Visualizzazione post con etichetta william haseltine affordable excellence. Mostra tutti i post
Visualizzazione post con etichetta william haseltine affordable excellence. Mostra tutti i post

lunedì 29 maggio 2017

Politica sanitaria: copiare quello che funziona altrove

Affordable Excellence: The Singapore Health System by William A. Haseltine
E’ importante conoscere la storia del sistema sanitario migliore del mondo…
… Affordable Excellence tells the story of the Singapore healthcare system, how it works, how it is financed…
Il costo è minimo…
… Singapore spends less on healthcare than any other high-income country, both as measured by fraction of the Gross Domestic Product spent on health and by costs per person…
***
Singapore: 50 anni di boom economico…
… In just 50 years, Singapore transformed itself from a low-income country to one that has one of the highest per capita incomes in the world…
***
Prima lezione: nella politica sanitaria la path dependence è fortissima, tornare indietro è difficile. Per questo programmare è molto utile (e un dittatura illuminata è avvantaggiata)…
… One point that emerges clearly: decisions made early on affect the course of later history. Once begun, it is very difficult to revise health finance and delivery systems, as such decisions profoundly affect the lives of individuals and economies…
Oggi i sistemi sanitari sono essenzialmente di tre tipi
… To finance healthcare, should countries adopt a mixture of private and public insurance as does the United States, the state approach to healthcare finance and operations as in the United Kingdom, or the public–private partnerships of Germany and Japan?…
Singapore, al contrario, punta sulla responsabilità personale del cittadino
… an entirely different approach be taken, that of Singapore, where emphasis is placed on individual responsibility supported by an enabling state…
***
L’invecchiamento della popolazione porterà la discussione sulla sanità al centro del dibattito politico…
… The world's most developed countries are facing a crisis of confidence in their healthcare systems. Costs are rising…
Singapore insegna la programmazione. Al momento la sua sanità è programmata per i prossimi 30 anni
… Singapore is relatively unique amongst governments in its ability to plan for the future. In the past, the government has planned and successfully executed, over a 30-year period… Today, the emphasis is on planning for the coming demographic crises…
Gli USA spendono molto? Singapore propone un modo per calmierare i costi…
… In the United States, healthcare accounts for almost 18 percent of the GDP and is rising. Most developed economies are facing twin demographic problems… The Singapore system offers a guide to controlling costs…
Il problema degli USA sono le assicurazioni private?
No, esistono anche a Singapore, nella sanità meno costosa che garantisce a tutti l’eccellenza.
***
Ma le obiezioni alla proposta di copiare non mancano: Singapore è un caso unico: sono in pochi, sono una dittatura illuminata
… In writing this volume, I have often been told that Singapore is unique and lessons learned are not applicable elsewhere… Others believe only a government with a long tenure in power (Singapore's ruling People's Action Party has been in power since independence in 1965)… Some even go so far as to describe Singapore as a dictatorship… such a healthcare system can only be imposed by a controlling government…
Per quanto l’obiezione sia ficcante cio’ non ci esime dallo studiare cio’ che funziona.
***
In effetti le tre condizioni cardine per costruire “il sistema sanitario nazionale migliore del mondo” non sono ubique…
… They are long-term political unity, the ability to recognize and establish national priorities, and the consistent desire for collective well-being…
Sulla sanità pesano mille variabili…
… Health would be affected by almost every aspect of life in an urban setting: housing, water supply, food supply, air quality, waste disposal, road traffic, parks, tree planting, and more…
La complessità è tale che stabilire delle priorità è l’operazione più importante.
All’inizio Singapore si occupò con successo dei bisogni minimi, quelli tipici del terzo mondo…
… Wisely, the initial focus in Singapore was on public health: putting proper sanitation procedures in place, controlling infectious diseases, all successful efforts. Early initiatives were launched to provide clean water, develop a vaccination program, and guarantee access to basic medications, clean food, and more…
Ma forse bisogna gettare un’occhiata più generale sul paese per coglierne al meglio le caratteristiche.
