El sistema sanitario de Alemania · 2014-01-20 · •ambodia, urkina Faso, some states of India…...
Transcript of El sistema sanitario de Alemania · 2014-01-20 · •ambodia, urkina Faso, some states of India…...
El sistema sanitario de Alemania: Características, retos, reformas
Sophia Schlette, MPH Encuentro, Madrid, 13 febrero 2013
Distintos o parecidos?
The Bismarck Model •Germany
•Belgium
•(France)
•Japan
•(Switzerland)
•USA: employer-related group insurance
The Beveridge Model •UK
•Scandinavian countries
•Spain
•Italy
•Cuba
•USA: VA, Indian Health Service
The national health insurance model •Austria
•Canada
•South Korea
•Taiwan
•USA: Medicare
The OOP model •Cambodia, Burkina Faso, some states of India…
•50 mio uninsured in the U.S.
Retos y reformas similares…
US ACA Triple Aim 2010:
• Better health
• Better care
• Lower cost
Desafíos en Alemania 2002-2010:
• Cost containment
• Care coordination
• Quality (and transparency)
Características del sistema sanitario alemán
• Basado en el principio de la solidaridad
– Cotizaciones según capacidad de pago (base salarial)
– Subsidios múltiples (healthy pay for sick, young for old, men for women, wealthy subsidize poor, singles subsidize families)
– Acceso universal
– Cobertura universal obligatoria
– Muchas posibilidades de elección
Los logros
• Buen acceso
• Cobertura universal y generosa
• Medicina de punta
• Sistema valioso: rango 6 por gasto PIB
para salud, 5 o 6 por gasto p.c.
• Moderación del gasto
International Comparison of Spending on Health, 1980–2008
Average spending on health per capita ($US PPP)
Total expenditures on health as percent of GDP
Source: Commonwealth Fund, OECD Health Data 2010 (June)
Health Spending per Capita, 2009 Adjusted for Differences in Cost of Living
* 2008.
Source: Commonwealth Fund, OECD Health Data 2011 (June 2011).
% GDP
Dollars
Los retos
Sectores y silos
• Separación hospital-ambulatorio-social
• Presupuestos siguen sectores
• 2 sistemas tarifarios
• 2 sistemas de medida de calidad
• 2 sistemas de seguro de salud
• Divisiones profesionales
• 2 tipos de ingresos: salarios vs. FFS
• Competencias centrales, regionales y locales
• Códigos sociales poco alineados
Dónde están los médicos?
Physicians per 100.000 pop 135,6 - 143,8 143,9 - 152,9 153,0 - 157,0 157,1 - 160,8 160,9 - 163,1 163,2 - 174,9 175,0 - 176,7 176,8 - 232,0 232,1 - 239,5 239,6 - 244,4 Year: 2010 All ambulatory care physicians per Bundesland
© 2013 versorgungsatlas.de
Physician-patient contacts 15,3 - 15,9 16,0 - 16,6 16,7 - 17,3 17,4 - 18,0 18,1 - 18,9 Year: 2007 All sexes All ambulatory care physicians per Bundesland
© 2013 versorgungsatlas.de
Falta de coordinación entre especialista y médico de familia
Medicamentos
Información crítica
Notificación médico cabecera en emergencias
Retos complejidad y alineamiento
• Muchos actores, muchas instituciones, muchos intereses
• Muchos médicos pero disparidades regionales pronunciadas
• Uso excesivo, insuficiente y mal uso de servicios sanitarios,
creciente volumen de servicios
• Poca utilización de HIT en la gestión clínica o a nivel de población
• Transformaciones en los recursos humanos: envejecimiento,
feminización, expectativas hacia work-life-balance
• Inercia, complacencia y poca curiosidad innovadora
Abordando los desafíos: qué hemos hecho?
… and the responses 1988-2010-??
