SANIT Basic Framework. Management in the Health Sector. System Comparison. Magdalene Rosenmöller. Prof. Magdalene Rosenmöller

Transcription

1 SANIT 2004 Management in the Health Sector System Comparison Magdalene Rosenmöller Basic Framework Financing Institution Patients Clients Users Citizens Health Care Providers 2 SANIT - System Comparison 1

2 Basic Framework II Collecting Authority Financing Institution Purchasing Agency Employer Patients Clients Users Citizens Health Care Providers 3 OECD system representation (The German system) OECD system representation (The German system) Cotizaciones obligatorias ligadas a los ingresos Cajas de seguro enfermedad Médicos Pago por acto Asociaciones de médicos Presupuesto global Población y empresas Orientación Pacientes Flujo de servicios Flujo de información Flujo de orientación Hospitales Presupuesto global (función, en cierta medida, del volumen de actividad) 4 SANIT - System Comparison 2

3 Different Type of Health Systems Semashko Systems Beveridge Systems Semashko/Beveridge Systems in low income countries Bismarck Health Systems Segmented Health Systems Private Health Systems 5 Challenges of Reform: Disintegration from more integrated more disintegrated from more complex more need for regulation Socialized Health system National Social Insurance Health Service Systems Social and private Insurance systems State MOF-MOH Hospitals Polyclinics Outposts State MOH Public hospitals specialized outpatient care GPs State MOH Social insurance Public and private hospitals Outpatient practices State MOH Social insurance Public and private hospitals Outpatient practices Private insurance HMOs assigned patients Subscribed patients Subscribed patients or free choice Subscribed patients or free choice Schneider, M. (1998). European Integration and Health Care Reforms in the CEEC. Recent Reforms in Organisation, Financing and Delivery of Health Care in Central and Eastern Europe 6 in the Light of Accession to the European Union. Brussels: EC Consensus, May 1998: Proceedings. SANIT - System Comparison 3

4 Semashko Czech Republic (1989) OECD, In principle: Semashko Systems All health staff salaried Services provided free of charge Private sector very small or non-existent In practice Substantial under-the-table payments Examples: Former Soviet Union and Central and Eastern Union countries (all in transition now) 8 SANIT - System Comparison 4

5 Beveridge Health Systems United Kingdom (1989) Beveridge report (1943) National Health Service Act (1946) OECD, Beveridge Health Systems (National Health Service - NHS) Largely publicly provided and financed May include some user charges Small private sector Examples: UK, Denmark, Sweden, Spain, New Zealand 10 SANIT - System Comparison 5

6 Semashko / Beveridge Health Systems in low income countries Government Ministry of Health Public health centers Public hospitals Private for profit clinics Zambia (pre-reform) Population /patients Private for profit hospitals NGO hospitals and clinics Informal and traditional sector OECD, Semashko / Beveridge Health Systems in low income countries Designed to be dominated by public provision / finance Range of publicly owned health facilities Direct employment of staff in public facilities Default privatization with under-the-table payments Large private sector (for-profit and not-for-profit) Examples: India, Pakistan, Kenya, Zambia 12 SANIT - System Comparison 6

7 Bismarck Health Systems (introduced in the 19th century) Private insurance Mutual Funds Statutory Insurance Funds Ministry of health Payment to providers Reimbursement to patients Public health Pharmacists France (1988) Population /patients Copayment GP s and specialists Municipal medical centers Public hospitals Private hospitals OECD, GERMANY 14 SANIT - System Comparison 7

8 Bismarck Health Systems (Social Health Insurance) Social Insurance arrangements dominate the system Often some component of voluntary insurance Both public and private providers Minor co-payments Examples: Germany, Belgium, France, Netherlands, Austria, 15 Segmented Health Systems Taxes Compulsory contributions Voluntary contributions Ministry of Health Social Insurance Private Insurance Community services Private facilities Ecuador Population Social Insurance facilities Patients Public facilities 16 SANIT - System Comparison 8

9 Segmented Health Systems Three important subsystems: public, social insurance, and private (both private insurance and out-of-pocket ) Different segments of the population are covered under each some are double-covered Each subsystem has its own providers which are public, quasi-public, and private, respectively Examples: Mexico, Peru, Ecuador, Uruguay, Colombia (changing) 17 Private Health Systems US (1990) OECD, SANIT - System Comparison 9

10 Private Health Systems Private voluntary insurance is the most important financing mechanism Provider institutions mainly privately owned Public involvement in finance and regulation still substantial Examples: USA, Switzerland (changing) 19 Main Characteristics Federalism & Corporatism Länder and Federal Government Corporate bodies (professionals, providers, insurers) Funded by Social Insurance contributions Hospital care (mix public, private, budget) ambulatory care (private office based physicians, FFS)Federalism & Coporatism (Länder and Federal Government / Länder / coporate bodies (professionals, providers, insurers ) Hospital care (mix public, private, budget) ambulatory care (private office based physicians, FFS) 20 SANIT - System Comparison 10

