Restricting supplemental insurance services

Restricting supplemental insurance services Country: Israel Partner Institute: The Myers-JDC-Brookdale Institute, Jerusalem Survey no: (10)2007 Author(s): Gross, Revital and Shuli Brammli-Greenberg Health Policy Issues: Role Private Sector, Funding / Pooling, Benefit Basket Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract The proposed legislation restricts inclusion of life saving and life extending medications in the Sick Funds' Supplemental Insurance programs, retrieving prior approval granted by the Ministry of Health in the last two years. The purpose of this policy is to restrict growth of the national expenditure on health and increase equality in the public health system. It will also benefit commercial health insurance companies who will have no competition from Sick Funds in this market. 2. Purpose of health policy or idea National Health Insurance Law allows sick funds to offer supplementary insurance Since legislation of the National Health Insurance (NHI) Law sick funds (SF) were allowed to offer supplemental insurance for additional services alongside providing the services in the mandatory benefits package. Each sick fund offers a standard supplemental insurance package in return for a premium that varies by age group only regardless of personal risk. Supplemental insurance includes services not covered by NHI (e.g. dental care, alternative medicine); enhanced coverage of NHI services (e.g. more physiotherapy treatments, more cardiac rehabilitation); alternatives to the services provided through the public system (e.g. private surgery, consultation with private specialists). Since 1998 sick funds are obligated to acept all applicants regardless of health status. Any change in the supplemental programs has to receive prior approval of the Ministry of Health (MOH). Expansion of supplementary insurance in 2004: life saving/extending medications Between 2004-2006 the MOH approved sick funds' requests to expand coverage of supplemental insurance programs to include "life saving" and "life extending" medications that are not included in the mandatory benefits package. Maccabi covers all medications approved for use but not included in the mandatory NHI basket of services; Clalit and Meuchedet cover only cancer medications. These benefits were added as a separate optional layer of the supplemental insurance, which is purchased for an additional premium. (The additional layer includes several new services but medications is the most visible and attractive service included in this layer). The fourth SF, Leumit, contracted with a commercial insurance company to provide the additional layer of insurance, under private insurance terms (i.e. premiums related to personal risk and medical underwriting). 2007: Exclusion of life saving/extending medications from supplementary insurance? - 1 -

The recent proposed policy stipulates that sick funds are not allowed to include "life saving" or "life extending" medications in their supplemental insurance programs. These can now be included only in private insurance policies offered by commercial insurance companies. Thus, sick funds have to change their new supplemental insurance programs (i.e. the new layer) and reduce the premiums accordingly. The stated purpose of the policy is to safeguard the public system by reducing inequality among sick fund members who do or do not have supplemental insurance. Another purpose is to decrease the growth of the national expenditure on health and encourage more transfers between sick funds. In addition, the legislation is expected to reduce SFs possible conflict of interests, arising from their management of the mandatory benefits as well as the supplemental benefits for members who purchase private insurance. Finally, an insurance program that includes all new medications (without prioritizing for cost/benefit value) is percieved as not efficient in use of scarce resources. Main objectives Restrict coverage of life saving and life extending medications in supplemental insurance programs in order to promote equality in the public health system and restrict the growth of the national expenditure on health. Type of incentives This restriction provides an incentive for the public system to pressure for increasing the health budget so as to provide adequate funds for adding important life saving and life extending medications to the mandatory benefits package. It also strengthens the competition between SFs on improving the services in the mandatory basket of services rather than competing on enhancement of the supplemental basket. Groups affected Public - 80% have supplemental insurance. Commercial policies have higher premiums and medical underwriting. Therefore lower access expected for the poor, elderly and ill, Sick funds will have more difficulty to market the new layer of supplemental insurance, as coverage of these medications was the most attractive service included in the new layer. This is a setback to their entrepreneur activities, Private health insurance companies have less competition and will find it easier to market their product - private health insurance with coverage for these medications 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 Innovation - Innovative in Israel. in the past if the MOH approved changes in supplementary insurance (SI) programs this was not retracted later. Not allowing life saving/extending services in the SI programs is also a new policy in Israel (never explicitly stated before). Controversy - very high, as described below. Systemic impact - changes the content of approved SI programs; changes the market power of SFs and commercial insurance companies. - 2 -

