I read with fascination an article published in the April issue of Health Affairs. The article was based on an extensive study of health status data that spanned ten countries: Austria, Belgium, the Czech Republic, Denmark, France, Germany, Italy, Spain, Sweden, and Switzerland. Looking at data derived from a huge survey of healthcare consumers known as the “Survey of Health, Ageing and Retirement in Europe (SHARE), a European panel database that consists of nationally representative samples of respondents ages 50 and older in 20 European countries, and includes information on respondents’ sociodemographic characteristics, health status (including presence of chronic conditions and disability), and health care use and spending,” the researchers derived some important conclusions about the state of disease management in those countries. Their article ran under the headline, “Multimorbidity And Health Outcomes In Older Adults In Ten European Health Systems, 2006-15.”
The article’s authors—Raffaele Palladino, Francesca Pennino, Martin Finbarr, Christopher Millett, and Maria Triassi—examined the issue in depth, using health outcomes data from ten European countries between 2006 and 2015, and finding that “the prevalence of multimorbidity rose from 38.2 percent in 2006–07 to 41.5 percent in 2015,” even as they note that, “Despite the increase in awareness of chronic disease, little is known about whether multimorbidity—defined as two or more coexisting chronic conditions—has had a diminished impact on health in Europe in the past decade.”
In fact, despite documented increases in multiple chronic conditions among healthcare consumers and patients in those ten countries, the researchers found that, “In many European countries chronic disease management programs have focused on single chronic conditions such as diabetes or COPD [chronic obstructive pulmonary disease], given the increased risk of avoidable hospital admissions and worse health outcomes for people with these conditions.” What’s more, the reality on the ground, the article’s authors have found, is that, “With aging populations, consequent longer exposure to risk factors, and improvements in medical technology, the increasing prevalence of multimorbidity has become a major challenge. European health care systems have been slow to respond, with care pathways typically fragmented and organized around single diseases. Exceptions include France, Germany, Spain, and the UK (which is not part of the Survey on Health, Ageing and Retirement in Europe project), where experimentation with integrated care approaches that target people with multimorbidity is under way. However, in the majority of cases, these approaches have not been rolled out nationally—with the exception of the UK, which has recently issued national guidelines for the assessment and clinical management of people with multimorbidity.”
There is a strange kind of healthcare policy puzzle here, on multiple levels. All of the nations studied have national healthcare systems, with the national governments of those countries the dominant payers (though one could argue that Switzerland sits somewhere between most of the western European nations and the United States in terms of its payment system), as well as the dominant providers of care delivery. Most also have payment systems involving global budgeting, within their national government-provided care delivery systems. Yet some of these countries—France and Germany, in particular—retain care delivery systems with extremely rigid inpatient/outpatient divides, with very intensive and extensive silos preventing the development of ideal forms of population health management across the continuum of care. Indeed, in France and Germany, even now, physicians on either side of the inpatient and outpatient divide are in effect forbidden from communicating with one another (though that explanation simplifies things a bit), inhibiting even the most basic care management programs from being developed across the care continuum.
Still, at the same time, on the outpatient side, some European countries have systems with some elements that continue to surpass what we have in this country. When I met with Spanish healthcare executives in Madrid and Barcelona in November 2017, I found that they were using their relatively limited resources to support robust population health management, nationwide, something that American healthcare leaders see as a vision probably only attainable decades from now. Or, as the medical director of a Madrid hospital’s outpatient section told me, “Well, what you Americans call population health management, we don’t really call anything—it’s simply the way in which we’ve been managing care for well over 30 years now.”
So, to be fair, comparing the situation on the ground in the United States with the situations across a number of European nations’ healthcare systems, is in many ways bound to be an apples-to-oranges intellectual and policy exercise. Some of the core care delivery systems in some of the European countries—I’m thinking in particular of the healthcare systems of the Nordic countries (Norway, Sweden, Denmark, Iceland, and Finland)—exhibit features that are light-years ahead of what we have here. As a Finnish medical leader told me when I met with Finnish healthcare policy leaders in Helsinki in 2000, and speaking of the subject of clinical guidelines and pathways, “On any of these issues, we literally could bring together the entirety of the people we would need to resolve any issue in this area, and fit them into one small room here in Helsinki, and hammer out the issue.” For perspective of course, it’s important to note that the entire population of Finland is about 5.3 million people—smaller than the metropolitan region that encompasses Chicago, which numbers up to 8 million, depending on who’s counting.
Still, all of this having been said, it interests me that certain elements of what healthcare delivery leaders are creating here in the United States genuinely are in advance of what’s been created in some of the European nations. That’s so partly because of differences in healthcare payment and delivery systems. For example, speaking of the Nordic countries, all of which are relatively small in population (Sweden, the largest, has 9 million people, while Iceland, the smallest, numbers only 500,000 people in its entire country), and which have global budgeting, national healthcare delivery systems with barely a fringe private care delivery sector, and exceptionally advanced data-gathering and analysis, those five nations already track patients through their delivery systems, using unified national electronic health records (EHRs); so they essentially have built-in national health information exchanges (HIEs), and tons and tons of data on their citizens’ and residents’ health status. Indeed, when I attended the HIMSS World of HIT Conference in Barcelona in 2016, I had the opportunity to interview a Finnish healthcare leader who was spearheading a nationwide initiative to develop a nationwide data lake that would bring together social determinants of health (SDOH) data with data in the unified national EHR and government health data, to help create a nationwide, living almanac of Finns’ health status, and to help providers to apply population health strategies to the national population. Also, it goes without saying that the Finns will never face the tremendous challenges that the pioneers of pop health in the U.S. are facing right now, in terms of marrying clinical and claims data, because there is no claims data in Finland and the Nordic countries, in the sense that we understand it. The government pays for something like 99 percent of the patient care provided in those five countries, so separate, disparate, unconnected data systems for care delivery and payment are simply not necessary; the national EHRs of those countries simply record the care delivered.
So the apples-to-oranges comparisons are inevitable here. Yet it is heartening to know that, despite our severely fragmented healthcare system, American population health management pioneers are breaking down silos that in countries like Germany and France remain rigid and, so far, impenetrable, based on structural aspects of their national healthcare systems. In any case, the healthcare policy and delivery leaders in all the European nations are aware that they will need to do something to address the growth of multiple chronic conditions in their populations, particularly as those populations age at an even faster rate than ours is aging (because of much lower birthrates, including, perhaps surprisingly for those who might think in stereotypes, in Italy, where native-resident Italians are demonstrating a birth rate that is below replacement, at this point).
So analyses like this one in Health Affairs will be useful on both sides of the Atlantic, as they can help guide national healthcare policy leaders in all countries, while shining a light on areas of healthcare policy and delivery that need high-level, concerted attention in the coming years. The leaders of all nations—including the leaders if the developing nations as well as of the advanced, industrialized nations—around the world, are going to need to move forward with alacrity to solve the persistent, vexing problems that are besetting societies across the globe.
