Dr.  JOSÉ LUIS ROJAS B. NATIONAL TRANSPLANTS COORDINATOR MINISTRY OF HEALTH 2011 ORGAN DONATION CONGRESS GES (Explicit Hea...
HEALTH SYSTEM <ul><li>MIXED SYSTEM. </li></ul><ul><li>PUBLIC AND PRIVATE PROVIDERS. </li></ul>
ISAPRE FONASA ISAPRES and FONASA Beneficiaries By Age Group  Age groups Percentage of the group
FUNDING FUNDING PUBLIC PRIVATE FONASA FISCAL CONTRIBUTION 7% Worker Institutional  Free Choice ISAPRES 7% Worker Voluntary...
Funding in the Health Sector in Chile Contributions  High income workers Low income workers Pensioner  Private providers L...
Basis: Equity <ul><li>Justice in funding: WHO. </li></ul><ul><ul><li>Families should not pay an excessive proportion of th...
Public/Private System <ul><li>Dilemma:  </li></ul><ul><li>Failures of the market </li></ul><ul><li>Failures of the governm...
Mixed Service: Public/Private <ul><li>Complementary roles: focus each sector on what they do best. </li></ul>
Areas of the health market in which the State  must  intervene <ul><li>Regulation of competition between insurers </li></u...
Main Health Problems in Chile
Synthesis of the Problems <ul><li>Country expenditure according to the development level </li></ul><ul><li>Excellent resul...
Source: Economic Studies OECD: Chile, 2003 Graph 28. GDP and expenditure on health per capita GNP Health care expenses
Demography  Chile CHILE: ESTIMATED POPULATION BY JUNE 30TH Men Women THOUSANDS OF PEOPLE Source: Population Projection INE...
Disease Burden AVAD Measurement (DALY)
Pocket spending per capita as percentage of the total per capita expenditure.  Chile and OECD, 2002 Source: elaborated by ...
Health Reform in Chile
MAJOR GUIDELINES OF THE REFORMS <ul><li>Target resources to activities with greater health impact  </li></ul><ul><li>Incre...
Prioritization <ul><li>Health targets for the decade:  </li></ul><ul><ul><li>Identify priority health problems, set goals ...
Health Guarantees System (AUGE Plan)  (Law 19.966) <ul><li>Compulsory coverage (Fonasa and Isapres) of a set of priority d...
LAW  19.966  GES UNIVERSAL ACCESS PLAN WITH EXPLICIT GUARANTEES   Explicit Guarantees Access  Quality  Opportunity  Financ...
Explicit Health Guarantees:  Progressive Incorporation DFL 170 DFL 228 DFL   44/69 DFL Nº 1 <ul><li>The  69 pathologies id...
69 Health  Problems Serious Accidents Serious Burning  Serious Polytraumatised TBI Severe Ocular Trauma  Elderly  Hip repl...
ACT  19,966 AUGE PROBLEM PRIORITIZATION Priority Problems The most frequent The most serious The most expensive Feasibilit...
Cervical  cancer Lung  Cancer Childhood  Leukemia Myocardial  Infarction Promotion  Prevention  Early Detection   Treatmen...
HEALTH CARE PROCESS ( with ges) Diagnostic  Suspicion Diagnostic Confirmation  Treatment  Follow-up  t t t Inclusion crite...
País 95,08% 96,6% 93,2% Second Semester Second Semester Second Semester Second Semester Second Semester Second Semester Fi...
Country Delays FONASA GES Delays
Natural History Population strategies Individual strategies Promotion  Prevention  Early diagnosis Treatment  Rehabilitati...
Some Key Messages CKD 1 <ul><li>CKD is a global public health problem because of its epidemic character, its high morbidit...
1.  Chronic Renal Failure   Vascular access within 90 days from confirmation <ul><li>New Benefits: </li></ul><ul><li>Vascu...
U$ 54.000 U$ 44.000 U$ 40.000 U$ 14.000 U$ 4.000
Conclusions  <ul><li>GES  ensures coverage, access, funding and quality of the Chronic Kidney Failure –transplant for all ...
Thank You.
