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Key trends and challenges in European statutory health insurance Dr. Ewout van Ginneken Department of Health Care Management Berlin University of Technology WHO Collaborating Centre for Health Systems, Research and Management Gastein forum, October 2, 2014
Introduction The context of statutory health insurance systems Trends in insurance markets Trends in purchasing Challenges 3
4 Statutory insurance systems have more shapes than you may realize Collecting and pooling resources purchaser Sickness fund(s) Insurers (private) Health care purchasing Examples: Austria, Belgium, Czech Republic Germany, France Single fund: many new Member States: Baltic States, Croatia, Hungary, Poland Examples: Netherlands, Switzerland, Slovakia, Massachusetts US exchanges Population Health care provision But increasing convergence with the classic NHS models: e.g. more tax funding, While purchaser-provider split and more choice common in NHS systems too Providers 4
Total health expenditure, PPP$ per capita, 1995-2012 Netherlands Austria Germany Belgium France Croatia Lithuania 5
Hospitals consume the largest share of THE (2010) in EU countries except for Germany (ambulatory care), Slovakia and Hungary (retail sale and medical goods!) Hospitals Nursing & residential care facilities Ambulatory health-care Retail sale & medical goods Admin. of public health programmes General health admin. & insurance Other (rest of economy) Rest of the world Bulgaria 41.0 0.8 16.7 36.9 1.8 1.1 1.7 0.0 Denmark 45.2 13.4 28.2 11.5 0.1 1.5 0.1 0.1 Germany 29.5 7.8 30.8 21.8 0.7 5.9 3.0 0.5 Estonia 45.6 2.7 20.2 26.9 2.1 2.4 0.0 0.1 Spain 41.0 5.5 26.3 21.7 1.3 3.2 1.0 0.0 France 35.3 7.1 27.4 21.7 0.7 7.0 0.8 0.0 Latvia 42.6 2.5 26.9 24.3 0.0 2.9 0.8 0.0 Lithuania 36.4 1.6 22.5 29.6 0.1 2.7 7.0 0.1 Hungary 32.3 3.3 20.3 37.7 2.7 1.2 2.3 0.3 Poland 34.3 1.3 30.6 26.1 1.6 1.4 4.6 0.1 Sweden 46.0 0.0 21.7 16.0 1.3 1.7 9.2 0.2 6
Huge variations in acute beds points to bloated hospital sectors Lithuania Germany Latvia +50%!! Poland EU13 EU France Estonia EU15 Denmark UK 7
and the number of acute discharges (cases) too Germany Lithuania +40%!! France Estonia Poland EU13 EU EU15 Latvia Denmark UK Could more cases be treated in day care? 8
In many countries yes.. Here an example for cataract surgery Switzerland (2002, 2008) Iceland (1998, 2008) Norway (2000, 2009) 52.7 79.6 79.0 87.3 93.6 96.8 Share of cataract surgeries carried out as day cases 2000 and 2010 Lithuania (2005, 2009 Slovak Republic Poland (2003) Austria Hungary¹ (2004, 2009) Luxembourg¹ (2000, 2010) EU-15 France¹ Italy (2000, 2009) Ireland Czech Republic¹ Portugal (2000, 2009) Belgium (2000, 2008) Spain (2004, 2010) Sweden United Kingdom Denmark Netherlands Finland Estonia 1.0 7.9 n.a. 3.8 1.2 0.1 n.a. 9.3 n.a. n.a. 16.8 17.4 32.8 38.6 28.4 31.6 37.6 32.0 48.9 53.2 71.2 85.3 80.1 85.4 89.1 90.4 85.9 83.1 82.8 82.0 91.9 93.4 95.9 92.8 97.4 98.1 98.2 98.7 99.0 99.6 2000 2010 % OECD (2012) 0 20 40 60 80 100 9
Many member states struggle with pharmaceutical cost Hungary (1997, 2011) Serbia (1998, 2010) Malta Greece Slovakia Lithuania (1998, 2010) Poland Latvia (1998, 2009) Estonia Czech Republic Slovenia Portugal Ireland Spain Italy France Belgium (1997, 2011) Iceland Germany Finland Sweden Austria United Kingdom (1997, 2008) Switzerland Netherlands Luxembourg (1998, 2008) Norway Denmark Romania (1998) 1998 2011 0 5 10 15 20 25 30 35 40 10
Trends and patterns in insurance markets Consolidation among insurance funds Return to single payer systems (e.g. Baltic States) Dramatic consolidation in others (e.g. Netherlands, Germany) Market shares Dutch health insurers 2007 2009 Achmea/Agis UVIT Moving from competition to oligopoly? CZ/OZ/Delta Loyd Menzis Multizorg De Friesland Zorg en Zekerheid Salland 11