Visibility - high, many reports in the media and pubic forums. Transferability - rather system neutral as such regulations could be adopted by other systems with SI programs. However, the specific structure of the SI programs is unique to Israel. 4. Political and economic background This policy was included in an agreement between the Minister of Finance and the Minister of Health (from August, 2007). It was then included in the "budget reconciliation act" of 2008 which is an addendum to the budget act, proposed by the Ministry of Finance. The policy is a measure to strengthen the public health system and to curtail the growth in the national expenditure on health. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea Concern that supplementary insurance creates inequality Since the enactment of the National Health Insurance (NHI) law, the clause allowing sick funds to offer supplemental insurance (SI) has been under debate, and has been the subject of several policy reforms (Gross & Brammli- Greenberg, 2004). SI in fact integrates private insurance into the public system since it is provided by SFs and enables those with SI to receive improved services from the same public providers (SFs) who provide the mandatory services under NHI. Over the years, the main concern of policy makers has been the inequality this creates in the public system between those who do or do not have SI and can thus get additional services from their SF. The issue of including life saving and life extending medications in the SI benefits basket has been the subject of many debates (Parliament committee of labor welfare and health, 2007; National Institute for Health Policy and Health Services Research Eighth Dead Sea Conference, 2007). The main arguments for including life saving/extending medicationsin SI are: Improves access to important services that cannot be provided through the mandatory basket, given the limited health budget. Increases overall equality since SI is relatively inexpensive such that many can afford to buy it. Also SFs are not allowed to reject applicants or limit eligibility so SI is accessible to patients at risk of needing to use the services. In contrast, commercial insurance is expensive and the elderly and ill may be entirely rejected or their eligibility limited. Increases the value of SI to its purchasers (value for money). The main arguments against including these medications are: Leads to inequality between SF members that do or do not have SI Adding these medications will bind members to their SFs because of the relatively long waiting periods required - 3 -

for eligibility to receive this service (24 months). Providing this "outlet" will weaken public pressure on the MOF to update the medications in the mandatory NHI basket of services. Prioritization of new medications: life saving/extending medications not included in mandatory benefit basket The idea of including coverage of life saving/extending medications in the SI programs relates to the Israeli mechanism developed for prioritizing new medications and technologies to be added yearly to the mandatory basket of services. Israel has a structured process for updating the medication list in the mandatory basket, based on recommendations of an multi-disciplinary expert committee appointed by the Minister of Health (Shani et al. 2000, Shemer et al. 2005 ). This priority setting process includes rating of a list of new medications each year. Those receiving highest rates are selected to be added to the benefits package. The rating is needed since the MOF allocates limited additional funds for this purpose (between 0.5% - 1.5% of the total cost of the mandatory basket), and therefore only some of the new medications can be added. This explicit rationing process implies that some medications approved for use in Israel and rated highly by the expert committee, are not included in the basket and thus are available only for private purchase (or throught private insurance policies). Each year as the committee publishes it's recommendations, there is a lively public debate with extensive media coverage, and advocacy group activities to include additional medications in the mandatory basket of services. Sick funds fill in the gap: supplemental insurance for life saving/extending medications The sick funds have identified this perceived need, and have seen the potential profits of offering coverage of life saving and life extending medications in their SI programs. Adding this coverage imitates, and thus competes, with commercial health insurance policies which include it. SFs have a large base of insurees and therefore are able to offer similar benefits with lower premiums (large collective insurance with cross subsidies between age groups), and consequently pose a competitive threat to commercial insurance companies. In 2004 the Meuchedet SF added a new layer to its SI program which included coverage for life saving and life extending medications for cancer patients. This was offered as a separate layer to be purchased for and additional premium. In 2007 Clalit SF (insuring over 50% of the population) offered a similar additional layer as well, covering these medications for all conditions (not only cancer patients). In 2007 Maccabi SF (insuring 25% of the population) also added this coverage to its program and raised the fees, with automatic inclusion of all holders of the policy. The last SF (Leumit) did not extend its SI program but contracted with an insurance company to provide commercial policies at reduced prices to their members. The MOH has approved these new developments of the SI programs as well as a raise in premiums to cover the additional benefits. We should note that the new layer is offered to all SF members; SFs are not allowed to reject applicants or limit their coverage because of pre existing conditions. Eligibility for the new medications begins after a 24 month waiting period. Premiums are community rated (defined by age regardless of personal health status). Supplementary insurance for life saving/extending medications challenged by various stakeholders However, this development has been challenged by many stakeholders in the health care system (see analysis below) and debated in the Parliamentary labor, welfare & health committee. On this topic a coalition emerged between the MOF and some officials in the MOH who influenced the Minister of Health (while other MOH officials opposed this move). In August 2007 the Minister of Finance and the Minister of Health signed an agreement for the years 2008-2011 which includes (among other items) a yearly budgetary increase for adding new medications to the mandatory basket of services, and at the same time prohibits the SFs to include life saving and life extending medications in their SI programs. This provision is also included in the 2008 budget reconciliation act. If approved by parliament this provision will go into effect in 2008. Following a transition period, the SFs will have to change their policies (e.g. delete this provision from their SI programs and lower premiums, or contract with an insurance company - 4 -

