Session 89 WS, Around the Globe: China--Closing the Financial Gap for Cardiovascular Disease. Moderator: Audrey A. Chervansky, FSA, MAAA

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1 Session 89 WS, Around the Globe: China--Closing the Financial Gap for Cardiovascular Disease Moderator: Audrey A. Chervansky, FSA, MAAA Presenters: Daniel Garrett Ryan Xiaojie Wang, FSA, CERA

2 Closing the Financial Gap for Cardiovascular Disease in China Daniel Ryan, Xiaojie Wang 2015 SOA Annual Meeting & Exhibit

3 Cardiovascular Disease (CVD) 2

4 Explaining the fall in CHD deaths in USA (NEJM 2007, 356, 2388) ,745 fewer deaths in Risk Factors worse + 1 7% Obesity (increase) +7% Diabetes (increase) +10% Risk Factors better - 65% Population BP fall -20% Smoking -12% Cholesterol (diet) -24% Physical activity -5% Treatments - 47% AMI treatments -10% Secondary prevention -11% Heart failure -9% Angina:CABG & PTCA -5% Hypertension therapies -7% Statins (primary prevention) -5% Unexplained -9%

5 Country differences in explanatory studies % reduction in CHD mortality Treatments Risk factors Unexplained United States, [14] 40% 54% 6% New Zealand, [15]* 40% 60% Holland, [17] 46% 44% 10% United States, [13] 43% 50% 7% IMPACT Scotland, [18] 35% 55% 10% IMPACT New Zealand, [19] 35% 60% 5% IMPACT England & Wales, [20] 38% 53% 11% IMPACT United States, (this study) 47% 44% 9% Finland, [16] 24% 76% IMPACT Finland, [22] 23% 53% 24% 0% 50% 100%

6 Leading causes of death in Years Lost to Life Analysis by region from Global Burden of Disease 2010

7 Leading risks factors Analysis by region from Global Burden of Disease 2010

8 Swiss Re and Harvard Chan School of Public Health Overlapping interests Swiss Re seeks to better understand future health and longevity drivers and model them into Swiss Re s current and future business The Harvard School would like to better understand public health challenges in different countries, and to make recommendations aimed at reducing morbidity and mortality Collaborating to better understand the relationship between cardiovascular risk factors and health outcomes Coinciding anniversaries 7

9 Swiss Re 2013/ 14 research grant funded 11 Harvard research fellows Cardiovascular risk factors analysed include smoking, air pollution, diet and metabolism, physical activity and health systems 50 experts working together 11 postdocs, 15 Harvard mentors 18 Swiss Re collaborators Academic articles, Risk Dialogue series Conferences in USA, Switzerland and each of the SEARCH countries 8

10 Rapid pace of improvements in life expectancy 1970 compared with year increase in life expe ctancy 25 year increase in life expe ctancy Source: Global Burden of Disease

11 Causes of death vary by country Injurie s Diabete s Neurological % deaths in 2010 Chronic respiratory Cardiovascular (CVD) Infectious diseases Cance r Source: Institute for Health Metrics and Evaluation (IHME). GBD Cause Patterns. Seattle, WA: IHME, University of Washington, Accessed March

12 Top 15 risk factors that account for the most disease burden in China during

13 Explaining increase in CHD Deaths in Beijing 12

14 Cardiovascular Disease (CVD) in China The leading cause of mortality and morbidity in China According to a 2012 report on cardiovascular diseases in China, around 41% of total deaths could be attributed to CVD every year* In China, it is estimated that there is one CVD death every 10 seconds* CVD risk factors such as hypertension, tobacco smoking, alcohol use and an unhealthy westernized diet have been trending upwards over the last 20 to 30 years.** *Report of Cardiovascular Diseases in China (2012). **Hu F, Li YP (2014). Time trends of cardiovascular disease risk factors in China. **Liu L (2011) Chinese Guidelines for the Management of Hypertension. Advanced Journal of Medicine in China. 5: **Tao S, Wu X, Duan X, Fang W, Hao J, Fan D, Wang W, Li Y (1995). Hypertension prevalence and status of awareness, treatment and control in China. Chinese Medical Journal. 108: **Wang L (2005). Summary report of 2002 China National Nutrition and Health Survey. Beijing: People s Health Publisher of China. **Li YC, Wang LM, Jiang Y, Li XY, Zhang M, Hu N (2012). [Prevalence of hypertension among Chinese adults in 2010]. Zhonghua yu fang yi xue za zhi [Chinese Journal of Preventive Medicine]. 46:

15 Cardiovascular Disease (CVD) The leading cause of mortality and morbidity in China According to a 2012 report on cardiovascular diseases in China, around 41% of total deaths could be attributed to CVD every year* In China, it is estimated that there is one CVD death every 10 seconds* CVD risk factors such as hypertension, tobacco smoking, alcohol use and an unhealthy westernized diet have been trending upwards over the last 20 to 30 years.** *Report of Cardiovascular Diseases in China (2012). **Hu F, Li YP (2014). Time trends of cardiovascular disease risk factors in China. **Source: National Bureau of Statistics of China 14

16 China Insurance Scheme In a Nutshell 15

17 The Social Health Insurance System UEBMI URBMI NRCMS urban employee basic medical insurance urban resident basic medical insurance new rural cooperative medical care system Covered population Covered population: the employees, the retired Covered population: unemployed, selfemployed, students, children Covered population: rural residents Financed by employers and employees Financed by central & local government and urban residents Financed by central & local government and rural residents Financing model Decreasing Coverage 16

18 Illustration of Insurance payment structure in China Co-payme nt Beyond Cap of CI Reimbursed by Critical Illne ss (CI) Insurance Reimbursed by basic medical insurance Cap of CI Cap of Basic Insurance Uncovered Expe nse Deductible 17