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Jose Luis Rojas - Chile - Monday 28 - Financing the Donation and Transplantation Process

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  • Chile is going through an advanced Demographic-Epidemiological Transition: the population is getting older; the courses for diseases and death of changing, from an infectious pattern to a pattern of chronic non-communicable diseases (ECNT, by its acronyms in Spanish). The National Health Survey (ENS, by its acronym in Spanish) aims at measuring the magnitude of the ECNT.
  • Jose Luis Rojas - Chile - Monday 28 - Financing the Donation and Transplantation Process

    1. 1. Dr. JOSÉ LUIS ROJAS B. NATIONAL TRANSPLANTS COORDINATOR MINISTRY OF HEALTH 2011 ORGAN DONATION CONGRESS GES (Explicit Health Care Guarantees) and Transplants: Funding System in Chile
    2. 2. HEALTH SYSTEM <ul><li>MIXED SYSTEM. </li></ul><ul><li>PUBLIC AND PRIVATE PROVIDERS. </li></ul>
    3. 3. ISAPRE FONASA ISAPRES and FONASA Beneficiaries By Age Group Age groups Percentage of the group
    4. 4. FUNDING FUNDING PUBLIC PRIVATE FONASA FISCAL CONTRIBUTION 7% Worker Institutional Free Choice ISAPRES 7% Worker Voluntary Contribution Clinics
    5. 5. Funding in the Health Sector in Chile Contributions High income workers Low income workers Pensioner Private providers LL Subsidies Free choice LL Subsidies LL Subsidies Note: the arrows represent the money flows and their thickness indicates their amount. Adapted from Cobarrubias, Álvaro. Unpublished FIGURE I. SUMMARY CHART OF THE CHILEAN HEALTH FUNDING SYSTEM, 2000 Indigents Bonuses Transferences Municipalities Own income State contributions Primary medical care Co-payment Payment health care provision
    6. 6. Basis: Equity <ul><li>Justice in funding: WHO. </li></ul><ul><ul><li>Families should not pay an excessive proportion of their income to receive health care. </li></ul></ul><ul><ul><li>Poor families must use a smaller percentage of their available income to healthcare compared to families with higher incomes. </li></ul></ul>Servicio de Salud Metropolitano Central
    7. 7. Public/Private System <ul><li>Dilemma: </li></ul><ul><li>Failures of the market </li></ul><ul><li>Failures of the government. </li></ul><ul><ul><li>Public policies based on imperfect methods of aggregating individual preferences </li></ul></ul><ul><ul><li>Regulation </li></ul></ul><ul><ul><li>Lack of incentives </li></ul></ul><ul><ul><li>Organizational isolation </li></ul></ul>
    8. 8. Mixed Service: Public/Private <ul><li>Complementary roles: focus each sector on what they do best. </li></ul>
    9. 9. Areas of the health market in which the State must intervene <ul><li>Regulation of competition between insurers </li></ul><ul><li>Consumers’ protection </li></ul><ul><li>Subsidy for poor people </li></ul><ul><li>Antimonopoly rules </li></ul><ul><li>Accreditation </li></ul><ul><li>Market regulation </li></ul>Servicio de Salud Metropolitano Central
    10. 10. Main Health Problems in Chile
    11. 11. Synthesis of the Problems <ul><li>Country expenditure according to the development level </li></ul><ul><li>Excellent results in healthcare, because of the level of expenditure, but: </li></ul><ul><ul><li>Changes in the epidemiological and demographic profile </li></ul></ul><ul><ul><li>Inequalities </li></ul></ul><ul><ul><li>Insufficient protection before health risks </li></ul></ul><ul><ul><ul><li>Financial protection </li></ul></ul></ul><ul><ul><ul><li>Access to timely attention </li></ul></ul></ul><ul><ul><li>Problems of “responsiveness” (treatment, autonomy, financial justice) </li></ul></ul><ul><ul><li>Cost scaling because of aging, technology and inefficiencies </li></ul></ul>
    12. 12. Source: Economic Studies OECD: Chile, 2003 Graph 28. GDP and expenditure on health per capita GNP Health care expenses
    13. 13. Demography Chile CHILE: ESTIMATED POPULATION BY JUNE 30TH Men Women THOUSANDS OF PEOPLE Source: Population Projection INE-CELADE Age (years) Age (years)
    14. 14. Disease Burden AVAD Measurement (DALY)
    15. 15. Pocket spending per capita as percentage of the total per capita expenditure. Chile and OECD, 2002 Source: elaborated by the author based on Dipres and OECD data % of pocket spending
    16. 16. Health Reform in Chile
