Preliminary summary the triangle and the building blocks (functions)
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1 Preliminary summary the triangle and the building blocks (functions) Managing and Researching Health Care Systems Reinhard Busse, Prof. Dr. med. MPH FFPH FG Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies 27 November 2017 Summary of building blocks 1
2 WHO building blocks 27 Nov 21 Nov 30 Nov/1 Dec 23 Nov 24 Nov 22 Nov (seminar) 24 Nov 21 to 23 Nov Week 8 27 Nov 28 Nov 29 Nov 30 Nov 28 Nov 30 Nov 23 Nov WHO November 2017 Summary of building blocks 2
3 Outline of the course- Week 1 Topic Date Lecturer Introduction and Outline of the course Uhr Introduction and frameworks Uhr Wilm Quentin and Daniel Opoku Reinhard Busse Financing I: Raising Resources Uhr Wilm Quentin Seminar on health system relevant databases and information for term paper Uhr (H8173/74) Anne Spranger Financing II: Pooling and re-allocation Uhr Reinhard Busse Financing III: Purchasing and payment systems Leadership and Governance + Care Delivery Uhr Medical products Uhr Wilm Quentin Uhr Reinhard Busse Reinhard Busse Introduction to group exercise Uhr Anne Spranger Workforce Uhr Claudia Maier 27 November 2017 Summary of building blocks 3
4 Outline of the course - Week 2 Topic Date Lecturer Preliminary Summary of building blocks Uhr Presentation by GIZ on health system related German development cooperation 27 November 2017 Reinhard Busse Uhr Ursula Bürger, Fachplanerin Kompetenz-Center Gesundheit und Soziale Sicherung, GIZ Access and Coverage Uhr Reinhard Busse Quality and Safety Uhr Reinhard Busse Financial and social risk protection Uhr Wilm Quentin Improved Health Uhr Efficiency and Responsiveness Uhr Summary of Health System Performance Assessment Group Presentations and Wrap-up Uhr Wilm Quentin Reinhard Busse Uhr Reinhard Busse Reinhard Busse or Wilm Quentin Summary of building blocks 4
5 The starting point: 2000 World Health Report This report sets out to analyse the role of health systems and suggest how to make them more efficient and, most importantly, more accessible and responsive. 27 November 2017 Summary of building blocks 5
6 Functions Financing II: Resource pooling & allocation Collector of Third-party Payer resources Financing I: Raising resources/ funding Steward/ Regulator Financing III: Purchasing/ contracting/ paying providers Population Coverage: Who? What? How much? Access to services Provision of services 27 November 2017 Summary of building blocks Providers 6
7 Functions Financing II: Resource pooling & allocation Collector of Third-party Payer resources Financing I: Raising resources/ funding Steward/ Regulator Regulation Financing III: Purchasing/ contracting/ paying providers Population Coverage: Who? What? How much? Access to services Provision of services 27 November 2017 Summary of building blocks Providers 7
8 System typology Financing II: Resource pooling & allocation Collector of Third-party Payer resources Income-dependent contributions Financing I: & sickness funds = Financing III: Purchasing/ Raising resources/ Social Health Insurance system contracting/ funding Steward/ Taxes paying & providers Regulator governments/ health authorities Regulation = tax-funded system (NHS) Population Coverage: Who? What? How much? 27 November 2017 Summary of building blocks Providers Access to services Risk-related premia & private insurers = Voluntary Provision of Health services Insurance system 8
9 To take home: despite the seemingly many options, there are just four main ways of funding health care: Financing I: Raising resources/ funding Social insurance payments = contributions based on income or community-rated premiums (everybody pays the same) Tax payments Voluntary (private) insurance payments = premiums (usually risk-related) Out-of-pocket payments by users 27 November 2017 Summary of building blocks 9
10 World-wide 2012 (large US market!) Third-party Payer Population Taxes 23% Social Health Insurance contributions Voluntary insurance Out-of-pocket 34% 22% 15% 58% public Public money can be handled by private-law institutions; publicly regulated may therefore be a better term. Providers 1170 $PPP = 8.6% of GDP 27 November 2017 Summary of building blocks 10
11 Social health insurance type Collector of resources: sickness funds, government agencies Not (health) risk-, but usually wage-related contribution Population Mandatory insurance (traditionally limited to employees, later extended to other groups) Resource pooling within and/or across funds; risk-based allocation Steward/ Regulator Due to delegation and self-regulation limited government control Choice among contracted providers Third-party Payer = sickness funds Contracts, collective or selective Providers Public-private mix 27 November 2017 Summary of building blocks 11
12 Traditional integrated NHS-type system (ca. 1990) Central government (Ministry of Finance) Central government (Ministry of Health) General taxation Population Universal coverage Direct government control ( commandand-control ) Limited choice NHS = Payer & Provider Public Providers 27 November 2017 Summary of building blocks 12
13 «New» NHS-type system Central government (Ministry of Finance) Regional governments Population Universal coverage 27 November 2017 General taxation Steward/ Regulator MoH: Regulation, supervision and enforcement Increased choice Purchaser - provider split Public (autonomous) and private Providers Summary of building blocks 13
