Transcript Peter Pazitný - European Health Forum Gastein

Addressing the demand side problems
by Intelligent Co-payment Scheme
Contribution to the
Roundtable discussion
Paying for the Health Systems of the Future
7th European Health Forum Gastein
Ing. Peter Pažitný, MSc.
Analyst of M.E.S.A. 10
Advisor to the Minister of Health
October 2004
MOH
October 2004
We're lucky that
the hole is not
on our side
MOH
October 2004
... ??? ...
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Content
I.
Introduction – Slovakia at the Glance
II.
The design of The Intelligent Co-payment Scheme
III. Evidence from introduction of marginal costs in
Slovakia
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I.
Population:
Introduction - Slovakia
5,4 million people
Living Standard: 51% of EU average
Middle income country
EUR 1 = SKK 40
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Slovakia at the Glance
Economic indicator
GDP growth
2002
2003
2004f
2005f
4,4
4,2
4,3
4,7
18,5
17,4
16,5
15,9
3,3
8,5
6,5
4,8
General Government
Balance/GDP
- 7,5
-3,6
- 3,6
-3,4
Current
Account/GDP
-8,0
-1,0
-2,6
-3,5
Unemployment rate
Inflation (CPI)
Source: M.E.S.A. 10
MOH
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Deficit of Public Finances
(% of GDP)
1999
2000
2001
2002
2003
2004
2005
0,0
-0,5
-1,0
-0,9
-0,8
-0,9
-0,6
-0,3
-0,1
-2,0
-2,0
-3,0
-4,0 -3,6
-3,6
-4,1
-3,6
-3,4
-5,0
-5,3
-6,0
-7,0
-8,0
MOH
-6,6
-6,1
-6,4
-7,5
October 2004
GFS 86
ESA 95
Health care
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Slovakia the leader in Reforms
I.
Tax Reform (2003) – Corporate and Personal Income Tax – 19 %
II.
Pension Reform (2003) – Two pillars - public (50%) and private
(50%)
III.
Public Administration Reform (2004) – Fiscal Decentralization
IV.
Labour Market Reform (2003) – Modern Labour Code
V.
Health Care Reform
MOH
- Stabilization (2003)
- Reform Acts (2004)
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Health System in Slovakia
Financing
Competitive Social Insurance
Payroll tax (contributions) - 60 %
Taxes – 30 %
Out of pocket – 10 %
Payment
mechanisms
Primary care – Capitation + Fee for service
Secondary care – Capped fee for service
Tertiary care – Broad band DRG per Case
Long term care – Beddays
Emergency – Capitation and fee for service
1-day Surgery – Per Case
Organization
Primary care – 97 % private
Secondary care – 83 % private
Tertiary care – 10 % private
Pharmacies – 99 % private
Regulation
Price regulation and Network regulation
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Generally, you have 4 types of
problems
I.
Demand side
II.
Supply side
III. Financing
IV. Regulation (Role of the MOH)
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II. The design of Intelligent Copayment Scheme
Act on Basic Benefit Package
Basic Principle:
Equal treatment to equal need.
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A European health politician
(old type) speaks:
„I oppose higher co-payments because this
instrument is not likely to reduce the demand for
health care.
But in case that demand is effectively reduced by
higher co-payments, I am also against this
instrument because demand is effectively
reduced.“
Source: Osterkamp, R., 2004
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Intelligent Co-payment Scheme (ICo-PS)
1. Separation of non-health care services
(setting small, flat co-payments)
2. Define the national priority list (diagnosis with
no co-payment) – The Basic Benefit Package
3. Establish catalogization committees (defines
the catalogue of procedures)
4. Establish categorization committees (defines
the financial co-payment)
5. Increase patient’s responsibility and
involvement
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1. Application of marginal
co-payments
Patient
Health Insurance
Fund
Provider
(pharmacy)
Primary care
20 Sk
0 Sk
20 Sk
Secondary care
20 Sk
0 Sk
20 Sk
Accomodation and
food in inpatient care
50 Sk
0 Sk
50 Sk
15 Sk
5 Sk
Transport
Prescription fee
MOH
2 Sk/km
20 Sk
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2. List of Citizens’ Priorities
Disease
%
Cardiovascular diseases
74.2
Cancer
68.8
Diabetes, metabolic disorders
26.2
Orthopaedic diseases
16.6
Mental, psychiatric, nerve disorders and stress
16.1
Influenza
12.1
Allergies
10.9
Respiratory diseases
8.6
Infection diseases, hepatitis, TBC and AIDS
6.3
Incorrect diet, obesity
6.2
Alcoholism, smoking, drug addictions
4.6
Source: Dental problem
FOCUS, Skin diseases
January 2004
Gynaecological diseases
MOH
1.4
0.9
0.8
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2. ICo-PS model in practice
1
2
3
...
Critical Risks:
 financial protection of
patients against the risk
of excessive costs
 urgent care
 chronic diseases
DISEASES
 

