2006 ISDC Session Report
Special Convened Session on the Dynamics of Health Care Reform and
Meeting of the Health Policy Special interest Group (HPSIG)
Session Reporter: Gary Hirsch
The Special Convened Session began with presentations of six papers that addressed
various aspects of health reform at the local, regional, state, and national level. There
was also a brief presentation on recent Dutch experience with health reform. These
presentations were followed by a discussion of common issues facing those who attempt
reform of health care systems. The final portion of the meeting was a discussion of
future directions for the HPSIG and possible topics for a session at the 2007 ISDC.
The first presentation on health reform by Gary Hirsch drew on the experience of several
states in the US to develop a causal model of health reform. These experiences suggested
the importance of coalition building, proposed programs that are fine-tuned to meet the
needs of specific groups, and financing that spreads costs evenly among multiple public
and private payors. He suggested that successful health reform efforts would also have to
shift spending toward “upstream” preventive services and reinvest savings. Gary’s work
also drew on work from political science such as John Kingdon’s agenda setting model
and on work by John McDonough in applying these models to health reform.
The next presentation by David Todd focused on the reform of depression services in the
UK. Todd described how an SD model helped to support the introduction of “stepped
care” reforms designed to reduce the overload on psychiatric services by moving more
care “upstream” to deal with patients’ problems before they become severe. The model
helped practitioners understand the potential benefits of reform and need to allocate
resources to earlier steps in the care process.
Eve Pinsker then spoke about the effects of Federal and state spending cuts on the public
hospital “safety net” that provides care for indigent, uninsured patients in Cook County
(Chicago) Illinois. Her presentation described how these funding cuts have created a
potential vicious cycle in which a resulting decrease in quality and effectiveness of
services and demand for payment from indigent patients could lead to reduced public
support for these services.
Geoff McDonnell presented the next two papers. One dealt with the transition of China’s
health care system in line with market reforms and the problems that resulted. These
included reduced access to care for poorer people and those living in rural areas and a
shift to more expensive high tech medicine and away from cost-effective care provided
by health workers in rural areas. Geoff's other presentation described different world
views of health care that guide people’s approaches to health reform (hierarchical control,
market, network/professional) and how differences in those world views have become a
barrier to reform. He also described some possible mechanisms for overcoming those
differences such as generic models of health system processes that facilitate international
comparisons.
A final presentation by Jim Thompson described a national model for projecting US
health care expenditures over a four-year time horizon based on anticipated changes in
utilization and prices. A key feature of the model is the role of pharmaceutical and
medical device technology in both adding incremental costs by treating things not
previously treatable and producing some savings by reducing complications of illness.
Jim described how an insurance company has used the model to project the potential
effect of particular developments such as an outbreak of pandemic influenza.
Etienne Rouwette then spoke briefly about recent Dutch experience with health reform.
This primarily entailed a shift from a uniform National plan with a mix of public and
private administration to mandatory private insurance with a basic package and
competition among plans on the additional benefits. An unintended effect of the shift
was a high rate of switching among plans (18-20% in 2006 vs. 3-8% previously) and
possible adverse selection in which healthier people may have avoided higher cost plans.
The remainder of the discussion focused on future directions for the HPSIG and potential
topics for a session at the 2007 ISDC. These included:
¢ Looking at some of the same topics across different countries. We could solicit
country-specific papers on a topic, using the same template to facilitate comparisons.
¢ Considering financing at a National level, but capacity issues at a local level to help
deal with differences in geographical distribution of resources. Ways of increasing
capacity might include tapping non-traditional resources and streamlining the care
delivery process. We could try to address these issues by working with policymakers
at multiple levels.
© Two topics that were suggested as ways we could help to move care “upstream”
toward more prevention of illness. One would be promoting the design of systems
that partner health care with related social services. The other would look at effects
of the environment on health care and vulnerability to illness and how adverse effects
of the environment could be reduced. If we pursue either of these topics, we would
have to better define what we mean by upstream interventions.
e Systems thinking training for health professionals was suggested as an additional
function that the HPSIG might serve. In general, people felt that the HPSIG should
be reaching out to the mainstream health community in order to have greater
influence on policy.
We agreed to continue thinking about these and other topics and to communicate our
ideas by e-mail in order to plan for next year’s conference.
At the conclusion of the session, Gary Hirsch was elected President of the HPSIG for
2006-2007 and David Rees was elected Vice President.