Singapore e Hong Kong: differenze tra le due tigri…
… A competitive, winner-takes-all society, like colonial Hong Kong in the 1960s, would not be acceptable in Singapore…To even out the extreme results of free-market competition, we had to redistribute the national income…
Il sistema pensionistico
… One important solution Lee and his ministers found was the Central Provident Fund (CPF). It was set up during British colonial rule as a compulsory savings program for workers to build a nest egg for retirement… The CPF has become one of the key pillars supporting social stability…
I contributi obbligatori:
… Mandatory contribution rates have risen over the years and now stand at 16 percent of wage for employers and 20 percent for employees. After age 50, the rates decrease…
La parte privata della pensione resta notevole…
… it helps control costs by instilling in patients a sense of responsibility about their spending—after all, it is their money to save or spend…
Donne e istruzione…
… Specifically, women's health education was deemed essential to the future of the country…
La responsabilizzazione è al centro di tutto…
… If anything may be identified as the guiding philosophy behind Singapore's success, it is Lee's conviction that the people's desire to achieve and succeed must never be compromised by an overgenerous state. The government made certain that Singaporeans developed and retained a sense of responsibility…
***
Il sistema sanitario è molto capillare
… An early move was to bring primary care services closer to the people by developing a network of satellite outpatient dispensaries and maternal and child health clinics….
Il singolo contribuisce sempre alla spesa sanitaria che lo riguarda: chi paga apprezza (e controlla)
… The ideal of free medical services collided against the reality of human behaviour, certainly in Singapore. My first lesson came from government clinics and hospitals. When doctors prescribed free antibiotics, patients took their tablet or capsules for two days, did not feel better, and threw away the balance. They then consulted private doctors, paid for their antibiotics, completed the course, and recovered….
La prevenzione ha un ruolo importante, così come la promozione di certi stili di vita salubre.
Il conto individuale sanitario è al centro di tutto…
… the Plan announced the creation of Medisave, Singapore's individual medical savings plan…
Serve per pagare l’assicurazione sanitaria, l’ospedale e i tickets…
… Workers contribute a certain percentage (set by the government) to their individual accounts, as do their employers. The money can then be used to pay for health services as well as health insurance plans… Medisave enables patients to pay their share of their healthcare bill…
Scaricare gran parte della spesa sul cittadino contribuisce a controllare i costi…
… It has also had the effect of keeping national healthcare costs low by shifting a large portion of expenses to individuals and their employers…
I 5 obbiettivi:
1. promuovere la salute,
2. promuovere la responsabilità individuale,
3. assicurare servizi di eccellenza,
4. creare competizione nell’offerta dei servizi,
5. regolare la concorrenza per combattere le posizioni di rendita.
Franchigie e i tickets sono il cuore del sistema: per ogni dollaro tirato fuori da terzi, il provato deve versare la sua quota…
… making patients pay directly a part of their healthcare expenses, excessive demand for services could be mitigated and overreliance on state welfare or third-party medical insurance…
Anche per questo vengono incentivate fiscalmente solo le assicurazioni che ne fanno largo uso…
… To avoid overreliance on comprehensive insurance programs that provided first-dollar coverage, the government incentivized the purchase of health insurance schemes with features such as deductible and co-payment components and guaranteed renewals by restricting the use of Medisave to only plans that met these requirements. Insurance plans that provided first-dollar coverage were viewed as playing a major role in raising costs in countries where they are readily available…
Lo stato fissa rigorosi pacchetti sanitari standard in modo da rendere trasparente l’offerta e la relativa concorrenza…
… The basic package had to be affordable and be provided by hospitals receiving government subsidies…
I pacchetti vengono revisionati di frequente…
… The package should be reviewed frequently to reflect, among other things, the purchasing power of Singaporeans and productivity increases in medical science…
Infatti, il problema della competizione sanitaria è sempre lo stesso…
… patients rely on doctors for advice and are themselves generally unaware of better or competing alternatives…
Il problema dell’offerta confusa
… Oversupply or overabundance of choices would in turn drive healthcare costs up rather than keep them in check…
La sanità è un bene particolare: di fronte alla confusione il consumatore tende a spendere in modo eccessivo per mandare segnali a terzi: “io sono un tipo che si prende cura dei suoi cari e di se stesso!”.
