(卫生经济学课件)HFupdated1

1、1Health care FinancingHengjin Dong, MA, MD, PhD1Health care FinancingOutline of SessionsConceptual framework for health care financingOptions for mobilizing resources for the health sectorOptions for health sector resource allocationHealth purchaser and provider payment2Outline of SessionsConceptual

2、 Topic 1Conceptual framework for health financing.3Topic 1Conceptual framework fo(卫生经济学课件)HFupdated1(卫生经济学课件)HFupdated1Allocation of Resources to the Health SectorWhat are the main expenditure allocation patterns and sources of finance for health sector?Health expenditures as % of GNPGovernment expe

3、nditure as % of totalPer capita health expenditures6Allocation of Resources to theHealth Expenditures and GDP (2005)CountryGNI p.c. ($)P.C. Health exp. ($)Health exp. (% of GDP)Gov. h. Exp. as % of total h. exp. (90-98)Low income584244.731.0Middle income2,6361385.954.4High income34,9623,68711.163.3O

4、ECD36,5063,84311.374.272000 and 2007 world development indicatorsLow income (2005): $10,725Health Expenditures and GDP (2The Role of Health InsuranceInsurance:Prepayment for services that will be paid for by a (public or private) third party (the insurer) if a pre-defined event occurs.A (full or par

5、tial) substitute for direct payment for services by the consumer of the services.8The Role of Health InsuranceInThe Rationale for InsuranceReduce risk to individuals by pooling risk across a group.Increase the predictability of unexpected losses.Redistribute the costs of unexpected losses (improve e

6、quity).9The Rationale for InsuranceRed10Individual Health Care CostsHealthySickThe Healthy Pay More than they UseThe Sick Pay Less than they UseSick individuals can become healthy and healthy individuals can become sickHealth Insurance ContributionPooling Health Care Risks10Individual Health Care Co

7、stsTopic 2Options for mobilizing resources for the health sector.11Topic 2Options for mobilizing 12Options for Financing Health CareCentralized public fundinggeneral tax financingsocial insuranceVoluntary insuranceCommunity-based insurancePrivate insuranceOut-of-pocket payments (User Fees)12Options

8、for Financing HealthEvaluation CriteriaEfficiencyEquitySustainabilityAccessQuality13Evaluation CriteriaEfficiency1Why public funding for health care?Public goods (efficiency)Financing care for the poor (equity)Risk pooling (private insurance market failure)14Why public funding for health Improved Eq

9、uity with Public Financing15Distribution of Health Spending by Income level% of Total Health SpendingSource: Gottschalk, Wolfe, and Haveman 1989Improved Equity with Public FiGeneral Tax Financing16General Tax Financing16Social Insurance17Social Insurance17Issues with General TaxSensitive to politica

10、l priorities.More of a problem in U.K.-national budgetLess of a problem in Canada-local province budgetsAchieving equity in resource allocation to geographic areas.U.K. population-based formulaAchieving purchaser-provider split.18Issues with General TaxSensitiIssues with Social InsuranceHow to achie

11、ve universal coverage.Appropriate structure of insurers (single insurer or competition).19Issues with Social InsuranceHo20Comparison of General Taxation and Social InsuranceAdvantages of general taxation:More progressive (equitable)Non-distortionaryLower administrative costsAdvantages of social insu

12、rance:Earmarked tax for health;Not viewed as social welfareIn practice, success depends on implementation20Comparison of General TaxatiDisadvantages of a Mixed System of Public FinanceDifficult to control the total flow of resources when there are multiple payers.Difficult to coordinate (mixed signa

13、ls to providers ; cost-shifting).21Disadvantages of a Mixed SysteCombinations of financing and service deliveryFinancingProvidersPublicPrivateMixedGeneral tax (G)Canada, UKSocial insurance (S)JapanBulgaria, Israel, Czech Republic, France, GermanyMixed (G+S)MexicoRussiaKoreaPrivate I (P)Mixed (S + P)

