Private Health insurance in the OECD

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1 Private Health insurance in the OECD Benefits and costs for individuals and health systems Francesca Colombo, OECD AES, Madrid, May

2 Outline Q Background, method Q Overview of PHI markets in OECD countries Q Impact on health systems, useful practices 2

3 Background 3

4 Part of OECD Health Project Q Working Papers: Q Final Report Case studies on PHI (Aus, EIRE, Slovakia, NL) PHI in OECD Countries (autumn 2004) PHI: Benefits and costs for individuals and health systems 4

5 Method Q Taxonomy Q Analytical framework Q Data collection: PHI statistics and policies Q Literature review Q Case studies 5

6 Taxonomy - What is PHI? INSURANCE: prepayment and pooling on the basis of the main source of financing: Public HI (general taxation; payroll taxes) Private HI (private premiums, contract) Q Q Q BUT: Borderline cases: Mandatory, non income-related, premiums (e.g, CH) Highly subsidised cover (e.g., CMU - France) Schemes for government employees 6

7 Taxonomy - PHI role Depend on structure of public systems Eligibility to public HI Health services covered by PHI Same services covered by public health insurance Co-payments on publicly insured services Additional/extra services YES Duplicate (UK, EIRE, Aus, Sp, Ita) NO Substitute /principal (USA, Ger, NL, CH, Sp) Complementary (Fr, USA, Bel) Supplementary (CH, NL, Ger, Can, etc.) 7

8 PHI markets 8

9 (2000) OECD average PHI share of THE Population covered % 6.3 About 30% USA Primary Main PHI Function Netherlands /64 Primary/Suppl. France Compl. Germany Primary/Suppl Canada Suppl. Ireland Duplic. Australia Duplic. Spain /10.3 Primary/Duplic. Source: OECD Health Data 2003, PHI Statistical questionnaire and other official sources. 9

10 Sources of health finances United States Netherlands France Germany Canada Switzerland Ireland Australia Austria New Zealand Spain Finland Luxembourg Denmark Italy Mexico Japan Hungary Iceland Czech Republic Slovak Republic Norway % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Public expenditure on health Private insurance All other private funds Out-of-pocket payments Source: OECD Health Data

11 Private spending breakdown Turkey United States France Germany Netherlands Canada New Zealand Ireland Austria Switzerland Australia United Kingdom Luxembourg Spain Finland Denmark Mexico Italy Japan Hungary Czech Republic Iceland Slovak Republic PHI - % TPHE OOP - % TPHE All other private funds - % of TPHE Source: OECD Health Data

12 PHI not substituting for OOP USA 30 PHI (% of THE) NLD y = x R 2 = DEU FRA LUX CZE SLK IRL NOR CAN NZL AUS AUT DEN ICE JAP ESP FIN ITA HUN Source: OECD Health Data OOP (% of THE) 12 CHE MEX

13 Variation in PHI spending p.c United States Netherlands France Germany Canada Switzerland Ireland Australia Austria New Zealand Spain Finland Luxembourg Denmark Italy Mexico Japan Hungary Private insurance per capita, US$ PPP Source: OECD Health Data US $ PPP

14 PHI not correlated with GDP NLD DEU CHE 300 FRA CAN PHI per capita (US$ PPP) AUS AUT IRE y = x R 2 = NZL 50 0 MEX HUN ESP FIN ITA JAP 14 DEN 0 10,000 20,000 30,000 40,000 50,000 60,000 GDP per capita (US$ PPP) Note: If the USA is included, the equation becomes y = x , with R2 = Source: OECD Health Data LUX

15 Real GDP and PHI growth PHI per capita, average real growth rate (%) DEU ITA FRA CHE NZL CAN DNK ESP USA FIN AUT AUS y = x R 2 = IRL -2 GDP per capita, average real growth rates (%) Source: OECD Health Data

16 PHI financing slightly growing Q Q Q For 12 countries, from% 8.5 to 9.4% of THE Increased in NZ, Germany, Canada; Reduced in Australia, Austria, Ireland % Australia Austria Canada France Germany Ireland New Zealand Source: OECD Health Data

17 PHI and THE Q Q Weak correlation, especially if U.S. is excluded Countries with either: High PHI share in THE High PHI pop. coverage tend to have high per capita health spending (U.S., CH, Germany, France) Per capita THE (US$ PPP) 3,500 3,000 2,500 2,000 1,500 1, ITA JAP HUN MEX LUX DEN FIN ESP NZL IRE AUS AUT CAN FRA y = x R 2 = Per capita PHI (US$ PPP) Source: OECD Health Data CHE DEU NLD 17

18 Why differences in market size? Q Historical factors Q Public policy Entitlement to public coverage Degree of policy support to PHI (individual responsibility; fiscal/regulatory interventions) Q Role of employers: growing Q Perception of public sector quality (waiting times) 18

