The Denia Project: Concession for integrated HC

Transcription

1 The Denia Project: Concession for integrated HC Country: Spain Partner Institute: Centre de Recerca en Economia i Salut (CRES), Universitat Pompeu Fabra, Barcelona Survey no: (6)2005 Author(s): Dr. Fidel Campoy Health Policy Issues: Public Health, Role Private Sector, System Organisation/ Integration, Funding / Pooling, Access, Responsiveness Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change Featured in half-yearly report: Health Policy Developments Issue 6 1. Abstract The "Denia Project" is a private health insurance development formula, through a collaboration with the public sector, operating the integrated care business in the Denia region in Valencia, Spain ( inhabitants) based on an innovative per-capita insurance model. The 15-year-concession includes investments to improve health services and the management of integrated primary and specialised care in the region. The concessionaire must invest more than 96,6 mio?. 2. Purpose of health policy or idea The Denia model is not an isolated experience: it is part of a map of changes in the organisation of the public health service system in the Valencia Region (The Valencia Model). This change is characterised by the following issues: 1. There is a strong component of integral management decentralisation in all the health areas of the Valencia Region, which will no longer be controlled by a single manager. 2. A capitation financing system is implemented in all the health areas. 3. An invoicing system is introduced between health areas in order to pay for the transferred patients. 4. There will be areas directly managed by the public administration and 3 areas with the management ceded to private health care companies. For the patient, this model means: Health systems are public, of universal access, with the same portfolio of services as in Spain's National Healthcare System, SNS. Freedom of movement in the whole public health system for the patients from Denia Area (without gate keeping). Scheduled clients can come to the Denia area from other areas, with previous authorisation of the Commission - 1 -

2 (with gate keeping). Main objectives The Denia model is based on the temporary cession, from the public administration to a private health company, of both the management of all public health facilities of a certain geographic area and the insurance of all public health benefits of the population living and insured in this area. This is a mixed model with a big part of health service provision and a part of insurance system for all included benefits: 1. The temporary cession of public health facilities (provision part) includes the management, organization and operating of public health buildings. The range of competencies involves all levels of care: primary care, specialized care, hospitals, emergencies, home care and compulsory health prevention programs. It includes a public tender defined investment plan, including total invested amount and its assignment. 2. The guaranty of the health benefits (insurance part) is based on an insurance done by the adjudicated company. The premiums are paid by the public administration for the whole population included in the tender in form of a per capita payment (411 for the year 2004). That means that health services that this population receives outside of the designated health area but in the framework of the National Health System must be paid by the adjudicated company. This insurance component is the reason why the two previous public tenders have been adjudicated to health insurers: Adeslas in Alcira, and Asisa in Torrevieja. This situation allows the per capita payment to be considered as health premiums because it is the same financial system as in the publicly funded health care system for Spanish civil servants (MUFACE). The funding of the publicly covered health services has two main ways: 1. A per capita payment for the resident population of a certain area who have the rights to public health assistance. 2. A fee for service payment done by means of a balance system between the incomes of the services done by the adjudicated company to public insured people coming from other parts of the country (other regions of Valencia, the rest of Spain and European citizens with European health card), and the expenses of the services done to people included in the capitative payment but done in other geographic areas. The operation of the facilities gives an additional income to the concessionaire. In this model the public administration has included up to now two important security clauses: 1. A limitation of the IRR to 7.5%. The reason for this security clause is to fix a politically "reasonable" benefit for the management of the public health services. 2. Technical and financial solvency of the project adjudicated company, demanding that the proposal should always be from a company with experience in health management (health insurer or hospital service provider). These requirements can be explained by the obligation of the public administration to guarantee the right to health protection for all citizens that is stipulated in the Spanish Constitution, article 43rd. In the case of this tender it is especially important because the management of all public health care services for the area (area number 12 of Valencia region) is totally given to a third party. For this reason the administration looks for solvent companies who want to orient themselves towards public health care services management. These services are characterized by having a high turn over, stable customers, a state guaranty, a low risk level, long lasting time and a low operating rate. Type of incentives For the Public Health Care Administration: - 2 -