Year passed Name of legislation 1988 Health Care Reform Act of 1989
1992 Health Care Structure Act of 1993
1994 Social Code Book XI (Statutory Long-Term Care Insurance)
1996 Health Insurance Contribution Rate Exoneration Act
1997 First and Second Statutory Health Insurance Restructuring Acts
1998 Act to Strengthen Solidarity in Statutory Health Insurance
1999 Statutory Health Insurance Reform Act of 2000
Act to Equalize Statutory Provisions in SHI 2001
2000 Infection Protection Act
2001 Social Code Book IX (Rehabilitation)
Reference Price Adjustment Act
Pharmaceutical Budget Redemption Act
Act to Reform the Risk Structure Compensation Scheme in SHI
Act to Newly Regulate Choice of Sickness Funds
2002 Pharmaceutical Expenditure Limitation Act
Case Fees Act
Contribution Rate Stabilization Act
2003 Twelfth Social Code Book V Amendment Act
First Case Fees Amendment Act
Statutory Health Insurance Modernization Act
2004 Act to Adjust the Financing of Dentures
Second Case Fees Amendment Act
2007 Statutory Health Insurance Competition Strengthening Act
2008 Long-Term Care Insurance Reform
2009 Care Structures Act
2010 Pharmaceutical Market Restructuring Act
Medidas y remedios en los 80 y 90: entre solidaridad y competición
• 1980s-90s: Enfoque en costos, moderación de los
gastos y estabilidad de cotizaciones
• 1990s: Pasos hacia la competencia entre
aseguradoras públicas (level playing field),
elección, proyectos pilotos en coordinación,
introducción del seguro de dependencia
Reformas estructurales 2000-2008: hacia calidad y transparencia
2000-2008 Legislación accelerada y sistemática hacia
• Coordinación de servicios: incentivos para GP gatekeeping,
DMPs, contractos de integración, policlínicas/centros de
salud, LTC one-stop-shops
• transparencia: medida de calidad obligatoria (sector
hospitalario) public reporting, patient engagement
• eficiencia: value-based purchasing
• Reformas estructurales: centralización de la toma de
decisiones, evidence-based decision making
Reformas estructurales: Centralizando la toma de decisiones
2004 Federal Joint Committee (www.g-ba.de)
2004 Institute for Quality and Efficiency in
Health Care (www.iqwig.de)
2009 Health Fund
[Políticas desde 2009]
• Acceso accelerado a innovaciones (AMNOG)
• Eliminación de incentivos hacia la coordinación
• Reforma de la planificación de capacidades
• Fortalecimiento del GBA
• Delegación de competencias del GBA hacia los
Länder
• Vacío de liderazgo estratégico
Auto-gestión en el sistema de salud alemán Autoridad entre el Estado y la Sociedad Civil
Government Parliament
Federal Joint Committee (GBA)
statutory health insurers
provider organizations
citizen physician
dentists
hospital
Legal framework
Delegation of authority and tasks
Self-governance
Civil Society
consultation
•patient (choice) •provider
•electorate (voice)
State
•member •representation •member (choice)
•contract
Federal Joint Committee aka G-BA (Gemeinsamer Bundesausschuss)
5 patient representatives
can file motion, cannot vote
5
Provider
representatives
5
SHI
representatives
Impartial Chairman
2 impartial chair members
13 voting members
Federal Joint Committee
§ 91 SGB V
Revised voting rights
since 1/12
El Fondo Sanitario
Financiamiento desde el 2009
14
Health Fund (100%)
Employees/Insured (49%)
Employers (48%)
Taxes (~ 3%)
Morbidity-adjusted
allocations Sickness
funds Sickness
funds Sickness
funds Sickness
funds Sickness
funds Sickness
funds 145
Sickness funds
Additional flat premiums /
Bonus payments
El impacto de las reformas estructurales 2002-2009
“The First Law of Improvement”
Every system is perfectly designed to achieve exactly
the results it gets.