19 Impact of PHI, useful practices 19

20 Access to Care Q Enhanced access to care when public coverage has large gaps (e.g., USA, France) Q Enhanced insurees timely access to hospital care in duplicate systems (e.g., Eire, Aus) Q Contributed to higher service volumes and development of private capacity (e.g., Aus) Q Trade-offs in terms of equity: distribution of service utilisation; providers incentives 20

21 Decomposition: prob. of doctor visits Source: Van Doorslaer et al. (2004), for OECD. Note: A negative contribution means that the effect is to lower inequality in visits favouring the rich (a positive contribution has the opposite interpretation). 21

22 Useful practices: equity Q Rules of access to care for public and private patients (e.g., Aus public hospitals) Q Unique waiting lists (e.g., NL) Q Specifying/monitoring providers commitment to public patients (e.g., UK, Eire) Q Regulation of public-private sector prices (e.g., NL) 22

23 Access to PHI coverage Q PHI has not developed much in some OECD countries with large OOP (e.g., Mex, Kor, Turk) Q Not accessible/affordable to low-income/highrisks without interventions (e.g., USA; NL; Fra) Q Insurers or employers shift cost onto insurees (e.g., U.S. less comprehensive/defined contribution PHI) 23

24 Useful practices: PHI coverage Q Regulatory standards for all PHI market: combine issuance and rating reforms (e.g., community rating; guaranteed issue): Australia, Ireland, few US States) Q Safety net approach: well-funded high-risk pools and standard PHI policies for high-risks (e.g., NL, Germany, many US States) Q Impact of subsidies: mixed evidence (less targeted, cost: e.g., U.S. tax credit, Aus) 24

25 Responsiveness Q Generally PHI enhances choice, but: Provider choice depends on choice in public systems and insurers networks (e.g, US managed care) Barriers to switching of insurers Too much product diversity limits ease of choice and creates selection by product (e.g., Aus) Q Generally insurers more prone to innovate, adopt new technologies, but: Cost effectiveness? Government regulation to protect equity reduces incentives to innovate 25

26 Useful practices: choice Q Comparative information on plans and benefits by governments or private sector (e.g., US HEDIS) Q Regulation of benefits and products - Minimum benefit (e.g., Aus, EIRE, many U.S. states) - Benefit standardisation (e.g, US Medicare Supplement, NL and Germany for high-risks) Q Assess trade-offs between consumer choice and insurers incentives to innovate 26

27 Economy: little cost shifting Q Public sector bears cost of expensive risk Q Duplicate PHI (e.g., Aus, Eire) Patients continue to utilise public sector PHI raises total utilisation, not only shifts demand Q Supplementary PHI (e.g., NL) less expensive services delisted (dental, optical) Q Primary PHI (e.g., U.S., Ger, NL) Some groups not publicly covered, but spend no less on public system than OECD average 27

28 Public health spending as share of GDP and health financing by PHI % Germany Iceland France Denmark Czech Republic Norway Canada New Zealand Australia Japan Italy Switzerland United States Netherlands Austria Spain Slovak Republic Hungary Finland Luxembourg Ireland Mexico Average Public expend. on health (% GDP) Private expend. on health - % gross domestic product PHI (% of THE) Source: OECD Health Data

29 Economy: add to THE Q PHI has less bargaining power over the price and quantity of care than public systems Q Pressures on public budgets: To affect coverage levels, substantial subsidies required (not self financing) (e.g., Aus) Complementary PHI: cost of utilisation increases fall onto public systems (e.g., France) Supplementary PHI: interdependence with public system utilisation (e.g., New Zealand) 29

30 Useful practices: Economy Q Encourage private insurees to use privately financed services Q Apply same cost controls to public and private system (e.g., Netherlands) Q Weigh opportunity cost of any subsidies Q Avoid full PHI coverage of cost-sharing on statutory/public systems (e.g., CH) 30

31 Efficiency Q Little managing of care by insurers Desire not to restrict choice, opposition by medical profession (e.g., backlash against managed care) Regulation (e.g., limits on selective contracting) Cost, lack of know-how by insurers Q High administrative costs Q Competition yet to deliver efficiency gains Few demand signals (e.g., often little switching) More incentives to select than to manage risks Not favourable conditions in the delivery market 31

32 Useful practices: Efficiency Q Introduce policies to encourage insurers involvement in cost-effectiveness: Removing obligations to contract with all providers Incentives for prevention and care management Q Regulate competition on risk selection E.g., Risk equalisation: balance between retrospective/prospective; choice of risk adjusters Q Promote effective competition Information disclosure, product comparability 32

33 In sum Q Pros/cons of PHI, by and large : PHI has enhanced responsiveness But less positive impact on equity and efficiency Q However, performance vary PHI role Government interventions Market structures and insurers behaviours Q Interaction with public systems raise trade-offs Policy makers to choose permitted PHI role and degree of interventions 33

34 Click on: OECD Health Project Then click on: Private Health Insurance 34

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