Iadnam ooc presentation 3 oct
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Transcript of Iadnam ooc presentation 3 oct
UHI – What needs to happen, when
Oliver O’Connor [email protected] www.oliveroconnor.co
Irish Associa8on of Directors of Nursing and Midwifery Kilkenny, 3rd October 2013
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A way of thinking about it • This presentation will distinguish between
• UNIVERSALITY
• and
• INSURANCE
• To help untangle the many complex issues involved
• And perhaps give a pointer to likely developments
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Universal Health means… • A set of health beneJits for EVERYONE • With Equity: no faster access to these beneJits for ANYONE
• Compulsory funding by ALL • graduated contributions according to means
• ALL (essential) areas of healthcare covered • And all providers (hospitals) available to all patients
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And Insurance implies… • BeneJits speciJied by rules • not just HSE/hospitals funded to do their best
• A personal contract‐based entitlement to a service • not limited by resources of a hospital or insurer • radical difference in law and budgeting
• A requirement to maintain solvency and reserves
• Usually, payor and provider are different organisations
• Choice: social insurance (like unemployment beneJit) or
• Run through commercial insurance companies • With choice of insurers ✔
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To distinguish… • We could have Universal Healthcare (NHS, Sweden, Spain)
• without
• Universal Health Insurance (NL, Germany, France) • but decision made: it will be insurance • it will be multi‐insurers, not just one
• Still, helpful to identify which elements of the Government plan involve ‘universality’ and which ‘insurance’
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Two essential problems • Primary Care: fees prevent some people getting care
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Address with • Universality: medical card/GP card expansion
• Insure annually?
• Hospital care: two‐tier hospital access
• Universality: enforce equity, access private hospitals
• Same insurance for all
• EfJiciency, cost and quality
• Universality? indirect role
• Insurance? small role now, but should grow
Other issues….
Common issues for both • People: create new public law entitlements and obligations • You all get the same beneJits • But some people pay more than others, and more than now
• Money: merge two funding streams • Public capitation and private fees • Exchequer funding and private health insurance
• Insurers as intermediaries • Customer facing: administer all beneJits and claims • Innovation: scope to design new policies, beneJits • Money: receive funding and pay providers
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Free GP care – current Jlows
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€445m Practice Fees and Allowances
€280m out
‐of‐pocket f
ees?
2.6m Non medical Card holders
Avg visits per year non medical card adults: 2.1 Avg fee per visit €51 (2010) Numbers: 2.62m
2,800 GPs
Primary care ‐ free GP care
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• Cost of extension of GP care: €40m for under‐5s • GP fee: €70 per year per child capita8on • Avg 3 visits per year per child under 5* • Will GPs agree? Difficult to implement without agreement
• Free GP care for whole popula8on: • €445m paid now to cover c.43% of popula8on • Cost for rest depends on GP payment • Anywhere from €400m up: more usage
• What will 2,800 GPs agree? Fee, capita8on or salary? How much? A replacement of all private fees?
• Health policy balance: cost as barrier to access vs over‐use of ‘free’ service
• Hiring of new primary care staff for full service: slow
*Source: ESRI, Resource Alloca8on Group Report, 2010, old data back to 1987
Free GP care – future Jlows
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€725m ‐ €900m?
4.6m, but ?n unsubsidised
+ or ‐ €445m?
+ or ‐ €280m?
2,800
Primary care – insurance issues
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• Will free GP care first be paid by Exchequer? • Increase taxa8on, increase public spending
• Later insurance policies will incorporate this benefit. Will this then reduce Exchequer spending?
• One way or another, a compulsory annual payment by some people to eliminate GP fees at point of use
• More logical to require people to buy GP insurance now as “free GP care”, saving the Exchequer cost
• What else will be covered by the insurance policy? • All primary care
• No fees (deduc8bles) at the point of use for any service? • Insurers not ready for some years to fund primary care services • Apart from limited cash‐plans => fees, not capita8on, for doctors
Hospital UHI – all about Equity • Whole population can already use public hospital care • 1970 Act Jirst, then extended to all in 1993/4 • Universality in place but…
• Equity test: • What about faster access to private care in public hospitals? • Access to private care in private hospitals?