Uwe Reinhardt, Princeton
Impacto sobre las aseguradoras públicas I
Foundations remain untouched:
• Solidarity principle
• Choice of 144 sickness funds (nonprofit)
• Family insurance
• Contribution-based financing
• Opting out-option toward PHI remains
Impacto sobre las aseguradoras públicas II
• Contribution rate set by Gvt (15.5%) – Shared employer/employee (7,3%/8,2%) contributions – Income cap of 44.100 € p.y. / 3.675 Euro p.m. – Contributions go to Health Fund, and are then allocated to
insurers based on population risks
• SF can raise community-rated supplementary premiums, or pay out surplus to SHI members
• Tax funding: 4 billion € in 2009 to be increased successively by 1,5 billion €/year till reaching 14 billion/year
• PHI to offer standard benefit package to all new clients
Impacto sobre los servicios de salud
• Financial incentives for care coordination • Political endorsement for primary care • New contractual freedoms, easing horizontal
integration and cooperation: – integrated care contracts – medical care centers – ambulatory surgery in small clinics – hospital outpatient care at polyclinics…
• New mandatory offers: Disease Management Programs
• Enhanced public reporting on outcome measures de los hospitales
Impacto sobre los servicios de salud: aumentan contratos de integración
Source: BQS Register 140d, 30th June 2008
Impacto sobre los servicios de salud: aumentan centros de salud
Source: KBV. Entwicklung der Medizinischen Versorgungszentren aktuell. 11/2011
“House of Health” Berlin-Alexanderplatz
50 Physicians
22 Specialties
Salary-based
• DMPs for six conditions - Diabetes type I & II
- CHD
- COPD
- Asthma
- Breast cancer
• Specific requirements for care targets, drugs, documentation
• Certification by Federal Insurance Authority, run by every SF
• 5,9 million enrolled patients, 48% in diabetes II DMPs (2011)
• Large scale evaluations show positive effects on care quality, fewer hospitalizations, higher patient satisfaction, quality of life
Impacto sobre los servicios de salud: condiciones crónicas
Impacto sobre transparencia (toma de decisiones y calidad)
• Federal Joint Committee holds monthly plenaries in public
• Patient groups have observatory status on GBA
• Public reporting - every hospital must publish outcome quality data
• Rankings are being published and search engines allow to screen providers based on criteria and services (www.weisse-liste.de)
• Quality measures and QI in ambulatory care harder to do, not aligned with inpatient care
De aquí en adelante: nuevas herramientas para nuevos desafíos?
• Sistemas de pago
• Flexibilización de contratos y modelos de prestación
• Gestión de poblaciones
• Orientación hacia el paciente
• Calidad & coordinación
• Trabajo en equipo multiprofesional
• Solidaridad
• “Going Dutch”: Rol de las aseguradoras privadas
Lecciones?
• “Governance” doesn’t mean “government take-over”
• Self-governance is actually a smart thing
– A ‘little lawmaker’ avoids political interference and political instability
– At best it can build trust among payers, providers, and patients
• Payers need to become competitive, smart purchasers
• Why data: What isn’t measured won’t get changed
• Quality measures need to be aligned across settings
• Governance reform needs bipartisan support, windows of opportunity
• Governance reform needs good PR and transparent communication
• No pain point, no reform…
• No quick fixes
“The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants.”
Don Berwick
Back ups
• OECD Health Data 2011
• Commonwealth Fund International Health Policy Surveys
• Sachverständigenrat Sondergutachten 2012
Further readings
• Blum, Kerstin. "Care coordination gaining momentum in Germany". Health Policy Monitor, July 2007. Available at www.hpm.org/survey/de/b9/1
• Busse, Reinhard. The health system in Germany. Eurohealth 14(2008)1
• Lisac, Melanie. "Health care reform in Germany: Not the big bang". Health Policy Monitor, November 2006. Available at www.hpm.org/survey/de/b8/2
• Lisac, Melanie, Henke, K.-D., Reimers, L., Schlette, S. Access and Choice – Competition under the Roof of Solidarity in German Health Care. An analysis of health policy reforms since 2004. Article accepted for publication, Health Policy, Economics, and Law, forthcoming.