to provide this coverage for their members). Initiators of idea/main actors Government Providers Civil Society Private Sector or Industry Others Approach of idea The approach of the idea is described as: new: Stakeholder positions Ministry of Finance The budget divisionstrongly supportedthis policy and pressured the Minister of Finance to accept it and cancel the permission previously granted to the SFs. The main arguments raised are: Including life saving/extending medicatons restricts competition; for new SI purchasers, eligibility for medications is dependent on a waiting period of 24 months therefore it might restrict transfer between funds (people will be wary of losing their eligibility without alternative coverage). Including these medications in the SI blurs the distinction between the public mandatory basket of services and private insurance and there is a concern of conflict of interest of SFs responsible for both. If SFs include all new medications in their SI, the national expenditure on health will rise, since there will not be a prioritization process. The insurance comptroller also supports this policy. His main argument is that there should be a clear distinction between the public system (services provided by the SFs under NHI) and private insurance for services not covered by NHI. These, in his opinion, should be provided by private insurance companies and other private providers. Note that the insurance comptrollers office has objected in the past to the general policy of allowing SFs to provide SI. Ministry of Health The official position of the MOH is support of this new policy, retracting the approvals given a year ago to all SFs to expand their SI programs to include life saving/extending medications. The Minister of Health endorsed this policy as part of an agreement with the Minister of Finance which includes a yearly allocation of 350 million NIS for 3 years to update the mandatory NHI basket of services. However, senior officials in the MOH are divided regarding this issue. The head of the Economics and Health Insurance Divisionsupports the new policy and advocated for it over time. The main argument he presents is that inclusion of life saving/extending medications in the SI programs leads to greater inequality. Inequality is expected to increase because the premiums will increase over time and those of low socio-economic status (SES) will consequently not be able to afford it and drop out. Inequality will be more prominent because SI services have copayments which will be relatively high for these medications and consequently deter poor patients from using their eligibility. Another argument he presents is that this policy will also harm the priority setting process for adding medications to the mandatory basket of services which will result in less efficient use of resources in the system and an increase of the national expenditure on health (because all medications will be accessible to many patients, and they will be over-used). Finally, he argues that inclusion of these medications in the SI - 5 -

programs will lessen the pressure on the MOF to allocate funds for updating the mandatory NHI basket of services, and undermine the ministries efforts to negotiate a permanent update rate for this purpose. The head of the division supervising the SFs and the SI programs is strongly opposed to the new policy. He had approved, a year ago, the extension of the SI programs to include life-saving/extending medications as well as other medications not included in the mandatory NHI basket of services. The main arguments he presents are: According to the NHI law SFs may cover through SI any service that is not included in the mandatory basket of services including medications. Based on past experience with update of the mandatory basket, even when medications were not included in the SI programs, there were years when no budget was allocated for updating the basket. Furthermore, the additional budget is usually significantly lower than needed to include all the medications that received high rates by the priority setting committee, and were recommended for inclusion by this committee. Since 80% of the population have SI, including medications in the SI basket will better answer the medical needs of the population. He also argues that this policy does not contradict the effort to establish a permanent rate of update for the mandatory NHI basket of services. Finally, he notes that commercial insurance is not an option for those who are ill (because of underwriting and exceptions). Sick funds The three sick funds that have extended their SI programs to include new life saving/extending medicationsstrongly oppose the new policy. They object to the process in which the MOH allowed them to extend their SI programs and then retracted this permission. They argue that the reason is that the government gave in to pressures of commercial insurance companies who wanted to safeguard their market share, compromising the interests of consumers. They also say that the "inequality" argument is misleasding. It is more equitable if 80% of the population (holding SI) has access to these medications than if only the very rich who can afford private insurance or out-of pocket payments can get them. They argue that if equality is a top concern, the government should subsidize SI premiums for the low SES population (even just the part that covers the new medications). Also, the SFs could slightly raise the premiums and thus cross-subsidize SI for those who can't afford it. Finally, they argue that the MOF tricked the MOH, and the addition of 350 million NIS is not real ("smoke screen"), because at the same time they reduced the SFs budget in other items by 500 million NIS. Furthermore, the agreement is only for 3 years and after that the MOF may not approve additional funds for updating the mandatory NHI. Leumit SF, who did not extend its SI program supports the new policy. Their main argument is that this extension increases inequality between SF members who do or do not have SI. Their position is that all life saving/extending medications should be included in the mandatory NHI basket of services, and that the health budget should be increased at a permanent annual rate that covers these new medications. Commercial insurance companies They support the new policy. It is obvious that it improves their competitive power and maintains their market share. It may also contribute to their ability to market a new product "medication insurance" that includes coverage only for medications not in the mandatory NHI basket. Their formal argument is that the SFs did not price this item correctly and therefore a deficit in their SI budgets can be expected or a need for a sharp increase in the premiums. They say that similar to long-term care insurance, SFs with no actuarial reserves cannot insure against the catastrophic risk of needing life saving/extending medication. Pharmaceuatical companies They oppose the new restrictions since they prefer that these expensive medications will be available to many patients increasing the demand for their products even when they are not included in the mandatory basket. At the same time they are concerned that if they are added to the SI programs, the SFs will be able to negotiate low prices given their strong market power. - 6 -

