By David Betts, Principal, Deloitte Consulting LLP
This week's blog, by David Betts from the US firm, first appeared on the US Center for Health Solutions blog site. The blog, while mainly aimed at a US audience, looks at how several countries are utilising digital technologies, moving from volume to value and examines what roles governments are playing in healthcare.
During a recent visit to Australia, I had the opportunity to visit Rottnest Island, which lies off the western coast. This island is fascinating to me for many reasons. For example, it is the only place in the world where you’ll encounter quokkas—small marsupials that look like a cross between a house cat and a small kangaroo.1 Quokkas being unique to this island got me thinking about what being unique really means.
So, what does this have to do with health care? Many of us see the US health system as being one of a kind, and we tend to think of the challenges we face as being truly unique. But they aren’t unique at all. As we move toward the global future of health, many countries face many of the same issues we are trying to overcome in the US. These challenges include improving consumer engagement, solving interoperability issues, transitioning from paper to a digital platform, and figuring out how to prevent illness so that we don’t have to devote as many resources to treating it.
In talking with clients and colleagues from around the globe, it has become clear to me that health systems—regardless of the country—are more similar than they are different. Every country is trying to get to the same future of health that we envision in the US.
However, each country is at a different point along this journey.
When it comes to digital, some countries are further ahead
Radical interoperability has the power to truly change health care, but achieving it is no small task for any country. Singapore and Vietnam are relatively new to the game and don’t have the decades of legacy baggage that can make change difficult in the US and other countries. In some respects, this puts Singapore and Vietnam ahead of the pack in their ability to adopt a fully digital model. These countries can start with digital rather than having to digitize paper and outdated processes, which could make it possible to leapfrog ahead of other health systems. Consider this: Singapore’s Ministry of Health launched the country’s national Electronic Health Record in 2011 and is preparing to launch a next-generation EHR by next year. Low participation in earlier versions prompted the Ministry of Health to make it compulsory for providers to participate and share their data.2 In Vietnam, several hospitals are piloting EHRs, and the country expects to expand it nationally by 2020. Each citizen will have his or her own EHR, which will be monitored and stored for a lifetime.3 These represent interesting leading developments in the creation of a consolidated digital health record model, but it is still early in its evolution.
Other countries aren’t as far ahead when it comes to moving to a digital model. In Japan, for example, EHRs are still experimental, and interoperability between providers remains a challenge. Experiments are under way to make personal health information available to patients and providers via cloud computing, but it yet remains an experiment.4
In the Netherlands, most clinicians and all hospitals have an EHR, but there are no national standards, and interoperability between systems can be a challenge. In 2011, hospitals, pharmacies, and other provider groups established the Union of Providers for Health Care Communication, which is responsible for the exchange of data via an IT infrastructure, but patients must approve their participation and can drop out if they want.5
Australia is also making the move to digital. It has been about three years since the government launched the Australian Digital Health Agency to create a national digital health strategy. About 4 million patients—along with many of the country’s primary care providers—are now registered in an interoperable national e-health program. The record supports prescription information, medical notes, referrals, and diagnostic imaging reports. Patients are also able to add their own health information about allergies and adverse reactions, but some percentage of patients and practitioners have opted out.6
All of these models demonstrate both the promise and challenge of moving toward radical interoperability and consumer ownership of health data but in slightly different ways and with slightly different measures of success.
Many countries are trying to move from volume to value
We’ve been talking about the need to move from a volume-based health system to one that is based on value for several years. In the US, we tend to think that this idea is further along in other parts of the world. But based on conversations with clients and colleagues from other parts of the world, and my own recent observations, many countries are finding it difficult to transition away from the fee-for-service (FFS) model. This is another challenge that is far from unique.