11 The German system at a glance... Choice of fund since 1996 not (health) risk-, but wage-related contributions Financing Institution Third-party payer Strong delegation & limited governmental control ca. 300 sickness funds with self-government organised in associations Contracts, mostly collective Population SHI insures 88% (75% mandatorily, 13% voluntarily) Free access Providers Public-private mix, organised in associations adapted from Reinhard Busse, TU Berlin 21 Germany: challenges Strict separation between ambulatory and hospital (inpatient) care with different regulatory environment and rules Financial incentives vary between sectors and are changed frequently solutions to old problems create new ones Moving between funds, young and health less mixed risk adjustment fund Quality and Cost Effectiveness (WHR 2000 #27 in terms of performance (efficiency) 22 SANIT - System Comparison 11

12 Enlistment in hospital plans Prof. Magdalene Rosenmöller Problem 1: Strict separation between ambulatory and hospital (inpatient) care with different regulatory environment and rules Federal Ministry of Health Proposals for health reform acts Federal Assembly (Bundestag) Federal Parliament Federal Council (Bundesrat) Representation State Ministries responsible for health Legislative frame Supervision Obligation to secure hospital care Supervision Physician Obligation to treat 23 (Regional) Physicians Associations Federal Association of SHI Physicians Freedom to choose Financial negotiation Obligation to secure ambulatory care Insuree/ Patient Freedom to choose Obligation to contract Financial negotiation Obligation to treat Freedom to choose Hospital 16 Regional Hospital Organizations Federal Hospital Organization Supervision Supervision of country-wide funds (via Federal Insurance Office) Supervision Fed. Com. of Physicians and Sickness Funds: Decisions on ambulatory benefits Valuation Committee: Setting of relative point values Sickness fund Sickness funds in one region Federal associations of sickness funds Coordinating Committee Supervision of regional funds Supervision Fed. Com. for Hospital Care: Decisions on in-patient benefits DRGs: Decision about types and valuation Statutory health insurance Problem 2: Financial incentives vary between sectors/providers / frequent changes Solutions to old problems create new ones Voluntary private insurance premiums 8.3% Contributions 57.0% Contributions 7.0% General taxation 7.8% Private health and long-term care insurers Statutory sickness funds Statutory long-term care funds Federal and state governments Reimbursement of patients (pharmaceuticals, amb. care) or payment to providers Payment to providers, sick pay to patients Payment to providers, cash benefits to patients Public health services 0.8% Investment & salaries Ambulatory nursing care providers 2.7% Fee for service Population and employers Patients (and private organisations) Co-payments and nonreimbursed health expenditure 12.3% Public, private non-profit and private for-profit hospitals 27.4% Dentists 6.5% Ambulatory care physicians 13.6% Nursing homes 7.0% Pharmacies 13.7% Fee for service Per diems Investment Investment Fee for service (via Dentists associations) Physicians associations Per diems, case and procedure fees Per diems, case and procedure fees plus fee for service Prices Fee for service Fee for service Mainly capitation 24 SANIT - System Comparison 12

13 Problem 3 (actually No. 1): Increase of contribution rate Background: no tax subsidies; sickness funds are not allowed to incur deficits Expenditure Sub-problem: sickness funds did go into debt estimated to be up to 10 billion (< 1 monthly expenditure) Contributory income (wages up to threshold; pensions; 50% of wages for unemployed...) = contribution rate Sharp increases ( ; ) have always triggered major reforms! 25 Responses: ongoing Reforms Reform act Year Health Care Reform Act 1989 ("First step") 1988 Unification Treaty (extension of SHI to eastern part) 1991 Health Care Structure Act 1993 ("Second step") 1992 Introduction of Long-term Care Insurance 1995 Health Insurance Contribution Rate Exoneration Act st & 2 nd Statutory Health Insurance Restructuring Act ( third step") Act to Strengthen Solidarity in Statutory Health Insurance Reform Act of Statutory Health Insurance SANIT - System Comparison 13

14 Solutions: latest developments Restructuring financial incentives Disease Management Programmes The SHI Modernisation Act 2003 Funding basis to entire population? from income based to per-capita? 27 United Kingdom 28 SANIT - System Comparison 14

15 Spain 29 UK Health System: Main Characteristics Devolution responsibility to countries, then to local bodies. Tax based funding Primary care by GPs, multiprofessional teams in health centres (capitation) Public hospitals, independent trust status Little private care to private insured and direct pay 30 SANIT - System Comparison 15

