TB CARE II Case studies on coverage of TB care costs in insurance-based systems

Transcription

1 TB CARE II Case studies on coverage of TB care costs in insurance-based systems 29 April 2013

2 Examine the extent to which TB services have been integrated within state-supported insurance schemes. Examine the roles of TB stakeholders within the design and implementation of health insurance programs Develop a framework for analyzing TB service integration in insurance-based systems Outline recommendations for delivery of TB services within health insurance models.

3 Why examine TB services in insurance-based systems? Almost all LMIC in Asia and Africa have adopted formal UHC policies and that health insurance programs form a critical part of the social protection measures developed to attain UHC objectives Impact of state-supported health insurance programs on use of TB services and outcomes is unclear. Different insurance programs currently in place or in development in high burden TB countries include a varying degree of integration of TB services State-supported health insurance programs may have a positive impact on TB service use, but difficult to quantify. Insurance programs may have additional health systems requirements or may not support all TB control objectives (i.e., for active case finding)

4 Questions related to TB service delivery in insurance based systems: Integration of TB control needs in design of NHI program Coordination and collaboration between relevant agencies NTP oversight capacity in insurance-based delivery system Data sharing and use between insurance program and MOH/NTP Affect of insurance programs on intensified case finding, social support and community based care

5 Framework for Evaluating TB Services within UHC Universal Health Coverage Coverage: Coverage includes high risk TB populations TB services included in coverage package (including MDR TB, EPTB) Service package promotes community level services Access and Use: Distribution of services sites targeted to reach high risk TB populations Supports active case finding Transport and social support addressed Linked awareness and messaging with TB awareness efforts Quality of Services: In-service providers comply with TB service delivery standards Sufficient infrastructure/supplies for TB diagnosis and drugs Providers have capacity to provide TB diagnosis and treatment Linked to communitybased care Improved TB Outcomes

6 CASE STUDIES

7 Case Study Methodology The project team identified Thailand, India, Peru and the Philippines as target countries for the case studies, which were selected based on the TB burden and the existence of national insurance schemes Country level study protocols were developed around the information gaps identified in the desk review Interviews guides were developed to target four levels: Policy/ program level: MOH/ NTP manager NHI program: Insurance Managers Implementation level: District/Regional or Facility manager Community level: Community TB partners (NGO/DOTS supporters, or other)

8 Focus of case studies Thailand: Universal Health Coverage (UC) 80% population; Managed by NHSO; Possession of Thai ID number, not otherwise covered (Civil Servants Benefits Scheme or Social Security Scheme) Philippines: PhilHealth 75 million members; mix of semi- and fully subsidized India: Max Bupa, Star Health, RSBY, and ESI Targeting different population segments, BPL, formal sector workers etc Peru: EsSalud and MINSA MINSA- semi- and fully-subsidized; EsSauld- employer contribution

9 Thailand- main findings Coverage: comprehensive benefit package for TB services; strong coordination between NTP and NHSO and use of TB Fund Limited treatment sites for DR TB; No coverage for nonregistered migrants Access and Use: high enrollment; high utilization by poor/ vulnerable; seems to reduce direct costs as a barrier to accessing TB services Patients restricted to pre-registered service site; some issues with service delays/ wait times Quality of services: Challenge of maintaining QA and oversight capacity of NTP at implementation level

10 India, main findings Coverage: limited TB services are covered under ESI insurance for workers Routine TB services excluded from benefits package in most cases Access and Use: Available to formal sectors and BPL Benefits not available to TB patients; high OOP costs Quality: Responsibility of RNTCP Little or no formal follow up or referrals between insurance providers and RNTCP Linkage with private providers: Some collaboration between RNTCP and the private health sector Emphasis on service delivery within RNTCP

11 Philippines, main findings Coverage: includes TB DOTS outpatient benefit package through accredited providers Limited coverage for MDR TB, social support Access and Use: Widely available; provides benefits to target different vulnerable population groups; patients can use any accredited DOTS center Availability and use of accredited facilities inconsistent; Subsidies for TB patients for transport/ social support; may lower motivation;

12 Philippines, continued Quality: Accreditation requires meeting service standards Length of time required for certification/ accreditation and renewals, as well as length of time for reimbursement may affect motivation of providers Linkage with private providers: Mechanism for integrating private DOTS providers via accreditation Challenges remain with referrals and links to other private providers

13 Peru, main findings Coverage: Both models (MINSA and EsSalud) provide nominal comprehensive coverage for all forms of TB Weak coordination or coverage for community level services Access and Use: Available to all (MINSA), enrollment continues to increase Large percent of eligible population (poor & vulnerable) not fully registered for subsidized services; passive enrollment Quality: Collaboration between EsSalud and MINSA to fill gaps Some reports that stock outs of commodities effect service quality Linkage with private providers: EsSalud coordinates with private insurance providers on limited basis Stronger linkages are needed other private sector actors (i.e., employers and NGOs)

14 MOVING FORWARD

15 Main points from findings Coverage Access and Use Quality Emphasis on basic (facility-based) DOTS Administrative barriers in registration and enrollment (Difficult to measure) Weak or lacking coverage for complicated cases (including pediatric, MDR TB) Lack of awareness of insurance program and benefits for TB patients Capacity of inservice TB providers varies widely Lack of direct patient reimbursement mechanisms Access barriers persist (lack of transport and patient support measures) Administrative barriers relating to reimbursement and accreditation seems to effect quality

16 Avoiding Fragmentation in an Insurance-Based system Coordination challenges identified in all cases NTP Insurance provider Insurance provider Other patient support partners Key coordination challenges and needs: Setting targets, establishing quality standards and sharing data to measure impact Managing referrals and follow up of patients between innetwork providers and other TB services Promoting a continuum of care, incorporating active case finding, treatment support and community-based care Providing information on insurance systems and benefits linked to TB awareness and messages

17 Critical future needs Mechanism for providing direct benefits for TB patients (safety net) Expansion of the TB benefits package (i.e., MDR TB) Streamline quality assurance and enforcement of quality standards for TB service providers Increase involvement of more care providers to provide TB services (explore possible reimbursements for informal or community-based service providers) Develop role of insurance providers in health promotion and prevention programs

18 Thank you!