10 Years of the NHF - Performance Challenges and Lessons of Experience

Transcription

1 10 Years of the NHF - Performance Challenges and Lessons of Experience 8 th Caribbean Conference on Health Financing Initiatives - Jamaica, Nov , 2013

2 Presentation Topics.. Background.. Program Design.. Financing Model.. Operating Framework.. 10-Year Review.. Challenges.. What s next

3 . a contributory health-financing plan to cover all residents of Jamaica for a stipulated package of medically necessary services. Source: GOJ Green Paper, 1997

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5 1) Health goals not being met 2) Increasing resource gaps 3) Escalating health costs 4) Inequity in access 5) Resource constraints Source: GOJ Green Paper, 1997

6 Contributory - Mandatory Standard Package of Benefits Pharmaceuticals In-patient services Diagnostic and laboratory services Source: GOJ Green Paper, 1997

7 1) Universality - all residents eligible 2) Equity - full access to package of benefits 3) Efficiency - securing value for money 4) Quality - high standards of care 5) Integration of Health Services 6) Accountability - transparency and accountability

8 NHIP would require significant resources Phased Implementation - more appropriate

9 The National Health Fund Same as NHIP Tax-based instead of SHI (contributions by members)

10 1) Universal Coverage (for the entire population), 2) Equity (sharing of costs and benefits), 3) Efficiency (value for money in all services), 4) Quality (consistently high standards of care), 5) Integration (optimal collaboration within and among sectors), 6) Accountability (clear stakeholder responsibilities).

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12 Universal Declaration of Human Rights

13 Kazakhstan

14 Health Promotion & Protection - essential to human welfare, and sustained economic and social development. Alma-Ata Declaration - Health for All contributes to a better quality of life and to global peace and security. Member States of WHO in 2005 committed to develop their health financing systems so that all people could have: Access to healthcare services and not suffer financial hardships paying for them. This Goal is defined as Universal Coverage

15 1) How is such a health system to be financed? 2)How can the system protect people from the financial consequences of ill-health? 3)How will the system promote optimization of available resources?

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17 Transition to UC is slow 8 SHI Countries with UC Years to Transition % Population Covered (Year) Austria 79 96% (1980) Belgium % (1969) Costa Rica 20 85% (1990) Germany % (2000) Israel 84 96% (1995) Japan % (1961) Republic of Korea % (1989) Luxembourg % (1973) Source: Social health insurance: Carrin & James (2004), Key factors affecting the transition towards universal coverage. WHO Report

18 Design Phase

19 Universal Coverage - all residents regardless of age, gender, medical condition, or economic status Drug Subsidy Specific Illnesses selected first, then drugs Beneficiary utilization to be managed Providers would be reimbursed, not Beneficiaries

20 Selected on the basis of Impact on Healthcare System Asthma Diabetes Breast Cancer High Cholesterol Ischaemic HD Psychosis Vascular disease BPH Arthritis Epilepsy Prostate Cancer Hypertension Rheumatic HD Major Depression Glaucoma

21 Pharmaceuticals Selected on the basis of Efficacy Over 200 drugs Active Pharmaceutical Ingredients (API), over 1,200 labels

22 Reference Pricing Mechanism Drug selected based on API (coverage of both brand & generic drugs) Reference price determined by lowest cost source of drug Subsidy fixed at percentage of the reference price to a maximum of 95% of the retail price of the drugs At the pharmacy the subsidy is a fixed dollar value

23 Choice of Providers All registered pharmacies may be Providers Provider Payment system - Feefor-Service Benefit items are identified by their NDC Providers submit claims electronically and are reimbursed weekly

24 Risk assessment- based on estimated prevalence Liabilities estimated based on research findings (Healthy Lifestyles Survey) Reference Pricing helps to manage economic risks

25 Transaction quantity limits are set Quantity limits are set for each drug - Mild / Severe Benefit items specified by drug and strength Drug utilization and frequency of use is monitored Audits of providers and beneficiaries

