Formula Funding and Purchaser-Provider Systems

1. Formula Funding andPurchaser-Provider Systems 公式拨款和买方-供方体系 Performance Budgeting Course, APFDC, Shanghai, October 2010 绩效预算课程 APFDC，上海，2010年10月 Prepared by Marc Robinson

2. Introduction 引言 • Two mechanisms for creating tighter funding/results link 建立更紧密的拨款和结果关联性的两种机制 • Formula funding (FF) 公式拨款 • Purchaser-provider (PP) 买方-供方 • PP is a type of FF system 买方-供方是公式拨款体系的一种 • Explain how these systems work 解释这些体系如何运行 • Potential advantages to boost performance 提升绩效的潜在优势 • Limitations 局限 • Risk of perverse effects 产生负面效果的风险 • Appropriate for only some types of government services 只适合某些类型的政府服务 • Not techniques for government-wide budgeting 并非政府范部门的预算技术

3. Formula Funding 公式拨款

4. Vaccination Example 接种疫苗的例子 • Suppose unit cost of vaccinations is $25 假设接种疫苗的单位成本是25美元 • Use unit cost of vaccinations in budget 在预算中采用接种疫苗的单位成本 • Provide $1m vaccination funding to ministry 给政府相关部门提供疫苗拨款1百万美元 • Indicate that expect 40,000 vaccinations 指出预期接种疫苗4万例 • Makes performance expectations explicit 明确绩效预期 • Like setting a performance target 如 设置绩效目标 • Hold ministry accountable if fewer vaccinations 如果接种疫苗数少于预期，则让政府相关部门承担责任

5. Formula Funding (FF) 公式拨款 • Funding determined by formula 由公式决定的拨款 • Based on, e.g., population, services provided, size of geographic area served 由人口、提供的服务和服务的地理区域大小等因素决定 • Partially or wholly formula-based 部分或全部基于公式 • Performance budgeting form of FF: 公式拨款的绩效预算形式 • Formula links funding to results 公式将拨款和结果联系起来 • Outputs or outcomes 产出或结果 • And aim is to promote better results 目的是改善结果 • Quantity x Unit Cost = Budget 数量 x 单位成本=预算

6. Designing the Funding Formula 设计拨款公式 • Different funding for different outputs 针对不同的产出给予不同的拨款 • E.g. in university funding systems 如 大学拨款体系 • Funding for science students different from that of humanities students 给理科学生的拨款不同于给文科学生的 • Science much more resource intensive 理科要求更多、更密集的资源 • Simple unit cost funding formula 简单的包含单位成本的拨款公式 • Funding = output quantity x unit cost 拨款=产出数量 x 单位成本 • Rarely as simple as that 很少如此简单

7. Complexities in Formulas 公式中的复杂性 • Danish “Taximeter” system example 丹麦“出租车计价器”的例子 • Course completion payments 行程结束支付款项 • The results-based element 结果导向的要素 • Vary with course types 随行程类型而变化 • But other elements in funding system: 但拨款体系中的其他要素 • Building and maintenance component 创立和维护的部分 • Collective expenses (overheads) component 共有开支部分 • Supplementary grants for small institutions 给小型慈善机构的补助 • And a range of other payments… 以及一系列其他支付

8. Purchaser-Provider Systems 买方-供方体系

9. University Funding Example 大学拨款的例子 • Universities funded for courses provided 大学因其提供的课程被拨款 • As main funding mechanism 作为主要的拨款机制 • E.g. $3000 per year for full time law student 如，全脱产法学学生每年拨款3000美元 • $5000 per year for science student 理科学生每年拨款5000美元 • Money linked to students actually taught 拨款资金额与实际被教的学生数相关 • Not to numbers planned to be taught 而非计划要教的学生数 • Incentive for output delivery & efficiency对完成产出和效率的激励 • High cost universities suffer 大学承担的高昂成本 • Incentive to actually deliver planned outputs 对实际完成计划产出的激励

10. Definition of a PP system 买方-供方体系的定义 • Type of cost-based FF system 基于成本的公式拨款体系的类型 • Funding for outputs actually delivered 按实际完成产出拨款 • Not for planned outputs 不是计划产出 • Usually funding for outputs, not outcomes 通常按产出而不是按结果拨款 • Government purchases outputs 政府采购的产出 • From provider agency 从供应部门来看 • Main funding source 主要拨款来源 • Not just supplementary bonus funding 不只是补充性的奖励基金 • Incentive to boost output quantity 对提高产出量的激励

