Exploring the role of insurance-based financing reforms to improve universal coverage of TB

services

December 11, 2014

Manila, Philippines

Alisha Smith-Arthur

URC/ USAID TB CARE II Project

Outline

I. Why examine the role of health insurance in the context of TB service delivery?

II. Meeting on TB and insurance based financing reforms, Bangkok, Thailand, Sept 2014

III. Discussion of outcomes, main points, and implications going forward

Current context for examining TB in insurance-based systems

• Continued adoption of the principles of Universal Health Coverage, including emphasis on increasing access to care and reduction of financial burden, with health insurance as a key component

• Introduction of health insurance programs and push for decentralization leading countries to explore integration of TB services within insurance coverage packages

• Unclear impact of state-supported health insurance programs on use of TB services and outcomes

• More information needed to understand the processes and mechanisms to optimize TB service delivery in the context of health insurance introduction

Starting point 1: What is the benefit of health insurance (through a TB lens)?

Insurance aims to:• Protect households from impoverishment due to high out-of pocket

spending for TB services.– Requires a system to catch patients early and avoid other

spending; needs to minimize costs for more expansive, in-patient curative care 

• Increase access to and use of TB services where payment is normally required at the time of need.

• Influence provider and consumer behavior to improve quality, efficiency, and effectiveness.

• Harness private providers to provide TB services within a framework of quality and accountability– Requires high level of oversight, adequate compensation levels,

and timely payments.

Landscape of health insurance options

Types of insurance

Financing source Management

National health insurance

General taxes Public sector

Social health insurance

Payroll taxes fromemployers and employees

Social security agency,health/sickness fund

Community-based health insurance

Premium paymentsfrom individuals and/orcommunity

Community or insurance association

Private voluntary health insurance

Premium paymentsfrom individuals oremployers / employees

Commercial insurance company

Adapted from Health Insurance Handbook, World Bank

Starting Point 2. What are the implications of introducing a health insurance program (through a TB lens)?• Defining the degree of integration of TB services • Establishing roles and responsibilities of NTP and

insurance authority• Developing coordination mechanisms for decisions

around policy, coverage, oversight, targets • Affect of insurance programs on TB objectives:

outcomes, case finding, reduced financial burden (i.e., social support and patient-centered care)

I. Policy: TB and UHC policy objectives

• Defining landscape of insurance programs and relationship to TB

• Incorporating strategic TB objectives within UHC reforms

II. Administration and organization

• Outlining coordinated responsibilities for insurance and TB authorities

• Defining mechanisms for routine engagement and coordination

III. Service delivery • Defining a benefits package for TB services• Ensuring all patient needs are covered

IV. Facilitating access and utilization

• Continuum of care between service providers (referrals and follow up)

• Informing and educating TB patients around access to services, required costs

V. Engaging more care providers

• Accreditation and role of other professional associations

• Reimbursement and incentivizes

VI. Ensuring quality of care • Monitoring patient outcomes• Promoting patient-centered care

Current approach to health insurance in WPR representative countries

• Among representative countries: 3 with existing or planned national health insurance programs

• Health insurance funding used for clinical services, diagnostics, enablers (wide variation between program models)

• Universal perception among respondents that introduction of health insurance will positively impact TB case notification and quality of care, and decrease patient OOP expenditures

Meeting on TB and insurance-based UHC financing

“Exploring the promise of improving access and delivery of TB services through insurance-based financing reforms,” Bangkok, Thailand, Sept 2014• Participation from 9 countries in WPR and SEAR• Participation from NTP, Finance, Insurance

authorities, others

Diverse models, experiences and goals for UHC financing

Meeting Objective and Purpose

• Provide a forum for information sharing and review of current systems for ensuring access to, and provision of, essential TB services and core public health functions in the context of UHC financing reforms in Asian countries

• Discuss and develop common principles, best practices, and policy options around essential public health functions and core services for TB control and care in insurance-based systems

• Create a foundation for further investigation and development on framework guidance

Topic areas for presentation and discussion

• TB and Universal Health Coverage • Overview of regional models of insurance-based

financing and TB service delivery• Defining a benefits package for TB services• Planning and administering TB services effectively in

an insurance-based system• Engaging more providers effectively through

insurance-based financing

I. Programmatic and policy roles

The role and functions of the NTP in an insurance-based financing system and the impact of decentralization: • Necessity of defining the essential public health

functions of a national TB program– Policy and supervision functions– Oversight and support for supply and TB commodity

management– Division of responsibilities for TB and MDR TB diagnostic

and clinical services

I. Programmatic and policy roles

Coordination vs. fragmentation:• Importance of step-based, coordinated planning for

phased introduction of health insurance between Finance, insurance authority and NTP– Avoid disruptions in free access to services– Rational decentralization – Two-tiered delivery networks (NTP and insurance based

providers)

II. Provider engagement, payment, and quality of care

Effectiveness of payment mechanisms and provider engagement function:• Address the complexity in the development of

effective purchasing and reimbursement mechanisms for TB providers– Potential models (i.e., case-based payments, capitation, fee-

for-service) with relative (dis)advantages depending on the type of service, service site, and administrative requirements

– Strong oversight functions needed– Development of additional organizational layers

II. Provider engagement, payment, and quality of care

Provider follow up, monitoring and quality of care:• Mechanisms for ensuring in-network providers deliver

services according to TB standards– Effectively matching payments to incentives or incorporate

targets for service delivery outcomes or outputs– Linked payment mechanisms to structured accreditation and

certification systems• Facilitates oversight by NTP and/ or insurance authority for

compliance to standards and quality of care• Requires robust organizational management, in the context of

decentralization

III. Patient needs and patient-centered care

Impact on reducing patient costs:• More evidence needed to demonstrate impact on

reducing OOP costs for TB patients. Common challenges:– Access to an accredited provider vs. shopping around– Utilization of insurance benefits – Gaps in coverage for needed clinical services– Lack of coverage for social support benefits

Conclusion

• Stronger engagement and continued consultations between National TB Programs and other planning authorities around UHC financing and the role of health insurance

• Develop further evidence on the impact of the impact of health insurance on the TB outcomes and economic wellbeing of beneficiaries

• Introduce guidance on development of financing and/or insurance-based reforms in the context of national TB and UHC objectives

Change has a considerable psychological impact on the human mind. To the fearful it is threatening because it means that things may get worse. To the hopeful it is encouraging because things may get better. To the confident it is inspiring because the challenge exists to make things better.

-King Whitney Jr.

Thank you!