Israel Medical Association They support the new policy. They agree with the MOH and MOF that including life saving/extending medications in the SI increases inequality between patients who do or do not have SI. They are also concerned that if SFs are allowed to offer medications in their SI programs the MOF and the SFs would have a weaker incentive to add them to the mandatory basic basket. Consumer organizations They oppose the new policy arguing that SI provides access to these medications to the majority of patients. If the new policy will be approved, only the rich will be able to purchase commercial insurance or buy out of pocket medications. Furthermore, those who have a chronic or severe illness already are rejected by commercial insurance companies or are excluded from coverage for their illness, while all are eligible for SI. Nevertheless, they strongly advocate that the NHI law includes a significant permanent yearly update of the mandatory NHI basket (about 2% of the total health budget) that wil enable to include all important life saving/extending medications. Actors and positions Description of actors and their positions Government Ministry of Finance very supportive strongly opposed MOH economic and health insurance very supportive strongly opposed division Ministry of Health Division overseeing very supportive strongly opposed Sick Funds and Supplemental Insurance Minister of Health very supportive strongly opposed Providers Maccabi, Meuchedet and Clalit Sick very supportive strongly opposed Funds Leumit Sick Fund very supportive strongly opposed Civil Society Consumer organizations very supportive strongly opposed Private Sector or Industry Commercial insurance companies very supportive strongly opposed Pharmaceutical companies very supportive strongly opposed Others Israel Medical Association very supportive strongly opposed Influences in policy making and legislation Yes, the proposal to restrict sick funds from including life saving/extending medications in their supplemental insurance programs is part of the 2008 budget reconciliation bill (which includes many structural changes) and is approved in parliament together with the annual budget act. The legislation of this item will be part of the wider legislation of these acts (which is approved as a whole). Therefore the stakeholders who oppose this policy (sick funds in particular) are trying to influence the MOF to take this item out of the budget reconciliation bill. They are also lobbying among Parliament members against including this item in the budget reconciliation bill. Legislative outcome pending - 7 -

Actors and influence Description of actors and their influence Government Ministry of Finance very strong none MOH economic and health insurance very strong none division Ministry of Health Division overseeing very strong none Sick Funds and Supplemental Insurance Minister of Health very strong none Providers Maccabi, Meuchedet and Clalit Sick very strong none Funds Leumit Sick Fund very strong none Civil Society Consumer organizations very strong none Private Sector or Industry Commercial insurance companies very strong none Pharmaceutical companies very strong none Others Israel Medical Association very strong none Positions and Influences at a glance - 8 -

