Foreword 5
Acknowledgements 6
Table of contents 7
Executive summary 13
Acronyms and abbreviations 17
Chapter 1. Ineffective spending and waste in health care systems: Framework and findings 19
Introduction: Why tackling waste is an effective value-enhancing agenda for health care systems 20
Box 1.1. Country-specific estimates of potential savings from eliminating waste 21
1. Framing “waste”: Definition, classification of wasteful activities, and policy options 21
Figure 1.1. Three categories of waste mapped to actors involved and drivers 23
2. Wasteful clinical care: When patients do not receive the right care 24
2.1. Care that adds little value or is even harmful is not rare 24
Figure 1.2. Postoperative sepsis in abdominal surgeries, 2013 (or nearest year) 25
Box 1.2. Low-value care with high stakes: Tackling overprescription of antimicrobials 27
2.2. Changing behaviours is central to the promotion of high-value care 28
Box 1.3. Improving patient safety in OECD health care systems: Patient Reported-Incident Measures in Norway 29
Box 1.4. Reducing low-value care in OECD health care systems: The Choosing Wisely® initiative 30
Box 1.5. Improving patient safety in OECD health care systems: Encouraging handwashing in Australia and the United States 31
Table 1.1. Who, why and what to do? Summary of findings on wasteful clinical care 32
3. Operational waste: When care could be produced using fewer or cheaper resources 33
3.1. A range of opportunities exist to spend less on pharmaceuticals 33
Figure 1.3. Trends in generics market shares by volume in OECD countries between 2005 and 2015 (or nearest year) 35
Box 1.6. Current and future savings from the use of biosimilars 36
Box 1.7. Collaborative procurement’s benefits: Reduced prices, improved stock management and expertise 38
3.2. Use of resource-intensive hospital care can be better targeted 38
Figure 1.4. Diabetes-related admissions per 1 000 patients with diabetes, 2011 (or nearest year) 39
Figure 1.5. Delays in transferring patients from hospitals in three OECD countries (total number of days per year per 1 000 population), 2009 to 2015 40
Box 1.8. Making alternatives to hospital care more widely available 41
Table 1.2. Who, why and what to do? Summary of findings on operational waste 43
4. Governance-related waste 42
4.1. Spending on administration is unavoidable but needs to be well targeted 42
Figure 1.6. Administration as a share of current health expenditure by financing scheme, 2014 (or nearest year) 44
Box 1.9. E-prescription in Estonia 47
4.2. Wasting with intention: Fraud, abuse, corruption and other integrity violations in health 48
Table 1.3. Examples of integrity violations in health linked to potential perpetrators 49
Figure 1.7. Percentage of global and OECD countries’ population that considers various sectors corrupt or extremely corrupt 49
Box 1.10. Momentum for Sunshine regulations in OECD countries 51
Table 1.4. Who, why and what to do? Summary of findings on governance-related waste 52
Conclusion: Additional benefits of tackling waste 53
Box 1.11. Mobilising stakeholders to identify and tackle waste in health and long-term care: The Dutch experience 54
Notes 55
References 56
Part I. Wasteful clinical care in health care systems 63
Chapter 2. Producing the right health care: Reducing low-value care and adverse events 65
Introduction 66
Box 2.1. Wasteful clinical care: Definitions of key terms 67
Table 2.1. Wasteful clinical care: Conceptual framework and terminology 67
1. Low-value care in OECD health care systems 67
1.1. What constitutes “low-value” care depends on the perspective taken 68
1.2. Low-value care almost certainly exists at all stages of the care pathway, from health promotion to end-of-life care 69
Box 2.2. Overdiagnosis of cancer 70
Figure 2.1. Cholesterol-lowering drug consumption, 2000 and 2014 (or nearest year) 71
Box 2.3. Common instances of overdiagnosis or overtreatment 72
Box 2.4. Overtreatment and end-of-life care: Striking a sensitive balance 73
1.3. Significant uncertainty remains about the extent of low-value care, but patterns of practice variation suggest widespread occurrence 72
Figure 2.2. Changes in caesarean section rates, 2000 to 2014 (or nearest year) 74
