As the leaders of the U.S. healthcare system strive to make population health management an operational reality, “evidence increasingly shows that to improve population health and constrain the rate of growth in healthcare costs, it is necessary to address the underlying social determinants of health,” a group of policy researchers and leaders is writing in The Health Affairs Blog.
In an analysis posted online on July 9, Roberto Nuño-Solinís, Stephen M. Shortell, Richard M. Scheffler, and Meg A. Kellogg look at some of the key lessons the Spanish healthcare system has to offer U.S. leaders—and in particular, the regional healthcare delivery and payment system in the Basque Country in northern Spain. As Nuño-Solinís et al write, “The Basque Country is an autonomous region in the north of Spain with a gross domestic product a third higher than the rest of the country and more than 40 percent higher than the European Union average.” Further, they note, “The healthcare system in the Basque Country is a single-payer system, funded by taxes, offering universal coverage for all 2.2 million residents. The main provider is Osakidetza (the Basque Health Service), a public organization where all health care professionals are salaried public employees. The Basque Ministry for Health oversees policy planning, financing, and contracting of health care services, acting as the single payer.”
Meanwhile, “In 2010, in a context of an aging population, increasing prevalence of chronic diseases and facing an economic crisis, the Basque government launched the “Strategy to Tackle the Challenge of Chronicity in the Basque Country” with the vision to transform Osakidetza in the long run, to cope with the growing challenges of chronic illness, aging, health system fragmentation, and financial sustainability.” As the article’s authors note, “Central to the Basque approach has been developing a culture of shared leadership and achieving a balance between top-down and bottom-up change. Policy-makers took time and effort to refocus a system that was used to exclusive top-down, centralized, decision making, to one that would give frontline staff permission to find solutions and innovate.” The strategy at the Osakidetza includes five core elements: a population health approach; prevention of chronic illnesses; patient responsibility and autonomy; integrated care; and efficient interventions adapted to the needs of the chronically ill patient.
In the case of the Osakidetza, these strategies are being carried out through the implementation of integrated health organizations, or IHOs; and part of the aim has been to merge hospital and primary care structures under a single organization, with an integrated strategic plan. Indeed, the article’s authors write, “The Basque Strategy holds many lessons for US population health initiatives. Foremost among these is the need to achieve strategic alignment among the parties involved. The Basque Strategy of top-down guidance but with extensive bottom-up input and ideas is instructive. Each organization needs to see its involvement in the partnership as important for advancing its strategic goals. The development of backbone organizations such as the Basque IHOs is critical for providing the information systems and related tools for collaboration, building trust, and accountability. The IHOs helped to set common goals for both primary care and secondary care and for the relationships with the community-based social support agencies.” And while data availability, management, and governance have proven to be problematic—"health and social data are collected in silos using different platforms and with varying regulatory and privacy constraints”—the fact that Spain invests all of its autonomous regions with considerable power and autonomy, means that the Osakidetza has had a level of flexibility in reorganizing healthcare operations that is far more akin to what the Canadian provincial governments have had, rather than to any U.S. analog. Even state Medicaid programs have lacked the Osakidetza’s level of authority and autonomy.
All of this is very intriguing indeed. Granted, there are huge differences between the Spanish and U.S. healthcare systems. Spain’s, like the national healthcare systems of all the western European countries, and really all the European countries, broadly speaking, is centralized in a way that simply doesn’t exist in the U.S., with our highly fragmented payment and delivery systems. Much can be directed from above, and clearly, in the case of the Basque Country, is being directed thus.
That having been said, Spain, like all the European countries, struggles at least as much with financing issues as does the United States. Indeed, with central government control, global budgeting, and an economy that still has more than 10 percent unemployment nationwide, Spain’s healthcare system continues to struggle with some of the same core issues as all the national healthcare systems of all the advanced, industrialized nations do. A recent report from the Instituto para el Desarrollo e Integración de la Sanidad noted that the aging of the population, the explosion in chronic diseases, advancing medical and information technologies, medical-legal and liability issues, and increasing consumer empowerment, are major challenges for Spain now, with budgets strained at a 10-percent-of-GDP level of spending. These same challenges emerged in discussions and interviews that I was involved in, in Madrid and Barcelona in 2017 and 2018, with Spanish healthcare leaders coming back repeatedly to the same themes once and again. Sound familiar?
So this analysis of what’s happening at the Basque Osakidetza is of real interest. How these findings might be translated into the U.S. context is a question with a considerable degree of nuance and complexity. But it’s also clear that what the Basque healthcare leaders have been doing with their IHOs speaks to some of the very same types of questions that the leaders of accountable care organizations (ACOs) and the developers of other alternative payment models have been wrestling with over here. For now, we’ll have to stay tuned for further reports from the Basque Country—or as they say in Spain, ¡mantened todos al tanto!