Trasparenza, prezzi sul web e offerte omogenee dissipano la confusione…
... One step the Ministry of Health has taken to stoke competition is to provide price transparency by publishing the hospital bills for common illnesses on its website…
Singapore: capitalismo calibrato
… I view Singapore's chosen approach to the healthcare market as a kind of highly-calibrated capitalism…
Esistono anche ospedali pubblici con lo scopo di tenere a bada i cartelli del privato…
… This approach is seen in the fact that it funds public hospitals and other care facilities but also encourages the participation of private hospitals and clinics…
L’intervento pubblico è importante in molti ambiti del sistema sanitario. Ecco un breve elenchino…
… Situations that might demand government action included preventing an oversupply of healthcare services, moderating demand, and creating incentives to keep costs down… For example, over the years, intervention has included creating and adjusting medical savings programs, sponsoring insurance programs, providing subsidies to hospitals and polyclinics, determining the number of beds and their distribution in public hospitals, funding new medical schools, regulating the number and type of doctors who can practice in the country, and regulating and limiting the type and number of private insurance programs available to Singaporeans…
***
Ma vediamo più da vicino gli esiti brillanti che ha fatto registrare questa impostazione…
… By most common measures, the nation has achieved noteworthy outcomes in all areas of healthcare. It has increased the life expectancy of its citizens; increased infant survival rates, and achieved one of the lowest under-five mortality rates in the world. Singapore's cancer survival rates are similar to Europe's, while its cardiovascular disease death rate is half that of the rest of the Asia Pacific region…
Aspettativa di vita, mortalità infantile, mortalità neonatale, diabete, cancro, malattie infettive… il sistema sembra reggere senza fatica il confronto con quelli occidentali più avanzati.
Ma i risultati diventano da record se analizziamo i costi
… A quick look at cost comparisons with other nations brings the point home… The United States, for example, spends almost 18 percent of GDP on healthcare. Singapore, on the other hand, spends slightly under four percent of GDP. The government's expenditure for healthcare has been slightly under one percent, far less than other most developed countries… Singapore's Healthcare Expenditure… less per capita than any other high-income economy…
La soddisfazione dei clienti
… Not only does Singapore perform well in terms of achieving world-class outcomes, the quality of care as experienced by consumers is also one of the system's highest accomplishments. The Ministry of Health regularly conducts “Patient Satisfaction Surveys”…
Qualche esempio più specifico in tema di costi…
… the cost of an angioplasty in the United States is almost 83,000, while in Singapore the cost is about 13,000. A gastric bypass in the United States is almost US70,000, while in Singapore the cost is 15,000… Singapore's per capita expenditure was just over US2,000 in 2009…
Record!…
… Figures on government-only expenditure for the world's healthcare systems also show Singapore as the leader in keeping costs under control… Per capita studies reveal that in 2008, the government spent over 600 for care, while the United States spent almost 3,500, the United Kingdom over 2,600, Japan about 2,300… Singapore government expenditure as a percentage of total government expenditure was around eight…
***
Certo, questi risultati possono essere ottenuti anche grazie ad alcuni vantaggi. Infrastrutture
… Along with its excellent system of medical care, Singapore has developed an infrastructure that helps support healthy living and general wellness…
A Singapore, per esempio, non esiste campagna: tutto è una grande città omogenea! Il che, per molti versi, facilita le cose.
***
e adesso, qualche considerazione conclusiva.
Il problema USA sono le assicurazioni private? Non si direbbe visto che le ha anche la "miglior sanità al mondo" è finanziata dai privati.
Dubbi sul successo di Singapore: S. è un piccolo stato. S. è una dittatura. Quel che lì funziona altrove non funzionerà.
Singapore ci insegna la strada: prima lo sviluppo economico e poi la sanità d’eccellenza.
Medisave: conto individuale sanitario. Serve per pagare gli ospedali e le assicurazioni. Il contributo privato al finanziamento del sistema è sostanziale per responsabilizzare i cittadini e tener sotto controllo i costi.
L’intervento pubblico è basilare e la sua funzione è chiara: calmierare ma soprattutto ordinare la concorrenza.
Di fronte alla confusione e all’incertezza il consumatore di sanità tende a spendere in eccesso per segnalare il fatto che si prende cura di sè e dei propri cari. Un’offerta ordinata neutralizza questo bias.
Anche a questo scopo esiste un pacchetto di base ben preciso e dei pacchetti standard messi insieme a livello governativo che le assicurazioni devono offrire potendo concorrere solo sui prezzi.