Collection and pooling increasingly takes place at central or national level. Even countries with multiple pools, use mechanisms to allocate resources equitably. Nearly every country applies some kind of capitation approach to allocate resources from pooling organizations to purchasers and payers Especially in competitive environments, these formulas are becoming increasingly complex and important There is greater use of general government revenues to supplement earmarked contributions, e.g. Austria, Belgium, Estonia, Hungary, Lithuania, the Netherlands, Slovakia, and rising in Germany 12
Some countries use insurance competition Seen as a way to enhance efficiency in health care administration and delivery and ultimately performance Several countries rely on competition between risk-bearing funds (Belgium, Germany, Netherlands, Slovakia, Switzerland, Czech Republic) Introduced by several countries for various reasons, e.g. Netherlands (2006): less government regulation of health care supply, efficiency, cost control, more patient driven health care So expectations are Switzerland (1996): enhance high, but equity can of it access, strengthen solidarity, organizational innovation actually and expenditure deliver? control Germany (1996): Equity, efficiency, cost control Belgium (1995): Choice, cost control 13
Trends and patterns in purchasing Purchasing plays a key role in controlling cost and increase efficiency in the health system Potential to save is enormous but do insurance funds have the tools and incentives to do so? Proportion of commonly used treatments supported by good evidence Beneficial, 13% Unknown effectiveness, 48% Likely to be beneficial, 22% Trade off between benefits and harms, 8% Likely to be Unlikely to be ineffective or beneficial, 6% harmful, 2% Source: BMJ 2007 14
Purchasing for health services, ideally achieves. Optimal allocation of funds to reach set objectives (health, quality, costeffectiveness, responsiveness, cost control) What services? (scope, benefit package) What conditions? (contractual arrangements, payment mechanisms) From whom? (providers) Passive resource allocation using norms little/no selectivity of providers little/no quality monitoring Strategic performance-based payments selective contracting quality improvement and rewards Are we moving from passive payers to strategic/active purchasers? Is strategic purchasing the answer? What tools are missing? 15
The situation in the European countries In ambulatory care, most countries pay GP services on basis of capitation and specialist services through capped FFS, while quality-related bonus payments are gaining increasing importance. In hospital care, almost How all countries to pay for now quality, use a not variant volume, of DRGs to determine at least part of hospital when payment. meaningful performance indicators are still lacking? However: global budgets continue to play an important role, and different alternatives exist for mixing DRG-based payments with global budgets. As improved quality information is becoming available it is expected that countries will increasingly use this information for determining payment Increased interest in integration of care coupled with bundled payments 16
Key challenges for insurance funds: increased expectations but lacking tools? 1. Paying for quality, how? Developing meaningful indicators that measure performance Increase collaboration/ exchange on all levels? Need for better data systems? 2. Planning/purchasing tools, are they sufficient? Tools to reduce/transform beds, skills mix or close hospitals? How can insurers stimulate primary/outpatient care? How to steer patients to preferred providers or care with added value while maintaining choice for patients? Negotiate pharmaceutical prices? Obviously a strong political component 17
3. How to make it attractive to invest in prevention Especially if you may not receive the benefits (especially in systems with patient mobility) 4. Stimulating Integrated and coordinated care What kind of payment methods are needed (bundled)? What is the role of the insurance fund? 5. Dealing with European regulation and influence which may conflict with own set objectives 18