Social Health Insurance countries in western Europe an Observatory study

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1 Social Health Insurance countries in western Europe an Observatory study Reinhard Busse, Prof. Dr. med. MPH Professor of Health Care Management, Technische Universität Berlin Associate Research Director, European Observatory on Health Care Systems

2 Social Health Insurance or Bismarckian SHI definition Commonalities and variations between countries Analysis regarding impact on health status, efficiency, equity, satisfaction... Future dynamics and challenges countries in western Europe

3 What makes a health system a SHI system? Contribution Not (health) risk-, but usually wage-related contribution Choice of fund Limited government control Third-party payer = sickness funds bipartite self-government Contracts Population Mandatory Free access Providers Public-private mix

4 Other SHI system characteristics Solidarity: set of four cross-subsidies on the funding side (healthy to sick, well-off to less-well-off, young to old, and individuals to families) that provide equal benefits on the entitlements side. Pluralism: a complex mix of different public, quasipublic, not-for-profit, and sometimes for-profit actors. Participation: shared governance among these actors, sometimes described as self-regulation. Choice: insurees ability to select among contracted and, in some countries, among different sickness funds.

5 government But SHI are more complicated... SHI revenue supra-national institutions SHI risk pooler SHI payer = sickness funds Tax Private Other social courts Insurees and employers Patients Public Health parliament Acute care Longterm care and currently studied by the European Observatory

6 government supra-national institutions Chapter 1 SHI revenue SHI risk pooler SHI payer = sickness funds Tax Private Other social courts Insurees and employers Patients Public Health Acute care Longterm care parliament

7 supra-national institutions Chapter 2 SHI revenue SHI risk pooler SHI payer = sickness funds government role of fund member Other social Tax Private courts role of citizen Insurees and employers Patients choice & patients rights Public Health Acute care Longterm care parliament

8 government supra-national institutions Chapter 3 SHI revenue SHI risk pooler SHI payer = sickness funds Tax Private Other social courts Insurees and employers Patients Public Health Acute care Longterm care parliament

9 government supra-national institutions Chapter 4 SHI revenue SHI risk pooler SHI payer = sickness funds Tax Private Insurees and employers Patients Other social benefits/ covered services Public Health Acute care Longterm care courts parliament

10 Risk structure compensation SHI revenue supra-national institutions SHI risk pooler SHI payer = sickness funds Chapter 5 government Competition for members Other social Tax Private Selective contracting courts Insurees and employers Patients Public Health Acute care Longterm care parliament

11 government supra-national institutions Chapter 6 SHI revenue SHI risk pooler SHI payer = sickness funds Tax Private Other social courts Insurees and employers Patients Public Health Acute care Longterm care parliament

12 government supra-national institutions Chapter 7 SHI revenue SHI risk pooler SHI payer = sickness funds Tax Private Other social courts Insurees and employers Patients Public Health Acute care Longterm care parliament

13 government supra-national institutions Chapter 8 SHI revenue SHI risk pooler SHI payer = sickness funds Tax Private Other social courts Insurees and employers Patients Public Health Acute care Longterm care parliament

14 SHI: expensive and resource-intensive Belgium Austria Health employment (% of total) Health employment (% of total) 0,8 Physicians 0,8 0,2 France Health employment (% of total) 0,8 Germany Luxembourg Health employment (% of total) 0,8 Health employment (% of total) Physicians 0,8 0,2 Health employment (% of total) Physicians Switzerland 0,8 0,2 Employment Netherlands Expenditure Health employment (% of total) 0,8 Inputs Processes

15 at least in comparison to other Denmark Health employment (% of total) 0,8 Health employment (% of total) Physicians Finland EU countries 0,8 0,2 Health employment (% of total) Physicians Greece 0,8 0,2 Italy Ireland Health employment (% of total) Health employment (% of total) 0,8 Physicians 0,8 0,2 Portugal Health employment (% of total) 0,8 Spain Sweden U.K. Health employment (% of total) 0,8 Health employment (% of total) 0,8 Health employment (% of total) 0,8

16 SHI more responsive and citizens more satisfied Level of public's satisfaction, Eurobarometer P E GR IR L UK F B FIN I A NL 5,5 6 6,5 7 7,5 8 DK Level of responsiveness, WHO report 2000 S D L

17 Efficiency: SHI = better outcomes for more money Level (25%) Health Responsiveness Fair Goal Health Efficiency financing attainment expend./ ( Performance ) (25%) capita Distrib. (25%) Level (12,5%) Distrib. (12,5%) Level health A B DK D FIN F GR GB IRL I L NL P E S overall Mittelwert SHI GKV Mittelwert other andere

18 0,15 Equity in financing (Wagstaff et al.) 0,13 0, I UK 3 1 S F FIN DK E D NL P -9-0,11 CH -0,13-0,

Stewardship and accountability Stewardship role for government complicated as major health care responsibilities are in the hands of sickness funds

19 Stewardship and accountability Stewardship role for government complicated as major health care responsibilities are in the hands of sickness funds Sickness funds should be (and usually are) accountable, but only to their insured and regarding the benefits covered (i.e. no broad public health perspective)

Movement of patients

Movement of patients Reinhard Busse, Prof. Dr. med. MPH Professor of Health Care Management, Technische Universität Berlin Associate Research Director, European Observatory on Health Care Systems Three