Figure 2.3. Elderly people prescribed long-term benzodiazepines or related drugs, 2013 (or nearest year) 74
Figure 2.4. Elderly people prescribed long-acting benzodiazepines or related drugs, 2013 (or nearest year) 74
Box 2.5. Drivers behind the international rise in caesarean sections 75
Figure 2.5. MRI exams, 2014 (or nearest year) 76
Figure 2.6. CT exams, 2014 (or nearest year) 76
Figure 2.7. Knee replacement rate across and within selected OECD countries, 2011 (or latest year) 77
1.4. Drivers of low-value care include poor decision making, poor organisation and poorly designed incentives 77
Figure 2.8. Antidepressant consumption, 2000 and 2014 (or nearest year) 78
2. Adverse events in OECD health care systems 79
2.1. Adverse events are devastating for patients, wasteful for health care systems and often preventable 79
Table 2.2. Examples of preventable clinical errors in emergency departments 80
2.2. Numerous studies quantify the extent of adverse events but differences in definitions and reporting practices limit international comparison 81
Table 2.3. Selected studies of adverse events in hospitals, 1991 to 2016 81
2.3. The OECD indicators of patient safety represent substantial progress in standardising international methodology for measuring rates of adverse events 82
Figure 2.9. Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) in hip and knee surgeries, 2013 (or nearest year) 83
Figure 2.10. Postoperative sepsis in abdominal surgeries, 2013 (or nearest year) 83
Figure 2.11. Foreign body left in during procedure, 2013 (or nearest year) 84
Figure 2.12. Obstetric trauma, vaginal delivery with instrument, 2013 (or nearest year) 84
Figure 2.13. Obstetric trauma, vaginal delivery without instrument, 2013 (or nearest year) 85
3. Information systems to detect, characterise and prevent wasteful clinical care 85
3.1. Robust information systems are needed to identify low-value care 86
Box 2.6. Atlases of health care variation 87
3.2. Reliable reporting and learning systems are needed to reduce adverse events 86
Box 2.7. Selected initiatives to identify and report adverse events in OECD health care systems 89
3.3. Collecting patient-reported data will make health care systems safer and of better value 88
Box 2.8. Patient-Reported Incident in Hospital Instrument (PRIH-I) in Norway 90
3.4. Information campaigns that target both clinicians and patients have particular power 91
Box 2.9. Choosing Wisely® to encourage appropriate care 92
4. Initiatives to prevent and mitigate wasteful clinical care 93
4.1. Supporting behaviour change starts with defining safe, effective and appropriate care through standards and guidelines 93
Table 2.4. Joint Commission’s “Do Not Use” list1 of medical abbreviations 95
4.2. National campaigns seek to bring about system-wide, sustained improvements in health care value and safety 95
Box 2.10. Reducing health care-associated infections through improved hand hygiene 97
4.3. Adherence to standards and guidelines needs to be monitored, with findings fed back to clinicians 96
4.4. Patients should be enabled to recognise unsafe, ineffective or inappropriate care 98
4.5. Financial incentives can nudge clinicians towards high-value and safe care 99
Box 2.11. Use of financial incentives to reduce low-value care and adverse events 99
4.6. Organisational changes, such as the improved use of technology, can shape decision making of clinicians and patients and improve care co-ordination 101
4.7. Regulatory measures are needed to reduce adverse events and low-value care in health care systems 103
Box 2.12. Use of Health Technology Assessment to reduce low-value care 105
Box 2.13. Patient safety in Scotland 106
Conclusion 107
References 108
Chapter 3. Low-value health care with high stakes: Promoting the rational use of antimicrobials 117
Introduction 118
1. Stabilised antimicrobial consumption but high levels of inappropriate use 118
Figure 3.1. Trends in antimicrobial consumption for systemic use in selected OECD countries and groups 119
Box 3.1. Defining the rational use of antimicrobials 120
Figure 3.2. Estimated proportion of inappropriate use of antimicrobials by type of health care service 120
