Australia s s Experience with Health PPP s

Transcription

1 Australia s s Experience with Health PPP s Annette Schmiede Adj. Assoc Professor Menzies Centre for Health Policy Sydney University Berlin 2009

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3 Federal and State Governments Pop 23 mill high growth, highly urbanised Federal Government with six states and territories. Federal govt raises taxes States provide services States operate and fund the public hospital system and community health Federal govt funds primary care, GP s s and specialists. Complex system, poor accountability, major reform imminent

4 Mixed Private and Public System 70% funded by govt, 19% funded through out of pocket 70% provided by private providers Tax funded national health insurance system, all residents have access to hospital services through public hospitals free of charge. Private health insurance available to cover private hospital stay. Private health insurance subsidized by the Government.

5 Role of Private Hospitals Private hospitals are an essential component of the health system Account for 30% of all hospital beds but do almost half of all surgical episodes, mainly elective Do not provide trauma services or teaching Private hospitals owned by charitable groups (mainly religious) and investor companies.

6 First Generation PPP s First health PPP s introduced in the early 90 s by conservative State governments Began as an early adoption of ideology of liberalising public infrastructure, roots in Thatcherism Not driven out of health policy

7 First Generation PPP s Full service contracts All services bundled including clinical services, community health and emergency 20 year plus contracts Service prices to be discounted Demand risk shifted to operator Mainly replacement of existing hospital some new greenfields First project caused major public outcry Second project limited to not for profit operators 7 projects across country 3 projects reverted to public ownership in early years of contract Ideological opposition from bureaucracy and State Labor govts.

8 Project Year Capital value Beds Location Port Macq 1992 $40mil 160 country NSW Hawkes 1994 $47mil 127 outer met. NSW Joond lup 1996 $70mil 335 outer met. WA Latrobe 1997 $56mil 257 country Vic Mildura 1998 $37mil 130 country Vic Noosa 1998 $20mil 100 Regional Qld Robina 1998 $48mil 192 Regional Qld New or replace replace. replace new replace replace new new

9 SERVICE CATEGORIES SERVICE SUB- ACUTE CATEGORIES MENTAL INPTS ACUTE COMMUNITY A&E INPTS HEALTH OUTPTS HEALTH ACUTE MENTAL HEALTH SUBACUTE HAWKESBURY X X X X LATROBE X ROBINA X X

10 SERVICE CATEGORIES ACUTE INPTS SUB-ACUTE INPTS A&E COMMUNITY HEALTH OUTPTS MENTAL HEALTH ACUTE SERVICE CATEGORIES MENTAL HEALTH SUBACUTE HAWKESBURY Fee for Service Direct Billing Direct Billing LATROBE Case Payment Per Diem Annual Budget Annual Budget Per Diem Per Diem ROBINA Case Payment Per Diem Fee for Service Per Diem Per Diem

11 OPERATING FUNDING MODEL CASE PAYMENT FEE FOR SERVICE DIRECT BILLING OR LUMP SUM PER DIEM PRIVATE PATIENT REVENUE INFRASTRUCTURE OR TEACHING AND RESEARCH GRANT. COMPONENTS CAPITAL RECOVERY COSTS OF FUNDING THE DEVELOPMENT, PRINCIPAL & INTEREST. MAINTENANCE CAPITAL EXPENDITURE INSURANCE EQUITY RETURN (NOT ALWAYS) GROUND LEASE

12 Implementation Issues Risk exposure for operators around open ended demand, particularly with A&E services. Some projects significantly cross subsidised services from private patients. Growth assumptions in tender documents not reflected in annual operating budgets. Bureaucratic opposition, proposals mainly came from asset management and capital works branches. Service and policy areas were often opposed. Once facilities completed responsibility passed to these areas. Relationships often adversarial.

13 Implementation Issues Policy did not have bi partisan support at a State political level. Significant ideological opposition against many of the projects when governments changed. Failure to negotiate acceptable annual operating budgets. Disputes over the methodology for covering price increases, CPI versus real cost increases.

14 Process Issues Financing and ownership structures were complex. No standardised approach across the projects each state and almost each project differed in approach contract fundamentals and project structure.

15 Process Issues Methodologies used by State governments to set ongoing prices has not always been transparent, consistent or logical. Pricing methodologies were complex and not easily benchmarked to govt. services.

16 Lessons Policy intent should be clear. The community must be supportive. Process must be understood and driven by health not treasury. Health policy implications need to be clearly understood. Need for clarity about the role of the private sector in the overall health system. Need to understand the real costs of providing govt services, capital and operating. Accurate awareness of the capacity of the private sector to participate. Risk allocation must be equitable. Goodwill and commonsense.

17 Factors influencing outcomes. Lack of clear expectations of the desired outcomes of projects Shortage of experience and skills transfer. Unbalanced risk transfer. Lack of flexibility in implementation process. Inadequate commitment to averting and resolving disputes. Uneven capability within the public and private sectors. No bipartisan political support.

18 Project Updates Joondalup longest operating, 14 yrs, to have significant investment by government, $ 230mill, and operator, $90 mill. 530 beds. Emergency Dept busiest in Perth 63,000. Runs more efficiently than public sector Hawkesbury, flexibility allows quick responses to emerging needs, innovation

19 New Wave PPP s No clinical services Berwick Community Hospital, Victoria Royal Women s s Hospital, Victoria Royal Children s s Hospital, Victoria Orange Base Hospital, New South Wales Royal North Shore Hospital, New South Wales Long Bay Prison Forensic Hospital, New South Wales Newcastle Mater Hospital, New South Wales Royal Adelaide Hospital, South Australia

20 Future Need Australia needs substantial capital investment driven by past underinvestment, population growth and ageing Federal govt set up Hospital Fund as part of GFC response investing $5-10bill plus state investment. Most projects now over $1bill will still need private strategy

21 New Projects Sunshine Coast University Hospital Qld. Collocated private hospital

22 Noosa Hospital Mildura Base Hospital Joondalup Health Campus Hawkesbury District Hospital

23 Port Macquarie Base Hospital Robina Hospital

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