who tanulmány
TRANSCRIPT
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WHO’s perspective on the proposed reforms to the Hungarian health
insurance system
Health Insurance Reform 2007-200925-26 January 2007
Budapest, Hungary
Joseph KutzinWHO Regional Advisor, Health Systems Financing
Visiting Fellow, Imperial College Centre for Health Management
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Outline of presentation
• WHO’s approach to health financing policy in the European region
• Application of the WHO approach to the Hungarian reform proposal
• Some final questions for Hungary’s policy makers
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Main messages (up front)
• From WHO’s perspective, the analysis underlying the proposal to introduce a competitive insurance model in Hungary is flawed in two important ways– There is no logical link between the problems
identified and the solution proposed– More generally, the approach taken reflects an old-
fashioned way of thinking about health financing
• It is certain that the proposed approach will make the Hungarian health system much more expensive, but much less clear is whether it will bring any benefits
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rtWHO’s approach to health financing
http://www.euro.who.int/Document/RC56/ebd01.pdf
Regional Committee for EuropeFifty-sixth session
Copenhagen, 11–14 September 2006
EUR/RC56/BD/126 June 2006
Approaching health financing policy in the European Region 61099ORIGINAL: ENGLISH
This paper has been developed as a follow-up to the launch of the European health systems initiative by the fifty-fifth session of the Regional Committee (resolution EUR/RC55/R8).
The aim of this background paper is to elaborate an approach to health financing policy that countries can adapt to their own national context. This entails: (1) specification of a set of health finance policy objectives, grounded in WHO’s core values; (2) a conceptual framework for analysing the organization and functions of the health financing system; and (3) recognition of the way in which key contextual factors, particularly fiscal constraints, affect a country’s ability to attain policy objectives or implement certain types of reforms. Because of the great diversity of national contexts within the Region, there is no “blueprint” – no particular model or system of financing – that is appropriate for all countries. Hence, while the approach is fundamentally grounded in a common set of values and objectives, it permits analysis and recommendations that are country-specific and realistic. Key messages for decision-makers are to identify and address the harmful consequences of fragmentation in financing arrangements, and to ensure that the instruments of health financing policy are consistently aligned with the objectives.
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Fis
cal
con
text
Three pillars for approaching health financing policy and reform options
Des
crip
tive
fr
amew
ork
Po
licy
o
bje
ctiv
es
Health financing policy analysis and viable options
for reform
Starting point, direction, and reality check
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Normative policy question
• What should be the objectives of health financing policy? In other words, what should we be trying to achieve through health financing reforms?
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rtProposed generic policy objectives
(and assessment criteria)
• Health financing reforms should improve…– Equity in funding the system (who pays) and the
distribution of spending and services (who gets)– Protection of the population against financial risk– Transparency and accountability– Quality and efficiency through better incentives– Efficiency in the administration of the system
• …to the extent that can be sustained within the limits of available resources
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rtAre reforms linked to objectives or
based on faith??
Volunta
ry h
ealth
insu
rance
Social health insurance
DecentralizationInsurance competition
Single payer system
Purchaser-provider splitCo-payments
DRGs
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rtUnderstanding health financing systems and options for reform
• “Beveridge National Health Service”
• “Bismarck Social Health Insurance system”
• Collection• Pooling• Purchasing• Benefits and copayments
Classifications or models Functions and policies
• Understand systems (and reform options) in terms of functions, not labels or models– Because the devil is in the details
No – sources are not systems Yes – all reform instruments available
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rtCommon challenges facing the
region’s financing systems
• Fragmentation within financing systems takes many forms and contributes to inefficiency (duplication), inequity (in distribution of resources and services), and inadequate protection against risk (barriers to pooling)
• Mis-alignment of policy instruments with each other and with objectives contributes to inefficiency and can render reforms ineffective
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rtKey messages from the WHO approach to health financing(1)
• The most important thing to understand about Beveridge and Bismarck is that they are both dead– Don’t let labels like these limit your choices– Source of funds does not have to determine how
they are pooled, how providers are paid, nor how benefits and rationing mechanisms are specified
– Put another way, it is important to understand that German citizens are not more “insured” than British citizens just because their system includes the word “insurance” in its label
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rtKey messages from the WHO approach to health financing(2)
• WHO is committed to the objectives of health financing policy, but not to any model
• There is no blueprint– The starting point for each country is different, so
the specifics of reform must be adapted to this)– You can learn from the experience of other
countries, but you cannot import reforms– Try to learn from countries whose starting point is
similar to Hungary’s– Build on your own experience and past
investments
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WHO’s perspective on the Hungarian reform proposal
Concerns about some critical errors in the analysis, that in turn raise concerns
about the proposed reforms
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rt1. No link between problems and
solutions
• As in all countries, you have problems, e.g.– Loosely defined benefit package, and no
requirement for budget impact of adding new technologies, contributes to rising costs and lack of transparency (informal payments)
– Purchasing and benefit package policies do not support effective referral and care coordination
• But these are unrelated to issue of single vs. multiple insurers; and certainly, there are single payer systems that address these problems very well (e.g. Estonia, England, Slovenia)
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rt 2. Wrong analytic framework leads
to unimportant conclusions
• Background paper on the proposed reform analyzes the current system in terms of Beveridge and Bismarck– These labels have some political value, but offer
nothing useful to the understanding of a system– Purpose seems to be to label the current system as
“more Beveridge than Bismarck”. Not important.– The conclusion that the choice facing Hungary is
between “opening up the insurance market or a return to a tax-financed, state run Beveridge system” is simply wrong. Such analysis, and the identification of options based on this, is not consistent with modern health policy analysis.
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rt3. Looking for lessons in all the
wrong places
• Dutch, Slovak, German and Czech reforms are all very interesting, but irrelevant– Starting point for recent reforms in each of these
countries was fragmentation resulting from multiple insurers. So for them, reforms to enable choice of insurer and better risk adjustment aimed to reduce fragmentation and expand pooling.
– Hungary doesn’t have this fragmentation problem. By choosing to model reform on these experiences, Hungary would first have to import their problem before importing their solution. This will be costly!
– Instead, learn from countries with institutional structures more like Hungary’s (Estonia, UK, France, Slovenia). Not even considered, apparently
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It is possible to implement this
• But it will be very costly– You will have to create an insurance market– You will have to create a very sophisticated
regulatory machinery– You will have to invest in substantial education of
the population and providers to make it work– You will have to face the new burden of private
bureaucracy (just ask any American hospital manager or patient!)
• A high price for Hungarians to pay, especially when the benefits are uncertain
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rtFinal questions for Hungary’s policy
makers and people
• Are you willing to pay this price?– Either increase the level of public funding
substantially to meet the administrative and regulatory requirements of this new system, or suffer substantial losses in the performance of the health system (or both – spend more and get less)
• Why not build on what you have?– Rather than throwing out the knowledge and
investments already made in the system, why not focus reforms on trying to fix its problems rather than starting over?
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We are ready to help
• WHO’s approach to health financing is designed to be adapted to different national contexts, and can be fruitfully adapted to Hungary. This framework could be the basis for a thorough re-analysis of the challenges facing the Hungarian health financing system, followed by the identification of reform options to address these challenges in an affordable manner.