2. Consequences of inappropriate antimicrobial use: A significant health burden and increased health care costs 121
Box 3.2. Antimicrobial resistance: An economic perspective 121
2.1. Misuse of antimicrobials is intrinsically wasteful 122
Figure 3.3. Share of antimicrobial drug sales out of total pharmaceutical sales across OECD countries, 2014 122
2.2. The health and economic burdens caused by AMR are a significant challenge 123
Box 3.3. What is antimicrobial resistance? How does it develop and spread? 123
Figure 3.4. Trends in antimicrobial consumption and antimicrobial resistance, 2000-14 124
3. Determinants of inappropriate antimicrobial use 126
Box 3.4. Illegal drivers of inappropriate antimicrobial consumption 127
4. Tackling inappropriate antimicrobial use: Policy approaches across OECD countries 128
4.1. National strategies with clear targets, supported by comprehensive surveillance systems, provide the fundamental framework to address inappropriate antimicrobial use 129
Table 3.1. Target benchmarks for rationalising antimicrobial consumption 130
Box 3.5. Antimicrobial consumption monitoring in the European Union and the European Economic Area 133
4.2. Education and information activities are at the core of most strategies to reduce inappropriate antimicrobial use 132
Box 3.6. Public education campaign in France 133
Box 3.7. Continuing medical education (CME) in Australia 136
Figure 3.5. Choosing Wisely® recommendations to promote rational use of antibiotics 137
4.3. Incentives and organisational changes could significantly decrease inappropriate antimicrobial consumption 138
Box 3.8. Reimbursement of antimicrobials in Japan: Incentives for prudent use 140
Box 3.9. Regional antimicrobial stewardship programmes in Canada 142
Box 3.10. Point-of-care microbial diagnostic tests and antimicrobial susceptibility tests 144
Box 3.11. Policies to increase use of RDTs in Slovenia 145
Conclusion 145
Notes 146
References 146
Annex 3.A1. List of articles for the estimation of the proportion of inappropriate use by type of health care service (Figure 3.2) 154
Annex 3.A2. List of recommendations promoting rational use of antibiotics issued by the ChoosingWisely® initiative 157
Annex 3.A3. Guideline for antimicrobial stewardship strategies by the infectious disease society and society for healthcare epidemiology of America 159
Part II. Addressing operational waste in health care systems: Opportunities to spend less on pharmaceuticals and hospital care 161
Chapter 4. Reducing ineffective health care spending on pharmaceuticals 163
Introduction 164
1. Discard of unused pharmaceuticals and other medical supplies 164
1.1. To what extent are discarded medicines and other medical supplies wasted? 164
1.2. Errors, suboptimal decisions and organisational shortcomings drive unnecessary discard 165
1.3. Guidelines and education initiatives are the appropriate tools to tackle unnecessary discards 165
2. The untapped potential for generic drug substitution 167
Box 4.1. Current and future savings from the use of biosimilars 168
2.1. The opportunity for cost savings from increased generics uptake remains substantial 167
Figure 4.1. Trends in generics market shares in volume in OECD countries between 2005 and 2015 (or the nearest year) 169
2.2. Generics uptake and penetration can be slowed by regulation and stakeholder reluctance 168
2.3. A large array of policies can effectively increase generics uptake 170
Box 4.2. Pharmaceutical price regulations: Advantages and main drawbacks 171
Table 4.1. Policy tools to promote use of generics 172
3. Procurement as a core strategic instrument 174
3.1. Ineffective procurement increases the prices paid for pharmaceuticals and other medical goods 174
3.2. Organisational shortcomings and misaligned incentives drive inefficiencies in procurement 177
Figure 4.2. Levels of collaboration/consolidation of purchases in procurement systems 178
3.3. Policy solutions to improve procurement systems’ performance 182
Box 4.3. The NHS England Procurement Atlas of Variation 183
Box 4.4. Norwegian Drug Procurement Co-operation (LIS) 186
Box 4.5. Cornerstones of good tender designs: Alternative mechanisms for setting price 189
Conclusion 190
Notes 191
