The world's healthcare systems are in crisis, and the problems vary widely. A global expert tackles various approaches to reform.
2010 marks the beginning of a series of reforms that will shape healthcare services and outcomes in the United States. The issues that prompted the reforms aren't limited to the U.S., however. Every developed country has a finite amount of healthcare resources and high patient expectations; many also have aging populations. Developing countries have limited resources, period. Every country organizes its healthcare system in a different way, and all countries have something to teach others.
The International Hospital Federation (IHF) provides a forum for ideas and best practices to be exchanged, says the organization's CEO Eric de Roodenbeke. The IHF was founded in 1929 and after a hiatus during World War II, formed again in 1947. Its mission is to improve health for people around the world by promoting the exchange of knowledge and best practices and fostering partnerships between public and private hospitals among its 100-nation membership. That gives its CEO a broad perspective on healthcare issues worldwide.
An expert in public health and health economics, Dr. de Roodenbeke shared his thoughts from the IHF Secretariat's office in Ferney-Voltaire, France. For instance, he doesn't think healthcare organizations understand "the patient experience" -- try as they might to create it. They also have failed to reap the benefits of standardization available to other industries. As for the United States, he believes that competition isn't as influential in improving healthcare performance as Americans think it is. But, says De Roodenbeke, one of the biggest benefits of healthcare reform is that it makes politicians, who are least likely to want to discuss healthcare changes, work on them.
GMJ: Why the need for an international organization for hospitals?
Eric de Roodenbeke, Ph.D.: When the IHF was founded, the need was quite obvious. There were not many opportunities across the world for decision makers in the hospital sector to compare their practices and to exchange their tools and approaches. After World War II, there was a need to again [gather] the former members who had been for a while enemies. The idea of being able to share knowledge and practices across borders has sustained this organization all these years. Of course, things have evolved from a strict focus on hospitals to the whole spectrum of delivering care.
GMJ: What's causing the pressure to perform in developed countries?
Dr. de Roodenbeke: I'm not sure that competition, as it is described in the market economy, is the major driver for performance. The U.S. -- and I might be a little critical here -- is interesting because it's the system in which there has been the most emphasis on the role of competition, but it's also a system that has poor performance. Among OECD [Organisation for Economic Co-operation and Development] countries, if you measure [performance] through the cost effectiveness of service delivery, the U.S. [healthcare] expenditure per GDP and the health outcomes don't place the system as a top performer. So it appears that competition is probably not the most important driver [of healthcare outcomes] even though it can play -- and it should play -- a role.
So what improves performance? It's more about good public policies and financing systems. The government has played around with the payment mechanism for hospitals to push them to improve their performance. These payment mechanisms are based on the principle of the market economy, with which I would fully agree. But they are driven by public policy options, not a pure laissez-faire market. So you have elements of the market economy that are driving performance improvement, but not in a pure open market, because the service provision for health is not a commodity similar to any other.
I'm afraid that nobody has yet found the miracle approach that will have a better result in changing behavior.
GMJ: The president of the Institute of Medicine said that there is an inverse relationship. The more you spend on healthcare on average, the lower the quality of healthcare on average, because you're spending for mistakes and suboptimal care. Tell me about that.
Dr. de Roodenbeke: There is an idea of a critical mass of expenses that are necessary, and beyond that, you don't get any more economy of scale. And of course, you have all these elements related to spending on behavioral change for which it is difficult to measure the impact; there are behaviors that we know result in a large portion of the disease burden. So in a public health policy, it makes sense that you spend money to try to change these behaviors. But I'm afraid that nobody has yet found the miracle approach that will have a better result in changing behavior. If changing simple individual behavior is complex, what about [changing the behaviors of] large organizations like hospitals?
That's probably one of the reasons why this sector is such a headache for politicians, because there is no country in which you can say we have a highly performing hospital where there is no waste and where everything is perfect. There is still a lot of room for improvement, even in developed countries. Perhaps one of the reasons for that, and the economists often point it out, is that the practices in medicine are far behind in their approach to standardization. And that's probably one element of the cost of service delivery: the limited standardization.