    17. 17. MAJOR GUIDELINES OF THE REFORMS <ul><li>Target resources to activities with greater health impact </li></ul><ul><li>Increase the effective level of social protection and “ responsiveness ” </li></ul><ul><li>Higher efficiency in fulfillment of objectives </li></ul>
    18. 18. Prioritization <ul><li>Health targets for the decade: </li></ul><ul><ul><li>Identify priority health problems, set goals and define general strategies. </li></ul></ul><ul><li>Explicit Health Guarantees: </li></ul><ul><ul><li>Identify specific diseases and their related provisions, in the framework of the health objectives. </li></ul></ul><ul><li>More years of healthy life for peso($) invested: </li></ul><ul><ul><li>Focus on the most important health problems for Chilean population. </li></ul></ul><ul><ul><li>Focus on cost-effective provisions or for those in which there is evidence of efficiency. </li></ul></ul><ul><ul><li>Guidelines for public health actions targeted on priority problems. </li></ul></ul>
    19. 19. Health Guarantees System (AUGE Plan) (Law 19.966) <ul><li>Compulsory coverage (Fonasa and Isapres) of a set of priority diseases </li></ul><ul><li>Explicit Health Guarantees System (GES) </li></ul><ul><ul><li>Access, </li></ul></ul><ul><ul><li>Opportunity, </li></ul></ul><ul><ul><li>Financial Protection, </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><li>Additional Financial Coverage </li></ul><ul><li>Isapres forced to grant MLE coverage of Fonasa </li></ul><ul><li>Enforceable rights </li></ul>
    20. 20. LAW 19.966 GES UNIVERSAL ACCESS PLAN WITH EXPLICIT GUARANTEES Explicit Guarantees Access Quality Opportunity Financial protection Preventive Health Component Collective or population based actions Individual Actions People’s Health Component Priorities with maximum and intermediate guarantees
    21. 21. Explicit Health Guarantees: Progressive Incorporation DFL 170 DFL 228 DFL 44/69 DFL Nº 1 <ul><li>The 69 pathologies identified correspond to </li></ul><ul><li>80% disease burden </li></ul>Pilot Legal Regime
    22. 22. 69 Health Problems Serious Accidents Serious Burning Serious Polytraumatised TBI Severe Ocular Trauma Elderly Hip replacement Ambulatiry pneumonia Refractive defects Orthosis Knee and hip osteoarthritis Hearing loss Parkinson’s disease Chronic Diseases Chronic Renal Failure 1 Diabetes Mellitus 2 Diabetes Mellitus HTA Rheumatoid arthritis hemophilia HIV / AIDS Cystic fibrosis Adult epilepsy Children epilepsy Relapsing-remitting Multiple Sclerosis hepatitis B hepatitis C Juvenile Idiopathic Arthritis Heart and cerebrovascular diseases Operable Congenital Heart Disease AMI pacemaker CVA cerebral hemorrhage ESRD secondary prevention Respiratory Diseases ARI Adult Asthma Child Asthma COPD Eye Disease Strabismus Cataracts Diabetic Retinopathy Non-Traumatic Retianl Detachment Surgeries allbladder Your benign prostate Your benign brain spinal dysraphism cleft lip and palate scoliosis Lumbar hernia Cancer Cervical Breast Gastric Paediatric Prostate Lymphoma Leukaemia Pain relief and palliative cares Labor, premature births and newborn diseases Labor Analgesia Prematurity prevention Hearing loss Retinopathy Bronchopulmonary Displasia ) Newborn Respiratory Distress Hip Dysplasia Mental Health Depression Alcohol and drugs consumption in people under 20 years old Schizophrenia Oral Health Integral in six year-old children Dental Emergency Integral 60 years old Pregnant
    23. 23. ACT 19,966 AUGE PROBLEM PRIORITIZATION Priority Problems The most frequent The most serious The most expensive Feasibility Supply capacity of the system Resources available DEBATE AND SOCIAL CONSENSUS EXPLICIT GUARANTEES Effective Interventions Promotion Prevention Healing Rehabilitation
    24. 24. Cervical cancer Lung Cancer Childhood Leukemia Myocardial Infarction Promotion Prevention Early Detection Treatment Rehabilitation Palliative costs Health Subclinical Dis. Clinical Dis. Disability DEATH Health-Disease Continuum
    25. 25. HEALTH CARE PROCESS ( with ges) Diagnostic Suspicion Diagnostic Confirmation Treatment Follow-up t t t Inclusion criteria ACCESS OPPORTUNITY QUALITY FINANCIAL PROTECTION IN THE CASE OF ONE OF THESE 69 PATHOLOGIES, THE DOCTOR MUST INFORM THE PATIENT THROUGH A FORM CERTIFYING THE PATIENT AS GES.