PARLIAMENT

HIC
Vysoká miera spoluúčasti 
 Optimálna výška
Low participation
spoluúčasti





Ministry
cca 9 000
Experts
- HIC coverage
MOH
-patient’s participation
October 2004
5. Patient’s responsibility (§ 41)
HEALTH IS AN INDIVIDUAL GOOD (NOT A PUBLIC GOOD)
Materialized responsibility of the patient for prevention and
treatment regime (compliance)
The Health Insurance Company is entitled to
 Increase the co-payment if the care had to be provided
due to a violation of the treatment regime or in result
of a habit-forming substance abuse (no compliance),
 Decrease the co-payment, if the insured regularly
undertakes preventive examinations, preventive
vaccination and leads a healthy way of life.
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Analyzer Tool
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Summary: Elements of an intelligent
design of co-payments
Dr. Osterkamp, ifo Institute Munich, 2004:
1. High co-payments (may be 100%) for
small, frequent, cheap and every day
diseases
2. Low (or non) co-payments for rare, severe
and costly diseases
MOH Draft
Yes
Yes
3. Lower co-payments for the poor than for
the wealthy.
Yes
4. Upper limit of health-care costs as a % of
individual annual income
Partially
5. Disburdening the employer: once-and-forall increase of wages by former employer
contribution
MOH
October 2004
Not yet
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A European health politician
(new type) speaks:
„On one hand I still oppose higher co-payments. But on the
other:
 our co-payment rates are rather low,
 not each health treatment is equally important,
Therefore, I shall try to convince the electorate that a
moderate increase combined with a fair design of copayments is in the interest of all.“
Source: Osterkamp, R., 2004
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III. Evidence: Impact of marginal copayments
(Index 2003/2002)
1,2
1,1
1q
2q
3q
1
4q
0,9
0,8
Primary Care
Source: General HIC
MOH
Dentists
First aid
Zdroj: VšZP, 2004
Secondary Care
October 2004
Hospitals
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Dynamics of Drug Expenditures
25
20
15
19
15
16
11
10
5
8
9
4
HIC
Patients
0
-5
2000 2001 2002 2003 2004
-10
-15
MOH
Zdroj: MZ SR
-13
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The access to care was not hurt
The same
behaviour as
before
58,5%
Did not visit
doctor
22,0%
Stopped
1,5%
Less then
before
18,0%
MOH
Source: FOCUS
January 2004
October 2004
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The prescription of drugs was not hurt
The same
behaviour as
before
54,2%
Did not need
doctor
23,2%
Stopped
2,1%
Source: FOCUS
January 2004
Less then
before
20,5%
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Access to care was not decreased
The initial hypothesis came true, that
1. Only excessive demand felt down
2. The access to care was not decreased
3. The perception of corruption decreased (from 32 to
10%)
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Lessons learned
Reform requires many clear decisions on
day-to-day basis
... but ....
you always have only imperfect data and
information to support your decision
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Lessons learned
Whatever you do, according to the media
and public
… you are always WRONG!
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Thank you for your kind attention
www.reformazdravotnictva.sk
www.health.gov.sk
MOH
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