META Health System For Lebanon

- a vision synthesis -

Pierre Chidiac, Actuary

Healthcare costs at the Nation-Level are spiraling up, eating agreater proportion of the GNP …. A Major concern driven by:• Behavioral & Social considerations (at the population, patient,

healthcare providers level leading to over-consumption)• Increasing life expectancy• Advancing research, Technology• Incidental growing expenses (impact of administration cost,

financing/funding cost, malpractice…)Health reforms & New Health systems represent a majorchallenge to the whole world; the two basic & most applied healthsystems in the world being:• Lord Beveridge system (NHS financed through a General Taxation)• Bismark system (based on the Employer/Employees solidarity –

Social Security Concept)

The architecture of a new system could be based on acombination of the two basic systems restructured in conjunctionwith a specific healthcare program.

Setting the stage for the Meta-System

Drawing up a “Master Plan”

• Strategic thinking process leading to the Drawing up of the Master Plan which in turn will lay down the ground for the design & implementation of the Meta Health system.

• This is prompted by a very simple fundamental question:

What should be Role & Objective of the Government or the Welfare State in relation to the provision of healthcare to a given segment of the population or to the population at

large?

Answering a major question

The answer to the above fundamental question is in full consistency with the Constitution:

Give the right to each fellow citizen or resident to have access to free of charge healthcare

services, the scope and extent of such services being subject to their affordability by the State

at the Nation level.

The major objectives of the Project

Ultimately, the System should meet the following two fold objectives:

1. Fulfill the political and social obligation of the State by giving, to each citizen, the possibility to access a minimum level of quality healthcare.

2. Contain the cost of healthcare services within a certain economical limit for the purpose of balancing the so-called "Health Financial Equation".

The six point strategy

1. Redrawing the Health Policy2. Defining the minimum level and extent of quality of

healthcare services. 3. Reengineering the financing of healthcare (within a

system-mix between Public & Private Sectors) 4. The Solidarity Concept5. What actually is going to be financed?6. Implementing Appropriate Management i.e.

The Meta Health System

1. Redrawing the Health Policy

The rationale here being to:– Prevent & Maintain good health rather than Repair. – Treat as and when it becomes necessary. – Coordinate between all major players while adhering to

the Master Plan.

Needless to say that to achieve this vision model, the new health system requires:

– Rehabilitation of the public infrastructure: Hospitals, primary healthcare centers, etc.

– Implementation of Public Health Awareness and Preventive Medicine programs

2. Defining the minimum level of healthcare services

A consensus will define a Social Minimum Insurance Coverage for healthcare, to be provided at the initial stage by the Welfare State to the poorest of all.

This consensus will address the following two parameters, keeping them always in balance:

2. Defining the minimum level of healthcare services

The resulting package shall be called:

1. A Hospitalization Insurance component2. Primary healthcare services at Public Centers

It is a package combining benefits and services:

SMIC – Health

2. Defining the minimum level of healthcare services

A Primary Healthcare Center (PHC) will be assigned to eachFamily, its members carrying a SMIC-Health Card, which will act as a maintenance health unit as well as a gatekeeper for all the members assigned thereto.

In case of hospitalization authorized by the gatekeeper, thepatient will be channeled, in priority, to rehabilitated public hospitals.

3. Reengineering the financing of healthcare

There are different financing scenarios which may be envisaged. However, one should take into account:

• the socio-economical landscape of the country under consideration,

• the taxation system, • the efficiency of the public administration to collect

special taxes or new income Tax, • the appropriateness in allocating such specific income

to Health & not using it for other purposes and finally take stock of what is going actually to be financed?

In the Lebanese context, for example, it is obvious that it is NOT RECOMMENDED to:

• Engineer the financing by the State through general taxation – Lord Beveridge System

• Extend the Social Security to the rest of the population – Bismark System

• Go wholly private

The solution would be a System-Mix:

3. Reengineering the financing of healthcare

and

4. The Solidarity Concept

• Solidarity, being the keystone of any Health System, we will pool together – Healthy people with those who enjoy a rather good, down

to an average health state together with those whose health condition is fragile or poor health solidarity

– Very young & middle-aged people together with the elderly population generation solidarity

– Rich people supporting poor people financial solidarity

• To achieve this, a Special Law will be required to IMPOSE the purchase of a minimum level of health insurance coverage from an Accredited Health Fund.