References 191
Chapter 5. Addressing operational waste by better targeting the use of hospital care 195
Introduction 196
1. Wasteful use of high-cost hospital care in OECD countries 197
Figure 5.1. Categories of hospital overuse 197
1.1. Unnecessary hospital attendances are widespread 197
Figure 5.2. Number of visits to emergency departments per 100 population, 2001 and 2011 (or nearest year) 198
Box 5.1. Definition and criteria used to define (in)appropriate ED visits in selected studies 199
Figure 5.3. Diabetes-related admissions per 1 000 patients with diabetes, 2011 (or nearest year) 200
1.2. Inefficient processes within hospitals lead to unnecessary costs 200
Figure 5.4. Share of four minor surgeries carried out as ambulatory cases: Boxplots of OECD countries for 2014 (or nearest year) 202
Figure 5.5. Share of cataract surgeries carried out as ambulatory cases, 2000 and 2014 (or nearest years) 202
1.3. Delays in discharging patients from hospital are costly 201
Figure 5.6. Average length of stay in hospital, 2000 and 2014 (or nearest year) 203
Figure 5.7. Delays in transferring patients from hospitals in three OECD countries (total number of days per year per 1 000 population), 2009 to 2015 204
2. Drivers of hospital overuse 204
2.1. Lack of access to alternative options is a key driver of unnecessary hospital use 204
Figure 5.8. Comparing ease of access to after-hours care and the use of emergency departments 205
2.2. Poor co-ordination between hospitals and other settings can leave people stuck in hospital 206
2.3. Inadequate quality of primary care services leads to excess hospital use 206
2.4. Individual preferences shape decisions to seek care at hospitals 207
3. Policy levers to reduce hospital overuse 207
3.1. Many actions can contribute to effective organisational change 208
Box 5.2. Reducing the overuse of expensive long-term care settings 210
Figure 5.9. The weekly cost of meeting LTC needs through formal care services only, 2014 (USD PPP, average of 15 OECD countries) 210
Box 5.3. Primary care integrated within emergency departments in the Netherlands 212
3.2. Financial incentives can be used to change behaviour 215
Box 5.4. Incentivising providers to reduce avoidable emergency admissions: The quality premium in England 218
3.3. Behaviour change can be achieved by non-financial means 219
3.4. Better information is needed to identify hospital overuse 220
Conclusion 221
Notes 222
References 222
Part III. Governance-related waste in health care systems 229
Chapter 6. Administrative spending in OECD health care systems: Where is the fat and can it be trimmed? 231
Introduction 232
Figure 6.1. Levels of administrative inputs in health care systems 233
1. At the macro level: Wide variation in spending on governance and administration 234
1.1. Administrative costs are influenced by the type of financing system 234
Figure 6.2. Administration as a share of current health expenditure by financing scheme, 2014 (or nearest year) 234
Box 6.1. Administration services in the System of Health Accounts 235
1.2. The multiplication of funds has a significant impact on administrative costs 235
Figure 6.3. Government health administration expenditure related to share of total government expenditure financed by SHI or other compulsory schemes, 2014 (or nearest year) 236
1.3. Administrative costs for private insurance are much higher than for public schemes 237
Figure 6.4. Health administration expenditure as a share of financing schemes’ total health spending, 2014 (or nearest year) 237
1.4. Cost differences relate to the scope of administrative functions associated with different financing schemes 238
Table 6.1. Functions of various administrative tasks across health financing systems 238
Box 6.2. Spending on administration by French private and public insurance schemes 241
Figure 6.5. Administrative spending including profits among complementary PHI schemes in France, 2013 241
1.5. Administration at the health care system level cannot be equated with waste 240
2. Unpacking administrative costs at the health care provider level 240
2.1. Meso level: Administrative overheads can be considerable in health care organisations 242
