Abstract
BackgroundEquity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities.MethodsThe analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap.ResultsAll indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits.ConclusionsReducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.
Highlights
Equity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems
The potential resources to be reallocated in absolute terms refer to how many resources (€) each Local health authority (LHA) could have reallocated if the performance of patients with a low Socioeconomic status (SES) had been equal to the performance of patients with a high SES
Policy and performance management implications Improving the performance of patients with a low education can contribute to three key goals of universal health systems: 1) equity, by reducing the gap between patients with low and high education; 2) quality of healthcare, by following clinical protocols and ensuring the delivery of timely and appropriate care to patients with low education; and 3) financial sustainability, by generating opportunities for resource reallocation within a clinical pathway, as suggested by our results
Summary
Financial sustainability, and quality in healthcare are key goals embraced by universal health systems. Financial sustainability, and quality in healthcare are key goals embraced by universal health systems, and are recognized as overarching targets in several conceptual frameworks [1,2,3]. In order to measure the attainment of such goals, equity, financial sustainability, and quality indicators have been included in most performance evaluation systems (PESs). PESs evaluate performance units (e.g. nations, regions, local health authorities, hospitals, health districts) through benchmarking indicators in order to support stakeholders in defining objectives, targets, improvement strategies, and corrective actions [4, 5]. Barsanti et al [6] describe how horizontal and vertical equity [7] can be defined in performance management terms. For the purposes of our discussion, we will refer to horizontal and vertical equity in performance management terms
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