3 Transforming infrastructure investment into a current cost. Reducing the cost of health care (efficiency margin of 20%). Transferring the financial risk of health care services. Transferring the operational risk of health care services. Keeping definition, steering and control in the public health system. Having just one interlocutor in the management and investment of the health provision. This model allows the regional government to extend and strenghten the public healthcare resources network without incurring larger public debt and, at the same time, offering private healthcare standards (no waiting lists, single room, etc.) in public healthcare services. Furthermore, all the new and remodeled buildings and infrastructures will revert to the regional government once the concession period finishes. Groups affected Regional government, insurance companies 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral This is the only initiative that truly faces the challenges that the present healthcare services system raises. The created model allows a stable and long term collaboration between the public and the private sector in order to try to solve the main problems that the present system brings up: not enough financing, management inefficiencies and bad quality as perceived by customers. 4. Political and economic background There was a favorable political situation in Spain to the introduction of this formula (concession to a private insurance company to operate healthcare services): Partido Popular (right-wing party) was governing both in the national and the regional government. Marina Salud (Denia's adjudicatary company) is a daughter company held by DKV Seguros, a private health insurer, and Ribera Salud, a firm belonging to a savings bank. The concession constitutes the third initiative of the Valencia Government after Alcira (1997) and Torrevieja (2001), and it is expected to open a new, transparent and stable collaboration model between public and private health sectors in Spain. Nevertheless this is the first time the regional government of Valencia considers comprehensive care as the main object of a public tender

4 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea The implementation of the integrated health care model has had three stages: 1st stage - Concession of specialised care: it was the first step and it began in 1997 with the concession of specialised care in Area 10 (Alzira) for a period of 10 years. This first experience with concessions of health care showed the need to incorporate the management of primary care and the convenience in increasing the concession period to 15 years, extendable for 5 more years. 2nd stage - Concession of integrated health care (primary and specialised). This was done in 2002 with concessions in Area 20 (Torrevieja) and Area 10 (Alzira). In this case the concession of specialised care was rendered previously to the Public Administration for the redefinition of the model. Both in the case of Alzira as in the case of Torrevieja, the concession was given in a health area with no hospitals. Because of that the concessionary company had to build the hospital and get it working. 3rd stage - Concession of integrated health care in a health area with an existing hospital. This is the situation of Area 12 (Denia). The fact that a hospital existed previously gives a different dimension to the project and, if being a successful experience, would be a great backing to the feasibility of the model. It would show that this model can be a way of transforming public health service organisation from bureaucratic public management into company supply of health care services. Initiators of idea/main actors Government Providers Private Sector or Industry Approach of idea The approach of the idea is described as: new: Innovation or pilot project Stakeholder positions Stakeholder positions towards the model are: Valencia Government, promoter of the idea. Local governments from the affected cities which see in this model a way to improve their healthcare infrastructure and service quality. Paradoxically this is not the position of the Denia city council, probably due to an oposed ideology against the "public service - private management" model. Present management team of the health area

5 Main opposition comes from: Civil servants trade union representatives. Human resources board in the health area. Actors and positions Description of actors and their positions Government Regional Health Minister very supportive strongly opposed Local government (Mayor) very supportive strongly opposed Providers Health insurance company very supportive strongly opposed Private Sector or Industry Trade union very supportive strongly opposed Influences in policy making and legislation This model has been developed within Ley 14/94 (ACT) of new management in the Spanish National Health Service. Legislative outcome n/a Actors and influence Description of actors and their influence Government Regional Health Minister very strong none Local government (Mayor) very strong none Providers Health insurance company very strong none Private Sector or Industry Trade union very strong none Positions and Influences at a glance Adoption and implementation The colaboration of the local government and trade union representatives will be required. Relationship with the media and all the communication issues will also be critical. Review mechanisms Final evaluation (external) Dimensions of evaluation - 5 -

6 Process, Outcome 6. Expected outcome Some of the aims and effects of this formula related to healthcare services access and delivery are the following: To carry out the investments needed to be able to renovate and update the healthcare resources in the area (new hospital, renovation of the present hospital and renovation of the present ambulatory care center). To guarantee same access and rights as within the rest of public resources; Create conditions like in private healthcare sector facilities and to improve quality of service (no waiting lists, single rooms in hospital care, etc.); More efficient management of public funds and resources (more flexible HHRR policy, investments,...). Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Author/s and/or contributors to this survey Dr. Fidel Campoy - 6 -

7 Suggested citation for this online article Dr. Fidel Campoy. "The Denia Project: Concession for integrated HC". Health Policy Monitor, September Available at -