Table 6.2. Conceptual overview of administrative activities in health care settings 242
Table 6.3. Hospital administrative costs and spending in eight nations, 2010 244
2.2. Micro level: Time spent by health care workers on non-clinical administrative tasks is non-trivial 246
Table 6.4. Conceptual overview of functions contributing to administrative workload borne by health workers 246
Box 6.3. Organisation of administration by independent French physicians 247
3. Policies targeted at reducing administrative costs 249
3.1. Best practices can identify wasteful spending 250
Box 6.4. Methodology of the Standard Cost Model 251
Box 6.5. Twenty recommendations following the in-depth investigation of administrative processes and requirements among physicians, psychotherapists and dentists in Germany 252
Box 6.5. Twenty recommendations following the in-depth investigation of administrative processes and requirements among physicians, psychotherapists and dentists in Germany (cont.) 253
Box 6.6. Menu of reform options in French health insurance 253
3.2. Organisation and co-ordination are main areas in which to rein in administrative waste 255
Box 6.7. Estonia’s use of e-prescription 256
Box 6.8. A history of health care claim simplification strategies in the United States 257
Conclusion 261
Notes 263
References 263
Chapter 7. Wasting with intention: Fraud, abuse, corruption and other integrity violations in the health sector 267
Introduction 268
1. Setting the scene: Why worry about fraud, abuse and corruption? 268
1.1. Why would fraud, abuse or corruption be present in health care systems? 268
1.2. How much fraud, abuse and corruption really exists in the health sector? 270
Box 7.1. Measuring corruption in a given sector: Common tools and their limitations 271
Figure 7.1. Percentage of global and OECD countries’ population that considers various sectors corrupt or extremely corrupt 272
Figure 7.2. Corruption perception across sectors in EU OECD countries versus EU non-OECD countries 272
Figure 7.3. Percentage of the population that considers the health sector corrupt or very corrupt in OECD countries 273
Box 7.2. OECD countries’ published figures regarding the extent of detected health care fraud 274
1.3. Resource-diverting “integrity violations” can be grouped in three broad categories 275
Figure 7.4. Mapping integrity violations to various actors: A few examples 277
Figure 7.5. Three main types of integrity violations in health care systems 278
Box 7.3. Counterfeiting of medical goods and products: The MEDICRIME Convention 278
2. Variable levels of effort by OECD countries to tackle integrity violations in service delivery and financing 279
2.1. Integrity violations in service delivery and financing are varied and most often originate from providers 279
Table 7.1. Who commits which type of integrity violation in health care service delivery and financing? 280
Figure 7.6. Relative importance of integrity violations in service delivery and financing in 12 OECD countries 281
Box 7.4. Informal payments 282
Figure 7.7. Percentage of population that paid a bribe for a medical service in the past 12 months 282
2.2. Various types of institutions tackle integrity violations in service delivery and financing 282
Table 7.2. Examples of institutions detecting and responding to integrity violations in health service delivery and financing in OECD countries 283
2.3. Effective detection of integrity violations in service delivery and financing requires data mining and review campaigns responses must be well graded and credibly enforced
3. Inappropriate business practices: Opening the governance debate 287
3.1. The pursuit of legitimate business objectives can give rise to inappropriate business practices 288
Figure 7.8. Linking inappropriate practices to legitimate business objectives 289
Table 7.3. Levers, intermediary targets and ultimate targets of inappropriate business practices aimed at increasing demand for medical products or services 290
3.2. Regulation and emphasis on transparency play an increasing role in tackling inappropriate business practices 292
Table 7.4. Levers used to manage inappropriate practices: Examples from OECD countries 293
Conclusion 298
Notes 299
References 300