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Overview of health systems reforms Europe and USA Abdo Yazbeck Health Sector Manager Europe and Central Asia

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Overview of health systems reforms Europe and USA Abdo Yazbeck Health Sector Manager Europe and Central Asia

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    1. Overview of health systems reforms Europe and USA Abdo Yazbeck Health Sector Manager Europe and Central Asia Moscow, April 13 2010

    2. Main Themes Health outcomes Evolution of health financing and delivery system reforms Role of regulators,

    6. Russia gets less health value for money Efficiency is estimated with Data Envelopment Analysis (DEA) Based on observed inputs and outcomes DEA estimates a “production frontier”. The production frontier is the highest outcome observed given inputs. The distance of each region to this frontier is our estimate of efficiency. Efficiency is estimated with Data Envelopment Analysis (DEA) Based on observed inputs and outcomes DEA estimates a “production frontier”. The production frontier is the highest outcome observed given inputs. The distance of each region to this frontier is our estimate of efficiency.

    8. Historical Evolution of Health System Reform in Europe 1970s: last radical reforms in Western Europe (Mediterranean countries). 1980s: control expenditure (oil shocks of the 1970s) 1990s—2000s: Western Europe constant, every 3-5 years on average Fine-tuning-- (exception of the Netherlands) Concerns are quality of care and equity in access Central /Eastern Europe: fundamental reforms away from the Semashko system Reforms are ongoing—no endpoint; constant fine-tuning even when the “right” structure is in place

    9. Historical Evolution of Health System Reform in the U.S. It’s a long story… 1915: Progressive reformers ineffectively campaigned in eight states for a state-based system of compulsory health insurance 1920s: the Committee on the Costs of Medical Care, proposed group medicine and voluntary insurance….modest ideas, but enough to raise opposition, and the term “socialized medicine” was born American public generally supportive of guaranteed access to health care and health insurance for all, and government role in health financing Previous (mostly) failed attempts: 1934-1939 National health insurance and the New Deal 1945-1950 National health insurance and the Fair Deal 1960-1965 The Great Society: Medicare and Medicaid 1970-1974 Competing National Health Insurance Proposals 1976-1979 Cost-Containment overrides reform (as in Europe) 1992-1994 The Health Security Act (‘The Clinton Plan’)

    10. New U.S. Health Care Law

    11. Recent Reforms in Europe and USA aim to address four key-issues Escalating costs Growing health inequalities Ensure access/financial risk protection Get value for money

    12. Despite solidarity, important health inequalities remain across European countries The relative index of inequality is the ratio between the estimated mortality prevalence among men of the lowest education level and the highest level. A relative index of 2, for example, means that estimated mortality of men in the low education group is twice the mortality of men in the highest.. The relative index of inequality is greater than 1 for men (and women) in all countries. The magnitude of inequality varies significantly. Inequalities are also found related to income and occupation (blue collar vs. white collar). Most inequality in mortality is attributable to cardiovascular disease. Inequalities are related to inequalities in prevalence and duration of health problems, and in access to health care lead to inequalities in survival from chronic conditions.The relative index of inequality is the ratio between the estimated mortality prevalence among men of the lowest education level and the highest level. A relative index of 2, for example, means that estimated mortality of men in the low education group is twice the mortality of men in the highest.. The relative index of inequality is greater than 1 for men (and women) in all countries. The magnitude of inequality varies significantly. Inequalities are also found related to income and occupation (blue collar vs. white collar). Most inequality in mortality is attributable to cardiovascular disease. Inequalities are related to inequalities in prevalence and duration of health problems, and in access to health care lead to inequalities in survival from chronic conditions.

    13. Health Inequality in Russia Russian adults living in the most affluent regions live on average 20 years longer than those in the poorest region.

    14. Health Financing Mobilization of funding Pooling of health risks Purchasing of health care

    15. Most health financing systems have mixed funding sources Social health insurance are funded from Payroll taxes and Government budget (tax revenues) National Health Systems (in UK, Spain, Scandinavia) funded from: Government budget (tax revenues)

    16. The UK Government provides different Resource Allocation to improve Equity People living in the poorest neighborhoods in the U.K. live 7 years less than in the richest National health funding is allocated to regional Health Authorities through a needs-based formula In 2002 allocation formula adjusted to account for health inequalities: “Funding based on a capitation formula is directed at achieving equity.” (Report to the U.K. Secretary of State for Health) Formula now has 3 adjustments : Regional cost variations Service delivery needs—based on utilization Health inequalities (disability-free life expectancy)

    17. French Government Subsidizes Voluntary Complementary Insurance Life expectancy gap between manual workers and professionals reached 7 years Reforms aimed at increasing insurance coverage for the poor Universal Health Coverage Act (2000) Public health insurance coverage extended to last 15% of excluded population Free, means-tested complementary (voluntary) insurance coverage exempt the poorest from copayments Act on Health Insurance Reform (2004) Expanded access to subsidized voluntary insurance—raised income ceiling for subsidy Gap in service utilization for some conditions (e.g. cardiovascular disease) reduced or eliminated. Inequality in access to specialist services remains.

    18. Purchasing trend is towards capitation and DRGs to manage costs Outpatient care: Capitation payment adjusted by age/gender Fee-for-service Pay-for-performance experiment in UK Hospital care: Line item budgets Diagnosis Related Groups (DRGs) Global budget

    19. Regulation of health financing needs strong managerial and information capacity

    20. Regulators have a stewardship function Regulators (or supervisory authorities) are empowered to: Influence actors such that they act in the public interest enforce insurance legislation to ensure the effective functioning of the market, protect consumers, and assure the quality of care

    21. The Slovak Health Surveillance Authority (HSA) acts independently of the government The HSA is responsible for: supervising and registering health care providers and health insurers; licensing insurers and issuing secondary legislation; cooperating with the government in preparing insurance legislation; sanctions and remedies for health insurance companies.

    22. The Netherlands has 5 semi-public regulators The Dutch Health Care Inspectorate supervises the quality of the care, patient safety and effective care. Develops and publishes performance indicators providers The Dutch Health Care Authority supervises costs, prices, and contract conditions. Classify health care products and for disseminating adequate consumer information. The Dutch Competition Authority tasks are: (i) to prevent cartels; (ii) to authorize or forbid mergers; and (iii) to prevent abuses by insurers in dominant market position. The Competition Authority has forbidden horizontal price-fixing and market sharing agreements, entry regulations, and collective contracting practices by providers The Dutch Central Bank supervises the financial solvency of insurers based on the Insurance Supervision Act of 1993. The Financial Markets Authority ensures that insurers provide financial information properly, (e.g. insurer has to inform members about their different insurance options)

    23. Next presentations Pooling function of health financing system Easier to manage one pool Multiple pools require sophisticated equalization transfers if premium not risk-adjusted Purchasing health care: Ireland Most European countries introduced DRG hospital payment to set incentives for efficient provision The Netherlands Introduced substantial reforms in pooling and health care delivery, with “regulated competition”

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