Summer School. Types of national health systems: the Beveridge model, the Bismarck model and the private health insurance system

Transcription

1 Summer School Types of national health systems: the Beveridge model, the Bismarck model and the private health insurance system Dorte Sindbjerg Martinsen

2 Outline The three healthcare models Healthcare models in the European Union My own use of healthcare models in research Does EU patient mobility challenge some models more than others? Group work: Mapping countries into healthcare models or clusters

3 Beyond the world of welfare typology I Source: C Bambra (2005 Going beyond The three worlds of welfare capitalism: regime theory and public health research ) Author Measures Welfare State regimes Gøsta Esping- Andersen (1990) 18 countries Decommodi fication Social stratification Private- Public mix Liberal Australia Canada Ireland NZ UK USA Conservative Finland France Germany Japan Italy Switzerland Social democratic Austria Belgium Netherlands Denmark Norway Sweden Ferrera (1996) 15 countries Coverage Replacemen t rates Poverty rates Anglo-Saxon Ireland UK Bismarck Austria Belgium France Germany Luxembourg Netherlands Switzerland Scandinavian Denmark Finland Norway Sweden Southern Greece Italy Portugal Spain Navarro and Shi (2001) 18 countries Political traditions Liberal Anglo Saxon Canada Ireland UK USA Christian democrat Belgium Netherlands Germany France Italy Switzerland Social democratic Sweden Norway Denmark Finland Austria Ex-fascist Spain Greece Portugal

4 Beyond the world of welfare typology II Source: C Bambra (2005 Going beyond The three worlds of welfare capitalism: regime theory and public health research ) Author Measures Welfare State regimes Kautto (2002) 15 countries Expenditu re on services and social transfers Transfer approach Belgium Netherland s Austria Italy Service approach Sweden Norway Finland Germany UK Low approach Ireland Greece Portugal Spain Bambra (2005) 18 countries Healthca re services and decomm odificati on Liberal Australia Japan USA Conservative Austria Belgium France Canada Denmark Italy Social democratic Finland Norway Sweden Conservative subgroup Germany Switzerla nd Netherlan ds Liberal subgroup Ireland UK NZ

5 Structure of health systems Financing Delivery Examples Beveridge/Na tional health service Bismarck/Soc ial insurance system The private insurance system Mostly public. Tax financed Public and private. Compulsory insurance contributions Mostly private Mostly public U.K. Public and private Mostly private Germany U.S.

6 The Beveridge model/national Health Service Healthcare for all residents, provided and financed by government from taxes Most facilities owned by government. Most healthcare workers employed by government No medical bills, public service Supplemental private insurance for example dental care High-income may add private health insurance Best model for cost containment? Negative correlation between total health expenditures and share of public funding (Wendt and Kohl 2009)

7 The Bismarckian model/social insurance model Social Health Insurance made up by private, occupation-based sickness funds Financing: compulsory insurance contributions and eventually some additional payments for certain treatments Entitlement on basis of earmarked contributions Insurance Financed by Employers and Employees Non-Profit Sickness Insurance Funds Price controls on medical services and fees Hospitals can be both public and private High-income may opt-out of SHI and purchase private health insurance

8 Private health insurance For-profit firms: individual or group contracts, working with private hospitals - approved health centers. Meet individual needs by: * Providing quicker access * Giving choice of specialist * Comfortable hospital facilities * Access to additional health services

9 Healthcare system in the European Union Bismarck/Social Insurance System Beveridge/National Health Service Luxembourg Germany United Kingdom, Belgium Austria Ireland France Netherlands Denmark Bulgaria Czech Republic Sweden Romania Slovakia Finland Croatia Hungary Spain Estonia Poland Portugal Lithuania Slovenia Italy Greece Latvia Cyprus Malta

10 Social and healthcare expenditures as % of GDP in EU member states % GDP spend on social protection 2015 % GDP spent on health care 2015

11 Healthcare expenditures as % of GDP in EU member states % GDP spent on health care 2015

12 The health care services decommodification index (Bambra 2005) 3 measures: (1) Private health expenditure as a percentage of GDP (2) Private hospital beds as a percentage of total bed stock (3) The percentage of the population covered by the health care system

13 27/09/ My own use of healthcare models in research How does the EU internal market impact on different healthcare models? * Exemplified by the patient rights directive * Does EU patient mobility challenge some healthcare models more than others?

