1 Public / private mix in health care financing Dominique Polton Director of strategy, research and statistics National Health Insurance, France Couverture
2 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
3 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
4 1. Rationale for increasing private financing The growth of health care expenditure is desirable (value of health gains, superior good, innovation, ) The demand for health care is growing (ageing of the population, new technologies, consumer behaviour, ) Fiscal constraints, pressure on competitiveness limit on public financing Private financing could increase the resources devoted to health care without putting pressure on public finance + other arguments: greater choice, responsiveness of the health care system,
5 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
6 2. Forms of private health care financing Forms of private health care financing Funding of current health expenditure Funding of capital investment Out-of-pocket expenditures Private health insurance Private finance initiative
7 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
8 France Canada Slovenia Germany Switzerland Australia Netherlands Spain Portugal New_Zealand Korea Belgium Austria Japan Finland Hungary Denmark Poland Estonia Sweden Czech_Republic Out-of-pocket payments (1/3) Out-of-pocket is the first source of private financing 45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0 PHI and OOP as % of total health spending Source: OECD database
9 Out-of-pocket payments (2/3) Given the distribution of health care expenditure, there is a limit to the level of OOP: a large part of the costs is concentrated on a small proportion of individuals who could not pay their health care bills from their own resources (this is precisely why social insurance exists). Increasing out-of-pocket payments has consequences both for equity It increases vertical inequity (fairness of contribution) It can hinder access to care (which is again why public insurance exists) and efficiency They affect in the same way low value care and high value care They are often higher on less expensive care, which is contradictory with the wish of Gouvernments to move care from hospital to ambulatory care (wrong price signal given to the patient)
10 Out-of-pocket payments (3/3) What could be a «rational» increase of OOP payments? Either design them in a way that enhances efficiency, i.e. differentiated according to the value of care: Examples: brand drugs versus generics (reference price in Germany), choice of a referring doctor (France since 2005), but then they do not provide additional funding (there would be no user charges in a system which is totally cost-effective), Or finance services that are explicitely excluded from the statutory benefits package Which dividing line? Cf below
11 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
12 Coverage by PHI Source: Thomson et al., 2009
13 in commercial insurance in 2006 ( in 2001) Coverage by PHI An heterogeneous situation Ireland Source: OECD, 2004 France - % covered by PHI % % (1) (1) Including free meanstested complementary coverage (7%) Source: Thomson et al., 2009 A rapid growth of coverage in some countries, but not the case everywhere
14 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
15 2.1. Public/private mix of health insurance Different schemes: Separation based on: 1. Coverage of different populations 2. Coverage of different services 3. Access to different providers More integrated roles: 4. Purchase of additional quality 5. Joint financing (coverage of user charges) 6. Financing role / management role Each scheme has advantages and drawbacks, as illustrated by the experience of different countries.
16 Scheme 1: coverage of different populations (1/2) Public insurance Private insurance Population 1 Population 2 Same basket of goods & services Same providers US Germany: 11% of the population NL 2nd pillar before 2006 reform: >30% of the population Ireland before the extension of entitlements to public hospital care: 15%
17 Scheme 1: coverage of different populations (2/2) The population covered by private insurance is (generally) an affluent minority public financing is directed towards those who are more in need of social protection But Fairness of the financial contribution Loss of contributions of high earners for the public system Less support for the public system from upper-income individuals? If the providers have higher tariffs (e.g. Germany) or additional payments (e.g. Ireland) incentives to pay more attention to privately insured patients A scheme of the past?
18 Scheme 2: coverage of different health care services and goods (1/2) Public insurance Private insurance Population Goods & services 1 Goods & services 2 Same providers (or different because of the nature of services) e.g. : US : Medigap NL 3rd pillar, dental care for adults, patient transport, physiotherapy France : single room in private hospitals
19 Scheme 2: coverage of different health care services and goods (2/2) May appear as a more rational approach, allowing explicit and democratic choices on the boundaries of the benefit package that should be publicly financed But How to define the dividing line? Necessary care e.g. Canada : Physician & hospital care versus other services: drugs, physiotherapist, but technological change have shifted services out of hospital Care showing no effectiveness or low effectiveness e.g. France, delisting of drugs Minor risk (in terms of severity of disease) e.g. dental care in several countries (but does it help in terms of sustainability if the dynamic of costs is on chronic and severe diseases e.g. France) Care considered too expensive for the value they bring: e.g. UK: cancer drugs, reimbursement by PHI (BUPA, Axa PPP, ) socially acceptable?
20 Scheme 3: access to different providers (1/2) Public insurance Private insurance Same population Same basket of goods & services e.g. : UK, Ireland : hospital care in private hospitals Provider 1 Provider 2 Voir aussi Italie, Espagne pays scandinaves
21 Scheme 3: access to different providers (2/2) Provides more choice and may lead to a reduction in waiting times in the public health care system since people with PHI are treated outside. But If physicians are allowed to work both in public and private facilities, which is often the case, And if they are better paid in the private sector than in the public sector (which is also often the case), Then they have incentives to develop their private activity rather than invest in the public sector, and possibly to treat their patients better + competition to attract skilled staff
22 Scheme 4: financing additional quality (1/2) Public insurance Private insurance Same population Same basket of goods & services Private insurance allows to bypass waiting lists and get more attention (private bed, consultant treatment, ) Same providers UK, Ireland, Demmark, Spain, France to a lesser extent
23 Scheme 4: financing additional quality (2/2) Provides flexibility for people who are dissatisfied with the public health care system (safety valve reducing the pressure) But Inequity of treatment Same potential perverse consequences than the previous scheme (shared resources between public and private sector): The incentives created may exacerbate public-sector waiting lists instead of reducing them Often indirect subsidies (e.g. in Ireland Insurers have a financial incentive to have their members treated in private beds in public hospitals rather than in private hospitals because until now they did not pay the full economic cost of private beds in public hospitals).
