An evaluation of Georgia s Medical Insurance Program for the Poor

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Beverly Turner
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1 Georgia WB Health Sector Development Project An evaluation of Georgia s Medical Insurance Program for the Poor November 17, Tbilisi

2 1. Background and Methodology

3 Background Health system before MIP (~2005) was functioning poorly Low utilization rates High out-of-pocket spending MIP is among the most innovative health reforms to be undertaken in a low/middle income country in recent years It also represents one of the best examples in the world of trying to target limited public health spending to the poor Many reasons to be interested in how it is performing

low/middle income country in recent years It also represents one of the best examples in the world

4 Why do an evaluation of MIP? MIP introduced in 2006, but significant changes to program since then (higher premiums, transition to private insurance) MIP budget accounts for about half of MoLHSA health spending GEL 130m budget (2009) Total MIP spending approx. GEL 450 million How is MIP working so far? Not a lot of evidence to date Growing international momentum to strengthen M&E Impact evaluation: the art of the counter-factual MIP is a unique program that is of interest outside Georgia

budget accounts for about half of MoLHSA health spending GEL 130m budget (2009) Total MIP spending 2006-2010 approx.

5 Methodology Evaluation undertaken by Health Sector Development Project Survey firm, international experts Survey of ~3600 households (~11,000 individuals) conducted in Nov/Dec 2008 in most regions of Georgia Sample only households just above and below the eligibility threshold of 70,000 (or 100,000 in Tbilisi and Adjara) Common technique for doing impact evaluation Based on assumption that households very close to these thresholds (on both sides) are on average identical except for whether they are beneficiaries of MIP program or not This provides us with valid treatment and control groups to measure the true impact of MIP Validity of research design has been confirmed using the data collected

impact evaluation Based on assumption that households very close to these thresholds (on both sides) are on average identical except for whether they are beneficiaries of MIP

6 Methodology (continued)

7 Outcomes studied Utilization Out-of-pocket spending Self-reported health status Health system responsiveness Preventive care/health-related behavior Knowledge and attitudes towards MIP Implementation process of private insurance

Preventive care/health-related behavior Knowledge and

8 2. Results

9 Results: Utilization Preliminary results find no evidence that MIP is having an impact on utilization: Out-patient use in 70,000 regions Out-patient use in 100,000 regions In-patient use in 70,000 regions In-patient use in 100,000 regions No effect on average length of stay in hospitals Some evidence of impact on provider choice: 70,000 regions: beneficiaries less likely to use pharmacies than nonbeneficiaries

In-patient use in 100,000 regions No effect on average length of stay in hospitals Some evidence of

10 % of individuals using services: No statistically significant differences

11 Why no differences in utilization? (1) Possible answers: There is evidence of some difficulties in implementing MIP, so that not all beneficiaries were aware of their eligibility or what the program offered them For outpatient care, the exclusion of drugs from MIP may reduce the chances that beneficiaries seek care at all For inpatient care, these are typically more serious illness episodes so people are more likely to seek care regardless of insurance coverage (i.e., less sensitive to price changes induced by insurance)

eligibility or what the program offered them For outpatient care, the exclusion of drugs from MIP may reduce the chances that

12 Why no differences in utilization? (2) Possible answers (continued): The program is quite new, and in other countries (e.g., Kyrgyz Republic), utilization has been slow to respond to health financing reforms as households that have become accustomed to paying for care take time to realize that out-of-pocket payments are lower than before If households perceive the quality of care to be low, they may not seek care regardless of its cost (although the survey did not find clear evidence that this is an important factor) Utilization rates may not increase if insurers and/or providers make it difficult for those with MIP to obtain the care they want

, Kyrgyz Republic), utilization has been slow to respond to health financing reforms as households that have become accustomed to paying for care take time to

13 Results: Out-of-pocket spending OOP among those who used care Out-patient care 70,000 no difference in OOP Out-patient care 100,000 49% less OOP under MIP In-patient care 70,000 49% less OOP under MIP In-patient care 100,000 61% less OOP under MIP

100,000 49% less OOP under MIP In-patient care 70,000 49%

14 Out of pocket spending: Significant impact of MIP

15 Results: Out-of-pocket spending Beneficiaries are ~50% more likely to say they received care for free or at a reduced price because of insurance Beneficiaries are ~50% less likely to report that they could not pay for the costs of care out of their usual income But Many beneficiaries still report paying for care that should be covered by MIP Still some beneficiaries who said they should have been hospitalized but were not because of high costs of care

costs of care out of their usual income But Many beneficiaries still report paying for care that should be

16 Results so far: is MIP achieving objectives? To improve health by increasing access and utilization of care Results suggest the program is not reaching its potential yet To provide financial protection against high cost of health care among those who do seek care Results suggest the program has had a large impact, with potential to do better still Not uncommon to see this pattern of impact Colombia Vietnam U.S. Medicare (1965)

its potential yet To provide financial protection against high cost of health care among those who do seek

17 Other results No evidence of program impact on: Health status (either self-reported or based on activities of daily living ) Health system responsiveness (measured using WHO approach) Health behavior/use of preventive care Program is probably too new to expect significant changes in these domains

responsiveness (measured using WHO approach) Health behavior/use of

18 Room for improvement: Knowledge and attitudes When asked to list components of benefit package: Less than half mentioned surgeries or out-patient care About 15% erroneously mentioned drugs Almost no one mentioned preventive care About 15-20% of beneficiaries in Tbilisi, Adjara, Imereti were incorrect about their beneficiary status according to SSA database On average, respondents rated their satisfaction with MIP in between fairly satisfied and neither satisfied nor dissatisfied

of beneficiaries in Tbilisi, Adjara, Imereti were incorrect about their beneficiary status according to SSA database On

19 Room for improvement: Implementation issues Many beneficiaries report not receiving voucher How did you get your voucher? - very wide range of responses (most common is family doctor or out-patient staff 40%) About 70% report they did not have a choice of insurer; market data indicate some regions have more competition than others (e.g., Adjara has least competition) Among those who did choose their insurer: 25% based their decision on reputation 19% on advice of neighbors/friends 9% due to gifts/supplemental benefits 9% due to advertising

20 3. Challenges Ahead

21 Challenges ahead Need to improve knowledge of the program among beneficiaries (but this is easier said than done) Ongoing M&E: Information flows are needed between insurers, providers, and government to help monitor program implementation and make adjustments as necessary Supply-side improvements in quality of care are needed to complement the mainly demand-side MIP Further reductions in out-of-pocket payments for MIP households will depend largely on providing some coverage of drugs 80 percent of Georgia s population does not receive MIP, and many are vulnerable households. To reach them, the major challenge will be to successfully expand the affordable (GEL 5) health insurance program

22 Lowering OOP Lower OOP without more spending: -- legal reform to encourage lower drug prices -- close down unnecessary infrastructure and re-invest in services Lower OOP with more spending -- add some drugs to MIP -- expand subsidy for affordable insurance

23 Looking ahead MIP impact may evolve as the operating environment changes and stakeholders adapt Population learns more about program Insurance companies improve capacity to purchase health care and process claims Providers upgrade quality of care Government stewardship strengthens Importance of continued monitoring of MIP

24 Thank you

Medical Insurance for the Poor: impact on access and affordability of health services in Georgia

Medical Insurance for the Poor: impact on access and affordability of health services in Georgia The health care in Georgia is currently affordable for very rich and very poor Key informant Key Messages: