WELFARE AND MARKET REGULATION Health system financing: Overview

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1 WELFARE AND MARKET REGULATION Health system financing: Overview Prof. Alberto Holly Fall semester

2 Outline Introduction Basic aspects of health and heath care systems: Functions Objectives Health financing (Introduction) Health systems financing models Page 2

3 Outline Organization charts of health care systems of several countries Efficiency and equity issues Page 3

4 Introduction Aim of this session: Set up a framework for the discussion of some important aspects that will be presented in more detail in the following sessions. Review the main characteristics of health financing models Page 4

5 Objectives and Functions of Health Systems Three fundamental objectives: Improving the health of the population they serve; Responding to people s expectations; Respect for dignity, confidentiality, autonomy, prompt attention, quality of amenities, access to social support networks, choice of provider Providing financial protection against the costs of ill-health. Page 5

6 Relations between functions and objectives of a health system Functions the system performs Objectives of the system Stewardship (oversight) Responsiveness (to people s non-medical expectations) Creating resources (Investment and training) Delivering services (provision) Health Financing (collecting, pooling and purchasing) Fair (financial) contribution Page 6

7 Objectives and Functions of Health Systems A health system is: On one hand a health care production system On the other hand a system of health insurance But one should be approach both globally, i.e. the relationship policy-holder-insurers insurer-producer insured (patient) - producer. Page 7

8 State/Regulator The Health Care Triangle Financing Insurers or third-party payers Reimbursement Patients or consumers Out-of- pocket fees Medical services Health-care providers Production Page 8

9 Health System Financing Functions Three basic principles of public finance: Principle 1. Raise enough revenues to provide individuals with a basic package of essential services financial protection against catastrophic medical expenses caused by illness and injury in an equitable, efficient, and sustainable manner. Page 9

10 Health System Financing Functions Principle 2. Manage these revenues to pool health risks equitably and efficiently. Principle 3. Ensure the purchase of health services in ways that are allocatively and technically efficient. No single-road to achieve these goals Page 10

11 Health System Financing Functions Three interrelated crucial functions of health system financing: Revenue collection Pooling of resources Purchasing of interventions Page 11

12 Health System Financing Functions Revenue collection: the process by which the health systems receive money from households and organizations or companies. Various ways of collecting revenue: General taxation Mandated social insurance contributions (usually salary-related and almost never risk related) Page 12

13 Health System Financing Functions Revenue collection: the process by which the health systems receive money from households and organizations or companies. The funding mechanisms include Taxation, Social insurance contributions, Private insurance premiums, Individual savings, Page 13

14 Health System Financing Functions Out-of-pocket payments Loans, grants and donations. Taxes can be levied on individuals, households and firms (direct taxes) or on transactions and commodities (indirect taxes). Direct and indirect taxes can be levied at the national, regional or local levels. Page 14

15 Health System Financing Functions Indirect taxes can be general, such as a valueadded tax, or applied to specific goods, such as an excise tax. Some social or compulsory insurance contributions are, in fact, a payroll tax collected by government. Taxes can be general or hypothecated that is, earmarked for a specific area of expenditure. Page 15

16 Health System Financing Functions Social health insurance contributions are usually related to income and shared between the employees and employers. Contributions may also be collected from selfemployed people, for whom contributions are calculated based on declarations of income or profit Social health insurance revenue is generally earmarked for health and collected by a separate fund. Page 16

17 Health System Financing Functions Private health insurance premiums are paid by an individual, shared between the employees and the employer or paid wholly by the employer. Premiums can be: individually risk rated, based on an assessment of the probability of an individual requiring health care; community rated, based on an estimate of the risks across a geographically defined population; Page 17

18 Health System Financing Functions or group rated, based on an estimate of the risks across all employees in a single firm. The agents collecting private health insurance premiums can be independent private bodies, such as private for-profit insurance companies or private not-for-profit insurance companies and funds. Government may subsidize the cost of private health insurance using tax credits or tax relief. Page 18

19 Health System Financing Functions Medical savings accounts are individual savings accounts into which people are either required to, or given incentives to, deposit money. The money must be spent on personal medical expenses. Medical savings accounts are usually combined with high-deductible catastrophic health insurance. Page 19

20 Health System Financing Functions Out-of-pocket: Patients may be required to pay part or all of the costs of some types of care in the form of user charges. These charges may be levied as a Co-payment (a flat-rate payment for each service), Co-insurance (a percentage of the total cost of the service) Deductible (a ceiling up to which the patient is liable after which the insurer covers the remaining cost). Page 20

21 Page 21

22 Health System Financing Functions Pooling: the accumulation and management of revenues so that: Members of the pool share collective health risks, Thereby protecting individual pool members from large, unpredictable health expenditures. The pooling of financial risks is the core of traditional insurance mechanisms. Traditionally known as the insurance function within the health system Page 22

23 Health System Financing Functions Its main function of is to share the financial risk associated with health interventions for which the need is uncertain. Differs from collecting, which may allow individuals to continue bearing their own risk from their own pockets or savings (individual saving accounts) Page 23

24 Health System Financing Functions Pooling deals with the accumulation and management of revenues so that members of the pool share collective health risks, thereby protecting individual pool members from large, unpredictable health expenditures. Page 24

25 Health System Financing Functions As a result of large pools, society takes advantage of Economies of scale, The law of large numbers, Cross subsidies from low risk to high risk individuals. Page 25

26 Health System Financing Functions Ensures: Predictability The potential for redistribution across individual health risk categories The risk of having to pay for health care is borne by all members of the pool. Prepayment provides various options for financing these risks Page 26

27 Health System Financing Functions Prepayment allows pool members to pay for average expected costs in advance, relieving them of uncertainty and ensuring compensation should a loss occur. Pooling coupled with prepayment enables the establishment of insurance and the redistribution of health spending between high- and low-risk individuals (risk subsidies) and high- and low-income individuals (equity subsidies). Page 27

28 Health System Financing Functions Purchasing (of interventions): the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of interventions. Purchasing can be performed passively or strategically Page 28

29 Health Financing Functions Page 29

30 Sponsor (Government/ Employers) A Model of a Health Care System Subsidies/ premiums Insurers or third-party payers Patients or consumers Out-of- pocket fees Medical services Health-care providers Page 30

31 Health System Financing Functions How these various functions are arranged has important implications for the way health systems perform, relative to Amounts of funds available (currently and in the future) and concomitant levels of essential services and financial protection (the depth and breadth of coverage) for the population; Fairness (equity who bears the tax/revenue burden) with which funds are raised to finance the system; Page 31

32 Health System Financing Functions Economic efficiency of such revenue-raising efforts in terms of creating distortions or economic losses in the economy (the excess burden of taxation); Levels of pooling (risk subsidization, insurance) and prepayment (equity subsidization); Numbers and types of services purchased and consumed with respect to their effects on health outcomes and costs (the cost-effectiveness and allocative efficiency of services); Page 32

33 Health System Financing Functions Technical efficiency of service production (the goal being to produce each service at its minimum average cost); Financial and physical access to services by the population (including equity in access, benefit incidence). Efficiency and equity are critical aspects of all health financing systems and are relevant for all financing functions. Page 33

34 Health Systems Financing Models Organizational forms National health service: relying on general taxation as the main source of revenue, usually heading a large network of public providers Example: Canada (National insurance), Denmark, Italy,Latvia, Romania, Poland, Portugal, Spain, Sweden and the United Kingdom Page 34

35 Health Systems Financing Models Social insurance organization (single or multiple, competing or not), mostly relying on salary-related contributions, owning provider networks or purchasing from external providers Examples: Austria, Croatia, the Czech Republic, Estonia, France, Germany, Hungary, the Netherlands, Slovakia and Slovenia Page 35

36 Health Systems Financing Models Private health insurance fund (regulated or unregulated), mostly relying on voluntary contributions (premiums), which may be risk-related but are usually not income related Compulsory savings (Medical Savings Accounts, MSA) (partially subsidised, Singapore) Page 36

37 Health Systems Financing Models From the policy perspective, all health systems embody features of the different models The intermingling of tax-like and premium-like features is common in the financing of social health insurance programs Page 37

38 Example: Italian Health-Care System References for Italy: France, G., F. Taroni, and A. Donatini (2005): "The Italian Health-Care System," Health economics, 14, S187-S202 Lo Scalzo A., A. Donatini, L. Orzella, A. Cicchetti, S. Profili, A. Maresso (2009). Italy: Health system review. Health Systems in Transition, 11(6)1-216 Page 38

39 Italian Health-Care System: Organization Italy s health care system is a regionally based national health service (Servizio Sanitario Nazionale (SSN)) It provides universal coverage. It is organized at three levels: national, regional and local. Under the Italian Constitution, responsibility for health care is shared by the state and the 20 regions. Page 39

40 Italian Health-Care System: Organization At the national level, the state Has exclusive power to set the essential levels of care (livelli essenziali di assistenza (LEAs)), or basic package, or catalogue of SSN benefits, which must be available to all residents throughout the country, Is responsible for ensuring the general objectives and fundamental principles of the national health care system. Regions have virtually exclusive responsibility for the organization and administration of publicly financed health care. Page 40

41 Italian Health-Care System: Organization Regional governments, through the regional health departments, are responsible for ensuring the delivery at the local level of a benefits package through a network of population-based health management organizations (azienda sanitaria locale, local health enterprises (ASLs)) and public and private accredited hospitals. The ASLs are public entities which are directly accountable to the regions. Page 41

42 Italian Health-Care System: Organization In the health care sector, the public sector owns most hospitals and service providers. Major hospitals are semi-independent public enterprises hospital enterprises (aziende ospedaliere (AOs)). Page 42

43 Page 43

44 Page 44

45 Italian Health-Care System: Organization The decentralization of the health care system: a key issue in the development of the SSN since its inception in During the period : Devolution of political power to the regions. A process of transition towards federal reform of the state was put in place, Transferring the funding of the SSN from the central to the regional level, Strengthening the fiscal autonomy of the regional health departments. Page 45

46 Italian Health-Care System: Organization Since 1992, the SSN underwent a process of delegation (aziendalizzazione) Page 46 Oriented towards providing management with autonomy from political influence. Under this new governance model, the ASLs and the AOs were given greater financial and decision-making autonomy. The top management teams were given responsibility for the resources used and the quality of services delivered.

47 Italian Health-Care System: Financing Taxes Currently, the main source of finance for the Italian SSN is a mix of hypothecated (earmarked) taxes applied both at the regional and national levels: The IRAP (Imposta Regionale sulle Attività Produttive) is a regional corporation tax Imposed on the value added of companies (corporations, partnerships and self-employed workers) and on the salaries paid to public sector employees. Page 47

48 Italian Health-Care System: Financing In both cases, the employer pays the tax. The regional IRPEF (addizionale IRPEF, Imposta sui Redditi delle Persone Fisiche) is a piggyback regional that gets imposed on top of the national income tax (IRPEF). From 2000, each region can set the rate between 0.5% and 1.0%, Page 48 With the national income tax rate decreasing accordingly to keep the total tax burden unchanged for the taxpayers. In 2012 taxation represented 77.3 % of total health care expenditure

49 Page 49

50 Italian Health-Care System: Financing Out-of-pocket payments Inpatient care and primary care are free at the point of use. There are two main types of out-of-pocket payment. Cost-sharing: patients pay a co-payment for diagnostic procedures, specialist visits and pharmaceuticals in those regions that have chosen to levy co-payments on drugs for the purposes of containing rising drug expenditure. Page 50

51 Italian Health-Care System: Financing Since 2007, a fixed co-payment has been levied for unwarranted access to hospital emergency departments. Direct payment by users to purchase private health care services and over-the-counter (OTC) drugs. Cost-sharing exemptions exist for various groups, including Children under 14 years of age, Page 51

52 Italian Health-Care System: Financing Elderly people over 65 years of age with gross household income less than per annum, People with chronic or rare diseases, Disabled people, People with HIV, Prisoners Pregnant women. In 2012 out-of-pocket payments represented 18.8 % of total health care expenditure Page 52

53 Italian Health-Care System: Financing Voluntary health insurance (VHI) Due to near universal coverage, voluntary health insurance (VHI) does not play a significant role in funding health care in Italy. Spending on VHI, both as a percentage of total expenditure and of private expenditure, is well under 5%. Page 53

54 Page 54

55 Page 55

56 Sources of revenue as a percentage of total public expenditure on health, Sources of funding IRAP and regional IRPEF VAT and Excise duties Other government transfers Regional transfers and contributions from public and private sources Revenues and own revenues of the ASLs Extraordinary income and capitalized costs Source: Ministero d Elleconomia e delle Finanze Page 56

57 Italian Health-Care System: Financing The IRAP tax is collected nationally, but 90% of its revenue is allocated back to the region in which it is levied, thus favouring those regions with a stronger industrial base. This has led to a long-standing debate between the regions and central government over health care funding mechanisms. Page 57

58 Italian Health-Care System: Financing Extreme differences in fiscal autonomy coexist with substantial geographical imbalance in per capita expenditure. A main feature of Italy s health care system is the presence of deep regional inequality in health care expenditure and in the supply and utilization of health care services. Page 58

59 Page 59

60 Italian Health-Care System: Financing The important differences in fiscal autonomy require that fiscal devolution be complemented by substantial redistribution of funds through central transfers. To address this problem, a fiscal equalization mechanism (National Solidarity Fund) has been developed in 2001 to redistribute resources to those regions that are unable to fund the basic package. Page 60

61 Page 61

62 Italian Health-Care System: Financing The Fund is financed by indirect value-added taxes (VAT) In recent years, the redistribution formula has been based on population, weighted by age-specific utilization rates for hospital care, drugs and residential care for the aged, Page 62

63 Italian Health-Care System: Financing The standardized mortality rate (SMR) as a proxy for need An adjustment for interregional patient flows. Many elements of the allocation formula have attracted criticism. The allocation of resources for the SSN is the object of debates; an agreement has not yet been reached over an equitable redistribution formula. Page 63

64 Conclusion How to justify the existence of different organizational forms? Public and private financing health care arrangements observed today are the result of Cultural, economic, and historical decisions about how to organize risk pooling and prepayment, Implicit and explicit decisions about income redistribution and social solidarity. Page 64

65 Conclusion They can be justified, in part, as responses to the same limits and market failures of a competing health insurance market. Their analysis in terms of efficiency and equity illustrates a fundamental trade-off between these two objectives. Page 65

66 Appendix: Organization Charts of Health Care Systems of several countries The following organization charts have been collected by the OECD from different national sources. They appear in alphabetical order Page 66

67 67

68 Austria: Organization health-care system, 2012 Page 68

69 Austria: Financial flows in the health-care system, 2010 Page 69

70 70

71 71

72 72

73 73

74 74

75 75

76 76

77 77

78 78

79 79

80 Portugal: Financing of Heath Care

81 81

82 82

83 83

84 84

85 85

86 Austria: Organization health-care system, 2012 Page 86

87 Austria: Financial flows in the health-care system, 2010 Page 87

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