14 Typical private (indemnity) health insurance Limited resource pooling (for companies, insured within one tariff etc.) Private health insurer Population (Health) riskrelated premium Reimbursement of costs (Voluntarily) insured part of population Steward/ Regulator Very little government control Free choice (no contracts) Providers Public-private mix 27 November 2017 Summary of building blocks 14
15 PHI Health Maintenance Organization (HMO) Limited resource pooling (for companies, insured within one tariff etc.) Private health insurer Population (Health) riskrelated premium Reimbursement of costs (Voluntarily) insured part of population Steward/ Regulator More regulation, supervision, enforcement Access to HMO only Managed care HMO HMO Providers 27 November 2017 Summary of building blocks 15
16 Fragmented system Government +CBHI Sickness funds Private insurance Population Providers: often separate for different segments 27 November 2017 Summary of building blocks 16
17 Different sets of (intertwined) reforms Third-party payers Commandand-control/ laissez-faire Regulation 1 split from providers & regulator Relationship: integrated contracts none integrated contracts contracts more sophisticated (volume, price, quality) Providers Institutions: (i) public autonomous, (ii) diversification (incl. private sector) Settings: simple community; specialized centralization Workforce: composition & skill-mix 27 November 2017 Summary of building blocks 17
18 Third-party payers 1 split from providers & regulator 27 November 2017 Summary of building blocks 18
19 2 Commandand-control/ laissez-faire Regulation Often an initially unplanned side product of provider and/ or purchaser reforms Requires a new mindset in MoH and new skills Chance to develop system strategically (driven by objectives), and not ad hoc 27 November 2017 Summary of building blocks 19
20 3 4 5 Providers Institutions: (i) public autonomous, (ii) diversification (incl. private sector) Settings: simple community; specialized centralization Workforce: composition & skill-mix 27 November 2017 Summary of building blocks 20
21 WHY? efficiency quality choice for patients 3 Core public sector Budgetary Broader public sector Autonomous Privatized Corporatized Markets/ private sector From A Conceptual Framework for the Organizational Reform of Hospitals (A. Harding/ A. Preker, Worldbank) 27 November 2017 Summary of building blocks 21
22 Care provision reform trends (simplified) 4 Individual Health Center/ Group Hospital GPs Individual Day surgery, simpler cases 27 November 2017 Summary of building blocks 22
23 Shifting demands on health professionals 5 Population growth & ageing, epidemiological transition Retirement, supply of graduates Source: World Health Report November 2017 Summary of building blocks 23
24 Public policy levers to shape health labour markets 5 Source: WHO (2016) Working for health and growth: investing 27 November 2017 Summary of building blocks in the health workforce. Report of the High-Level Commission on 24 Health Employment and Economic Growth.
25 Third-party payers Relationship: integrated contracts 6 none integrated contracts contracts more sophisticated (volume, price, quality) Providers 27 November 2017 Summary of building blocks 25
26 What is purchasing? Collector of resources Population Third-party Payers Steward/ Regulator Strategic purchasing = proactive decisions about which services Providers Who should buy? For whom? What services? How much? From whom? How to buy? should be purchased, how and from whom (WHO 2000) 27 November 2017 Summary of building blocks 26
27 Aims of provider payment: What do we want providers to do? That they care for patients when they need care? and do not risk-select they provide services? and are not idle services are provided only if appropriate? and not unnecessarily expenditure is well controlled? and not sky-rocketing services are efficiently provided? and money not wasted service provision is transparent? and not opaque provided services are of high quality? and do not endanger patient safety 27 November 2017 Summary of building blocks 27
28 Basic forms of payment (for services) Fee-for-service (FFS): every single service is paid separately (each ECG, each physical examination ) Capitation: a provider (most often a general practitioner) receives a sum of money per patient per year (or 3 months) for all services for that patient during that period Per diem: an inpatient provider recives a sum of money per patient per day (independent of diagnosis and threatment) Diagnosis-related group (DRG) payment: a provider (usually an acute care hospital) receives a sum of money for a patient depending on diagnosis for all services (from admission to discharge including surgery, pharmaceuticals ) Global budget (for hospitals/ institutions) and salary (for physicians): a fixed sum of money for all patients treated within a certain period of time 27 November 2017 Summary of building blocks 28
29 Necessary evidence for pharmaceuticals Safety and Efficacy are first steps to provide evidence for a new drug; Effectiveness and Efficiency need to be proven Safety Efficacy Effectiveness Efficiency Measure of adverse effects Measure of effect under ideal conditions Licencing/ market access Measure of effect under real life conditions and vs. other drugs Relationships between costs and benefits Health Technology Assessment (HTA): coverage? reimbursement price? 27 November 2017 Summary of building blocks 29
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