14 27/09/ The EU patients rights directive Adopted in March 2011 Aims of the directive To facilitate access to safe and highquality cross-border healthcare in the Union To ensure patient mobility in accordance with the principles established by the Court of Justice Ensure clarity for the citizens about their rights and entitlements Help the patient to make an informed choice by knowing the rules in advance and have appropriate information

15 Tough political negotiations resulted in considerable derogations from the free movement objective 1) The patient can only access the treatments one is already entitled to back home = no top up effects. 2) One will only be reimbursed up to what a similar treatment is tariffed to back home = no immediate economic incentives. 3) The patient will have to pay up front = economic disincentive. No prior notification/voucher system 4) The system of prior authorization is maintained for hospital care and highly specialized and cost-intensive care = maintained national control for the most important public treatments. 5) Treatment of foreign patients can be refused for capacity, planning and financial reasons = modified principle of non-discrimination.

16 Content of the directive Article of the directive Article 4 Content MS of treatment is obliged to; Ensure healthcare providers provide info on treatment options, availability, quality and safety, provide clear invoices, clear information on prices Article 5 Article 7 Article 8 Principle of non-discrimination but possible to limit inflow of patients if necessary and proportionate MS of affiliation obliged to inform patients of cross border rights and entitlements, appeal procedures MS obliged to have transparent, objective and non-discriminatory mechanisms for the calculation of costs Prior authorisation justified for hospital care as well as highly specialized and cost intensive care PA has to be issued where treatment cannot be granted within a medically justifiable time limit MS of affiliation shall make publicly available which healthcare is subject to PA

17 Denmark The Netherlands Poland Spain Does information exist on healthcare standards, treatment options, quality and safety Yes, information exists. Publicly available at: et.dk (quality). (waiting times) og er.dk (patient satisfaction). Yes, still somewhat limited; see kiesbeter.nl; reports Health Care Inspectorate; Consumer Quality Index (available on internet and in libraries) Limited Varies significantly across regions. More developed regions (Catalunya, Balaeric Islands) have them, but very sporadic and not very useful in other regions. No attempt to standardize due to the Directive.

18 Denmark The Netherlands Poland Spain Does informatio n exist on prices? Are there transparen t mechanism s for the calculation of costs DRG prices administratively determined based on estimated average costs. Yes; DRC-based pricing system on websites hospitals ( walk-in tariffs for non-contracted care); not really transparent (prices include first consultation to final check, as well as overhead such as education, research etc.) Different prices in different regions. Not transparent mechanisms for the calculation of prices Prices vary across regions. And they exist at different levels (hospitals/regions etc). And hard to get access to prices. This means that reimbursement levels will vary depending on which region citizens reside in.

19 Denmark The Netherlands Poland Spain Change in procedur es for outflow. Prior authoriz ation for which treatments? Hospital care + specialized care Based on characterization of level of specialization by the NBoH. With discretion to add additional treatments temporarily Prior authorization not in basic health insurance law (ZVW): option of reimbursement (but yet in many health insurance policies) / Prior authorization in law on costs for longterm care (AWBZ) Hospital and specialized care. Considerable discretion for authorities. Plans of developing a positive list Hospitals and specialized care. and relatively extensive list of treatments requiring PA

20 Change in procedures for inflow Denmark NL Poland Spain Public sector No; except The Polish Yes. Individual regions will now to open up for NCP government is receive the payment. previously for planned criticized for not money would go to Madrid, and they treatment of dealing would reimburse. There has been a foreign sufficiently with lack of admin capacity to collect this treatments this issue funding from abroad. Now money will be collected at the hospital/regional level. Probably with requirement to put up security up front. There is a concern that the very long waiting lists in Spain will be further worsened by inflow of foreigners

21 21 Mapping healthcare systems Countries Expenditu res (% of GPD) Financing Out of pocket payment Coverage & Entitleme nt to healthcare Regulatio n of access to healthcare Which model or cluster Main challenge s to the healthcare model Working group 1: Spain Working group 2: Sweden Working group 3: UK Working group 4: Poland Working group 5: USA Working group 6: Germany

22 22 Mapping healthcare systems Consult * The article by Wendt (2009) * WHO/Europe country hit reports; * World bank data on health spending; HEX.GD.ZS