Methods of financing health care

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1 International Social Security Association Fifteenth International Conference of Social Security Actuaries and Statisticians Helsinki, Finland, May 2007 Methods of financing health care Finnish national health insurance: The Financing Reform of 2006 Chief Actuary Social Insurance Institution Finland ISSA/ACT/CONF/15/5(c)

2 Methods of financing health care Finnish national health insurance: The Financing Reform of 2006 Chief Actuary Social Insurance Institution Finland 1. The Finnish health care system 1.1. Public and private health care and the volume of health care In Finland, as in the other Nordic countries, health care is provided predominantly in the public sector. Extensive services are offered to all residents. Responsibility for the provision of primary health services rests with municipalities, which produce the services either in their own units or in intermunicipal health centres. The number of municipalities in Finland is at present 416. They have the authority to collect taxes to fund the provision of health services. The municipalities also receive state subsidies to enable them to arrange the services they are obligated to provide. The main decision-making power lies within the municipal council, which is elected every four years by the local population. For the purpose of providing specialist medical services, Finland is divided into 21 hospital districts operated by federations of municipalities. Membership of such a federation is compulsory for municipalities. Public health services are complemented by private-sector services, which are mainly of an outpatient nature. Private-sector services are available primarily in the larger cities and towns. Typical private-sector providers include medical centres, occupational health units and physiotherapy businesses employing just a few workers. The single largest scheme offering reimbursements for the cost of private health services is the National Health Insurance (NHI). A compulsory, universal coverage programme, NHI is operated by the Social Insurance Institution of Finland, which is supervised by the Finnish Parliament. Reimbursements are also provided by sickness funds and by voluntary private medical insurance plans, which, however, play a relatively minor role in Finland. Service development and policy guidance in social security, social welfare and health services come under the responsibility of the Ministry of Social Affairs and Health. The Ministry sets broad development goals, prepares legislation and other key reforms, oversees their implementation and maintains contacts to political decision-makers.

3 2 Figure 1 presents the development of health care spending in Finland at 2004 prices, starting from In 2004, total health care spending in Finland was 11.2 billion euros, or 7.4% of the Gross Domestic Product. The ratio of health spending to GDP was one of the lowest among the Organisation for Economic Co-operation and Development (OECD) countries. In 2004, outpatient health services accounted for 37.9% of total health care spending, inpatient services for 34.8%, and pharmaceutical products for 16.3%. The volume of spending has grown steadily since the severe economic recession of the 1990s. Immediately before the recession, spending on health care, as a percentage of GDP, briefly topped 9%. Figure 1. Health care spending in Finland at 2004 prices, million euros Other services Investment Medicines (outpatient care) Outpatient care Inpatient care Financing of health care There are in Finland two publicly funded systems for the provision of health services: (1) health centres and public hospitals, which are under public management and tax funded, and (2) private health care, which is publicly reimbursed and financed from a special fund collected from various sources (NHI). In 2004, 76.6% of all health care spending was financed from public funds, with 39.7% coming from municipalities, 19.9% from the State and 17.0% from the National Health Insurance administered by the Social Insurance Institution of Finland. The NHI share only includes spending on benefits classified as reimbursements of either medical expenses or of occupational health care costs. The NHI share has expanded by over 7 percentage points since The largest increase has occurred in pharmaceutical expenses.

4 3 Private funding for health care services in 2004 represented 23.4% of total spending and can be broken down as follows: households, 18.9%; employers, 2.1%; private insurance plans, 1.9%; and sickness funds, 0.4%. Reimbursements of occupational health costs represent most of the employers share. The individual shares of financing from the State, the municipalities, NHI, the private sector and households since 1960 are shown in Figure 2. The State s share of the financing dipped in the early 1990s, mainly as a result of the abolishment of tax deductibility for medical bills and a reform of the state subsidy system for municipalities. Figure 2. Health care spending in Finland according to the source of financing, % 90 % 80 % 70 % 60 % Households Other privatesector financing 1) The Social Insurance Institution 50 % 40 % Municipalities 30 % 20 % 10 % State 0 % ) Employers, relief funds and private sector insurances. 2. The National Health Insurance (NHI) System 2.1. Description A universal, compulsory health insurance system was introduced in Finland in The system offers compensation to insured persons for loss of earnings caused by sickness or child birth, and provides reimbursements for expenses on private-sector medical services. Its purpose is to make it possible for all insured persons to choose regardless of their place of residence or income level whether they wish to obtain medical services from the private or the public sector. Along with loss of earnings coverage and reimbursement of medical expenses, the system offers partial compensation to employers for the cost of providing statutory occupational health services.