24 Scheme 4: joint financing (copayments) (1/2) Public insurance Private insurance Same population Same basket of goods & services Same providers Public insurance covers a % of the tariff or up to a certain amount Private insurance covers user charges e.g. : France copaymets are the rule - 94% of the population is covered by VHI
25 Scheme 4: joint financing (copayments) (2/2) Might be a way to spread the financial burden with a second layer of coverage (partial solidarity) and maintains a common interest in the quality of the public system But Problems of moral hazard & conflicts of interest between public and private insurance neutralisation by PHI of financial incentives for patients & providers (e.g. copayments, billing above the schedule ) regulation: e.g. banning private insurance for these copayments (Australia), contrats responsables in France Equity & access to care subsidy for the low income population (e.g. CMU, ACS in France) with problems of non take up and efficiency (management costs)
26 Scheme 6: financing vs management (1/2) Public insurance = financing Same population Same basket of goods & services Private insurers = management For some populations: US Medicare / Medicaid: enrollment in managed care organisations For the entire population: NL: 2006 reform Same providers
27 Scheme 6: financing vs management (1/2) This scheme might not be classified in «private financing» since the financing stays publicly organised The exemple of the Netherlands shows that Risk selection by health insurers for basic health insurance can be avoided by a careful design, but the risk adjustment scheme needs constant refining to eliminate perverse incentives for insurers and to ensure fair competition. Concerns have also been expressed over the use of voluntary health insurance (VHI) as a tool to select individuals with expected higher profitability levels (which raises the issue of basic and complementary insurance) The competing insurers have been able to make efficiency gains in some areas (e.g. generic drug prices) and are increasingly putting pressure on hospitals and engaging in selective contracting with health care providers (results are yet to see)
28 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
29 3. Issues raised and possible solutions (1/4) Issues Does private finance simply augment the resources devoted to health care, or does it drain resources from the publicly financed system? Is it a safety valve that reduces pressure on the public system and helps meeting demand, or does it leverage an increase in public expenditure rather than complementing / substituting for it? Does an increased role for private finance erode political support for the publicly financed system? How to set the dividing line between publicly and privately financed health services? VHI is often subsidised by tax deductions for companies. Would the money be better spent in direct resources for the public health care system?
30 3. Issues raised and possible solutions (2/4) Efficiency issues Avoid risk selection (as a source of inefficiency) Response = Regulation of PHI, e.g. NL, Ireland: Community rating, open enrolment and lifetime cover, risk equalization scheme Consider the efficiency of subsidies (explicit or indirect) to PHI Direct (tax relief) but also indirect subsidies (e.g. public funding of coverage of low income people in France, payment of a fraction of full economic costs (Ireland), Response: billing of full economic costs, regulation of management costs,
31 3. Issues raised and possible solutions (3/4) Equity issues Ireland Source: Sarah Thomson and Elias Mossialos, Private health insurance in the European Union, 2009 France PHI non take-up by social class
32 3. Issues raised and possible solutions (4/4) Equity issues Avoid risk selection (as a source of inequity in access to care) Réponse :Regulation of PHI, e.g. NL, Ireland: Community rating, open enrolment and lifetime cover, risk equalization scheme Debate in France : generalisation of complementary health insurance?
33 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
34 2.3 Funding of capital investment Private finance initiative: the least we can say is that there is no unanimous opinion. The world of PFI attracts an almost religious fervour with passionate advocates and equally vociferous detractors. (National Audit Office, 2009). Report of the National Audit Office (February 2003) : a positive view Most construction work under the Private Finance Initiative (PFI) is being delivered on time and at the cost expected by the public sector. Central government has generally obtained a much higher degree of price certainty and timely delivery of good quality built assets, compared to previous conventional government building projects.
35 2.3 Funding of capital investment But the recent reports are less positive. Report of the Treasury select committee (August 2011) The use of PFI has the effect of increasing the cost of finance for public investments relative to what would be available to the government if it borrowed on its own account. Government has always been able to obtain cheaper funding than private providers of project finance but the difference between direct government funding and the cost of this finance has increased significantly since the financial crisis. The substantial increase in private finance costs means that (this) method is now extremely inefficient.( ) PFI will only provide value for money if this differential in the cost of finance, which has significantly increased, is outweighed by savings and efficiencies during the life of a PFI project. Evidence we have seen suggests that the high cost of finance in PFI has not been offset by operational efficiencies.
36 2.3 Funding of capital investment Report of the National Audit Office (August 2011) There has not been a systematic value for money evaluation of operational PFI projects by departments. There is, therefore, insufficient data to demonstrate whether the use of private finance has led to better or worse value for money than other forms of procurement. In France, an experience of PPP to build a new hospital near Paris is now considered as a public scandal (delays, defects, additional costs, ) Issue of governance and negociation skills?
37 Public / private mix in health care financing 1. The rationale for increasing private financing in health care systems 2. Forms of private health care financing 2.1. Out-of-pocket expenditure 2.2. Health insurance Pros and cons of different schemes of public / private mix in health insurance Issues raised and possible solutions 2.3. Funding of capital investment Conclusion
38 To conclude: The rationale for more private financing may look good, but in practice the international experience shows that the benefits of raising additional funds (in a field in which there is probably a willingness to pay) may be offset by adverse impacts on the equity and efficiency of the system. Collective choices, management of the performance of the system to get the best value for money and public financing: this would be the most rational thing to do in theory, but it is theory! In practice our systems are mixed, and the experience shows that a careful design of the relationship between public and private finance is necessary. In this area there is a need for more research, empirical work and benchmarking.
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