11. Prices, profits and losses 价格、利润和损失 • Agencies paid prices for outputs 部门为产出支付价格 • Might also be some non-output funding 可能也有一些无产出的拨款 • E.g. separate capital funding 如，独立投资基金 • Loss if agency’s unit costs > price 如果部门单位成本大于价格，则亏损 • Incentive to improve efficiency 对改善效率的激励 • Payment only for outputs produced 只为实际产出支付 • Less output means less funding 较少的产出意味着较少的拨款 • The closer prices are to efficient cost 价格越接近有效成本 • The greater the pressure for efficiency 改善效率的压力就会越大

12. Cost, Price and Loss 成本、价格和损失 Price 价格 Unit cost 单位成本 如何拨款 How to fund? X quantity 数量 Total revenue 总收入 Loss 损失 Total costs of production 总生产成本

13. PP is the market mechanism 买方-供方体系属于市场机制 • The principle of simple markets 简单市场的原则 • Purchasers pay prices to arms-length suppliers 买方支付价格给独立供应商 • Revenue only earned for products delivered 只因提交产品而赚取的收入 • Loss if products aren’t supplied 因产品不能提供而遭受的损失 • Loss for inefficiency 因低效而遭受的损失 • PP also called quasi-market mechanism 买方-供方体系也被称作准市场机制

14. Casemix-based Funding Example 基于病例组合而进行拨款的例子 • Payment to hospital for outputs 对医院产出的拨款 • Based on Diagnostic-Related Groups (DRGs) 以诊断关联群为基础 • Prices for each DRG category 对每个诊断关联群种类的支付价格 • $x for hip/knee replacement 置换髋关节或膝关节的价格为x美元 • $y for heart transplant 心脏移植的价格为y美元 • Funding depends on output 拨款取决于产出 • Losses if costs exceed DRG price 如果成本超过诊断关联群的价格，则会带来损失 • Market (purchaser-provider) principle 市场（买方-供方）原则 • Replaces “block” budgets 代替“整体”预算 • Funding like that of ministries 像政府部门那样的拨款

15. Objectives of Casemix Funding 基于病例组合拨款的目标 • Improved efficiency 改善效率 • Pressure to deliver services at lower cost 以低成本提供服务的压力 • Increased specialization 提高专业化 • Timeliness of treatment 治疗的及时性 • Only earn money when treatment provided 只有提供治疗才能赚钱 • Patient choice 患者的选择 • Funding follows the patient 拨款遵照病人的选择 • Equitable funding of hospitals 医院的公平拨款 • Relative to block budgets 相对于整体预算 • Where funding poorly related to output 整体预算中的拨款与产出的关联度较小

16. Fears about Casemix Funding 对病例组合拨款的担忧 • Skimping 克扣行为 • Cost-cutting at expense of quality 以牺牲质量为代价削减成本 • E.g. use of inferior but cheaper prostheses 如使用廉价劣质的假肢 • Dumping 推卸行为 • Avoiding expected higher cost patients 避免接诊费用预期较高的病人 • Result of heterogeneity 异质性结果 • Creaming 揩油行为 • Actively selecting expected low cost cases 主动选择预期低成本的病例 • Heterogeneity again 也是异质性 • Considerable professional resistance 相当多专业性的阻力

17. However, outcome was good 但是，结果良好 • Surprisingly few adverse consequences 令人惊奇的是，很少有负面影响 • Important role of medical ethics 医德的重要作用 • Practitioner power over treatment choices 医生选择治疗方案的权力 • Public hospitals not profit-seekers 公立医院不以追求利润为目的 • Loss-avoiders 损失规避方 • Quality assurance systems 质量保证体系 • Peer review, accreditation etc 同行审查，认证等 • No right to refuse to treat patients 无权拒绝治疗病人 • Addition of quality element to payment? 支付款项之外的质量因素？