• Policy op8ons • Implement single appointments system in public hospitals
• Underpin with legal obliga8on to give certainty of equity • Allow private hospitals par8cipate in public benefits provision
• On condi8on they offer first‐come, first‐serve appointments
• Actual policy: equity will be achieved the same insurance contracts for all, using both public and private hospitals
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Money Flows to hospitals now • Taxation, patient charges and insurance
48 Public €5bn total HSE Annual Report 2012
€4.1bn + €275m*
€700m+ (est)
€100m
€5.7bn total, excluding consultant fees * Pension contributions and other income, HSE Annual Report, 2012, p.77; May Performance Report Supplement p.52
€2.1bn
21 Private
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Money Flows under UHI • Taxation and insurance premiums
7 Hospital Groups
21 Private €5.7bn excluding consultant fees
+ or ‐€4.4bn?
+ or – €2.2bn w
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UHI issues for hospital care • Why do you need insurance to address the equity issue?
• Would people voluntarily con8nue to buy private health insurance if equity of access were built in before insurance is made compulsory?
• How to sustain the insurance money flow while merging with taxa8on?
• Must any merging of the two money flows await a Big Bang?
• Even with UHI, do you allow people buy private hospital care outside the State system, as in UK?
• Will private hospitals fully join the State system or will some stay out?
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Hospital access ‐ present
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People with Benefit Direct Payment*
No insurance Public hospitals only Slowest access, least choice
None
Low to Mid level insurance
Public hospitals, public and private beds; some private hospitals Faster access, more choice
€500‐€1000 per adult
High insurance All hospitals, public and private Fastest access, most choice
€2,500 ‐ €4,000
* Excluding statutory bed night charges, ED charges, applicable to all except medical card holders
UHI Hospital care – who wins?
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People now with
Popula>on Win Lose
No insurance 2.6m 56%
Most get faster access, free
Some neutral or lose – have to pay
Low to mid‐level insurance
1.8m 39%
Some may get subsidy
Most lose faster access, s8ll pay
High level insurance
220k 5% est. at most
None Some neutral – may keep faster access
• Who will no8ce they win or lose, and when? • Perhaps everyone happy that all have equal access and everyone
pays according to means
UHI ‐ Hospital Care ‐ Progress? • Universality/equity: no change yet • implementation of 2008 consultant contract
• Insurance: VHI authorisation near, risk equalisation needing revision, market under price/cost pressure
• Governance: creation of 7 hospital groups: good, but not directly relevant to universality, equity and insurance
• Access: private hospitals still limited to private insurance • Charging all private patients in public hospitals: • aimed at increasing income for public hospitals • payment remains bed night charge, not per procedure • increases incentive for public hospitals for more private patients
• Awaiting UHI White Paper at end this year
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Clarity – on key issues • Decide if key goals on universality and equity must wait for payments and beneJits to be routed through insurance companies
• Recognise that the transition to insurance is most complex: Payments systems and pricing Reserves requirements BeneJits deJinition Supplementary insurance scope Relationships with providers Competition law Risk equalisation Private contracts replacing public law provision
• And put in place sufJicient expertise to deal with these
• Grasp the nettle early: budget‐cap and spending control
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Clarity for providers, insurers • GPs and primary care staff: payments, contracts, services
• Consultants: salary/fee mix, employee/contractor
• Seven public hospital groups and 21 private hospitals • Anticipate future funding sources, sustainability • Pricing, competition, standards, commercial freedoms • Scope for services outside the State beneJits package • Who will survive, doing what?
• Insurers: complex issues only starting to be talked about
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Clarity for the public • Free GP care: 3 options • Pay by Exchequer – raise taxes, increase public spending • Compulsory private cash‐plan contracts, part subsidised • Modify: include graduated private fee payments (as per Resource Allocation Group Report 2010); rest paid by taxes
• UHI in hospitals: make clear it has beneJits and costs
• Who will pay, and how much • Means‐tested contributions: what are the limits • What choice will there be of doctor, hospital, beneJits
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What is needed, when • White Paper with serious policy detail, 2013‐14 • Including an estimate of cost of UHI and how it is borne
• Decisions on free GP care or variations: 2013‐15 • Negotiations with GPs: 2013‐14 • Huge amount of technical work with insurance experts: 2013‐20
• Stabilisation of insurance market and risk equalisation: 2014 ‐>
• New consultant contract: 2018? • Strategic agreement with public and private hospitals to allow planning: 2014‐15
• Post‐White Paper implementation plan: 2014‐15
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