|Implemented in this survey?|
The Danish Ministry of Health has announced a new policy-goal: the stated intention is to publish data on the productivity performance of individual hospitals and providers in general. An additional goal is to make the Danish health care system "the best in the world" to develop productivity data regarding health care services.
The main objectives are:
The understanding appears to be that regional purchasers (partly the regions that will replace the existing counties, partly the municipalities) will have a financial incentive to put pressure on producers (as they can use freed resources to alternative initiatives), and that the additional information will strengthen this incentive. Though not put in those words, the underlying rationale could be that by lowering the cost of information various groups (voters, purchasers etc.) will make more use of it.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The initiative is traditional in the sense that productivity studies have been pursued sporadically for a number of years. It is, however, a novelty in a Danish context that the Minister of Health explicitly puts so much emphasis on the monitoring of productivity.
The idea can be viewed in the context of the present ministers goal to improve transparency of the system. The basic goal is to improve productivity performance by putting pressure on providers. There has been no pressure from the out-side: not from opposition parties, not from media, not from academia, not from producers, not from consumers or voters and not from abroad.
|Implemented in this survey?|
The origin of the idea is to be found mainly in the Ministry of Health and the Ministry of Finance. The use of DRG's for productivity comparisons started in the 1990'es and a circle of civil
servants have persistently sought to develop this kind of information. It would be incorrect to view this effort as a part of any Libertarian conspiracy to transform the sector into
a market-like process (the civil servants in the both the Ministry of Health and the Ministry of Finance have traditionally been strongly opposed to any market-oriented reform of the sector
and have instead been exponents of the view that the mere observation of a formal market-imperfection justifies government intervention). Rather, the motivating force has probably been primarily a
sort of technocratic or managerial common-sence ('it might be helpful to be able to compare the production of hospitals') and an ambition to put pressure on
The additional step to not only make comparisons of productivity but to make them public probably reflects the advent of a particular pro-active minister of health. That is: it is not an idea which has been embedded in the core community of civil servants. In this sense the development of the idea has been politician-driven and crucial depends on who holds the office.
It is perhaps noteworthy that the idea did not originate with the Association of Counties (the regional body which owns and runs hospital in the Danish system), nor within the community of health care experts within social-science departments. The Association of Counties has rationally found that imperfect information on performance, rather than constituting a nuisance, can be very helpful to its particular interest. The community of experts is generally very concerned with the implications of the emergence of additional information - the concern is based on the risk that additional information in particular areas might distort incentives and thereby fail to be instrumental to an overall improvement.
As part of the annual negotiations ("budget game") between the central government and the Association of Counties it has been agreed that systematic productivity analyses' should be made and that
the results should be published. The Minister/Ministry of Health was the driving force.
Producers - hospitals etc. and counties (which have a dual role both as payers and providers) - have generally been reluctant to adopt the idea. The official reason is that in a complex sector it is very difficult to meausure performance accurately. The underlying rationale may be that additional information may undermine their bargaining power.
|Minister of Health||very supportive||strongly opposed|
|Govt and supporting parties||very supportive||strongly opposed|
|Opposition parties||very supportive||strongly opposed|
|Hospitals||very supportive||strongly opposed|
|Association of Counties||very supportive||strongly opposed|
The initiative is still at the idea stage. It can, however, be implemented without any explicit legislation. The agreement between the government and the Association of Counties sketches certain initiatives and a timetable for their implementation.
|Minister of Health||very strong||none|
|Govt and supporting parties||very strong||none|
|Opposition parties||very strong||none|
|Association of Counties||very strong||none|
Adoption and implementation is pending.
No particular mechanism has been suggested for reviewing the implementation of the idea. The plan appears to be that the Ministry of Health will do the reviewing.
One objection to the policy-idea is that additional information risks distorting performance so that effort which is valuable but difficult to observe is given a lower priority by producers. It is an open question whether this will be the case or if it is possible to collect broad enough information so as to achieve a net-gain. Assuming that a net-gain is possible (or at least accepting that we do not know and that a trial-and-error process is worth pursuing) the policy-initiative is reasonable. In fact, the main concern may well be that it will either not be carried out, or that, within the given structure of incentives, it will have no effect. The reasons to expect it to have little or no effect are the following:
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The likely outcome is that the additional information on productivity will have little impact on cost efficiency since purchaser (i.e. the counties/regions) have little incentive to put pressure on their own providers. Consequently there is also little risk that providers will increase shirking that reduces quality.
The policy-idea paper - Produktivitet på Sundshedsområdet [Productivity in the Health care Sector] is avaiable in Danish only. In September 2005 it was available at the followin link from the Ministry's homepage: Produktivitet på Sundshedsområdet [Productivity in the Health care Sector]
Michael O. Appel