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27 NHF revenue sources; 20% SCT (sales) - tobacco products 1% payroll deduction 5% of a SCT (imports)- petrol, alcohol, tobacco, motor vehicles

28 * The Social Health Insurance a Guidebook for Planning WHO, ILO 2 Models Considered; Operating Philosophy Establish a Trust Fund and pay benefits from the income of the fund* Pay benefits from the revenues collected each year. Establish a prudential reserve*

29 The NHF Model

30 The NHF Model COVERAGE - Chronic NCD s based on prevalence, sustainability & healthcare impact BENEFIT Subsidy of Prescription Drugs based on efficacy of Active Pharmaceutical Ingredient (API) ACCESS Universal & comprehensive FINANCING - Tax based (earmarked) SUBSIDY FIXED based on Reference pricing mechanism PROVIDER PAYMENT Fee for Service

31 NHF Framework SUBSIDY PAYMENT REVENUE NHF INST. BENEFITS

32 provides specific drugs free of cost for Beneficiaries 60 years of age and older provides the drugs to Provider pharmacies for dispensing to Beneficiaries Beneficiaries may be asked to pay a dispensing fee of up to US 40 for a month s supply of each drug provided Beneficiaries may apply for the NHF Card

33 COVERS THESE CHRONIC ILLNESSES Asthma Arthritis Diabetes Glaucoma BPH Hypertension Cardiac illnesses High Cholesterol Psychiatric conditions Vascular disease 72 prescription items + 8 supplies

34 JADEP framework JADEP drugs REVENUE NHF

35 Looking Back past 10 yrs

36 326,141 as at Mar 31, 2013

37 The Jamaica Lifestyle Survey 2000* TYPICALLY 24% aware and treating the condition Group 1 36% aware but not treating the condition Group 2 40% not aware and not treating the condition Group 3 Group 1 + Group 2 = 450,000 ENROLMENT 24% aware and treating the condition 180,000 36% aware but not treating the condition 270,000 40% not aware and not treating the condition 300,000 *Wilks et al, (2000)

38 350,000 NHFCARD CUMULATIVE ENROLMENT 326, , , , , , , , , , , , ,749 50,000 72,307 35,424 50,

39 NHFCARD ENROLMENT BY CASES 886, 741 Cases of Illnesses HIGH CHOLESTEROL 13% DIABETES 13% ARITHRITIS 15% VASCULAR 8% HYPERTENSION 25% BREAST CANCER 1% RH FEVER/HEART 1% EPILEPSY 1% MAJOR DEPRESSION 2% PSYCHOSIS 1% PROSTATE CANCER 1% ISCHAEMIC HEART 6% GLAUCOMA 5% ASTHMA 5% BENIGH PROSTATIC HYP 3%

40 NHF Card Conditions ACTUAL PREVALENCE Arthritis 15% Asthma 5% Cancer(breast & prostate) 2% Diabetes 13% Epilepsy 1% Glaucoma 5% High Cholesterol 13% Hypertension 25% Ischaemic (heart disease) 6% Major Depression 2% Psychosis 1% Rh Fever (heart disease) 1% Vascular 8% Estimated PREVALENCE 1.5 million cases -> ¾ million persons Psychosis 1.4% Major Depression 12.9% Ischaemic 1.0% Hypertension 29.2% Rh Fever 0.3% NHF High Cholesterol 4.3% Glaucoma 1.5% Vascular 1.8% Arthritis 19.3% Asthma 15.8% Cancer 0.3% Diabetes Epilepsy 10.1% 2.1% 15 illnesses - - >750,000 persons

41 $274M 278,000 54%

42 $2,000 $1,750 NHFcard Claims $1,500 $1,250 $1,000 $750 $500 Avg Claim Avg Subsidy $250 $0 Aug-03 Aug-04 Aug-05 Aug-06 Aug-07 Aug-08 Aug-09 Aug-10 Aug-11 Aug-12

43 60% 50% 40% 30% 20% NHFcard Subsidy 10% 0% Sep-03 Sep-04 Sep-05 Sep-06 Sep-07 Sep-08 Sep-09 Sep-10 Sep-11 Sep-12

44 Revenue Performance

45 Revenue Sources 06/05 US$ 25M 33% 42% US$ 49 M 50% 25%

46 HEALTHCARE SPENDING ( ) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 Indiv. Benefits Instit. Benefits Health Promo.

