HEALTH INSURANCE: A viable solution. Dr. Ziad Mansour, M.D.; ABOG, MHs/HE

Transcription

1 HEALTH INSURANCE: A viable solution Dr. Ziad Mansour, M.D.; ABOG, MHs/HE June 23 rd, 2011

2 PRIVATE HEALTH INSURANCE Definition (1) Basic function of heath insurance: access to care with financial risk protection Collection of funds Pooling of funds Purchasing of services Public insurance: funded through taxes, either general or social security taxes Private insurance: provided through the direct payment of premiums to insurers; it includes: Voluntary insurance Mandatory insurance if it is not in the direct control of government for-profit insurers non-profit and community based insurers fair financing and equity in access insurers providing primary or secondary coverage (primary insurance serves as the main form of risk pooling for those enrolled; while secondary insurance complements cover provided by a publicly funded system) Tiered pricing 1

3 PRIVATE HEALTH INSURANCE Definition (2) A review of insurance arrangements around the world shows that the boundaries between public insurance and private insurance are becoming increasingly blurred spectrum of insurance arrangements classified along three key dimensions: Enrolment (whether insurance is mandatory or voluntary) Underwriting/ pricing (whether contributions are risk-rated, community-rated or income-based) Organizational structure (whether management of the scheme is commercial for-profit, private nonprofit, or public/quasi-public) 2

4 OVERVIEW Palestinian Refugees 1948 Palestine War: massive exile of 750,000 Palestinians more than 100,000 hosted in Lebanon 2008: 416,608 Palestinian refugees registered in Lebanon by UNRWA Almost 35,000 Palestinian refugees not registered at UNRWA but registered at the Lebanese Government 3,000 refugees not registered at UNRWA nor at the Lebanese government (PRCS - ECHO, 2008) 2011: 289,510 Palestinians in Lebanon (beneficiaries) HEALTH is one of top three priorities for Palestinian refugees in Lebanon Most of the efforts are focused on assuring quality health care services and improving the access of the population to care as many determinants of access to care are not available to Palestinians, mainly the one related to financial barriers 3

5 DETERMINANTS OF ACCESS TO CARE Household expenditure Health policies Health market regulation HEALTH SERVICES Environment (water, sanitation, polution, ) Transportation Infrastructure (facilities) Health Education Taxation System % GDP on Health (=UNRWA) FUNDING Technology HEALTH CARE Individual Income Health Insurance Staff Training HEALTH CONDITION S Business & availability of consumption goods and services Out-ofpocket Donors Human Resources for Health Patients perceived needs FINANCIAL FACTORS HUMAN FACTORS Patients consumption habits 4

6 Palestinians Age Pyramid > , ,450 9,860 23,000 5

7 UNRWA as a health insurer Paradoxical positions: pushing for a quality of care; cost containment strategy Health care providers and purchaser of services. A fund and a provider of a three level of healthcare Good negotiators with the HCP Limited advocacy at the level of the Key for cost containment: PHC management Per capita expenditure on health: USD 6A

8 UNRWA as a health insurer Cost containment strategy Admission criteria: role of the DMO Audit and control Purchase of service contracts Flat rate Discounted rates Ceilings (Annual) List of drugs 6B

9 UNRWA as a health insurer Patients Cost Aver/Patient Tyre 5857 $ 1,138, $ Bekaa 1609 $ 337, $ Saida 9467 $ 2,335, $ CLA 3648 $ 853, $ North 7333 $ 999, $ Total/ Sept 2010: $ 5,548, $ December Number of patients 21, , ,915 Expenditures $ 3,929, $ 3,941, $ 5,548, Average per Patient $ 140 $ 165 $

10 UNRWA as a health insurer Total Tertiary Tyre $71, Bekaa $31, Saida $529, CLA $179, North* $648, Tertiary / Sept 2010 $1,459, Forecast Dec 2010 $2,150, Tyre $1,220, $ 1,342, Bekaa $345, $ 483, Saida $2,638, $ 3,702, CLA $738, $ 844, North $999, $ 999, Projections $5,942, $7,372,

11 Private Secondary Healthcare Hospitals rates and eligibility criteria 9

12 Governmental Secondary Healthcare Hospitals rates and eligibility criteria 10

13 PRCS Secondary Healthcare Hospitals rates and eligibility criteria 11

14 Feasibility of a private insurance fund Main illness and epidemiological profile of the population Risk perceived by families Access to care: difficulties Financial difficulties related to health Existence of health care providers and how they are perceived Mutual aid practices Previous fund pooling : UNRWA experience Pools in the vicinity 12

15 community Types of plans Mutual fund Real MF do not exist in Lebanon Part of an insurance for profit scheme Based on professional similar profiles fund Formula= solidarity. A community or a group of people decide to protect each other against the financial risk of adverse health events. A per individual contribution is collected with an equitable pooling. If the fund is depleted, another round of collection is made. 13

16 Types of plans Mutual fund رعاية Priests: 7000 beneficiaries Closed loop: insurer and providers Beneficiaries Providers FUND 14

17 Types of plans Private insurance plan There are no open plans such as full coverage without ceilings for all diseases Plans growth in time in term of beneficiary package Depends crucially on the Re-insurers Main reinsurers: Hannover, Munich Re, Swiss Re They are all risk based, individual policies (family) Reinsurer set the Net Premium 15

18 Types of plans Calculation of the premium: Total Premium= Net premium+ services+ functions Services=office operations + policies+ TPA (third party attendants, brokers) Functions= share paid for providers 16

19 Types of plans Stop loss 100% hospitalization by the reinsurer The local insurance becomes a broker and a policy seller Excess of loss Most common in Lebanon A ceiling is negotiated above which reinsurer covers Usually set at 10,000 USD per case Most of the funds are locally managed Losses are covered by other insurances such as car and life 17

20 Types of plans Quota share À ratio per hospitalization is set such as 70/30 More efficient in terms of premium rate cuts Risk sharing Premium are sold at 35 to 370 USD per policy: risk based Most of the so called mutual funds are of this type 18

21 Types of plans Plans are not usually open without limitations Open plans are very expensive and usually not appealing to both insurers and beneficiaries In the case of the Palestinian population: the counter balance of an open not restricted plan is the large number of enrolees with a large under 18 years old proportion 19

22 Best scenario plan For an open no limitation plan An average of 300USD total premium would be required so for a total of 84,000,000 USD If limitations are set such as a ceiling per admission and a total annual ceilings of 5000 to for chronic diseases and an assumption that chemotherapy drugs are provided through donations better rates can be negotiated 20

23 Best scenario plans Age < Premium (USD) > In fact if we add the premium of the under 18 and those of above 60 and divides them by 2, we will have the average premium of 140 USD Total policy of 40, 000, 000 USD NB: all premium are calculated based on in patient care 21

24 thoughts Private plans are usually inefficient, inequitable in collections and pooling They tend to purchase services at higher rates They are risk based marginalizing people with health issues Cannot be envisaged without a risk transfer to the beneficiary thus a policy purchase is a must (policy, plan, annual health card...) They will allow access to quality care 22

25 thoughts Subsidized premium Pooling of all donors funds Negotiating UNRWA rates for Providers Limitations Unforeseen individual financial contributions Where do you see the benefits of a private medical insurance model?????? 23