• Schlette, Sophia, Lisac, M., Blum, K.. Integrated Primary Care in Germany – The road ahead. Article accepted for publication, International Journal on Integrated Care, forthcoming
• Melanie Zimmermann, reviewers: Reinhard Busse, Sophia Schlette. "Health financing reform idea: health fund". Health Policy Monitor, June 2006. Available at www.hpm.org/survey/de/b7/1
Aseguradoras de salud en Alemania
Population: 82.5 million
Aseguradoras públicas (144 entidades)
• Ambito de cobertura
– Prevención
– Hospital (Copay: € 10/day)
– Servicios ambulatorios (Copay: € 10/quarter)
– Libre selección de médicos de familia y especialistas
– Prescripciones (Copay: € 5-10/script)
– Salud mental, salud dental
– Rehabilitación &
– Compensación de ingresos
Aseguradoras privadas (47 entidades)
– Seleción de riesgos
– Individual underwriting
– Beneficios definidos por contrato (hay requerimientos minimos)
– Acceso privilegiado, tarifas superiores para médicos
• Quien es eligible? – Auto empleados, por cuenta propria
– Funcionarios del estado, de entidades públicas
– Ingresos altos (> € 49 500 / year)
• In teoría 20% de la poblacion, en práctica 75% se quedan en el sistema público
• Decisión para cobertura privada “via única”
Aseguradora pública
Paciente médico
Asociación Regional de
médicos Remuneración global
ajustada
Distribución de remuneración FFS
(pago por servicio no cubierto)
Pago de médicos en Alemania: Contratos colectivos regionales
Overall Remuneration
►Paid by sickness funds to regional physician associations
►Consists of a budgeted component (morbidity-based overall remuneration MLV) and a non-budgeted component (fee-for-service ELV)
►Negotiated between regional physician associations and regional associations of sickness funds
► Increase based on changes in morbidity (Reference Conversion Factor – Orientierungspunktwert)
►Gov’t intervened for 2011 and 2012: Increase restricted to 1.25 %
Distribution of Remuneration
►Physician remuneration based on a fee-for-service basis
►Uniform Value Scale (EBM)
►Bundled Elements
►Payment = Relative Value x Conversion Factor
►Conversion Factor = Reference Conversion Factor +/- Regional Correction
►Reference Convergence Factor negotiated by Physician Payment Commission – Bewertungsausschuss) between Federal Association of Sickness Funds and Federal Association of Physicians’ Associations
►Change based on changes in morbidity
Cost Control Mechanisms
►The Overall Remuneration is broken down to the individual practice level
►Standard Service Volume (SSV) = Case Value of Speciality x No. of Cases x Age Adjustment
►Physicians get full payment within the SSV, and reduced payments for volume above the SSV
►Physician Associations have to hold back overall remuneration for payments above SSV
►Efficiency review for prescriptions ► In theory, physicians are liable for non-efficient prescriptions
Pago de médicos: Discontento pese a aumentos
Source: National Association of Statutory Health Insurance Funds
German Health Care System Organizational Chart of Key Players
Federal Ministry of Health
Federal Parliament
Physicians Hospitals
Institute for Quality and Efficiency
17 Regional Physician
Associations
Federal Association of SHI Physicians
16 Regional Hospital
Associations
German Hospital Association
Sickness Funds
Accredited Patient Organizations
Insured Patients
Federal Joint Committee
State Ministries of
Health
Free to choose Free to choose
Choice
Nonvoting
Pharmaceuticals
• All registered prescription drugs covered – Co-pay of € 5-10/ script (no tiered co-payment system)
– Co-pay waivers for small children & chronically ill
– Co-pay waivers for “low priced” drugs (<70% reference price)
– Second opinion needed for expensive drugs
• Lifestyle drugs not covered (ie. Viagra)
• OTC drugs not covered (few exceptions)
• Pharmacy profit margins fixed by law: € 8.10 + 3%
• No manufacturer price limits, but reimbursement
ceilings within drug categories
• Generic prices higher than U.S. or other EU