Adoption and implementation If this legislation is approved, the Sick Funds will need to change their SI programs and reduce the premiums. They will need to notify members of this change, and give them the option to opt out of the program. The SFs will also have to terminate agreements they have with insurance companies who were co-insurers for this item. The SFs with the MOH will need to address the problem of SF members who are already receiving life saving/extending medications through the SI program, and whose entitlement will be terminated once the change in the SI programs goes into effect. Review mechanisms n/a 6. Expected outcome Costs - SI premiums and expenses will be reduced; Commercial insurance and out of pocket payments will grow; therefore it is uncertain what will be the total effect. The purchasing power of Israel in the global medication market will decrease because SFs had power to negotiate low prices with pharmaceutical companies and to import new medications to Israel. This may have cross effects on other medications as well and consequently the national health expenditure may increase. Quality - The impact on quality depends on the medical neccessity of the medications. Overall there will be less access to new life saving and life extending medications since those of low and medium income (who can afford SI but not commercial insurance) will not have access to these medications. Furthermore, those with chronic or severe illness will not be eligible for commercial insurance coverage and may be adversely affected. Satisfaction - Public satisfaction is expected to decrease since many have purchased the additional layer of SI because it included these medications. Equity - More equity in access to SF services among SF members - none will have access to these medications through their SF. However, less equity overall since only the high socio-economic groups can afford commercial insurance or out of pocket purchase of these medications. Supplemental insurance ownership is quite comprehensive (80% of residents have SI), but only some have purchased the new layer which includes the additional medications. About 10% of Clalit members (this program is new in the market), about a third of Meuchedet members, and about 80% of Maccabi members (given the automatic inclusion of SI members). Furthermore, commercial insurance premiums for the ill and elderly are very expensive and some are rejected. Thus, many who need this insurance do not have access to it. It is important to note that SI is regulated and SFs must accept all applicants; premiums are based on community rating by age alone. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Quality - depends on the neccessity of the medications for the patients. Equity - increases among insurees in the same SF who do or do not have SI. However, if the mandatory NHI basket is not adequately updated, overall access to necessary medications is expected to decrease. Before, all members who purchased the policy had access to the new medications and now only those with a high socio-economic status who can afford them privately will have access. - 9 -

Efficiency - If patients have access to all life saving/extending medications there is a concern of unnecessary overuse. Also, patients may use medications with low QUALY values which is also not efficient. On the other hand, some of these medications may be efficient if they prevent need for other more costly services (such as hospitalization), or if they significantly improve quality of life and enable the patient to function normally. 7. References Sources of Information Gross, R. and S. Brammli-Greenberg. "Evaluating the Effect of Regulatory Prohibitions against Risk Selection by Health Status on Supplemental Insurance Ownership in Israel." Social Science & Medicine 58(9) 2004. 1609-1622. Brammli-Greenberg, S. and R. Gross. "The private insurance health care market: development since implementation of the National Health Insurance law". In Bennun, G. (ed.). Ten Years of National Health Insurance in Israel. The Israel National Institute for health policy and health services research. 2006. (Hebrew). Brammli-Greenberg, S and R. Gross. The Private Insurance Market in Israel, 2001. Research report RR-403-03, JDC-Brookdale Institute, Jerusalem. 2003. (Hebrew with English abstract). Brammli-Greenberg, S and R. Gross. Supplemental and Commercial Health Insurance, 1998: Changes in Policy, Financing, and Consumer Behavior. Research Report: RR-349-99, JDC-Brookdale Institute, Jerusalem. 1999. (Hebrew with English abstract). Gross, R and S. Brammli. "Alternatives for the Organization of the Supplemental and Commercial Health Insurance Market in Israel following the Enactment of the National Health Insurance Law". Social Security Journal of Welfare and Social Security Studies 50 1997. 40-58. (in Hebrew) Gross, R. and S. Brammli. Supplemental and Commercial Health Insurance in Israel - 1996. Research Report: RR-272-96, JDC-Brookdale Institute, Jerusalem. 1996. (Hebrew with English abstract) Ministry of Finance. Economic considerations in managing supplemental insurance programs. Presentation at the ADIF conference on health insurance, September 4, 2007. Parliament committee of labor, welfare and health. Protocol 188. March 13, 2007. Parliament committee of labor, welfare and health. Protocol 258. July 10, 2007. State of Israel. Budget Reconciliation Bill. Draft, August 2007. Personal communications and media publications. August -September, 2007 Shani, S, Siebzehner, MI, Luxenburg, O, and J. Shemer. "Setting priorities for the adoption of health technologies on a national level - the Israeli experience." Health Policy 54 2000. 169-185. Shemer J, Abadi-Korek I and A. Seifan. "Medical technology management: bridging the gap between theory and practice." Israel Medical Association Journal 7(4) 2005. 211-5. Chairperson Prof. Leon Epstein Inequality in the health system. National institute for Health Policy and Health Services Research, Fourth Dead Sea Conference. July 2003. Chairperson: Prof. Jacob Glazer. The HMOs' Corporate Governance Boundaries and Baskets of Services. National institute for Health Policy and Health Services Research, Eighth Dead Sea Conference. May 2007. - 10 -

Author/s and/or contributors to this survey Gross, Revital and Shuli Brammli-Greenberg Suggested citation for this online article Gross, Revital and Shuli Brammli-Greenberg. "Restricting supplemental insurance services". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/is/a10/5-11 -