18. Accrual Output Budgeting 应计产出预算 • PP model for whole government budget 适用于全部政府预算的买方供方模式 • Applied to ministries, not just NPIs 适用于政府部门，不仅是非盈利机构 • New Zealand, mid-1990s 新西兰，20世纪90年代中期 • Australia, late 1990s 澳大利亚，20世纪90年代晚期 • Now abandoned... serious failure 现在已经放弃...严重失灵 • Ministries receive prices for outputs 政府部门接受产出价格 • Govt to act as a “purchaser” of their services 政府部门充当服务买方 • Budget documents or supporting material to state output deliverables用于说明可交付产出的预算文件和相关材料

19. Accrual Output Budgeting 应计产出预算 • Aim to introduce payment for results 目的是保证根据结果来支付 • Revenue only earned when outputs delivered 只有当产出交付时，才会获得税收 • Quarterly invoicing in Victoria, Australia 澳大利亚维多利亚州的季度拨付 • Aims to set price = efficient cost 目的是让价格等于效率成本 • Simulate operation of a competitive market 模拟竞争市场的运作 • Efficient cost supposed to be determined by market comparators, market testing etc... 效率成本应该由市场参比和市场测试等来决定

20. Objectives of AOB System 应计产出预算系统的目标 • Efficiency pressure on ministries 提高政府部门效率的压力 • Pressure to deliver outputs 交付产出的压力 • Pressure to reduce costs to efficient level 将成本降低到有效水平的压力 • Facilitate competition with private sector suppliers 促进与私人部门供应商的竞争 • Ministries would be treated exactly like external suppliers 像对待外部供应商一样对待政府部门 • Tenders would be held on equal footing 政府部门与私人部门供应商平等地进行投标 • Would loose the work if the private sector could supply more cheaply 如果私人部门能供给更便宜的产品和服务，政府部门将放松控制

21. System Failed Badly 系统严重失灵 • Unworkable for many services 该系统对许多服务不适用 • Police, defence, fire services, foreign affairs etc 警察、国防、消防、外交等 • Never succeeded in basing prices on efficient cost 从来没有能够依照有效成本设定价格 • Too difficult to determine 设定价格的难度太大 • Required detailed research 需要详细的研究 • Still difficult if no market comparator 如果没有市场参比，依然很困难

22. When can formula funding and purchaser-provider work? 公式预算和买方-供方体系可以有效运作的情况

23. Heterogeneous services 异质性服务 • Services where unit cost varies greatly 单位成本变化较大的服务 • Because of tailoring of service to customer/case characteristics 因为根据具体顾客或情境而定制服务 • FF/PP can manage some heterogeneity 公式拨款/买方-供方体系能控制某些异质性 • If average unit cost is stable 如果平均单位成本稳定 • Some clients/cases cost more than others 有些顾客/情境耗费成本比其他的多 • But it averages out 但是达到平均水平 • Approximately true for hospital services 医院的服务大约就是这样 • But many public services with severe heterogeneity 但是许多公共服务具有严重的异质性 • No stable average unit cost 平均单位成本不固定 • Can’t apply a cost-based funding formula 不能运用基于成本的拨款公式

24. Contingent Capacity Services 临时能力服务 • Example of fire services: 消防服务例子 • Unpredictable demand for services 服务需求无法预料 • Must be responded to immediately 必须立即作出响应 • Spare response capacity maintained 维持一定备用响应能力 • Relation between funding and services actually provided is therefore weak因此拨款和实际提供服务之间的关系较弱 • Can’t fund on output formula 不能按产出公式拨款 • Many services like this in government 许多政府服务都属于这种情况 • Insurance-type services 保险型服务

25. What scope for FF and PP? 什么领域适合运用公式拨款和买方-供方体系？ • Selective rather than general application 选择性的而不是一般性的应用 • Apply only to right types of programs 只应用于合适的项目类型 • Relatively standardized services 相对标准化的服务 • Complexity involved in setting formula 设置公式时涉及的复杂性 • Argument for gradualism and selectiveness 对渐进主义和选择性的争论 • Focus on one or two major services areas 集中关注一或两个主要服务领域 • Rather than immediately introducing in many areas 而不是立即引入许多领域

26. Conclusions 结论 • FF and PP valuable performance budgeting tools 公式拨款和买方-供方体系是宝贵的绩效预算工具 • Should be selectively applied 应该有选择地应用 • Technically demanding to implement 实施的技术要求比较高 • Developing countries 发展中国家 • Need to be particularly selective 特别需要有选择地应用 • Very gradual approach to use of these tool 以渐进的方式使用这些工具