GMJ: American hospitals are putting in substantial efforts to improve the patient experience, with spotty business results. What's the view of the patient experience in Europe or Asia?
The healthcare crisis is a worldwide crisis, and that's the reason why it has been considered as a priority by the World Health Organization.
Dr. de Roodenbeke: The satisfaction of the patient is through the utilization of the services provided by the hospital. That always has been an important issue for our organization. Fifteen or twenty years ago, we had already published guidelines and booklets for our members to invite them to take into account the data about better care of the patient expectation. But taking care of patient expectations is much more about human relations, good information, and risk factors than an issue of providing beautiful surroundings. If people bring you flowers every day but are rude to you, what will you remember? The rudeness or the flowers?
Last May, I participated in a congress in Italy [organized] by an organization of hospital architects, and they have done a very interesting survey. There is an assumption that patients all want to have a single bedroom to be more comfortable, and therefore we have to build a large hospital to give them single bedrooms. And what was quite interesting is that -- and remember, this was in Italy so there are certainly cultural elements [affecting the results] -- most of the patients prefer multi-bed rooms rather than single bedrooms. In hospital, people feel isolated, and they prefer to be able to talk to other patients. They can talk about their disease and how they face it and things like that rather than watch a dumb movie on TV because they are stuck alone in their room. As you said, patient experience and patient expectation is a major driver and very important, but we have to be very open and adaptive to patients' real expectations and not make them for patients.
GMJ: Do you think hospital quality is a function of a well-structured regulatory environment or a result of human capital investments?
Dr. de Roodenbeke: I would say it's both, but quality comes from organization and process. Quality results from the behavior of each of the health workers in the structure. Behavior is the weakest [link] of the chain and also the one that will give you the level of quality. Patients deal with a lot of health professionals, so their experience and the quality outcome will be high if all along the chain there is a consistency in the level of quality. If there is a crack, the final outcome will be related to the one crack in the whole chain.
GMJ: Some have said that healthcare is one of the last industries to globalize. Why is that?
Dr. de Roodenbeke: I was having this conversation with a friend at the World Bank. We noticed that there isn't a brand name that is franchised all over the world providing a consistent standard of service. We don't have that with hospitals. Even the large hospital chains are small players. And the whole market is very fragmented.
Probably one reason is the differences in practice and culture and the fact that the professionals have been holding very much in their hands the delivery of the care. Therefore there is limited capitalistic development. Perhaps another is that even though people rightly say if you spend, as a portion of GDP, too much money on healthcare, the healthcare industry is not one of major profit. The private sector in healthcare does not make the kind of profit that, for example, Microsoft does with software. A more open but regulated healthcare industry might create less of a major hurdle to investors in the business.
GMJ: Meanwhile, many hospitals worldwide are facing severe staffing shortages. And as access to healthcare increases in the U.S., doesn't the problem become exacerbated?
Dr. de Roodenbeke: The healthcare crisis is a worldwide crisis, and that's the reason why it has been considered as a priority by the World Health Organization. There have been a lot of efforts around this issue. One of these is a code of ethical recruitment that just has been adopted in the World Health Assembly, with American support. There is a concern not to deprive the poorest countries that have the highest staffing problems of part of the workforce, mainly nurses, who are the most in demand. So there is a lot of work that still must be completed in scaling up education and reengineering the process of work to make it less labor consuming.
There is a lot of thinking to be done on the issue. Perhaps we need a gatekeeping mechanism so that people with just a headache or a cold don't overwhelm the general practitioners. But still, interest in reform is a good thing in the sense that the overall trend of the aging workforce and the demands of the aging population are creating a human resource crisis for health. The crisis is there, reform or not, and has to be seriously addressed. If reform is getting extra emphasis, I think that is a positive because it will oblige the decision makers -- the politicians -- to put this issue high on their agenda. Healthcare issues have been around for a long time, and it was not at a high place in the priorities or in political agendas. It is now, and that is a good thing.
-- Interviewed by Christopher Khoury and Jennifer Robison