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1 Innovations in sickness funds management: a three country study European Health Management Association Annual Conference, Potsdam 1st July 2005, Barcelona Dr. Jonas Schreyögg, Dpt. Health Care Management, Berlin University of Technology The evolution of competitive Social health insurance markets Introduction of competition between sickness funds in, the Netherlands and during the nineties Free choice of sickness funds in all three countries Financial risk for sickness funds has been increased to 100% in, nearly 100% in and 54% in the Netherlands In all three countries one of the main goals was to increase incentives for sickness funds for costcontainment and therefore increase efficiency The main question: do sickness funds have the necessary means to differentiate from each other in competition or is competition mainly based on passive risk selection? 1
2 Country Belgium Netherlands (within each premium region) Country Austria France Japan Korea Luxembourg Risk Structure Compensation Schemes SHI-Schemes with competing sickness funds Year of Implementation Year of Implementation ne ne ne ne ne Risk-adjusters -Age, sex, social insurance status, employment status, mortality, urbanization, income -Age, sex, social insurance status, employment status, mortality urbanization, income, diagnostic and pharmaceutical cost groups -Age, sex, disability pension status -Age, sex, disability pension status, participation in disease management programmes -Age, sex -Age, sex, region, disability status -Age, sex, social security employment status, region of residence -Age, sex, social security employment status, region of residence, diagnostic and pharmaceutical cost groups -Age, sex SHI-Schemes with non-competing sickness funds Risk-adjusters Switching rates (consumer mobility) as an indicator for competition : 4% (1997) to 5% (2000), slightly higher now : 5.4% (1998) to 4% in () : <1% before 2000 to about 2.5% (2003) -> switching rates do not necessarily indicate active competitive behaviour; could as well be due to passive risk selection and thus poorly designed risk adjustment schemes -> There is no optimal switching rate 2
3 1 Netherlands Market concentration as an indicator for competition Decreasing number of sickness funds in all three countries : 3 largest sickness funds have 20% market share the Netherlands: 3 largest sickness funds have 35% market share but regionally 50%-90% market share for largeste sickness fund : largest sickness fund has 14% per canton maximum market share of 13-44% for one sickness fund -> high market concentration can also be due to risk selection and is not necessarily an indicator for active competitive behaviour -> both high switching rates and market concentration can only be an indicator for real competition if sickness funds have the necessary means to differentiate from each other? Change The framework for sickness funds management Financial parameters Target groups Contributions Revenuespayments fromto RSC and other RAS New customers Market selection processes Benefit costs Existing customers Price Quality Quantity of benefits -70.6% -35.1% -57.7% Administrative costs Parameters of competition Global Image Services Management categories Tariff Management Selective Contracting Managed Care Claims Management 3
4 Tariff management Deductibles Degree of Implementation -claims bonuses Degree of Implementation Additional benefits as part of the compulsory insurance arrangement Additional benefits as part of supplementary private health insurance arrangements Variation of financial conditions For voluntary sickness fund insured (income above 46,800) on a voluntary basis, if the fund chooses to offer the scheme For voluntary sickness fund insured (income above 46,800) on a voluntary basis, if the fund chooses to offer such schemes Compulsory for all sickness fund insured (minimum of 300 SFr, but higher deductibles can be chosen) (40.5% even choose higher deductibles in ) All sickness fund insured can opt for them if fund chooses to offer such schemes (0.12% in ) Tariff management Variation of benefit basket Sickness funds can offer supplementary benefits (e.g. alternative practitioner services) Sickness funds arrange for supplementary private health insurance (but not allowed to offer them on their own) variation of benefit basket Sickness funds can offer supplementary private health insurance; but separate financial administration ne Compulsory for all sickness fund insured (planned for 2006) variation of benefit basket Sickness funds can offer supplementary private health insurance; but separate financial administration (ca. 70% of all open sickness funds offer them) (10.7%) (90% have suppl. private health insurance) 4
5 Managed care Gatekeeping Disease Management Insured are free to choose gatekeeper schemes; no restriction of providers possible; tied to financial incentives, but rising (estimated 10-30% reg. Rate) Insured are free to choose gatekeeper schemes; choice of providers can be restricted; tied to financial incentives (7.6% in ) (the two largest health insurers) (ca. 5% reg. rate) Mandatory Mandatory Mandatory Main problems: Pre-selection of regions and diseases necessary especially for DMP; but necessary data is often not available for sickness funds Gatekeeper systems are not very popular Individual selective contracts regarding provision of services Degree of Implementation Individual contracts regarding prices and other elements of remuneration of ambulatory care of hospital care Provider Networks of ambulatory care of hospital care Provider Networks Selective contracting (few capitation approaches) (more and more capitation approaches), but maximum prices are set Main problems: transaction costs of individual contracts Supply constraints imposed by Governments, but maximum prices and budgets are set 5
6 Conclusion Sickness funds have more and more instruments to differentiate from each other but cannot use them as they Do need more claims data e.g. diagnoses Do need more know how to analyse data and plan programmes successfully (Problem: caps on administrative costs) RSC schemes have to be improved, especially in the case of and to give sickness funds with lower risks an incentive to use the instruments Do not co-operate enough to reduce transaction costs for selective contracting -> improving RSC schemes is only one prerequisite for competition; if we want competition, sickness funds need still more instruments and the necessary means to use them 6
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