IMPLEMENTATION OF THE SYSTEM OF HEALTH ACCOUNTS: THE GREEK EXPERIENCE. Professor Em. L. Liaropoulos (Project coordinator)

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1 MINISTRY OF HEALTH CENTER FOR HEALTH SERVICES MANAGEMENT AND EVALUATION U. OF ATHENS HELLENIC STATISTICAL AUTHORITY IMPLEMENTATION OF THE SYSTEM OF HEALTH ACCOUNTS: THE GREEK EXPERIENCE Professor Em. L. Liaropoulos (Project coordinator) Dr Olga Siskou (Coordinator of the working group) Dr Markus Schneider (Technical Adviser-Director of BASYS) This study was co-funded by Greece and the European Union 1

2 Background of the project (1/2): The Greek Health Sector The Health Sector has been blamed as a major factor of the Economic Crisis in Greece, due to wastefulness and corruption. In 2009, THE stood at 10.6% of GDP, with almost 40% private (OECD Data Base, 2012) The health sector under intense scrutiny by the Troika (IMF, ECB, EU Commission) Major cuts required in Pharma and Hospital expenditure In 2012 the requirements of 9% of GDP for total and 6% for public expenditure have been achieved. 2

3 Background of the project (2/2): The start up point Policy Makers realized the need for accurate health expenditure data to meet EUROSTAT and OECD as well as national policy requirements. In December 2010 a Memorandum of Collaboration was signed by the MoH, the Hellenic Statistical Authority (ELSTAT) and the University of Athens (Center for Health Services Management and Evaluation-CHESME) A proposal for funding ( 120,000) through EU funds was accepted in the Summer of 2011 In September 2011 the project started and it is planned to be finalized in November ELSTAT will take ownership of the SHA methodology in CHESME will provide consulting for one more year 3

4 The Methodology (1/6) The system was built up according the bottom up approach from the point of view of the financing agents We used data from the providers point of view (e.g data derived from ESYnet (a hospital reporting system developed by MoH in 2011) in order to fill some gaps of data (from the financing point of view), to balance with the supply side, and to create keys We drew data from : Ministries of Health, Finance, Defense and Internal Affairs The five major SSF (91% of the population) Local Authorities ELSTAT (data from Household Budget Surveys) Private Insurance Companies Association Non Governmental Organizations We drew Health Expenditure data as officially kept (Administrative Data) by National Codes for Expenditures (KAE codes) initially for the years We focused on 2009 and 2010 (lack of accurate analytical data for previous years) 4

5 The Methodology (2/6) We developed a Data Base in Excel with about 800 records for both years 2009 & 2010 and Pivot Tables Each National ΚΑΕ Code has been classified according to ICHA codes: Financing Scheme-HF (MoH, SSF, Households) Health Provider -HP (General Hospitals, Health Centers, Private Doctors), Health Function HC (in-patient, diagnostic imaging) We classified the available data according to the two-digit analysis of the ICHA codes For National use, we classified Financing Sources, Health Providers and Health Activities in a more analytical way 5

6 The Methodology- Important Points of the Data Base (3/6) Mainly used administrative data secondary data was used only for private payments (HBS & Private Health Insurance Survey) Keeping both National & International Codes Reference to Keys Reporting type of transaction (accrual, cash) Reporting descriptions of the Health Functions Links to other systems like COFOG 6

7 PART OF THE DATA BASE 7

8 The Methodology (4/6) - Major Obstacles KAE codes of the MoH Budget reflect only economic activities (expenses for wages, operational expenses) but not health functions In some cases, KAE codes of the MoH don t reflect explicitly the type of provider. - e.g Health Centers (out patient care units) use the same KAE codes for wages and operational expenses with the public hospital to which they are attached. SSF codes and HBS (COICOP) reflect health activities adequately. However, both set of codes, do not reflect the type of hospital providers : General, Psychiatric and Specialty We had to create about 20 Keys in order to allocate rude categories of health expenses to the appropriate HC & HP codes. Example: From a sample of 20 Health Centers reporting Wage and Operational expenses separately from the associate hospital, we estimated the relevant expenditures for all Health Centers (N=205). Then we expressed these monetary figures as a percentage of the corresponding centers are financed MoH KAE codes, from which public hospitals and health 8

9 The Methodology (5/6) - Major Obstacles Results of the 2010 HBS, aren t yet released. Based on 2009 results and changes in the Price and Volume indices, we got estimates for As the 2010 HBS results come in, we will update the base The majority of available data is reported on a Cash Basis, not in Accrual Basis. Because of increasing outstanding payments due to the financial crises we had to correct the data base, to reflect, as much as possible, real Final Consumption per year. Examples: According to Law 3867/2010 there was the settlement of public hospital debts to suppliers for the period The problem is, that we lack information on the annual allocation of settlement funds. The Ministerial Decisions refer to more than one year. We ignored the haircuts of GG Bonds to suppliers, as the SHA refers to final consumption and not to final payments We have added 300 million as SSF payments to public hospitals in Public hospitals report, on accrual basis, for mil. more than SSF report as payments to public hospitals (mostly in cash basis) 9

