entsprächen
15 % von 12.000 DM)
1991Airbag seit 10 Jahren
verfügbar
Airbag ERSTMALIG verfügbar1.120 DM (Fahrer + Beifahrer)6% bzw. 3% von 18.000 DM
2001 Airbag = Serienausstattung Airbag = Serienausstattung
Reducing Health Inequalities | Seite 15 Berlin | May 9, 2009
How „high equity countries“ can stimulate the innovation process
Allow early use of services only for out-of-pocket-payers
Establish innovation insurance scheme as add on
Allow choice within public health care systems