• Accredited Health Fund– National Social Security Fund– Public Funds & Provident Funds– Insurance Companies & Mutual Society Funds

4. The Solidarity Concept

In this manner,we would achieve a double objective:

1. Access to a minimum level of quality healthcare

2. Injecting solidarity contributions into the System

5. What actually is going to be financed?

• Poorest of all– Population whose income is below a pre-defined threshold

of poverty• Public Sector

– Civil Servants, Armed Forces, Internal Security Forces, General and National Security, etc.

• Private Sector– Employees, Retired, Self-employed, Unemployed,

Professionals, Agriculture, Artists, Craftsmen, etc.– These would be considered to be subscribers of any of the

private Accredited Health Funds – NSSF, Insurance, Mutual, etc.

• Exceptions– non eligible people who cannot afford to enroll in any of the

Accredited Health Funds

Segmentation of the Population

5. What actually is going to be financed?

The cost of the SMIC-Health to be provided free of charge (FOC) to the poorest of all, will be estimated as follows:

(po) – number of beneficiaries benefiting from FOC SMIC(ho) – average hospitalization cost per beneficiary(Mc) – cost of running the PHCs

The first element aggregate cost stands at:

(po) x (ho) + (Mc)

Cost of SMIC-Health

5. What actually is going to be financed?

Health Financial Equation

5. What actually is going to be financed?

Articulation of Billing & Recoveries – Public Hospital

5. What actually is going to be financed?

Articulation of Billing & Recoveries – Private Hospital

6. Implementing the Meta Health System

Problems & Expectations Map

Regulators

Payers Providers

Good relationship with providers & clients

Standardized procedures Streamlined workflow

Feedback and monitoring tools enabling comparison with others

Cost containment

No Standard (each payer has own workflow/documents)

Healthcare growth hard tp control Shift focus from administrative issues to

delivery of care Still do not have access to fundamental

data/healthcare trends/articles… Need to measure performance but there is still a

lack in timely, easy-to-grasp and actionable feedback

Guarantee system viability & quality of care delivery

Drive evolution & mutation Transparency Streamline administrative cost &

procedures Understand and be able to analyze the

outcome and cost of healthcare expenditure

Patients

Good quality care Good quality servicing Trust relationship Contained Cost

(especially when paying the bill out of own pocket)

6. Implementing the Meta Health System

Vision & MissionsSet-up the standards/communication and a “buffer” between all

players and make possible the long-dreamed hope of optimizing healthcare delivery for the entire population. – Reorganize the healthcare market in stabilizing it and set the

stage for a smooth mutation and accompany its evolution.– Bring information/technology and make possible the required

changes in knowledge, attitude and behavior.

• Require a semi-public Central Health Agency at the nation level, depending from the Ministry of Health, but having its own management – The Central Body

• Like the Central Bank, this institution will remain there to regulate and ensure the efficient, smooth and continuous functioning of the System

6. Implementing the Meta Health System

The Central Body will finance & implement appropriate standards & IT platforms– Communication & Standards: develop software components

& infrastructure for claims handling and administrative procedures using Internet standards and make all components easy to use and accessible to all partners in adopting web-services and Intranet based solutions.

– Administrative claims handling: develop procedures to be able to interface between all players (set forms, coding, protocols & communication standards)

– Centralize all the information on the whole population in relation to health

– Create a Data Bank on healthcare issues enabling cost analysis, statistics and other parameters, benchmarks, performance rating index

– Implement efficient control & monitoring systems best practices

– Reorient policies and enforce new corrective measures based on data analysis

In other words, the Central Body would be:

1. Streamlining the information and cash flows

2. Controlling the quality of healthcare delivery

3. Accompany the mutation of the system with more interactivity between all players

4. Watching closely & act early to maintain the financial equilibrium of the system

5. Operating as the reinsurer of SMIC, pooling the solidarity contributions and offsetting any amount due

6. Implementing The Meta Health System

Thank You