LA COPERTURA DEI SERVIZI SANITARI NEI PAESI OCSE Annalisa Belloni
Agenda Com è organizzata la copertura sanitaria? Come misurarla? Quali cambiamenti e quale impatto? Il ruolo dell HTA
Three Dimensions of health coverage Source: Adapted from Busse, Schreyögg and Gericke, 2007
How is Health Coverage Organised? Main source of basic health care coverage Countries Tax-funded health system Health insurance system National health system Local health system Single payer Multiple insurers, with automatic affiliation Multiple insurers, with choice of insurer Australia, Canada, Denmark, Iceland, Ireland, Italy, New Zealand, Norway, Portugal, Spain, United Kingdom Finland, Sweden Korea, Luxembourg, Poland, Slovenia, Turkey, Hungary Austria, Belgium, France, Greece, Japan Chile, Czech Republic, Germany, Israel, Mexico, the Netherlands, Slovak Republic, Switzerland, United States 4
Coverage of Population % of population covered for basic health care needs (left) and by private health insurance (right) Total public coverage Australia Canada Czech Rep. Denmark Finland Greece Hungary Iceland Ireland Israel Italy Japan Korea New Zealand Norway Portugal Slovenia Sweden Switzerland United Kingdom Austria France Germany Netherlands Spain Turkey Belgium Luxembourg Chile Poland Slovak Rep. Estonia Mexico United States Primary private health coverage 53.1 17.0 0.2 11.0 0.9 0 20 40 60 80 100 France Netherlands Israel Belgium Slovenia Canada United States Luxembourg Australia Korea Ireland Austria Germany New Zealand Switzerland Denmark Portugal Chile Finland Spain Greece Mexico Turkey Iceland 96.1 89.0 80.0 79.6 73 68.0 60.6 54.0 52.5 51.1 47.5 34.2 Primary 31.9 30.8 Complementary 29.5 Supplementary 20.8 19.8 Duplicate 17.0 14.2 13.4 12.0 6.9 4.6 0.2 0 20 40 60 80 100 5
What do patients pay for? Shares of OOP spending by services and goods, 2011 Note: This indicator relates to current health spending excluding long-term care (health) expenditure. 1. Including rehabilitative and ancillary services. 2. Including eye care products, hearing aids, wheelchairs, etc. Source: OECD Health Statistics 2013, www.oecd.org/health/healthdata
There might be a gap between Entitlement and Actual Health Coverage Entitlement to «core» health benefits (prevention, health care services, medical goods, etc) + Cost-sharing requirements (incl. exemptions, caps) Availability of health care supply Affordability of health care services and goods Actual level of coverage for health spending (macro-economic) Equal and timely access, financial protection, quality of health care Social barriers to health care utilisation
Equity in health care utilisation Need adjusted probability of a doctor visit in last 12 months Need-adjusted probability of a doctor visit in last 12 months by income quintile by income (age quintile 16-85) (age 16-85) Low income Average High income France Germany Belgium Canada Czech Republic* Hungary Spain Slovak Republic New Zealand United Kingdom* Switzerland Slovenia* Poland Estonia Finland United States Sources: households survey with revenue, health care utilisation and health status Not collected / computed systematically in OECD countries 0.40 0.50 0.60 0.70 0.80 0.90 1.00 (*) not significant inequity in Czech Republic, Slovenia, and the UK. Source: OECD Health Working Paper No 58.
Waiting Time 80% % of patients who waited for elective surgery 70% 60% 50% 40% 30% 20% 10% 0% Less than 1 month 4 months or more Source: 2010 Commonwealth Fund International Health Policy Survey in 11 Countries
CHANGES IN POLICIES AND IMPACT ON HEALTH EXPENDITURE
Changes in Coverage in the EU Source: WHO, EU Observatory. Health systems and economic crisis in Europe
Additional Changes Changes to public financing Cutting the prices paid for publicly financed health care Reducing the supply of services, through cuts in the number of facilities, beds or personnel Structural reforms aimed at changing the incentives in the system or price negotiations. 12
Strong health spending growth to 2009 Annual growth 7% 6% 5% Close to 5% average annual growth 4% 3% 2% 1% 0% -1% 0.5% 0.1% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Health Expenditure Source: OECD Health Statistics 2013
Driven by cuts in public spending Annual growth 7% 6% 5% 4% 3% 2% 1% 0% -1% -0.4% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Health Expenditure Public health expenditure Source: OECD Health Statistics 2013
Inpatient care Outpatient care Long-term care Pharmaceuticals Prevention/Public Health Administration Annual growth Public Health Spending by Function OECD average, annual growth in 2008-2011 10% 8% 6% 4% 2% 0% -2% -4% 2007/08 2008/09 2009/10 2010/11-2.8% -2.6% Source: OECD Health Statistics 2013
Total Health Spending by Financing Agent OECD average, annual growth in 2008-2011 Annual growth 7% 2007/08 2008/09 2009/10 2010/11 6% 5% 4% 3% 2% 1% 0% -1% -0.4% 0.0% General Govt./SHI 72% of total exp. Private Health Ins. 6% of total exp. Out-of-Pocket 20% of total exp. 0.5% 0.1% Total Health Exp. Source: OECD Health Statistics 2013
THE ROLE OF HTA IN COVERAGE DECISIONS
Pharmaceutical reimbursement and pricing in 14 countries Countries using formal pharmaco-economic assessment (CEA, CUA, CBA) Countries using formal assessment of the added therapeutic value over comparators Australia, Denmark, Belgium, Canada, Netherland, Korea, Norway, Sweden, United Kingdom Germany, France, Italy, Spain, Japan Source: OECD Health Working Paper No 63 18
Product-specific agreements for some drugs or indications Used to address uncertainties about: Clinical efficacy or effectiveness CED Registries Cost-effectivenes s Performancebased agreements Budget impact Cap on spending per patient Dose-capping Also used for cancer medicines with variable ICER / by indication (price discrimination across indications) Italy and the UK are frequent users 19
Consideration of budget impact Some examples of explicit consideration: Australia: Cabinet consulted for all decisions since the beginning of the crisis (delayed some listing due to budget constraints) Norway: Drug agency consults MoH for any decision with BI > NOK 5 mlo in year 5 Canada: at the level of P&T or federal public plans, except for cancer drugs (new committee advising on reimbursement). Italy, Spain etc. Source: OECD Health Working Paper No 63 20
In Summary Limited changes to the population coverage Increased user charges and cut in prices Some structural reforms to improve efficiency Difficult to selectively cut least costeffective services
Way Forward Savings Efficiency Clearly defining what is publicly funded is preferable to broad based co-payments HTA can help to enhance value in public spending (e.g. pharma) Ensure appropriateness in the healthcare use Ensure health systems sustainability