In Singapore, for example, most primary care is delivered by private general practitioners (GPs) who are paid by the government through a FFS model. They can make referrals, but they do not function as gatekeepers, giving consumers the ability to navigate the system on their own as well.7 Australia’s public health model pays GPs under a FFS model, but the breadth of services that are reimbursable under this framework is fairly limited. Similar to the US, this has created a perverse incentive structure in which the flow of funds can hamper innovation. For example, there is little reason for a traditional GP to consider conducting a virtual visit if there is no payment for it. Australia, primarily through its private health insurance system, is beginning to experiment with telehealth to extend the reach of physicians to the country’s underserved rural areas, but these efforts are in many ways nascent. That being said, the Royal Flying Doctors (one of the largest aeromedical organizations in the world) have been delivering telehealth services for as long as there have been telephones!8
What role should the government play in health?
Many countries are trying to figure out the role government should play in community care. While many governments are working to encourage consumers to take more control over their wellbeing and to treat illnesses at home when possible, stakeholders are simultaneously trying to figure out how to position themselves for this future. Many are beginning to recognize that consumers are becoming better informed and more engaged in their own care.
To help empower consumers, Singapore’s government has launched a health portal through which patients can research typical costs for common tests, surgeries, and other treatments. They can also see the number of cases performed in each hospital.9
The Vietnamese government is trying to encourage more treatments to be delivered in the home, which is seen as a highly effective model in a country not constrained by the same infrastructure as other countries. To improve care access to people in rural and underserved areas of Vietnam, the Ministry of Health requires a rotation for physicians.10
The federal government regulates virtually every part of Japan’s universal Statutory Health Insurance System (SHIS). Citizens are mandated to enroll in one of the SHIS plans based on age, employment status, and/or place of residence. Although the majority of the population holds some form of private health insurance, it plays only a supplementary or complementary role. All enrollees have to pay a 30 percent coinsurance for services and goods received. There are no deductibles.11
Health insurance in the Netherlands is mandatory for residents and anyone who pays Dutch income taxes. There are two types of insurance—one covers common medical care while the other pays for long-term care. The publicly funded health system is facing the challenges that come with a growing population. To ensure everyone has a financial stake in their health, insured adults are responsible for an annual deductible for expenses including hospital admissions and prescription drugs. GP visits do not count toward the deductible.12
Multiple paths lead to the future of health
While many countries have primarily government-funded health systems, they are still dealing with many of the same issues we are trying to overcome in the US where reimbursement is a mix of government and third-party funding.
In the US, it is easy to dismiss what we might be able to learn from other countries because we have this notion that every health system is unique to that country. But the challenges we face in getting to the future of health don’t recognize international boundaries, and many health systems are more similar than they are different. While each country might be on a slightly different path when it comes to the future of health, we are all headed to the same destination.
Rottnest Island is the one place on earth where quokkas uniquely exist, but the US health care system is not the one place on earth dealing with the challenges and opportunities represented in our vision for the future of health. We have more in common than we may believe, and we should explore these problems and opportunities together.
1 Rottnest Island Authority (https://www.rottnestisland.com/)
2 HealthcareITNews, “Leveraging IT for better health outcomes/recent developments in Singapore,” October 2018
3 Viet Nam News, “MoH plans to digitise all VN medical records,” August 15, 2018,
4 The Commonwealth Fund/International Health Care System Profiles, Japan (https://international.commonwealthfund.org/countries/japan/)
5 The Commonwealth Fund/International Health Care System Profiles, The Netherlands (https://international.commonwealthfund.org/countries/netherlands/)
6 Australian Digital Health Agency, Department of Health (https://www.myhealthrecord.gov.au/statistics)
7 The Commonwealth Fundy/ International Health Care System Profiles, Singapore (https://international.commonwealthfund.org/countries/singapore/)
8 The Royal Flying Doctor Service (https://www.flyingdoctor.org.au/)
9 The Commonwealth Fundy/ International Health Care System Profiles, Singapore (https://international.commonwealthfund.org/countries/singapore/)
10 Health Affairs, “Vietnam’s Health Care System Emphasizes Prevention And Pursues Universal Coverage,” November 2014 (https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1141)
11 The Commonwealth Fund/International Health Care System Profiles, Japan
12 The Commonwealth Fund/International Health Care System Profiles, The Netherlands