11 Health Care Reform Current Problems and Possible Future Content · The Model Before 1990 · Basic Concepts of the Reform ­ objectives ­ principles · Reform Steps and Issues · The Future · Discussion The Model Before 1990 · hierarchically organized centralized services paid for through government budgets · no linkage between the performance and budget assets · state monopoly in providing, financing and managing the health services · private practice prohibited · health care managerial structures were a part of the state administration. 22 Capacity of the past HCS · relatively high ­ 110.8 beds per 10,000 popul. (1989) U.S. 48.5 ­ 27.2 physicians per 10,000 U.S. 22.5 · seemingly not high enough - excessive demand ­ waiting lists · relatively low costs - 4.8 of GDP in 1988 Problems · low level of remuneration of the health workers, especially qualified nurses, but physicians too · obsolete medical and non-medical equipment · almost critical lack of some drugs. Health Status · significantly lower than other European nation at that time · shortening of the mean life span · an increase of morbidity and partial and total disability · SMR for diseases of the circulatory system was significantly higher than the European average 33 Reform Principles 1 · an obligatory health insurance system · free choice of a provider · increased responsibility for own health · an income for physician and/or the health service facility should depend on their performance in terms of quantity and quality Reform Principles 2 · decentralization, privatization, competition · equal access to ,,adequate" levels of services · plurality (the prevailing form of health care should remain the public health service, but there will be plurality within the health service - state, municipal, church, and private sectors) Reform Steps - insurance · Comprehensive Health Insurance Act was passed in 1992 · first insurance company General IC (VZP) was established at the same time · other smaller insurance companies have been founded (up to 27) · insurance premium is paid by employees, employers, and the government, and its amount is based on a gross income. 44 Reform Steps - reimbursement · fee-for-services relative scale system with a cap on the total health care expenses · it was applied to all kinds of services · a massive increase in services produced was an immediate reaction (,,inflation of a point") · the cap was replaced lately and a deficit development was started Some Outcomes · the volume of provided care increased significantly · dtto for the amount of hi-tech equipment · the quality of care rose too (?!) · a rapid increase in the life expectancy could be observed between 1990 and 2001 (male 67.63 in 1990 72.14 in 2001). cardiac operations heart kidney liver pancreas lungs 1991 9 178 2 - - 1 657 1992 19 190 2 - - 1 825 1993 34 313 2 2 - 2 471 1994 50 406 11 8 - 3 330 1995 60 389 31 13 - 4 008 1996 75 393 42 19 - 5 043 1997 96 445 49 21 1 5 943 1998 55 366 66 21 8 6 463 1999 64 316 67 24 14 6 868 2000 58 353 61 23 7 7 640 2001 49 330 58 25 10 8 277 Zdroj: Institut klinické a experimentální medicíny Number of transplantations and cardiac operations Year Transplantations 55 medical equipment Year Equipment CT 48 59 64 69 73 117 Mammograph 44 56 68 87 106 125 Lithotriptor 11 22 25 25 29 30 MRI 4 6 7 10 11 19 Lasers 86 111 156 515 1,02 1,4 Lung ventilators 843 988 980 983 1,188 1,683 1996 20011992 1993 1994 1995 Life expectancyat birth, in years, males 63 64 65 66 67 68 69 70 71 72 73 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 Health care expenditures 0% 1% 2% 3% 4% 5% 6% 7% 8% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 66 current situation · 7,4 % of GDP · 1+8 HICs, · same premiums, same benefit package, practically no copayments, slightly different reimbursement level to providers (has no real meaning for providers' behavior ) · General Insurance Company · 69,50% of the population · + some services for the whole system (central register, redistribution account, center for capitation, DRG experiment....) · other HICs also open, some national wide, some regional reimbursement methods · GPs - capitation plus limited services extra · Ambulatory specialists - fee-for-service with time limitation · Hospitals - mostly lump sum payment following their output in the previous year, (originally was introduced as an temporary and provisional tool to save critical financial imbalance...) cost structure 1998 (VZP) 5% 6% 10% 50% 25% 4% GPs Dentisty Ambulatory Hospital drugs other Source:Source: VZPVZP''ss Yearbook 1998Yearbook 1998 77 cost structure 2001 (VZP) 5% 6% 10% 50% 21% 8% GPs Dentisty Ambulatory Hospital drugs other major issues 1 · risk selection (or at least some indications) · dialysis, transplantation, pacemakers... more than 90% for VZP · drug expenditures escalation (increase from 1990 to 2001: 130% measured in daily doses per 1 000 inhabitants; and 711% in consumption per inhabitant in CZK) major issues 2 Hospitals: · 70% fixed costs · 18% growth of wages Debt (9 billion CZK, 30.6.2002) 2003 income from local (municipal) budgets (previously from state budgets) debt transferred to municipals!!! 88 major issues 3 · physicians' complains ­ salary in hospitals ­ heavy income regulation for ambulatory specialists ­ administrative complications (overall) · lack of vision, clear strategies perspective 1 · several possible strategies depending on political circumstances I. stronger government regulation, reducing the number of HIC, standards of care, centralization of the system, DRG II. no radical changes, a splitting VZP in order to create more flexible institutions, introduction of managed care principles... III. no changes at all perspective 2 (in any case?) · to put together health and sickness insurance · some reduced definition of guaranteed care (it is still not clear who and how will do it) · a private insurance market development (extra services or quality of care...) · an improvement in ability to negotiate for a volume and price of provided care, selective contracting, (further) reduction of supply