14、HungaryUSChina, Chile22Combinations of financing and 23Voluntary InsuranceDifferent from mandatory insurance-actuarially fare premiums.Market imperfections:Adverse selectionMoral hazardRelationship to public funding:Supplementary rather than competitive23Voluntary InsuranceDifferentCommunity-based I

15、nsuranceRisk-sharing scheme for health care expenditures that is owned and managed at the community level.Usually focuses on primary care, but may include referral services.Often has a broader community development focus.Other types of voluntary risk-sharing schemes: health facility, cooperative, NG

16、O. 24Community-based InsuranceRisk-Types of Risk-Sharing SchemesType 1High-cost, low frequency eventsTend to be hospital-ownedTend to cover whole districtUse actuarial basis or variable costs to calculate premiumCommitted to meeting certain designated costs.Type 2Low-cost, high frequency eventsTend

17、to be community ownedTend to be based at the village levelPremium set mainly according to ability to payCommitted only to raising extra revenue for services.25Source: Creese and Bennett 1997Types of Risk-Sharing SchemesT26Out-of-Pocket Payments (User Fees)May provide supplemental resources and utili

18、zation incentivesNot adequate as main source of financing because:Does not generate sufficient resourcesDoes not pool risksInequitable26Out-of-Pocket Payments (UseUser Fees in Public FacilitiesGoals:Revenue generationStrengthen the role of marketsquality-based competitionintroduce price signals- gre

19、ater efficiencyincentives to increase supply of services (access)Reduce excess utilization (moral hazard)Improve sustainability (affordable)Reinforce decentralizationPrivate sector development27User Fees in Public FacilitiesPossible Negative Affects of User FeesMay reduce utilization of necessary se

20、rvices.May reduce utilization disproportionately among the poor.Administrative costs are high.May add to “under-the-table” payments.28Possible Negative Affects of UPerformance of User FeesPeople are willing to pay for some quality improvement, particularly drugs (Cameroon, Ghana, Nigeria, Kenya, the

21、 Philippines).Utilization may decrease (Zaire), increase if quality (pre-natal care in Niger), or shift to private sector (Indonesia, Lesotho)Impact on health outcomes (Indonesia- in duration of illness, infectious disease symptoms, physical function age 50)29Performance of User FeesPeoplePerformanc

22、e of User Fees, cont.Cost of collecting fees may be higher than revenue generated.Evidence that quality or access to services has improved?Interpretation of performance often ideologically based.30Performance of User Fees, contIssues with User FeesHow to set prices:relate to costs (cross-subsidizati

23、on of services)relate to demand (willingness vs. ability to pay; elasticity; role of quality)Exemption policies (protect the poor).Efficient administration and fee collection.Do revenues stay in the facility, the health sector?31Issues with User FeesHow to se32Topic 3Options for allocating resources

24、 in the health sector.32Topic 3Options for allocati33Resource Allocation within the Health SectorService activities (preventive vs. curative; primary vs. secondary/tertiary)Population groups (rural/urban, regions, income levels, etc.) Input combinations (personnel, medical/nonmedical supplies)Diseas

25、e patterns and categories (infectious vs. chronic)33Resource Allocation within tMore Cost-Effective Resource Allocation3475% of Resources to Inpatient Care25% of Resources to PHC50% of Resources to Inpatient Care50% of Resources to PHCMore Cost-Effective Resource ATopic 4Health purchasers and Provid

26、er payment35Topic 4Health purchasers and P36Examples of Possible Health PurchasersMinistry of HealthLocal government health authorityArea health boardsSocial health insurance fundsPrivate insurance funds/companiesEmployersMember-owned/community-based insurance funds36Examples of Possible Health 37Ma

27、rket Structure of PurchasersSingle purchaser (Canada, U.K.)Multiple purchasers:competitive (Germany, Korea) or non-competitive (Mexico, Kyrgyzstan)unified payment systems (Germany, Japan) or different payment systems37Market Structure of Purchase38Role of Health PurchasersAn agent on behalf of the enrolled population promoting improved quality and efficiency in the delivery of services.Example: traditional indemnity insurance vs. HMOs in the U.S.38Role of