Experience of western European Social Health Insurance countries: reflections for Slovakia

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1 Experience of western European Social Health Insurance countries: reflections for Slovakia Reinhard Busse, Prof. Dr. med. MPH FFPH Professor of Health Care Management, Technische Universität Berlin Associate Research Director, European Observatory on Health Systems and Policies

2 Social Health Insurance or Bismarckian countries in western Europe

3 What makes a health system a SHI system? Contribution collector Not (health) risk-, but usually wage-related contribution Third-party payer Population Providers

4 Funding of health care in the old EU Member States: % contributed from three main sources social insurance, taxes, and private % social insurance % private % taxes

5 Funding of health care in the new EU Member States: % contributed from three main sources social insurance, taxes, and private (in 2000) % of TEH from social health insurance SLO LIT SK CZ H EST TR MT CYP PL LV BG RO % of TEH from taxation

6 Distribution: fairness in financial contribution (1.00 = max.) % of households with catastrophic payments (total expenditure) Threshold % of households with catastrophic payments (out of pocket) Slovakia United Kingdom Denmark Sweden Germany Hungary Czech Republic Belgium Finland Spain Slovenia France Lituania Estonia Greece Portugal Latvia Data: Murray & Evans Health Systems Performance Assessment: Debates, Methods and Empiricism, WHO 2003: 525-6

7 What makes a health system a SHI system? Contribution collector Not (health) risk-, but usually wage-related contribution Limited government control Third-party payer = sickness funds bipartite self-government Population Providers

8 Principal organisational forms of sickness funds One national monopoly fund: e.g. Hungary Several regional monopoly funds: e.g. Romania (+ de facto Austria) Several monopoly funds organised on other principles (e.g. occupation): e.g. France, Luxembourg, Germany -96 Several funds in competition: e.g. Belgium, Czech Rep., Germany (since 96), Netherlands, Slovakia, Switzerland Bi-partite: self-government is shared between employers and employees government supervises (tri-partite = government participates directly)

9 More than one fund raises many questions: Uniform benefit catalogue? For equity reasons yes; but for competition? Uniform contribution rate (or per capita premium)? A, B, F, L = yes; CH, D = no, NL = mix If rate is uniform, should there be one collector? How should the money be allocated to funds? Which risk factors? What happens if that is not enough? Otherwise: re-allocation between funds needed (as in CH & D)! Is it worth it to have more than one fund???

10 1991 cosmetic surgery 1993 spectacles/ lenses 1995 dental care adults 1996 physiotherapy >9/ year Third compartment Netherlands 1989 flat-rate contribution 1996 medical aids and appliances, pharmaceuticals, genetic testing, rehabilitation, audiology 1996 cervical cancer screening 1997 dentures for adults 1992 free choice of fund, end of uniform charges (WTG) and mandatory contracting, 1993 prospective financing to funds Second compartment 1999/2001 new supervising structures 1989 amb. psychiatric services, medical aids and appliances 1992 pharmaceuticals, genetic testing, rehabilitation, audiology 1986 WTZ (access to standard package) 1986 MOOZ (to cover elderly under ZFW) 1994 Van Otterloo Act: low-income pensioners 1998 stay-where-you-are & low-income elderly opting-in 2000 low-income self-employed 1997 homes for the elderly flat-rate contribution First compartment benefits money beneficiaries other reforms (tax-financing)

11 1991 cosmetic surgery 1993 spectacles/ lenses 1995 dental care adults 1996 physiotherapy >9/ year Third compartment Reform plans 1989 flat-rate contribution 1996 medical aids and appliances, pharmaceuticals, genetic testing, rehabilitation, audiology 1996 cervical cancer screening 1997 dentures for adults 1992 free choice of fund, end of uniform charges (WTG) and mandatory contracting, 1993 prospective financing to funds Second compartment 1999/2001 new supervising structures 1989 amb. psychiatric services, medical aids and appliances 1992 pharmaceuticals, genetic testing, rehabilitation, audiology 1986 WTZ (access to standard package) 1986 MOOZ (to cover elderly under ZFW) 1994 Van Otterloo Act: low-income pensioners 1998 stay-where-you-are & low-income elderly opting-in 2000 low-income self-employed 1997 homes for the elderly flat-rate contribution First compartment benefits money beneficiaries other reforms (tax-financing)

12 Net loss/gain in members (X 1,000) WEST ,8-0,6-0,4-0,2 0 0,2 0,4 0,6 0,8 1 Deviation from average contribution rate (in percentage points) Germany EAN AOK EAR IKK Overall BKK Gains/ losses in sickness fund membership in the western part of Germany in relationship to contribution rate

13 Transferred money through risk structure compensation West East Germany RSC* / expenditure** (billion Euro) RSC as % of expenditure RSC* / expenditure** (billion Euro) RSC as % of expenditure RSC* / expenditure** (billion Euro) / / / / / / / / / / / / / / / / / / / / / / / / RSC as % of expenditure

14 What makes a health system a SHI system? Contribution Not (health) risk-, but usually wage-related contribution Choice of fund collector Limited government control Third-party payer = sickness funds bipartite self-government Population Mandatory insurance Providers Public-private mix In Germany discussed in years after SHI introduction!

15 Public-private ownership of acute care hospital beds in SHI countries Public Not-forprofit For profit Austria 69% 26% 5% Belgium 60% 40% France 65% 15% 20% Germany 55% 38% 7% Luxembourg 50% 50% Netherlands 100%

16 What makes a health system a SHI system? Contribution Not (health) risk-, but usually wage-related contribution Choice of fund collector Limited government control Third-party payer = sickness funds bipartite self-government Contracts Population Mandatory insurance Free access Providers Public-private mix

17 Stewardship and accountability Stewardship role for government complicated as major health care responsibilities are in the hands of sickness funds Sickness funds should be (and usually are) accountable, but only to their insured and regarding the benefits covered (i.e. no broad public health perspective)

18 What does this all mean? Social health insurance systems with more than sickness fund are close to the actors but complicated to steer and manage! We do not have convincing data that it s really worth it in terms of improved health outcomes especially for the chronically ill who need coordinated/ integrated care (disease management programmes) more than competition!

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