19 Drug Classification in China Expensive Drugs not covered by RDL Innovative and imported drugs High price Reimbursement Drug List (RDL) Lower reimbursement rate Include both national and provincial RDL Essential Drug List (EDL) Priced by Government Low prescription incentive High reimbursement Narrow List The latest EDL was released in 2013 and expected to be updated every 3-5 years. 18

20 Reimbursement Rates by Regions Inpatient reimbursement rates of UEBMI and URBMI by province in 2010 as a percent of total expenses The provincial average of inpatient reimbursement rates is around 70% for UEBMI (Employe e ) and 55% for URBMI (Resident). X Huang. Expansion of Chinese Social Health Insurance: Who Gets What, When and How? 19

21 Regional Financial Projection Comparison in 2011 Meng Q, Xu L, Zhang Y, Qian J, Cai M, Xin Y, Gao J, Xu K, Boe rma J T, Barber SL (2012). Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study. 20

22 Components of CVDs Medical Expenses 21

23 Components of CVDs Medical Expense Short-Te rm Direct Cost Long-Te rm Direct Cost Indire ct Cost Medication Radiological examination Laboratory examination Clinical Tre atme nt Diagnostic exam Transportation Nursing Medication Nursing Radiological examination Laboratory examination Re habilitation *Early retire me nt *Family absenteeism from work *Patient absenteeism from work 22

24 Direct and indirect costs components of AF-related stroke Stroke is an acute cerebrovascular accident and atrial fibrillation (AF) is the major risk factor which could increase the incident rate by five times About 60% of the cost was incurred during the acute hospitalization phase, and 40% during the first year after discharge. Medicine is the biggest component of direct costs. Hu SL, Zhan L, Liu B, Gao Y, Li Y, Tong RS, Wu L, Yu B, Gao S (2013). Economic Burden of Individual Suffering from Atrial Fibrillation-Related Stroke in China 23

25 How Expensive CVDs Medical Expense could be? 24

26 2012 CVD-specific inpatient medical cost between urban and rural areas (in RMB) In general, CVD-specific inpatient medical costs are much higher in urban areas than rural areas. The quality of medical service and care in urban areas is better than that in rural areas. 25

27 2012 Average CVD inpatient medical cost vs. annual expenditure per capita The average CVD inpatient costs are about 130% of annual expenditure per capita in urban areas and 230% in rural areas. 26

28 CVD Medical Cost Trends 2007 medical costs were used as baseline. The average annual cost increases for acute myocardial infarction, congestive heart failure, and cerebral haemorrhage were around 8% to 11 %. Source: China Health Statistical Yearbook (2 013 ) 27

29 CVD Medical Cost Trends 2007 medical costs were used as baseline. The average annual cost increases for acute myocardial infarction, congestive heart failure, and cerebral haemorrhage were around 8% to 11 %. 28

30 Financial protection gap of cardiovascular diseases 29

31 Two Barriers to Purchase Insurance in China Affordability Lack of Knowledge Swiss Re Asia Medical Survey

32 Healthcare Cost Trend Swiss Re As ia -Pacific study 31

33 CVD expenditures and income effects among different income strata 45.0% CVD expenditures and income effects 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Low Income Middle Income High Income Proportion 15-month OOP/annual total household expenditures Decrease in household income Huffman MD, Rao KD, Pichon-Riviere A, Zhao D, Harikrishnan S, Ramaiya K, Ajay V, Goenka S, Calcagno JI, Caporale JE (2011). A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low-and middle-income countries. PLoS One. 6: e

34 CVD expenditures and income effects among different income strata 45.0% CVD expenditures and income effects 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Low Income Middle Income High Income Proportion 15-month OOP/annual total household expenditures Decrease in household income Huffman MD, Rao KD, Pichon-Riviere A, Zhao D, Harikrishnan S, Ramaiya K, Ajay V, Goenka S, Calcagno JI, Caporale JE (2011). A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low-and middle-income countries. PLoS One. 6: e

35 CVD expenditures and income effects among different income strata 45.0% CVD expenditures and income effects 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Low Income Middle Income High Income Proportion 15-month OOP/annual total household expenditures Decrease in household income Huffman MD, Rao KD, Pichon-Riviere A, Zhao D, Harikrishnan S, Ramaiya K, Ajay V, Goenka S, Calcagno JI, Caporale JE (2011). A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low-and middle-income countries. PLoS One. 6: e

36 Imported drugs and devices Cross-region treatment Long-term costs Cross-region treatment Social Me dical Insurance Sche me?savings, liquid assets, Family Support Overtreatment and excessive charge Insufficient medical facilities Continuous increase on me dical costs 35

37 A Glance at Perspective Role of Commercial Insurance in China 36

38 An Important Pillar of the Social Security System Participation in critical illness insurance, long-term nursing insurance, investment-linked products and etc. Coverage on cross-region treatment Coverage on innovative or western drugs which are not reimbursable under social medical insurance Coverage on income protection and long-term care. 37

39 Legal notice 2015 Swiss Re. All rights reserved. You are not permitted to create any modifications or derivative works of this presentation or to use it for commercial or other public purposes without the prior written permission of Swiss Re. The information and opinions contained in the presentation are provided as at the date of the presentation and are subject to change without notice. Although the information used was taken from reliable sources, Swiss Re does not accept any responsibility for the accuracy or comprehensiveness of the details given. All liability for the accuracy and completeness thereof or for any damage or loss resulting from the use of the information contained in this presentation is expressly excluded. Under no circumstances shall Swiss Re or its Group companies be liable for any financial or consequential loss relating to this presentation. 38

40 39

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