16 UK: Last Developments Health policy = high profile Recognised that health care has been under funded 9% of GPD (??), increase NHS workforce numbers Long waiting lists for hospital appointments, poor quality of hospital buildings contracting services in France / Belgium NICE - National Institute for Clinical Excellence Development of DRG health related groups Responsibility for purchasing to be passed from health authorities to primary care trusts / local health groups, = main purchaser of health services Modernisation Board, Commission for Health Improvement 31 Exercise Decide in which system would you prefer to become sick? Why? Draw a scheme describing the Chinese system and its characteristics and what is desirable?: Who benefits and what are the benefits? Who pays and how much? Who collects the money and where does it go? How much is it spent and on what? How do patients access services? Describe a typical patient journey through the system What are the major challenges? Definition of the Hospital what are the basic elements? 32 SANIT - System Comparison 16

17 Bismarck vs. Beveridge Contributions Wages Defined (explicit rationing) Occupational insurer Independent management AWP contracts/ reimbursement Citizenship/ resident All income Comprehensive (implicit rationing) State Insurer State control Integrated providers 33 Poor relief/charity Destitute Roman / Greek Mutuality Guilds Middle ages Voluntarism Blue collar workers Early industrialization Corporatism Employees Late industrialization Universalism Citizens Post WW-II 34 SANIT - System Comparison 17

18 Comparison: Collection of Funds Source: WHO HITs Health Care in Transition Profiles 35 Comparison: Reimbursement Systems 36 SANIT - System Comparison 18

19 Coverage (percentage of population with public/social insurance/ type) Private insurance (percentage of population with private insurance/ type) Benefits defined? By whom? Germany United Kingdom 88% 100% 9% (substitutive); approx.10% of SHI members (supplementary and/or complementary) Yes. Generic terms in Social Code Book V. More detailed benefits in ambulatory care are defined by Federal Committee of Physicians and Sickness Funds. Hospital benefits to be defined by Federal Committee of Hospitals and Sickness Funds in future. Main taxes/ contributions Varying by fund: Employer 6.75% mean, Employee 6.75% mean 10% rate for people earning below EUR 322. employer only. 11.5% (complementary and supplementary) No for medical services. Except where the decisions of NICE make explicit the inclusion/ exclusion of certain drugs or services. Negative list of drugs (Section 8a Drug Tariff) Income tax bands (10%, 22%, 40%) VAT (17.5%) Other contributions/ taxes No National Insurance contributions Employer 11.9% Employee 10% Ceiling on contributory income Yes. DEM 6525 monthlyincome in 2001 Yes for national insurance contributions Employee Lower GBP 87, upper GBP 575 Employer Lower GBP 87, no upper Determines contributions/ taxes Individual funds subject to approval Treasury by Länder (regional) government or Federal Insurance Office Collection of contributions/ taxes Individual funds Inland Revenue Global budget (frequency) No. Sectoral budgets Yes. 3-year cycle Mechanism for national pooling or financial risk sharing among funds Risk-structure compensation mechanism at the federal level (for >90% of income) Risk adjusted allocations to health authorities/ health boards and in future direct to loca l purchasers (e.g. PCTs) 37 Payment - Incentives Payment method Advantages Disadvantages Budget Capitation Fee-for-service Allows strong control Predictable expenses Predictable expenses Provider has incentive to operate efficiently Eliminates supplier-induced demand Low administrative costs Increase health productivity No direct financial incentive for efficiency Provider may under-provide services Financial risk may bankrupt provider Provider may under-provide services Cost-escalating: strong incentives for induced demand High administrative costs Case Based Strong incentive to operate efficiently Provider has incentives to select low-risk within case categories Less suitable for outpatient care 38 SANIT - System Comparison 19

20 Responsiveness Internal Incentives WHO Pooling to redistribute risk, cross-subsidy for greater equity 40 SANIT - System Comparison 20

21 Health System Financing and Provision 41 Health System Financing and Provision 42 SANIT - System Comparison 21

22 Functions of a health system STEWARDSHIP Financing Provision Personal Health Services Revenue Collection Fund Pooling Purchasing Non-Personal Health Services RESOURCE GENERATION 43 Provider Payment mechanism and provider behavior Source: WHO Health Report SANIT - System Comparison 22

23 Exposure of different organisational forms to internal incentives Source: WHO Health Report Exposure of different organisational forms to external incentives Source: WHO Health Report SANIT - System Comparison 23

24 Efficiency Allocative efficiency Technical efficiency Equity Progressivity Equity of access Responsiveness Accessibility Choice Sustainability Objectives SANIT - System Comparison 24

25 49 50 SANIT - System Comparison 25

26 Data Exercise OECD Health Data Base WHO Europe HFA Health for All Database 51 Thanks!! SANIT - System Comparison 26