    26. 26. País 95,08% 96,6% 93,2% Second Semester Second Semester Second Semester Second Semester Second Semester Second Semester First Semester First Semester First Semester First Semester First Semester % Carried out within the period % Carried out outside the period
    27. 27. Country Delays FONASA GES Delays
    28. 28. Natural History Population strategies Individual strategies Promotion Prevention Early diagnosis Treatment Rehabilitation Health Disease Keeping healthy Avoid getting sick Early diagnosis Start early treatment Go back to initial stage Education Risky behaviour Examination Integral Control and Treatment EPM HTA DM1 DM2 Secondary prevention ESRD Dialysis Renal Transplant
    29. 29. Some Key Messages CKD 1 <ul><li>CKD is a global public health problem because of its epidemic character, its high morbidity and mortality, and its cost. </li></ul>CKD is common with a prevalence of 10%, and it can be treated in case of early detection
    30. 30. 1. Chronic Renal Failure Vascular access within 90 days from confirmation <ul><li>New Benefits: </li></ul><ul><li>Vascular access (3 Kinds Repair included) </li></ul><ul><li>Confirmation and treatment Skeletal delayed growth (Growth hormone in children) </li></ul><ul><li>Erythropoietin in adults </li></ul><ul><li>Donor evaluation (live and dead) </li></ul><ul><li>Treatment of rejection (immunosuppressants, plasmapheresis) </li></ul><ul><li>Prophylaxis of cytomegalovirus </li></ul>Patient with Chronic Kidney Disease Service: MEDICAL CONSULTATION Reasonable suspicion? SIGGES SIGGES Older patient with Chronic Kidney Disease Order of attention Provision: Hemodialysis 1901029 1901028 Provision: peritoneal dialysis 1901026 1901126 Erythropoietin Confirmation and skeletal delayed growth treatment Service Monthly Dialysis Consult to Specialist Specialty Code: Order of attention Order of attention PRE-TRANSPLANT STUDY 3005004 Consult to Specialist Service 1 Service 2 Service n Transplant Service Study of the Donor Immunosuppressive Drugs Cytomegalovirus Prophylaxis Kidney Transplant Rejection Autologous Vascular Access, with Prosthesis, high complexity Autologous; repair Diagnosis Process Report Referral Commission
    31. 31. U$ 54.000 U$ 44.000 U$ 40.000 U$ 14.000 U$ 4.000
    32. 32. Conclusions <ul><li>GES ensures coverage, access, funding and quality of the Chronic Kidney Failure –transplant for all the Chileans. </li></ul><ul><li>Extrarenal transplants are covered according to public insurance (Fonasa) and private insurance (Isapres) plans ensuring the universal access to this therapy or the Chileans. </li></ul><ul><li>75% of the transplants carried out to beneficiaries of the Public Health System in accordance with the distribution of health coverage for Chilean population which reflects the fairness and justice of the access to transplant in our country. </li></ul>
    33. 33. Thank You.

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