5 4 Sickness allowances are provided on a regressive scale, where insured persons with an average income receive about 70% of loss of earnings due to illness. A waiting period of 9 days applies, during which most employees are entitled to sick pay. Parental allowances are provided to compensate for loss of earnings due to child birth at approximately the same rate as the sickness allowance. Part of the parental allowance can be paid to the father. A minimum rate has been defined for both the sickness and the parental allowance, which is paid to low-income insured persons. NHI provides reimbursement for medicine costs, doctors and dentists fees, examination and treatment charges, and travel expenses. The rate of reimbursement varies with each type of reimbursement. The reimbursement is calculated in proportion to the actual cost. The insured person must always pay a co-payment, expressed either as a percentage of the cost or as an absolute amount. The effective rate of reimbursement is also constrained by the fact that, with doctors' and dentists' services and with examination and treatment charges, the reimbursement is calculated on the basis of predetermined schedule fees, which are typically lower than the going rate. For example, while the target rate of replacement for doctors fees was originally 60%, in practice the reimbursement only covers about 30% of actual expenses. NHI covers about half of the cost of employer-provided occupational health services. The development of NHI benefit expenditure is presented in euros (at 2005 prices) in Figure 3. The Figure includes expenditure on rehabilitation covered by the NHI fund. Figure 3. All payments from the National Health Insurance fund (at 2005 prices) million euros Occupational health care, rehabitilation etc. Refunds of medical expenses Parenthood allowances 500 Sickness allowances The biggest increase in NHI benefit expenditure is seen in refunds of medical expenses, especially pharmaceuticals. The jump in 1982 was caused by a move to tax the daily allowances and to increase their before-tax rate. The decline in expenditure seen in the early 1990s resulted from a recession leading to cuts in NHI benefits.

6 Financing of the National Health Insurance before 2006 NHI was financed primarily with contributions from the insured and from employers. The contribution revenue was collected in the NHI fund, which operated (and still does) on a payas-you-go basis. It is a buffer fund, which, under the rules in force until 2006, was required to hold calendar year-end reserves equalling at least 10% of annual expenditure. For the event of exceptional funding imbalances, the State provided guarantee payments ensuring the liquidity of the fund. Rehabilitation expenditures, too, were covered from the NHI fund. Along the years, contribution revenues were increasingly used as instruments of economic and incomes policy. For example, contribution rates were sometimes cut to support macroeconomic policies even in the face of growing NHI expenditure. Consequently, the NHI fund faced a growing funding deficit. The liquidity of the fund was further undermined by the decision to lower the minimum reserve requirement from 10% to 8% of annual expenditure. With the NHI funding deficit widening further, in 2005 less than 60% of the expenditure was financed by contributions. Over a half of the deficit had to be covered by the state liquidity guarantees, while the rest was met from VAT proceeds. Additionally, the contribution criteria were subject to change and not easily foreseeable. The financing of NHI no longer fulfilled the requirements of a sound financing system. Changes in the contribution criteria over the period are presented in Figure 4. Figure 4. National Health Insurance contribution percentages for employers and insured persons, % of income Employers, maximum Employees, maximum (pensioners) Employers, average Employers, minimum Employees, average The role of pension recipients in financing the National Health Insurance system has varied. Originally, pensioners were exempt from paying contributions, but later on, an NHI contribution was introduced. In the aftermath of the early-1990s recession, contribution rates