10 The Methodology (6/6) The Principles we applied for handling debts settlements Double-entry booking: supply & demand side (outstanding payments and extra payments) Equal distribution of payments among years when data refer to several years Correction of current payments to avoid double counting Plausibility checks of debts/balance sheets insofar available 10

11 SUMMARY AND PRELIMINARY RESULTS OF THE GREEK SHA PROJECT Also to be shown the Excel file 11

12 Health Financing The effect of the crisis: Greece , according to SHA first estimations 25 22,9 20, , ,1 4,7 4,6 9, ,5 6,5 6,2 5 0 HF 1-HF.0 Total Current (in bl euros) HF 1.1 GG (apart from SSF) HF 1.2 SSF HF 2.3 Households 12

13 Payment of providers by financing agent, 2010, billion euros HF 1.1 GG (apart from SSF) HF 1.2 SSF HF 2.3 Households ,5 2,5 3,8 HP.1 Hospitals 0,64 4 1,3 HP.3 Providers of Ambulatory Health Care 0,02 1,4 4,8 HP.4 Retail Sale & other providers of medical goods 13

14 OOP by Provider as % of total OOP Health Expenditures 14

15 HOW GREECE COMPARES: WITH OTHER COUNTRIES IN THE EURO ZONE??? 15

16 HEALTH EXPENDITURE AS % OF GDP IN EURO ZONE COUNTRIES Total : HC.1-HC.9 + HC.R.1 Euro-Zone 10,8% 10,8% Current HC.1-HC.9 Top 11,9% (Netherlands) 12% (Netherlands) Bottom 7,9% (Luxemburg) 8,9% (Finland ) Greece-SHA ,9% 9,1% Current Public C.1-HC.9 Euro-Zone 10,4% 10,4% Top 11,3% (Germany) 11,2% (Germany, France, Netherlands) Bottom 7,9% (Luxemburg) 8,5% (Finland, Slovakia) Greece-SHA ,9% 6,0% Current Private HC.1-HC.9 Euro-Zone 8,1% 8,1% Top 9,5% (Netherlands) 9,6% (Netherlands) Bottom 6% (Slovakia) 5,8%(Slovakia) Greece-SHA ,0% 3,1% Euro-Zone 2,3% 2,3% Top 3,3% (Portugal) 3,3% (Portugal) Bottom 1,2% (Luxemburg) 1,6%(Netherlands) Sources: Greek SHA & OECD Data Base, 2012 For Luxembourg 2010 data is N/A 16

17 DISTRIBUTION OF CURRENT HEALTH EXPENDITURE (HC.1-HC.9) TO MAJOR HEALTH PROVIDERS AS % OF GDP IN EURO-ZONE COUNTRIES AND GREECE IN 2009 & 2010 HP1 Hospitals HP2 Nursing & Residential Care Facilities HP3 Providers of Ambulatory Health Care HP4 Retail Sale and other providers of Medical Goods Rest Eurozone 2009 Greece 2009 Eurozone ,5 0,9 2,9 2,1 1,0 3,9 0,05 2,8 3,0 0,2 3,5 0,9 2,8 2,1 1,1 Greece ,5 2,6 2,7 0,2 0, Sources: Greek SHA & OECD Data Base,

18 DISTRIBUTION OF CURRENT HEALTH EXPENDITURE (HC.1-HC.9) TO MAJOR HEALTH FUNCTIONS AS % OF GDP IN EURO-ZONE COUNTRIES AND GREECE IN 2009 & 2010 HC1 -HC 2 Currative & Rehabilitative Care HC3 Long term nursing care HC4 Ancillary services HC5 Medical goods HC6 Prevention & Public Health Rest Eurozone 2009 Greece 2009 Eurozone 2010 Greece ,6 2,1 0, ,3 5,5 2,0 0,9 5,7 2,8 0,06 0,0 2,0 4,0 6,0 8,0 10,0 12,0 Sources: Greek SHA & OECD Data Base,

19 THE NEXT STEPS: 1) Finalize the Data Base for 2009, 2010 in collaboration with ELSTAT : to include investment (both private and public) to make a final decision concerning issues like accrual vs. cash data, a posteriori settlements of previous years debts etc to update the households health expenditures based to the results of 2010 HBS to be further developed Public health / prevention 2) Extent the Data Base for ) Fill the Joint Questionnaire with the appropriate explanatory notes: Decide how to fill the gap for