Health clusters may create more continuity for patients
Denmark is exploring a new health care reform that may lead to a more integrated health care system with better continuity for patients along all aspects of the patient journey – health promotion, disease prevention, diagnosis, care and rehabilitation. The new Danish model could be a compelling inspiration for health care systems in other countries, including the United States that is struggling with a fragmented and dysfunctional health care system.
Some international observers may be surprised, as Denmark often has been touted – not the least by Bernie Sanders – as an inspirational model for other countries due to its single-payer, universal health care with free and equal access for everybody. So why change such a system?
The fact that health care in Denmark is a tax-payer funded, universal health care system is not unique to Denmark as health care in most countries outside of the U.S. is based on a universal, single-payer model.
What is unique to Denmark is the comprehensive primary care system where independent, general practitioners act as coordinators and health advisors for all citizens and collaborate with hospitals for patients that need acute or complex care and with the municipalities that provide preventative care and rehabilitation support to the elderly and patients when they are discharged from hospital.
However, with the rise in the aging population and the increase in patients with chronic multi-morbidities (around 30% of all adult Danes suffer from multiple chronic conditions), the system is under financial pressure, and Denmark has realized that the current health care model needs some shake-up.
Why the Danish model needs innovation
There is consensus among Danish health care leaders and policy makers that there are several challenges in the Danish health care organization:
- Primary care needs to be strengthened: The primary care sector is expected to take over a larger part of the management of people with chronic conditions (for example people with type 2-diabetes, COPD and aspects of cancer care) to avoid unnecessary hospitalizations, better manage hospital costs, and improve the quality of care. The new national agreement between the primary care physicians and the regions is intended to enable this transfer of activity from hospitals to primary care. However, there is a shortage of primary care physicians in Denmark and many physicians who are educated as specialists in primary care today work outside of primary practice. At the same time, the number of hospital-based physicians have increased with about 50% over the last 15 years, while the number of primary care physicians has remained largely unchanged in the same period.
- Fragmentation of leadership and management: Each sector – primary care, municipality and hospital – has its own leadership. The primary care physicians who are independent contractors operate within the national agreement with the regions. The hospitals are run by the five regions and the regional councils are comprised of elected politicians. The municipalities are led by the city councils that also have their own elected politicians. Each sector has its own set of values, principals and goals for health and health care – and these are sometimes conflicting.
- Disconnected patient journeys: Due to the above factors – lack of resources in primary care and fragmented sector leaderships – patients experience that their care path is not well-organized and connected. This is particularly the case for elderly and people with chronic diseases who engage with health care services across all sectors on a regular basis. Patients often experience gaps in continuity and quality of services. This is not just a matter of improving patient satisfaction. A recent literature analysis in the British Medical Journal suggested that continuity of care with doctors is a matter of life and death, as the study of 726 published articles concluded that “increased continuity of care is associated with lower mortality rates.”
New idea about health clusters
Suggestions for changing the Danish health care organization have gained traction this year.
In February, three experts – Frede Olesen, Professor in Primary Care, Aarhus University, Kjeld Møller Pedersen, Professor in Health Economy and -Policy, University of Southern Denmark, and Leif Vestergaard Pedersen, CEO of the Danish Cancer Society – wrote a remarkable op-ed in the Danish newspaper Politiken proposing the establishment of health clusters where acute care hospitals, primary care physicians and municipalities are working together under integrated leadership with common goals, unified decision-making and quality of care metrics.
Primary care physicians have already started to organize themselves in practice clusters. The health clusters would elevate this integrated approach to cover all aspects of health promotion, disease prevention, acute and chronic care, and rehabilitation for the patients. This is in essence a Danish version of population-based health care.
The future of the regions
The discussion about the urgency of a new Danish health care reform gained further steam when the Danish Prime Minster Lars Løkke Rasmussen in May in the Danish Parliament announced that the Conservative government this fall will propose a big health care reform that will “improve the integration between the large hospital and the local primary care physician. So that patients are not lost in the system. We need to create a health care system that is connected,” said the Prime Minister.
The new reform will build on the health care reform about 10 years ago when Denmark abolished the counties as regional health authorities and replaced them with five regions. While the regions technically deal with other issues than health care, such as the environment, social and educational support to people with special needs and public transportation, their overarching responsibility is health care.
The Prime Minister’s announcement about a new health care reform has triggered a renewed debate about the future of the regions in Denmark.
Some argue that the responsibility for hospitals should be moved from the regions to the municipalities, but others fear that the municipalities are not equipped to handle this responsibility, that many of them are too small, and that this would lead to a decline in the quality of care. Others suggest that the regions should be abolished all together and that large and acute hospitals should be managed by professional boards appointed by the Ministry of Health, similar to the model in Norway, rather than being run by politicians elected at a regional level. A third group of people argue that the regions have improved the quality of care over the last several years and that the regions should be maintained.
Some political parties that support the leading party of the government Venstre (the Conservative, Liberal Alliance and Danish People’s Party) also want to dismantle the regions all together, while the Social Democrats and the smaller left-wing parties want to maintain the regions.
While the future of the regions is uncertain at this point in time, it is likely that the reform will introduce new structural and financial mechanisms for a more integrated and connected Danish health care system.
Health care experts express concerns that the issue about the future of the regions become a political hot potato that will detract from the real issue about how to improve integrated and continuous care for patients:
“Whether we keep the regions or not, the most urgent need is to reorganize health care around the patient to improve the quality of care, address the burden of multi-disease, strengthen the continuity in the physician-patient relationship and enhance the patient experience no matter where the patient needs health or health care,” says Frede Olesen.
What the United States and other health care systems can learn from Denmark
Already today, there are important learnings from Denmark that can inspire other countries that realize the need for creating more integrated health systems. There are similar learnings from Scotland that introduced health clusters some years ago and developed a national vision for “Putting general practice and primary care at the heart of the health care system.”
As the new Danish health care reform unfolds, other countries should pay attention.