47 Performance Review WHO Health Financing Factor NHF Performance Impact on healthcare Efficiency in benefit distribution Equity in benefit distribution Access for beneficiaries Choice for beneficiaries Incentives for providers NHF has contributed over US $330 M in additional funds to the treatment of NCD s over the past 10 years NHF administrative expenses are less than 10% of revenue NHF benefits are universal; coverage is provided regardless of economic status NHF benefits are accessed through over 400 public and private pharmacies. Over 1,200 benefit items are available NHF reimburses providers weekly, on a Fee-For-service basis

48 Disease JHLS-2000 JHLSII-2008 Hypertension Aware Unaware Treated Not treated Controlled Not Controlled Control Not Known 41.3( ) 58.7( ) 42.0 ( ) 58.0( ) 36.4( ) 60.2( ) 3.4( ) 50.7( ) 49.3( ) 40.0( ) 60.0( ) 41.4( ) 57.5( ) 1.1( ) A. There has been an increase in the levels of awareness of specified chronic illnesses such as hypertension and diabetes over the period 2000 to Wilks, Younger, Tulloch-Reid, McFarlane & Francis (2008) Diabetes Aware Unaware Treated Not treated Controlled Not Controlled Control Not Known 66.8( ) 33.2( ) 67.4( ) 22.6( ) 36.0( ) 54.5( ) 9.7( ) 76.1( ) 23.9( ) 71.5( ) 28.5( ) 43.0( ) 51.5( ) 3.4( ) B. Increased access to drugs for hormone therapy, as a result of the NHF, has changed treatment patterns for prostate cancer in Jamaica. - Morrison, Aitken & Reid (2011)

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50 . the estimated cost of fraud related to healthcare in the USA, is estimated to be between 3 and 10 percent of all healthcare spending an estimated $68 billion to $260 billion annually. Source: FBI Report, to 10% US 2-26 billion

51 NHF Subsidy to-date: US $85 million dollars 6 Pharmacy Provider Agreements terminated Total Amount at Risk: US $1.8 million dollars ASSUMPTION If all payments to terminated Providers are fraudulent 2% Fraud

52 System Abuses COMMON TYPES Multiple Drug Claims for the same condition Tampering with / Inflating Prescriptions Submission of false/fraudulent Application Forms Over utilization of benefits Miscoding - using code numbers to claim a higher subsidy

53 Where do we go from here?

54 Fact 1 The population is ageing

55 Between 2001 and 2011 the total Jamaican population increased by 3.5%. However the 60 years and over population increased by 15.3% - Eldemire-Shearer et al. (2012)

56 Fact 2 Source:

57 Fact 3

58 Fact 4 FISCAL Shrinking Fiscal Space SPACE

59 The Long and Winding Road

60 Source: World Health Organization 2008

61 1. What should the package of benefits Benefits look like?

62 2. Cost of Benefits?

63 3. How will those Benefits be Funded?

64 References Government of Jamaica (GOJ) Green Paper, 1997 Carrin & James (2004), Social health insurance: Key factors affecting the transition towards universal coverage. WHO Report The Social Health Insurance a Guidebook for Planning WHO, ILO Wilks et al Wilks, Younger, Tulloch-Reid, McFarlane & Francis, 2008) Morrison, Aitken & Reid (2011) FBI Report, 2007 World Population Ageing, United Nations, Jamaica the demographic transition, Census Bureau Eldermire Shearer et al., 2013 Chronic disease and lifestyle. Wu, Shin-Yi et al Projection of chronic illness prevalence and cost inflation. RAND Corporation National Health Fund Annual Reports

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