7 6 were increased more for pensioners than for other insured persons. This was because of the introduction of a contribution to earnings-related pension insurance for employed insured persons. 3. Reform of the financing of the National Health Insurance system (2006) 3.1. Objectives of the reform Because of problems with the financing of the National Health Insurance system, plans were started in the early 2000s to overhaul the financing, and an agreement was reached in 2005 among the parties involved in the planning. The financing reform became effective on 1 January The main objectives of the reform were: to create a solid basis for the financing of NHI; to achieve balance between revenue and expenditure; to reinforce the insurance principle in the financing of the system; to curb growth in expenditure. The reform aimed to correct the problems identified in NHI financing and to increase the transparency and predictability of the system. As the reform was planned, particular attention was paid to achieving balance in the financing system, ensuring liquidity and strengthening the contributors commitment to cost containment Essence of the reform The reform saw the splitting of the National Health Insurance system, in terms of its financing, into two parts: an earned income insurance and a medical care insurance. The former mainly comprises the sickness and parental allowance, cash benefits paid during participation in rehabilitation, and reimbursements of occupational health costs, while the latter includes refunds of pharmaceutical expenses, doctors and dentists fees, examination and treatment charges, and travel expenses. The earned income insurance is financed by employers, the insured persons and the state. Employers pay a contribution towards the National Health Insurance while employees and the self-employed pay contributions towards the cost of the NHI daily allowances. In 2006, 73% of the total expenditure was funded by employers, with insured persons paying for the remaining 27%, with the exception of the minimum daily allowances, which were funded entirely by the State. Forthcoming changes in the contribution rates will be applied equally to the contributions levied from the employers and from insured persons. The costs of the medical care insurance are borne equally by the insured and the State, with the exception of reimbursements paid to recipients living in other European Union (UE) countries, which are funded by the State. For purposes of the medical care insurance, the insured population includes not only employees and the self-employed, but also benefit recipients, most importantly pensioners. Insured persons pay a contribution towards medical care coverage. The contribution is levied at a higher rate on pension and benefit income. Any changes in the contribution rates are applied equally to the State and insured persons.

8 7 As part the reform, a 10% maximum reserve requirement (along with the 8% minimum requirement) was set for the NHI fund. The goal is keep the liquid assets of the fund within these two limits. In the event of a fund deficit, the shortfall is added to the projected amount of contribution revenue for the following year, and in the event of a surplus, the excess is deducted from the projected revenue. Contribution rates as of 2006 (% of wages): Earned Income Insurance Medical Care Insurance Employers Employees Self-employed Benefit recipients (pensioners) The contribution rate for pensioners to the medical care insurance is 0.17 percentage points higher than that for employees or for the self-employed. However, pensioners are exempt from paying contributions into the earned income insurance scheme. Liquidity guarantee payments by the State were abolished as part of the reform. However, should the liquidity of the NHI fund be threatened, the State can provide emergency loans ensuring the continued payment of benefits, which must be repaid as soon as the liquidity situation has returned to normal Reform experiences The new arrangements for funding the National Health Insurance system have worked out as expected. They have increased the consistency and stability of the funding system as well as put additional weight on the insurance principle. A tighter link between revenues and expenditures has added clarity to the system, especially for the contributing parties. Transparency in financing has increased as well, as has the motivation of the contributing parties to keep track of financing trends and costs. Figure 5 presents the financing structure of the NHI system both before and after the reform. After the reform, the combined share of financing from insured persons and employers comes to a little more than 70% of total expenditure, with the State covering the rest.

9 8 Figure 5. Financing of National Health Insurance % Municipalities State Special proceeds Return of assets etc. Employers Insured persons As can be seen from Figures 4 and 5, both the contribution criteria for employers and insured persons and the shares of financing derived from different contributors fluctuated substantially before the financing reform. The goal for the future is to stabilise this situation. It appears that following the reform, annual changes will remain quite small, which will improve the predictability and stability of the financing. From an actuarial point of view, the new financing system is more challenging than its predecessor. In order to achieve the stability objectives set for the reform, estimates of the funding balance of the earned income insurance and the medical care insurance for the current and following year must be as accurate as possible. This, in turn, requires more advanced estimation methods. Given that there is considerable random variation in the revenues and expenditures of the NHI system, it is very difficult to keep the liquid assets of the NHI fund within the 8% and 10% limits. Indeed, this fluctuation margin has proven too narrow. Moreover, the lower limit, 8%, may not be enough to ensure the liquidity of the system in all situations, for example when revenue performance is lagging while expenditures exceed expectations. 4. Future outlook for health care financing 4.1. Forthcoming challenges Over the next 20 years, the age dependency ratio (the over-65s in proportion to those aged between 20 and 64 years) will increase more rapidly in Finland than almost anywhere else in Europe. The number of people over the age of 65 is expected to increase 1.5-fold over the next 10 years, while the population over 80 is estimated to increase 2.5-fold over the next 30 years.