Costi. Gli Stati Uniti hanno un servizio sanitario tra i più costosi al mondo, spendono il 18% del PIL per curarsi. Quasi 7.000 dollari a testa, e di questi 3.500 ce li mette lo stato. Il 52% della spesa resta sulle spalle dei privati i quali devono rivolgersi alle assicurazioni. Nei più avanzati paesi europei la sanità è socializzata, forse è poco innovativa ma costa molto meno: solo un 8/9% del PIL, circa 3.000 dollari a testa di cui 2600 ce li mette lo stato attingendo alla fiscalità generale. Il carico della spesa sui privati è solo un residuale 14% (contro il 52% degli USA!), le assicurazioni sono così ridimensionate. Ma il divario nei costi è dovuta alla presenza massiccia delle assicurazioni e alla loro azione di lobbing? Prima di rispondere occorre farsi un giro a Singapore, ovvero "il paese con la Sanità migliore del mondo". Lì il carico sui privati (e quindi l’affidamento alle assicurazioni) raggiunge il 65%, ben oltre quello USA. I livelli qualitativi garantiti sono di eccellenza - sopravanzano sia gli USA che l'Europa - ma soprattutto i costi del servizio sono estremamente compressi: giusto 2000 dollari a testa, il 4% del PIL (in Europa è il doppio!).

martedì 21 giugno 2016

CAPITOLO 2 -------- Affordable Excellence: The Singapore Health System by William A. Haseltine

CHAPTER 2   High Quality, Low CostRead more at location 472
Note: Indici di qualità: aspettativa di vita mortalità infantile mortalità primi 5 anni sopravvivenza cancro malattie vascolari... Livelli di soddisfazione alti... Costi. 4% PIL spesa complessiva 1% spesa governativa. Costo medio x abitante 2000 dollari. L' 8 della spesa governativa va in sanità... S. ha dei vantaggi oggettivi: pochi immigrati poca campagna...Edit
Note: 2@@@@@@@@@@@@@@@ Edit
By most common measures, the nation has achieved noteworthy outcomes in all areas of healthcare. It has increased the life expectancy of its citizens; increased infant survival rates, and achieved one of the lowest under-five mortality rates in the world. Singapore's cancer survival rates are similar to Europe's, while its cardiovascular disease death rate is half that of the rest of the Asia Pacific region.Read more at location 477
Note: RISULTATI Edit
A quick look at cost comparisons with other nations brings the point home.Read more at location 482
Note: COSTI Edit
The United States, for example, spends almost 18 percent of GDP on healthcare. Singapore, on the other hand, spends slightly under four percent of GDP. The government's expenditure for healthcare has been slightly under one percent, far less than other most developed countries.Read more at location 483
Life ExpectancyRead more at location 490
Note: TITOLO Edit
Newborn and Infant MortalityRead more at location 500
Note: TITOLO Edit
Under-Five Mortality RateRead more at location 513
Note: TITOLO Edit
DiabetesRead more at location 566
Quality of CareRead more at location 570
Note: TITOLO Edit
Not only does Singapore perform well in terms of achieving world-class outcomes, the quality of care as experienced by consumers is also one of the system's highest accomplishments. The Ministry of Health regularly conducts “Patient Satisfaction Surveys”Read more at location 570
Note: SODDISFAZIONE Edit
Singapore's Healthcare ExpenditureRead more at location 583
Note: TITOLO Edit
less per capita than any other high-income economy.Read more at location 586
the cost of an angioplasty in the United States is almost 83,000, while in Singapore the cost is about 13,000. A gastric bypass in the United States is almost US70,000, while in Singapore the cost is 15,000Read more at location 592
Note: ESEMPI Edit
Singapore's per capita expenditure was just over US2,000 in 2009.Read more at location 597
Figures on government-only expenditure for the world's healthcare systems also show Singapore as the leader in keeping costs under control.Read more at location 605
Note: RECORD Edit
Per capita studies reveal that in 2008, the government spent over 600 for care, while the United States spent almost 3,500, the United Kingdom over 2,600, Japan about 2,300.Read more at location 606
Note: PER CAPITA Edit
Singapore government expenditure as a percentage of total government expenditure was around eightRead more at location 609
Singapore's AdvantagesRead more at location 621
Note: TITOLO Edit
Along with its excellent system of medical care, Singapore has developed an infrastructure that helps support healthy living and general wellness:Read more at location 621
Note: INFRASTRUTTURE Edit
lack of rural areas, and relatively low number of immigrantsRead more at location 630
Note: OMOGENEITÀ E CAMPAGNA Edit
Chapter 2: KEY POINTSRead more at location 635
Note: TITOLO Edit