10 9 The impending demographic development will present enormous challenges for health care. Cost pressures in health care will be exacerbated not only by the demographic development, but also by the adoption of new and more costly methods of treatment, the growing need for care among the elderly population and increasing use of pharmaceuticals. Pressures to increase spending on rehabilitation will increase as well. At the same time, the total number of contributors is decreasing, which will pose a major challenge to the financing of health care. There are cost pressures on the National Health Insurance system as well. Expenditure on reimbursements of medicine expenses has seen a particularly strong increase in recent years. Figure 6 shows the estimated expenditure on medical services reimbursed by NHI up to The estimate takes little account of the effects of other possible factors besides the aging population structure. Despite the increasing real costs, there is little pressure to increase contribution rates, provided that GDP growth in real terms is 1.5 to 2.0% per annum. Figure 6. NHI and rehabilitation benefits in at 2006 prices millions euros 8'000 7'000 6'000 5'000 4'000 Rehabilitation Occupational health services Other health insurance benefits Medicines 3'000 2'000 Parenthood allowances 1' Sickness allowances One topic that currently draws considerable interest in Finland is the necessity to secure the financing and the availability of primary health services. The situation is especially problematic in small municipalities which have limited resources to obtain adequate health services and where an unforeseen increase in health care expenditure could result in huge budget problems. Furthermore, a wait times guarantee for patients introduced in 2005 has necessitated municipalities to obtain primary and specialist level services from the private sector.

11 Preparing for future challenges Adequate economic growth and cost containment are fundamental requirements to meet the future challenges facing health provision. Rapid increase of health care spending has led many countries including Finland to search for ways to solidify and reform the financing system. In Finland, an extensive report by a working group set up by the Ministry of Social Affairs and Health was completed in 2002, which focused on the evolution of social expenditures and the way they will be financed in the period leading to Some of the recommendations of this working group, such as reforming the financing of the National Health Insurance, have already been implemented. Various steps have been taken as well to control rising costs, especially in pharmaceuticals. Improving productivity and functionality is crucial to health care performance and financing. Good management, quality and organisation in health care are key to future success and to ensuring that processes function well and that comprehensive access to care is available according to need. Better productivity and processes rely heavily on information technology. A number of projects are currently underway in Finland which are aimed at speeding up the communication of patient information and eliminating duplication of effort. These include the creation of an electronic prescription system and a centralised national electronic archive of patient data. Administration of the latter system has been entrusted to the Social Insurance Institution. Current efforts to strengthen the financing of public health provision in Finland are tied to a local government reform project approved in 2006, which aims at the consolidation of local government by merging smaller municipalities in order to strengthen their ability to provide residents with access to adequate health services. The objective is to promote the creation of larger municipalities that are stronger economically. The status of the National Health Insurance system will not be affected. Health care in Finland appears likely to remain mainly based on public provision. Private services will probably play an important and increasing complementary role. The National Health Insurance system, providing reimbursements for medical services and especially for pharmaceuticals, will remain significant. By facilitating access to private services, NHI offers insured persons a choice when it comes to the use of health services. Private services, in turn, relieve the cost pressures on public health care, with insured persons paying a substantial share of the cost out of their own pocket. The financing of NHI appears now after the reform to be functioning well. No significant pressures to increase contribution rates can be discerned. However, one clear risk for the medical care insurance component of NHI is that the replacement rate of the reimbursements may be too low. The replacement rate has not been significantly increased since the 1980s, the scale of fixed charges having last been adjusted upwards as long ago as If the replacement rate is not raised, the system may wither away, because reimbursements that are too small serve no practical purpose for insured persons, in which case they may seek alternative solutions such as private medical insurance plans. Now that the financing of the National Health Insurance system has been fixed, it is time to develop the medical care insurance. To solve the problems of financing of public health provision, the Social Insurance Institution has formulated a model in which primary health care would be financed via a new national health insurance programme. Freed of their obligation to provide health services, municipalities would purchase health insurance coverage for residents from a national

12 11 insurance provider, which would acquire services from public or private service providers. This model would eliminate disparities in the financial burden between small and large municipalities and everyone would have the potential to enjoy equal access to health services. Adoption of this model would require a reorganisation of the financing system and an overhaul of the state subsidies to municipalities. To date, this proposed model has not led to any concrete measures being taken.

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